By Jill Stark, for the Sydney Morning Herald.
The number of children accessing medical treatment to help them change gender has increased 60-fold, leaving Australia's only clinic for transgender young people struggling to cope with the rise in demand.
Exclusive figures obtained by The Sunday Age show the Royal Children's Hospital gender dysphoria service is seeing 150 patients a year, with new referrals rising from one per year in 2003 to 60 in 2014.
Parents of children as young as three with gender dysphoria - which causes persistent and distressing feelings of being born the wrong sex - are facing a five-month wait for treatment.
Doctors say the surge in demand is being seen throughout the Western world as increased awareness of transgender issues prompts more people to seek help to transition to the gender with which they identify. But doctors fear services are not keeping up, and warn that delayed treatment puts patients at high risk of self-harm.
"For young people who aren't supported in expressing and having treatment for their gender dysphoria, approximately 30 per cent will attempt suicide and the evidence is that they are at greatest risk in the time between deciding they want to pursue treatment and actually being able to access that treatment," said Michelle Telfer, clinical leader at the Royal Children's Hospital's Centre for Adolescent Health, and head of the gender dysphoria service.
While gender non-conformity in itself is not a mental disorder, for those who experience distress around gender identity, treatment is critical.
"We see kids in early primary school who might be biologically female but have never worn a dress to school and have always worn typically male clothing and have been known as a boy throughout their schooling so to suddenly go through puberty and develop breasts, it's an emergency for that person to receive treatment."
Dr Telfer said further barriers are arising due to a "cruel and unnecessary" legal process that is forcing desperate parents to spend $20,000 or more in court costs to access medical intervention.
While the hospital can provide puberty-suppressing drugs without a court order - usually from the age of 11 onwards providing there is parental consent - Australia is one of the few jurisdictions in the world that requires court approval for stage two hormone treatment to help patients develop the characteristics of their affirmed gender. Long-term use of puberty-blockers can cause osteoporosis, meaning patients usually stop taking them at 16. But without access to hormone therapy they will revert back to their birth gender, causing significant distress.
The Family Court relies solely on the evidence of the hospital's medical team yet still forces parents to go to court for hormone approval, which has been granted in 100 per cent of cases.
Melbourne mother-of-three Therese* told The Sunday Age she spent her life savings on legal fees to help 17-year-old son Sam, who was born female, gain access to hormones after he was diagnosed with gender dysphoria.
"He was a really unhappy child. He was angry, and he couldn't deal with the changes happening to his body. I'm a single mum and I'm in debt now but I just don't want to think about what would have happened if I didn't do it. It's important that he feels comfortable in the body he's in so it's really unfair that you have to go through the legal system to make that happen.''
Sam*, who said he has felt like a boy since he was a young child, started hormone injections last month and said it was a relief to finally get the treatment.
"If I wasn't certain I would have waited until I was 18 when I wouldn't need a court order, but I was so certain this was the right thing to do. It's distressing to see your peers grow to six feet and start getting facial hair and basically growing up and you're not, and you're in a body you're really not comfortable with."
In a landmark case in August last year, the Family Court ruled that legal intervention was no longer required for puberty-suppressing drugs after the parents of "Jamie" challenged the need for court permission for their son, who was born female, to receive treatment.
The ruling stated that the therapy was reversible and, provided there was parental consent and approval from the child's medical team, court authority was not required. However, it ruled stage two treatment, which is only partially reversible, still required a court order.
Dr Telfer said the situation was absurd. "With really young children who show gender-identity concerns, approximately only 20 per cent will persist with those concerns into puberty – that's why we don't start medical intervention until the child is older. Once you hit puberty, if you identify as being transgender then 99.5 per cent of those people will continue to feel that way throughout adulthood," she said.
"The time that doctors are required to produce evidence for the court with the growing number of patients means we are going to need a huge amount of resources to keep up with demand."
The hospital is lobbying the state government to increase funding for the clinic and change legislation that requires court orders for hormone treatment, and The Sunday Age believes a ministerial advisory group on transgender issues has recommended both measures.