May 2016


Trans teens

By Jenan Taylor
Georgie Stone

Georgie Stone. © Penny Stephens / The Age

When human nature and the law intersect

At a Saturday farmers’ market, two little girls in floral sundresses gaze up at a tall, red-lipped, ponytailed busker with a guitar. Among the stalls, crowds and opportunistic seagulls, Georgie Stone is performing hits by artists such as Taylor Swift, as well as songs she’s penned herself. The coins that people toss into the pink-and-white polka-dot tin box at her feet are for a trip overseas, so she can present her music to a producer. That, Georgie tells me during a break, would be the culmination of a dream she nearly gave up on last May.

Shortly after her 15th birthday, Georgie had turned up for her routine appointment at the Gender Service of the Royal Children’s Hospital in Melbourne’s inner north. She thought she would just collect the result of a blood test, and perhaps a hug from her paediatrician, and then talk about needing to go to the Family Court of Australia soon, to get approval for moving on to the next stage of her treatment.

Her doctor had other news. Georgie’s testosterone count was almost ten times higher than it was supposed to be. It wasn’t the first time something like this had happened to her. Four years earlier, Georgie had found out her pubertal development was equal to that of a 14-year-old boy’s. It had knocked the air from her lungs then too. She’d rather die, she’d told her mother, than have her voice break.

Almost as soon as she could talk, Georgie, who was assigned male at birth, had declared she wanted to be a girl. The only memory she has of any of this is seeing Cinderella and knowing she had to have that dress. As her identification as a girl intensified, her parents took her to a GP. When she was seven, Georgie was diagnosed with gender dysphoria, a term used for people who do not identify with the gender they were assigned at birth. For the next eight years, the family would take regular excursions to the hospital for treatment.

During the sudden pubertal burst she’d had when she was ten, Georgie had stretched more than 3 centimetres in three months, the contours of her face had begun to toughen and her testosterone seesawed. Her parents and doctors rushed to put an application together for a court hearing so that she could begin a course of medicine that would stave off the approach of puberty. Taking GnRH agonists (a type of “puberty blocker”) gives transgender children who are approaching puberty time to decide whether to go ahead with serious change. At the time, those aged under 18 had to go to the Family Court if they wanted to start this first stage of medical treatment. Georgie’s parents and her specialists managed to get that precedent overturned, and in 2011 she became the youngest person in Australia to receive permission to take medicine that would suspend puberty. From then on, any child seeking access to puberty blockers needed only medical and parental consent.

Although the court granted Georgie access to the puberty blockers, it also decided not to give her automatic access to the second stage of treatment (cross-sex hormones) when she reached the key phase of puberty. For that, the families of adolescents like Georgie had no choice but to apply for another hearing, and the costs of having to apply each time ranged between $8000 and $30,000.

The family appealed and 18 months later went to court for a second time. For them it wasn’t about Georgie per se. It meant a lot for the wider community. For many families with transgender children, it could mean the difference between going broke and just being able to get on with their lives.

The judgement handed down in 2013, the Re: Jamie decision, was a mixed result. While confirming the earlier judgement about stage-one puberty blockers, it ruled that transgender adolescents who wanted to take the stage-two cross-sex hormones would first have to prove to the court that they were capable of understanding the changes they sought. Georgie would still need to apply to the court when the time came to start the hormones.

She had always been warned that it was impossible to stall biology forever. Because these hormones cause infertility in transgender women, however, this stage is considered partially irreversible. This is one of the main reasons that it is against the law in Australia for a transgender adolescent under 18 to access the treatment without Family Court approval.

For the small but fast-growing group of transgender children like Georgie, and their families, it is this law that separates them from many of their Western counterparts overseas and, it seems, is at the heart of a cycle that erodes their wellbeing.

Although Georgie’s doctor administered large doses of a blocker, to try to bring her testosterone levels down, her body was already thickening, darkening and lengthening. Two things stayed at the front of her mind. What if, as she waited to get the hormones, her voice was already breaking? And what if the court just didn’t think she ought to be a girl?

