 Good evening everyone. I'd like to begin by welcoming the 329 people that we have online at the moment watching the webinar and also to the viewers who will watch it later on as a podcast. MHPM would like to acknowledge the sovereignty of the traditional owners of the lands across Australia upon which our webinar presenters and participants are located. We wish to pay respect to the elders past, present and future and the memories, the traditions and the cultural hopes of Indigenous Australians. Hi, I'm Damien Rick and I'll be facilitating tonight's session. I'm an Associate Professor from Social Work at Fender's University, a fellow of the Australian Psychological Society and a psychotherapist working in private. I'd like to now introduce you all to the panel who will be speaking this evening. Our first presenter will be Associate Professor Michelle Telfer, a Victorian-based pediatrician. Michelle is the head of the Department of Adolescent Medicine at the Royal Children's Hospital in Melbourne. In addition to improving medical and mental health services for the transgender population, Michelle is currently advocating for legal change to allow transgender young people to access hormone treatment without the need for approval by the Family Court of Australia. Michelle, how far away do you think legislative sort of change is? Well Damien, unfortunately things are stagnated recently but we're working on a number of options both through the courts and with legislative change. Thanks Michelle, we'll keep our fingers crossed. The next person on our panel is Dr Otisworth Anne Riley, a Sydney Bous councillor, academic and clinical supervisor who specialises in gender diversity. Elizabeth provides support and counselling for children and adolescents with differences in gender identity and expression and their parents transgender youth, couples where a partner is transitioning and those seeking support for gender-related surgery. Elizabeth also delivers professional development in gender diversity for schools, clinicians and other service providers. Elizabeth, what are some of the common concerns you come across when training at schools? I think probably the big question is about bathrooms and when children go on camps or when they're doing sport activities, they're the big things that come up I can think of off the top of my head. Yeah I think definitely I think bathrooms are very much on the radar for everyone internationally in regards to concerns people have and issues that get raised. Next I'd like to introduce Associate Professor Campbell Paul. He's a consultant child and adolescent psychiatrist at Royal Children's Hospital in Melbourne. Over the last 15 years Campbell has worked with many children and young people expressing gender dysphoria and their families and he was involved in the establishment of the original Royal Children's Hospital Gender Service. Campbell, how much has the RCH gender service grown since its inception? It's grown quite a bit. Originally about 15 years ago there was Professor Gary Wong, endocrinologist myself but with exponential rise in the number of referrals. We've had around 200 referrals this year similar number last year and through the lobbying of Michelle Telfer particularly we've got funding from our state government for more stuff. So we've got three other pediatricians together four part time child psychiatrist part time pediatricians as well. Two child psychologists part time. Donna Ead who's the clinical nurse consultant organising as well. Pediatric endocrinologist, gynecologist, speech pathologist, admin person Chantel and we've got access to the children's ethics service of the children, our legal service, andrology at the children and an evaluation coordinate. So you can see it's expanded quite a bit but the demand is still there and we still have a significant waiting time for new referrals. It's amazing that it's being recognised and hopefully that has other states to come. Last but certainly not least I'd like to welcome Associate Professor Darren Russell. Darren is a sexual health physician and the director of sexual health at Kent Hospital. He holds the positions of clinical associate professor in the Department of Population Health at the University of Melbourne, adjunct associate professor in the School of Medicine and dentistry at James Cook University. He is a chair of the HIV Foundation Queensland and a past president of the Australasian chapter of sexual health medicine of the Royal Australian College of Physicians, Victorian AIDS Council and the Australian Federation of AIDS Organisations. He has an interest in transgender health, indigenous health and the elimination of HIV and hepatitis infections. Darren, what was the major shift from creepy work to sexual health work? Yes, I used to work predominantly in general practice in Melbourne but I found that more and more of my work was associated with sexual health. I started to enjoy it more and then specialised in it and when I moved up to Kent the job was just in sexual health and that lets me do a lot of work with transgender individuals which is something I really enjoy doing. Thank you, Darren. So the next thing to cover is to talk about some of the ground rules that we have established and also to remind you that if you find the general chat box too distracting, which sometimes can be because people are writing a lot down below, you're free to welcome to write things down there as well, questions or comments. You can minimise that by clicking the small down arrow at the top of the chat box. But if you feel comfortable listening to us watching us and also typing things in the chat box in the general chat, please do. So some ground rules just to cover before we start. We want to really make sure that everyone gets the most that they can out of the webinar, the live webinar. And so we need just to remember when we're commenting in the chat box to be respectful of other people on our panelist. We don't know who's in the room. We don't know where they come from or what their personal experiences are. So we want to really be sure that we're being inclusive. If you have any technical issues, if you can't hear, if your visuals cut out, then you can comment in the technical health and someone from the team will get back to you. Please remember that this is a professional development activity. So we