STANDARDS of CARE GUIDELINES for GPs on the TREATMENT OF CHILDREN & YOUNG PEOPLE with GENDER DEVELOPMENT ISSUES.
A child or young person who is experiencing unusual gender development may or may not continue to experience the condition of gender dysphoria in adulthood. However, it is vital that the individual concerned is shown understanding and respect for his or her current gender experience.
Treatment should be flexible and meet the needs of the individual as far as are consistent with clinically safe practice. Decisions about the nature and the extent of treatment may be taken by a young person if deemed to be Gillick competent by the practitioner. From 16 onwards the young person is automatically deemed Gillick competent (see below) Any young person deemed Gillick competent may, effectively, exclude a relevant adult (one with Parental Responsibility – see below) from the decision making process, but this would be extremely unusual and, in most cases, undesirable.
The General Practitioner may have to be aware of:
- Gender development disorders are rare in children and adolescents. They are sometimes associated with emotional and behavioural difficulties.
- Gender disorders in young people can be manifested in different ways: cross-gender play and interests, sometimes accompanied by an expressly stated wish to belong to the opposite gender to that assigned, or even a claim to actually be a member of the opposite gender.
- Associated with these symptoms may be a dislike of the sexual appearance of the body. This may be more marked if pubertal changes have started.
- Children and adolescents should be referred to a specialist team, where there is expertise in caring for younger individuals who are experiencing gender development issues.
- Initially, it is likely to fall to the GP to ensure that the young person and [bearing in mind the constraints of confidentiality] the young person’s family are fully informed of all the possible treatments and their outcomes, positive and negative. A young person who is deemed Gillick competent may refuse family involvement. Any information given to a child must be age appropriate. Educational literature and on going support of the family should be provided. If, whilst under the care of a specialist Clinic, an adolescent is prescribed hormone-blocking therapy at any time during puberty, the GP may be involved in on going treatment.
The GP should continue to liaise with the Endocrinologist at the Clinic, to ensure that the necessary, preliminary health checks are achieved and that responsibility for continuing monitoring is agreed.
- It is an essential requirement, prior to embarking on any reversible or partially reversible treatments, that a young person be Gillick competent. An INFORMED CONSENT form (Annex B ) must be provided to the individual and (for those under sixteen) the person with Parental Responsibility, at least six  weeks in advance of the treatment starting. The Clinic will usually be responsible for providing the Form and will have had the necessary discussions with the individual and relevant adult. The GP should also check that this protocol has been covered and should provide a further opportunity for discussion with the patient and his/her family.
- It is important to make the young person feel that help and support is available and that, under certain circumstances the effects of puberty can be delayed by medication.
- A young person, who is faced with the prospect of pubertal changes, or who is already experiencing them, could experience depression and even suicidal feelings. Much reassurance will be needed to make individuals feel that their condition is experienced by others, that although rare, it is not unique and can be treated.
- It is particularly important that where possible and appropriate, when a young person of male phenotype identifies as female, that beard growth is blocked, and that where a young person of female phenotype identifies as male, breast growth is blocked.
- If the GP is to provide on going prescriptions for any hormone blocking treatment, then liaison with the relevant Endocrinologist is important. Referral to, and liaison with, local psychological support systems should continue for the child/adolescent concerned and his/her family. Liaison with a school or college may be required, with the consent of the young person, and relevant literature provided.
- Sometimes these manifestations gradually disappear altogether, especially if the child presents before puberty, sometimes they resolve into a gay or lesbian sexual preference, sometimes the cross gender symptoms will persist into adulthood and the individual may then seek further treatment.
- At this stage, referral to adult services will be necessary. (See below) It is vital that there is good communication between those who have been caring for the young person up to that date, and those who will be taking over the future care. The GP has a vital role in liaising with these other agencies and ensuring that they liaise adequately with each other.
- It is especially important with young people, to encourage them to consider whether they may wish, in the future, to have a family. Specific information should be provided about local, private or NHS facilities suitable for storage of gametes.
N.b. It is inappropriate and may be considered misconduct for any medical specialist to assume that a patient, who opts for gamete storage, or had already done so, is in any way equivocal about, or not committed to, the transition process.