Georgie tried to find peace in her music. She’d write, and then she’d stop. She’d compose the lyrics but not sing the songs. She’d study the edge of Pink’s jaw, the span of Taylor’s shoulders, imagine a lump at Lady Gaga’s throat, and consider Miley’s voice – did it ever reach any heights, anyway? Then she’d turn her forensic gaze on her self and start to think about all the things that might possibly stop the course of puberty.

Shortly after giving birth to twins on a Melbourne autumn day in 2000, Carol* took them for a tour of the hospital, proud as a queen as she showed them off. When George announced at two and a half that he wanted to be a girl, Carol thought it might be a phase. But she was scared when she anticipated how bumpy Georgie’s path might become.

Primary school, in particular, was hard for Georgie, Carol recalls. One day, at a swimming carnival, school authorities insisted her child change in the boys’ toilets. Inside, Georgie endured slurs from the other children, eventually emerging sobbing and half-clothed. Carol dressed her behind a tree, then went to confront the principal and teachers who were refusing to acknowledge her requests for help. They didn’t address the incident at all, she says, and she soon went looking for a new school.

Carol knew the most dangerous time for transgender children usually begins when they ask for help to change their biological sex. From then until they get the interventions they seek, about 50% might start to self-harm, while 30% may attempt suicide.

It was Georgie’s mutedness at home after the testosterone scare that rattled Carol the most. Georgie would go to school composed, play with her friends, pay attention in class, but at night there were tears. Carol would hover near her room, hoping to hear Georgie’s usual trilling, but there was no singing in the shower, no music at all. “The whole house felt different.”

After Georgie’s fateful blood test last year, Carol called the family’s lawyers and spent a great part of that morning crying on the phone. She remembers pacing back and forth, imploring them to have the doctors get their papers together. They had to act now.

She’d dreaded the idea of going through the court process again. Their first experience with it, when they’d secured Georgie’s access to puberty blockers in 2011, was, Carol says, nothing short of adversarial. “Watching strangers make decisions for your own child is the very definition of powerlessness. As a parent, I’m fully capable of making difficult decisions, but because she is transgender [I’m] considered incapable of doing that.”

It involved evaluations from two psychiatrists, an endocrinologist, a court-appointed psychiatrist, an independent children’s lawyer, pro bono legal assistance (because they couldn’t afford the hefty fees) and interventions from government organisations.

The court appearance to determine Georgie’s competency to access stage-two treatment was scheduled for June last year. Children are rarely allowed to attend the Family Court, but the family was insistent Georgie be allowed to have her day. They wanted the judge to note Georgie’s resolve, and wanted the Family Court to see who she was. In a high-ceilinged, windowless courtroom on level four of the Family Court in William Street, Melbourne, Carol watched the judge address Georgie like an adult and appraise her ability to understand the medical intervention.

Carol started an online network for families of transgender children after she realised there was a paucity of information available about gender variance. “There was absolutely nothing on the internet for parents in Australia,” she says. At the height of the family’s worst experiences with the legal process, the network became an avenue for change that Carol could channel her anger into.

This February, Carol, Georgie and her twin brother, along with a group of other families and a small team of their medical and legal advocates, visited Canberra to lobby for a change to the law. Their meetings with members of the Parliamentary Friendship Group for LGBTI Australians were well covered by the media, but in another part of Parliament House a greater clamour arose, as conservative MPs unleashed their push against the Safe Schools Coalition.

Around the time of Georgie’s initial court hearing in 2011, the media headlines commonly emphasised the novelty and perceived abnormality of the situation, as in the Herald Sun’s ‘Boy, 10, the youngest Australian to have sex change’. Since then, a few things have helped transform the tone of the conversation. The coming out of Caitlyn Jenner (formerly known as Bruce Jenner and part of the Kardashian family), the LGBTI advocacy of Orange Is the New Black star Laverne Cox, the rise of transgender model Andreja Pejić, the gender transformation of Matrix directors Lilly and Lana Wachowski, and the personal life experiences of Greens senator Janet Rice (whose husband underwent gender reassignment surgery) and Australian Defence Force Group Captain Catherine McGregor have become part of the ever-increasing discussions about gender diversity.