want the comments if you're typing comments in the general chat to be on the topic of the professional development rather than more general discussions. And importantly, and I'll mention this again at the end, we really value your feedback. So we're going to improve these webinars or change anything that you think would be changed. So at the end of the webinar, there'll be a short exit survey. So we'd really like you to take a moment to complete that before you log out for the evening. Just to recap the learning outcomes that she would have already been sent. So we're going to be exploring a case study that you've already received and that I'll do a recap of in a little minute. And that is going to help us work together as a team to explore some of the general principles of providing a safe and supportive environment for young people seeking care for gender dysphoria, implement some of the key principles, how you might do that and providing an integrated approach in your services, and also identify some of the challenges and tips and strategies for how we provide a collaborative response to young people and to their families as well, especially with regards to risk of depression, anxiety, self-harm, or suicide with regards to gender dysphoria. So next on the slides, we're going to shift to Michelle. So we're doing things a little bit differently if you attended webinars in the past before. We often run through all the presentations in a row focusing on the case study. This evening, Michelle's going to start us off by giving a bit of a overview of the population group we're talking about and some sort of common general themes that we really want everyone to be aware of. And then I'll recap the case in case you have forgotten it and then we'll move on to Elizabeth and Campbell and down to give their specific interpretations of the case itself. So thank you, Michelle. Take it away. Thanks, Damien. My slides are just through a missed one. There we are. So I'm just as a quick introduction to gender dysphoria. I wanted to mention that it was first included in the Diagnostic Statistical Manual, version 3 in 1980. So a relatively new diagnosis as such that was renamed gender dysphoria in 2013. And what gender dysphoria refers to is the distress that may accompany the incongruence between one's experience or expressed gender and one's assigned gender from birth. And what's really important is that not all individuals who or will experience the distress as a result of the incongruence. But many are distressed if the desired physical interventions such as hormones or surgical interventions are not available. And the numbers are quite large in terms of incidents. The best study we have comes from New Zealand where they surveyed over 8,000 secondary school students. And 1.2% of that population, all adolescents reported being transgender with 2.5% reporting not being sure about their gender. And these numbers are reflected in increasing referrals that we're seeing at the Royal Children's Hospital here. And I have a graph there which shows the increasing numbers from one in 2003 when the service of staffers by Campbell Paul, as he mentioned earlier, to DCU where we will receive well over 200 referrals. We feel that the increasing number of referrals comes with social change and increasing acceptance of transgender identities in the general community. And what we've seen is celebrity culture reflecting these social changes with a number of famous families, if you could say. I mean, as with the closures of their gender identity. John Jolly Pitt is the son of Angelina Jolly and Brad Pish, who was assigned a female and named Shiloh at birth. And there's Chaz Bono, who was the son of, who is the son of Cher and Sunny Bono. And of course, the events of the Kardashians, which brought a lot of publicity to trans identities. And in Australia, we have a similar context with increasing acceptance of trans children and adolescents with programs such as the Four Corners program that was aired in 2014, which reached an audience of over 1.2 million people. In a recent Australian story episode featuring Georgie Stone, a transgender adolescent, also reaching over a million viewers and both very positive gender affirming stories trans youth. Sometimes we find acceptance in the places we least expected. This is a birth announcement from a rural town in Queensland. And I'll quickly read it out. The notice says, a retraction in bogus. In 1995, we announced the arrival of us, Robert Elizabeth Anne, as a daughter. He informs us that we were mistaken. Our bad. We would now like to present our wonderful son, Kai Bogut. Loving you is the easiest thing in the world to tie to your room. So why is it important that we affirm trans identities and provide not only support, but if required medical intervention? There are numerous studies both done overseas and within Australia that shows that adolescents who cannot access treatment have a 50% rate of self harm and 28% of adolescents attempt suicide. And this number increases only across one's lifetime from 28% attempting suicide and adolescents for 50% throughout adult age. Frightening statistics. Our treatment is based on international published guidelines, which will be available for you. And just to quickly run through the general process of treatment through a multidisciplinary team, such as the one that we have in Melbourne, but in similar tertiary centres across Australia, you'll find that all children will undergo a multidisciplinary assessment. Artists or psychologists, usually a combination of both pediatrician, fertility expert, nursing and other support. The first stage of treatment is with regards to puberty blocking, a hormone treatment that is reversible. And this tends to be started at kind of stage two when we're around the age of 10 to 12 years. The second stage of treatment is with hormone such as estrogen or testosterone, depending on your gender identity. And this stage of treatment has some irreversible effects. And in Australia requires approval by the family court. In Australia, it's not legal to have surgery under the age of 18. And we refer anyone who wants surgery in adult services to access that. And my last slide, just really wanting to reassure that the published data that we have shows that treatment in a supportive environment, which includes puberty blockers and