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  • Written by Fiona Kelly, Associate Professor, Law School, La Trobe University
imageNo four-year-olds in Australia are undergoing any irreversible treatment, as was implied in media reports yesterday. from

“Preschooler’s sex swap at age four”, read the Daily Telegraph’s headline on Thursday, sparking intense debate in the media over how to handle cases of young children experiencing gender dysphoria.

The story detailed the case of a pre-schooler who is transitioning to another gender.

But the fact is that no four-year-olds in Australia are undergoing any irreversible treatment. At that age, treatment for gender dysphoria consists mainly of counselling. No other medical treatment will occur until the child nears puberty.

What is gender dysphoria?

Diagnosis of gender dysphoria is governed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

To receive a diagnosis, a person must express a strong and persistent cross-gender identification for more than six months, a persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex, and the experience must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Medical treatment for gender dysphoria is regulated by international consensus guidelines published by the Endocrine Society of the United States and endorsed in Australia by the Australasian Paediatric Endocrine Group.

Treatment is also informed by the clinical guidelines contained within the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, produced by the World Professional Association for Transgender Health and drawing on the best available science and expert professional consensus.

The WPATH Standards were adopted by the Australian and New Zealand Professional Association for Transgender Health and guide clinical practice in Australia.

What do the clinical guidelines say about treating a four-year-old?

Clinical practice for the treatment of a four year old whose parents suspect may be experiencing gender dysphoria does not involve any treatment that is irreversible.

Parents can seek help from a range of health professionals, who may then refer the child to mental health clinicians. A full psychiatric assessment follows, with the aim of engaging the child in ongoing psychotherapy to monitor both their emotional well-being and whether their dysphoria remains persistent. No other medical treatment will occur until the child nears puberty.

When does treatment create irreversible effects?

For young adolescents entering puberty with profound and persisting gender dysphoria, the possibility of delaying progression of puberty may be discussed. This treatment is often referred to as Stage 1 treatment and is fully reversible.

Stage 1 treatment involves the administration of puberty “blockers” which supress the hormones responsible for puberty and can commence from Tanner pubertal stage 2–3 (the Tanner scale is a scale of physical measurements of pubertal development based on external sex characteristics).

For most children this will occur between the ages of 10 and 13. The current procedure in Australia for authorising Stage 1 treatment, which is consistent with international protocol, involves two independent child and adolescent psychiatrists undertaking a standardised assessment of psychological development, and a formal assessment of the child’s gender identification and capacity to understand the proposed treatment.

A paediatric endocrinologist establishes the child’s pubertal stage, excludes disorders of sex development, and discusses with the child and parents the effects and risks of puberty suppression. If a child does not wish to continue with Stage 1 treatment, he or she can cease taking the blockers and puberty will commence.

Stage 2 treatment for gender dysphoria occurs at approximately 16 years of age. That involves the administration of cross-sex hormones, which cause the child to develop the pubertal characteristics of the sex with which they identify. Some of these characteristics, such as voice deepening, are irreversible, while others, such as breast development, require surgery to reverse. A list of the side effects of cross-sex hormone treatment can be found here.

Approval for stage 2 treatment requires a multidisciplinary team consisting of a paediatrician, two mental health professionals (one must be a psychiatrist), and a fertility expert, to agree treatment is in the child’s best interests. It is then necessary to make an application to the Family Court for authorisation of treatment.

Surgery is not considered in patients aged less than 18 years and is only offered after transition to adult medical services.

A four year old, such as the one identified in the Daily Telegraph article, is not the subject of any irreversible decision-making or medical treatment.

Pre-pubescent children experiencing gender dysphoria are provided with counselling support, which may include supporting the child in some form of social transition. This might involve the child adopting clothing or an appearance that reflects their chosen sex.

However, no child experiencing gender dysphoria can access medical treatment that has irreversible consequences until they are at least 15 years of age, and only then after a multi-disciplinary team of experts has recommended treatment and Family Court approval has been obtained.

Fiona Kelly received funding from the Victorian Law Foundation to produce an information guide for families making a Stage 2 application to the Family Court of Australia.

Authors: Fiona Kelly, Associate Professor, Law School, La Trobe University

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