Despite this positive atmosphere, Carol says, the impending federal election and the attack on the Safe Schools anti-bullying program have overshadowed the chance for legal reform. For now.

Since Re: Jamie in 2013, the Family Court says it has taken a more streamlined approach to these cases. The court is able to settle more urgent ones within a few days, and requires medical experts to submit documents rather than to appear at hearings, for example. Many academics and legal critics still say the judgement is discriminatory and adds another layer of distress for the very people whose rights are at stake.

The court process is costly, time-wasting and emotionally draining for families, says Dr Fiona Kelly, associate professor in law at Melbourne’s La Trobe University. “Parents may have to take a great deal of time off work and risk being penalised for that, while many of the youngsters are typically at the age where they’re going through their final years at high school, and some find that they can miss up to a year of classes.”

Kelly has been working on a legal toolkit, in conjunction with the Victoria Law Foundation, to help explain the whole legal process for parents and families. She was part of the delegation that went to Canberra to ask parliamentarians to change the law. According to Kelly, Re: Jamie is a confusing judgement. The Family Court should be removed from the process, or the process should be simplified. “It may be that hormones will start being administered to younger and younger people if it’s left in the medical sphere, and there are moments I share that concern, but not enough to want a court involved,” she says.

Others are concerned that there are gender-diverse children elsewhere who, because their parents aren’t sympathetic, find their stage-two hormones on the street and administer them in an unhealthy way, or may respond to their predicament by even more damaging means.

It’s a human-rights issue, says Teresa Cianciosi, pro bono referral manager for legal-aid organisation Justice Connect. Overwhelmingly, lawyers want to see the back of this ruling, and are happy to act for free if the client is eligible. Some, however, are unsure if the under-18 legislation applies at state as well as federal level. In New South Wales and South Australia, children aged 16 and older are allowed to decide about their own medical treatment, Cianciosi thinks, but like many of her cohort, she isn’t completely certain about it in relation to cross-sex hormones.

Bree*, who lives with her parents on the suburban edge of a capital city outside Victoria, is 17, loves music, and once dreamed of being lead singer of an alternative band. She was assigned male at birth but by the time she came out as transgender and started puberty blockers, her voice had already broken. She says she is often told her voice isn’t feminine enough, but doesn’t care. She prefers jeans and shirts – they’re far more comfortable anyway, she says.

Her mother, Kate*, had no idea that Bree was transgender until two years ago, and only found out when Bree asked her for a lift to a community counselling centre. “In a way it was funny, because her siblings used to wonder why their clothes, which kept disappearing, were always in her room.”

Bree says she’d hidden what she was feeling because she was afraid her gender variance would not sit well with her family’s Christian faith. In fact, when she eventually told them, everyone accepted it straight away, apart from Bree’s father.

Kate says that she wishes the law wasn’t involved. Being in court, not knowing whether Bree would be granted access to cross-sex hormones, was nerve-racking enough, but the preparation for court was paralysing.

Kate and Bree found themselves going from specialist to specialist, looking for someone who had expertise not only with the health side but also with the legal side.

Kate says that on a private Facebook page for families of transgender children there are always people asking about the steps to getting help. “And everyone actually ends up seeing the same endocrinologist or the same psychiatrist or counsellor, because around here it seems there’s only about three or four of them who know about writing up the case papers.”

The family’s financial situation wasn’t good, so they also worried about legal representation. They might have given up, Kate says, if they hadn’t met someone who referred them to someone else, who knew a lawyer prepared to lend pro bono assistance.