hormone treatment, has been shown to improve mental health outcomes, improve quality of life. To the extent in this study was done in the Netherlands, the outcomes for this group of 55 trans adolescents, once they were in early adulthood, was that their quality of life was the same as the general population. They had higher education completion in the general population. And also their vocational outcomes were also very good. So reassuring data that the treatment we're following is helping a lot of trans children and adolescents. Thank you. Thanks so much, Michelle. I'm really glad that you covered all of it, of course, but especially around media representations. Because I know I often get a lot asked a lot when I speak to the media or get asked by other people, why are we seeing so many more people coming forward? I think it is that people hear other people's stories and they realise it mirrors their own story and they have a way to speak about their experiences. Yes, I think young people are feeling increasingly safe to come forward and express themselves in this way. And they're also finding a language to do that. Thanks a lot, Michelle. So as I said, now that Michelle's given us a fantastic overview of young people experiencing gender dysphoria and how we work with them, I'm just going to briefly recap the case in case you've forgotten some of the details and then we'll move on to Elizabeth. So in the case we have the story of Stevie, a young person who was 10, who was a child of male at birth, who's the youngest child of four. And from a very young age, Stevie has enjoyed playing with her sister's toys, wanting to be called Stevie. Stevie's parents have been very resistant to that, have refused to call Stevie Stevie insisting upon the calling of Steven, refusing to use female pronouns. Stevie's experienced bullying at school, has expressed suicidal thoughts and depression. Stevie was referred to a GP who was reluctant and Stevie was reluctant to talk to them. So then there was a referral to a psychologist and when speaking to the psychologist Stevie opened up about her gender experiences. So we'll now turn to Elizabeth who's going to talk through her perspectives as a counsellor. Thanks a lot, Elizabeth. Thanks Damian. I just want to start with what it is I do when people come to me. My aim is really to understand at a gut level how this young person feels about themselves and what's true for them. I let them know very clearly that I have no agenda about who they are or how they express themselves. So I want to see their perspectives and understand where they're coming from. I want to evaluate the consistency of how they're feeling about themselves over time. I want to assess the amount of support these young people have in their family and their community with their peers. I want to provide education and networking and you know what I do depends on the age of the child. If a parent rings me and says I have a two year old or I have a five year old or I have a seven year old I actually say to them look I'd rather you leave the child at home and come and talk to me yourself and I can support you in raising a gender variant child because I don't think it's fair to have children with gender diversity have to focus on their gender in a way that other children don't and I don't want that child to feel that they have a problem or that they're being pathologised because no intervention can really be done around their gender until they're approaching puberty. Now having said that there may be children with dysfunctional family situations with high anxiety in which case they need to see somebody about that but it's not about their gender it's really about the other pressures that are on them. So the process involves having the young person and their parents in the room together and asking everyone what they'd like to get out of this meeting and then I asked the young person to leave and I talked to the parents I want to know how they're feeling what their concerns are what kind of relationship do they have with the their child what is it that they know or understand about gender identity and gender diversity and particularly with their child. I want to know what resources and networks they might have be able to tap into and I can provide them some of that information. I want to understand their fears you know what is it that they're really concerned about with their child having this gender differences I want to know if they are having concerns about disclosure to the family whether they're concerned about acceptance. I want to know what kind of information that they have and that they need and you know other time frames that they're concerned about so it's really giving them an opportunity an opportunity to have their anger their feelings and their concerns and be really validated around that because that opens people up to being able to hear what's really going on for their child. So it's important that they understand that gender identity is how we think about ourselves it's how we identify with our whole body whereas sexual orientation is something very different it's about who we're attracted to sexually and that our biological sex is then about our anatomy and the gender roles are imposed externally so it's important that they understand these separate parts of ourselves and our identity with sex and gender so that they don't get confused about what it is we're talking about. So from my perspective I'm looking at a lot of areas to explore in the assessment with the young person I want to know if they've had any support prior I want to understand from their perspective what their family relationships are who is their main support who's the person that they could disclose to and feel comfortable about it I want to understand if there's any cultural or religious influences that may affect how they feel about themselves and what they want to do it feels important to know whether they've got issues with their weight or they're eating or sleeping you know do they have any visit or repetitive dreams because sometimes in streams children dream of themselves in their identified gender not in their anatomical gender so it gives me a bit of information about levels of gender dysphoria I want to know and understand what things that they're interested in what they do with their time have they been depressed have