In that time, Bree, who was heavily depressed, had been given puberty blockers to at least help soften her facial features. Because there were signs that she was looking for hormones online, her specialist began administering minute doses of cross-sex hormones, to try to mitigate the other changes that Bree was struggling with.

Bree also started at a new school, but was suspended after a few months when she got into a fight with someone who insisted on using her former name. Soon after, the family caught her – just in time – with a plastic bag over her head and a note outlining what pills she’d taken. Her father, who continued to have difficulty with Bree’s transition, has tried to suicide as well.

“The court just needs to let the doctors and psychologists do their job,” Kate says. “Let people get what they need.”

A great deal of this time is a blur for Bree, and she is reluctant to talk about it. However, Kate says that Bree is more settled now than she has been for years. Bree’s father is on his medication, and even though Kate suspects he still finds it difficult to accept, he also seems better for the first time in months. The entire family has been on a better keel. Kate is on anti-depressants too, but feels she can “lower her arms”, because they’ve carried everyone for so long.

At any time of the day there are at least a dozen people strolling the ground floor of the Royal Children’s Hospital in Melbourne. Kids stare at the serene and strange creatures gliding through the grand cylindrical aquarium, while grown-ups head for the clattering coffee machines in the cafes. In her noiseless office two floors above, Dr Michelle Telfer, the acting head of the Department of Adolescent Medicine, looks slightly distracted. She has just spent a day lobbying in Canberra, and much of the rest of the week negotiating media requests. Then her eyes glimmer. “But it was great seeing the kids sitting at the microphones, telling the politicians why they should change the law.”

Telfer, who has been involved in some of the cases that went before the court, says she has argued that transgender adolescents with enough internet savvy could just as easily find what they want on the black market.

It does tend to happen more interstate, she says, where services are under-resourced. She has also heard of physicians who, lacking any institutional support, make the decision to treat adolescents in urgent need of stage-two treatment before they make it to court.

Possibly the most frustrating thing about the court’s involvement is that doctors can prescribe cross-sex hormones for children with maladies like Turner syndrome at any time without intrusion. “Only transgender children have to go through the court first.”

A wall chart in Telfer’s office tracks the steep rise of new referrals to the Gender Service, from the first one in 2003 to 174 last year (and projected to be 200 this year). The clinic was fortunate to get funding for more clinical and research staff, to help deal with this tide, Telfer says. A new gynaecologist will oversee the adolescents’ understanding of fertility, “which means, yes, having discussions about babies with 11- and 12-year-olds”, and organise the collection and storage of semen or testicular tissue samples from transgender girls before they start taking cross-sex hormones. If Georgie, for example, wants to start a family one day, she can access her semen sample, which will be stored for up to 20 years.

A few weeks later Telfer introduces me to another new team member, the clinical nurse consultant, Donna Eade, whose role is possibly the only one of its kind in this field. Eade’s enthusiasm seems uncontainable, but there’s a chance she has one of the hardest jobs in the service. She looks after the families on the waiting list, and because it currently stands at up to 12 months for more than 150 children, this necessarily involves prioritising urgent cases. She also often provides telephone counselling for adolescents or families experiencing heightened anxiety. A number of patients have attempted suicide while on the waiting list, so she “strongly encourages people to engage with mental-health services”.

Like her colleagues, Eade also spends time seeing to the growing demand for education about the field from other service providers, both in Victoria and interstate.

The multi-disciplinary service, Telfer says, has been “very fortunate in Victoria, in that a number of things came together for us to make it work”, while in other states programs are fragmented or don’t exist. “In the Northern Territory, for example, there’s nothing.”

The Gender Service at the Royal Children’s Hospital follows the “Dutch protocol”. This medical-treatment model recommends psychological assessment followed by the administration of puberty blockers, then cross-sex hormones and, eventually, surgery. According to a recent study by the Dutch experts behind this approach, young people who’d gone through it function psychologically at a level consistent with the general population in the Netherlands.