they self-harmed do they have a history of mental self issues are they on any kind of medication is there any history of substance abuse risk behavior have they experienced any bullying or abuse how is school going how do they integrate there how social are they what is their awareness around their body and I that question comes through when I ask young people what happens to them when they look in the mirror and it gives me a lot of information about levels of gender dysphoria about their body about concerns they have about what they see I want to know how puberty has been for them is their post-pubital what happened was they expecting it and and what was their reaction to that I want to know if they understand their sexuality yet do they have a desire to have children you know what are their beliefs and awarenesses regarding gender expression and diversity is that they just want to behave differently but not actually change their body so getting really clear about what the nuts and bolts are is gender for them and as I mentioned assessing a level of gender dysphoria their knowledge of trans issues and trans people have they ever met people or spoken online with them you know do they have a particular pronoun or name preference that they have and who knows about this and when have they told them and then of course what level of support they have so then I share the relevant information with their parents with the adolescents consent I go through what I've written down I say this might be really useful for your parents to know I also say to them is there one thing you want your parents to know or is there one thing you want to tell your parents and then I'll discuss you know the urgent issues what they're immediate needs are and what the next steps are so with particular specific to this family I think there needs to be an awareness of the older siblings and how the situation will affect them I want to know what myths and stereotypes the family are holding and help dispel that I want to understand the family's attitudes I want to explain the differences between non-conforming gender behaviour and gender dysphoria and I want to know what their experience has been as their child I'm going to listen to their overwhelm their fears their anger their concerns for the future and they're regarding that statement God made them a boy and that can't be changed I want them to understand that gender dysphoria is a natural phenomenon that has occurred across time across countries um that it doesn't distinguish between different categories of people at all that I actually do a lot of gender diversity training in Catholic schools so if they're Catholic that could be useful and that there are severe mental health consequences if the parent don't support the child and Michelle mentioned the rate of suicide if the children don't have access to professional support well the rate of suicide jumps dramatically if the children don't have their parents support so I need the parents to understand that and there's a document called families in transition which is incredibly useful that I like to think parents so that's me finished thanks Danian thanks very much Elizabeth and I know that people in the chat are really enjoying what's being presented and particularly I'm interested around the issues of religious diversity and how do we respect parents religiosity but also support young children so hopefully we'll be able to come back to that a bit later in the question time I'd like to also just remind all of our viewers today that if you're interested in the resources that we've put together for you they're available in the resource folder which is down the bottom right hand side of your screen there's a little folder symbol next to a tool symbol and so click on the folder symbol and you'll be able to access those resources so now we'll move on to Campbell Paul and his presentation from a psychiatrist perspective thanks a lot Danian and thanks Michelle and Elizabeth too for starting us off on this journey I thought I'd focus my comments around clinical the case material provided around Stevie and her family and just reiterate the key things that have come out of that from me that here's a young person who's got a demonstrated persistent interest in stereotypic girls toys and clothing she's got strong identity statements that she is a girl refers her feminine name in a context where she's able to express these eventually to the psychologist and thinking of it from the perspective of the role of the family doctor the community psychologist and then the specialist gender service commission I think underlying all this overall objective is to support Stevie's optimal emotional social cognitive physical development and we have to do that through helping him explore her own experience itself and support the parents to support Stevie two streams clearly Stevie's become depressed anxious distressed and feels they may be unable to share this distress the source of the distress with her family and I think it's important for each of us each of our other professionals involved to help her feel safe and understood and not alone in it and to help her parents understand and help her explore safely and creatively who she is with as Michelle and Elizabeth have just mentioned there's clear evidence that parents support is crucial for a child's healthy emotional social development in the context of gender dysphoria without it there's this real risk of increasing severe depression and self harm and the case vignette clearly describes that so again two tasks help the child work through things both the internal conflict that they're needing to sort out and the relationship that they have with their family and peers one secondly to help the parents brief well there's a reference to the cover of a copy of Australian weekend magazine where a journalist was writing about her distress and concerned about strongly female identifying boy and she's trying to work out what's kind of happened what's kind of the evolution of his identity at that stage he was identifying as a boy with a strong interest in girl things and I guess that emphasizes one of the critical things that we don't precisely know how any particular child's going to go in their own development we do know that but for for very young children certainly by the end of the third year of life and