But not everyone wants to have medical intervention. Gender fluidity, the idea that a person’s expression of their identity might change over time in ways that don’t conform to binary views of gender, is increasingly accepted among the LGBTIQ+ community. So adolescents who view gender as a spectrum may also see trans-medicine regimes as reinforcing the dual notion of gender.

“Perhaps with time,” Michelle Telfer says, “we’ll get so comfortable with bodies not needing to be altered [that] surgery will be in less demand. But where society’s view is very binary in terms of male and female, demand for hormone treatment is going to be high.”

There can be severe complications when it comes to hormones, including weakened bones from puberty blockers and diabetes from oestrogen, so administering medical treatment is a balancing act, Telfer says. “When children start puberty suppressants early, say from around the age of ten, it’s better for them to not be on it for more than three or four years. It can become a problem if, for example, because of the court ruling, children who’ve been on blockers for some time then choose to not go to court to pursue the cross-sex hormones and so stay on the puberty suppressants until they’re 18 … About half my patients don’t pursue the court process.”

Not all children are distressed when they visit the Gender Service. “Some people come to just discuss how they feel and get advice on community supports or explore how they feel before they tell parents and families,” Telfer says, “so there are various interventions to match the [needs] of the child.”

Social transitioning, which might include suggesting children consider trying the clothing of the gender with which they identify or perhaps growing their hair, is a popular part of treatment. They may also be referred to peer, social and mental-health support networks. Education for their parents and siblings usually also takes place and might include information on being aware of pronoun use or the healthy administering of medication.

For a service that, as Telfer says, “gets more referrals than most of the programs in the hospital”, a good chunk of time is spent on lobbying and advocacy projects like the Safe Schools program. But these activities also form part of the clinic’s “interventions to improve the environment” around their patients so that, for example, arrangements for unisex toilets can be negotiated. From where Telfer stands, cultural change is the main driver of the increased number of transgender children presenting at the Gender Service.

Dr Elizabeth Riley, a Sydney counsellor specialising in gender variance, recalls that transgender adults used to tell her about their childhood experiences of dysphoria all the time. So where are all the kids, then? she used to wonder. She says that although it seems that the children have only appeared in the past five to ten years, it isn’t that they weren’t there before. “I still think there are lots of hidden cases because people don’t feel comfortable to even name what they have, and some people, even with internet access, don’t realise it until they’re 18, 19, 20 years old.”

Even though gender dysphoria is a recognised condition for which early intervention is the recommended professional practice, Riley says she still hears regularly about doctors who tell families not to concern themselves too much about their child’s anxieties, that they should resist their child’s requests for help, or that gender dysphoria is a phase that will pass.

There are no reliable statistics on how many transgender-identifying children will go on to be transgender after puberty. In any case, Riley believes that the risk of increasing the possibility of suicidal behaviour is too great for parents not to listen to their children. Too often, however, parents tell Riley that they don’t know what the right thing to do is.

“I say to them, ‘You know your child best. What makes them happy and vibrant and what … makes them sad and depressed? That’s your yardstick.’”

Riley doesn’t believe a diagnosis should exist for very young children, because there’s no intervention apart from a social transition that can be enacted before puberty. “[We] don’t know for sure until puberty comes that the child is going to be distressed that their body is going to change. And then, if that is the case, we can get the referrals to the proper clinics.

“It’s important to support the child in their identity, because if they’re fighting about what they’re going to wear or how they’re going to do something, then stop the fight. We know that if children are given something to fight about, they’ll push the other way, and much harder, which can distort the truth of the situation. If the focus moves away from what clothes they’re wearing … it becomes easier for them to explore that in a healthy way.”

Some people argue that there might be a biological explanation for gender variance: for example, that the brain of a transgender woman has the same physiological structure as that of someone born female, and likewise a transgender man’s brain has the same structure as that of someone born male. In 1995 a report in Nature magazine expanded on this concept, and in 2015 a review by researchers at the Boston University School of Medicine found there was further evidence for a biological basis for gender diversity. Proponents of the idea think it might help people accept that there can be biodiversity in gender. It would also, presumably, discourage the search for a “cure” for gender fluidity.

It’s irrelevant, counters Georgie’s mother. Carol argues that there isn’t any empirical evidence. “It’s a human-rights issue. I don’t need biology to convince me,” she says.

“How it happens and why is less important to me than treating somebody as a human being straight off the bat and supporting their human rights. It’s of no consequence to me how somebody becomes disabled or has darker skin or is left-handed … It doesn’t matter to me. What does is that they’re treated with dignity and respect.”

In Sydney, Elizabeth Riley shows me a copy of Being Straight Lesbian Gay Bisexual Trans Queer Intersexed & Androgynous, a book she has been reading that looks at this question and provides some background as to what the aetiology might be in this situation. “But when parents come in and they want to know why or where this came from, I really encourage them not to think about that. It’s a naturally occurring phenomenon, and in my mind it’s just another way of being human, really. It needn’t be sensationalised and pathologised. It can just be understood that there needs to be intervention because this person is different.”

Insisting on biological factors is being essentialist, she says, and may sideline expressions of gender fluidity. “There are as many ways of being transgender as there are transgender people.”

Riley has noticed higher attendances at, and increased requests for, her gender-variance workshops – from school staff, social workers, mental-health workers, GPs and youth workers. Legal professionals also often approach her, seeking advice about related issues and requesting her help with court reports for children. The ping of her email inbox is constant as she tells me about families that come for appointments from across the state and beyond. “I’m just trying to manage what I can at the moment,” she says. “I’m aware that a funding submission needs to be made to the New South Wales government to get a multi-disciplinary clinic up and running in Sydney, because we don’t have one, and Westmead Children’s Hospital is straining to process the children coming through, [who are then referred] back to me because they realise that it’s not just a medical procedure. Treating is a whole psychosocial process that family and child go through.”

In the United States, research is about to start regarding the long-term effects of puberty blockers and cross-sex hormones on adolescents. There is growing demand to let younger and younger children access the medical treatment, according to researchers at the Ann & Robert H Lurie Children’s Hospital of Chicago.

Michelle Telfer is convinced that the Royal Children’s Hospital will face the same situation soon. “What’s important is that we have protocols and processes in place to make sure we are providing a service that is safe and effective. At the moment, we base those on international guidelines, so we look at it from that context. And if the scientific evidence over time suggests that, yes, 13 is the age that we get those best outcomes, because we’re not damaging their bones by being on blockers and they’re having puberty at the same time as their peers, then certainly we’ll consider it.”

Downstairs in the foyer, a life-size poster of celebrities is being set up in preparation for the hospital’s Good Friday Appeal. As I leave the building I wonder whether anyone on the appeal’s TV and radio broadcasts will mention the hospital’s Gender Service and its patients. To my knowledge (and I submit that I didn’t spend the entire Good Friday watching it), it didn’t get a whiff. These are early times yet.

Carol laces one of her arms through Georgie’s as they sit together in their living room. The court case is over. Georgie was given access to the stage-two hormones. She has been taking the oestrogen, but says she still examines her body closely. “I’m not thinking that I’m going into male puberty, but I still have a lot more self-doubt when it comes to my body. It’s not as bad as it was, though.”

Still in her school uniform, and clasping a mug of tea, she tells me that she wants to get on with other things. “This is such a small part of my life, and I’m really busy. There’s schoolwork, for instance. Also, there’s this boy.” She giggles. “No. I just want my surgery next. I just want that to hurry up, now.”

Imagine being in a place where they don’t have the kind of holistic service Melbourne has, I say.

There’s a pause. “That,” Carol says, getting in first, “is a very, very stressful notion.”

* Names have been changed for legal reasons.

Jenan Taylor
Jenan Taylor is a freelance journalist based in Melbourne.

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