generally before kids are able to differentiate between male and female and to be able to identify the sex of their own gendered body so our job as therapist as the GP too I think and the psychologist is to affirm as to support the child in their exploration of who they are the child who might have a an ongoing transgender identity is one where there's evidence of insistence about their gender consistent about it persistence in their gender expression and strong identity statements I am a girl or I am a boy I guess if you think of it for most of us that's how we experience our identity our gender identity and for the kids we see who are strongly transgender this is how we can get a picture of who's going to be persistently in the transgender these are good indicators the early onset of expression of of a transgender identity is also crucial but we see lots of children young adolescents who present for the first time in the post pubertal period and certainly in adults so adulthood so with the first overt statements about their gender diverse existence so there are kids where there is a strong likelihood of this transgender identity persisting and there's other kids where there's gender diversity or a gender expansive expression of themselves and we don't know with the kids who are gender diverse, gender expansive how things are going to evolve so in the meantime it's really important for kids an opportunity to talk, explore, play share with their parents what their experience is I guess the other important thing is to make it clear that although there's maybe a tacit and an express view that the world is set up in a binary situation with their male and female with the kids we see I think it's important to let them know that there are options there are other positions the world is not as binary as one might think but how does the child work their pathway one of the difficult things is I think many children young adolescents may feel the need to keep their experience of their gender secret and feel unsafe to share it with people as was the case with Stevie and our job is to work with the young person with the parents provide a safe secure trusting environment where they can explore this this will require some subtlety so that if the young person reveals to the psychologist or the GP their private feelings about who they are we should explore that with them before telling their parents Stevie was making that clear I don't want my parents to know it's hard for kids to predict what their parents are going to say generally parents are trying to do the best by their child even in this context parents are frightened confused, dispersed when there's a suggestion that their child might not know who they're going to become it's a delicate process to support the child support the parents excuse interruption it seems like we have lost Campbell's audio sorry about that perhaps we might need to move on to Darren and come back to Campbell when his audio is back in play again I'm very sorry to everyone for that happening sometimes these things do happen if you attended webinars before sometimes technology gets the better of us but thank you to Campbell for everything he was able to relate to us which was incredibly interesting and a really useful addition to what Michelle and Elizabeth have already said so we'll move on now to Darren's presentation and perhaps come back to Campbell if we can if we have time and it sounds working at the end so Darren please take it away hi thanks for that Damian and hello everyone as I said at the beginning as Damian introduced me I'm a sexual health physician in Cannes so I'm someone here who's from a regional area not quite remote but certainly rural and in my part of the world and many other parts of Australia general practitioners are often the first thought of call in this situation possibly as they are in the city too but we have fewer other options in regional Australia and some sexual health clinics may also be contact particularly in Queensland where in rural areas some sexual health clinics do work with transgender individuals but a whole range of other people can be involved as well school-based nurses like colleges child and youth mental health services may all contact a primary care provider wanting some advice about the family or some help and it's often difficult because many clinics will have very little experience in a regional area and be problematic we don't have all the bells and whistles of the big cities so health for trans kids and teenagers can be very patchy outside the big cities and even within the big cities there can be real problems accessing specialist care and outside Melbourne Sydney Adelaide we're really struggling to find dedicated centres for transgender health there is one for in Brisbane as well for children that's done there are clinicians around the country who do do this work and there are experts around the country who use in contact as well but you really may need to ask around you often find that you're sort of working in the dark when a young transgender person a kid comes to see you if you don't quite know what to do or where to even start with it on in Cairns itself we'd offer counselling through our psychologists we're fortunate that we have psychologists in our service who are used to working with families and really work with the family around their issues in Cairns I think Elizabeth has thumbed those up wonderfully tonight we would also arrange a referral to the Child and Youth Mental Health Service and the Pediatric Endocrinologist we're fortunate that we have clinicians who are very keen and want to be involved so that's fantastic and as far as medical stuff is concerned there's really not much to do until puberty starts clearing its ugly head and then as Michelle said we have to do an assessment of the child and offer blockers if they're appropriate but that is done as much as possible and not as difficult as we've seen clearly the smaller the town the more difficult it is to do that and some clinicians are still comfortable doing this work but the families may not be able to travel to visit cities to get the extra care and they're really struggling as well often financial issues are involved and some of the services that are available private and not public and they're the cost involved too so I think in Australia we're lagging behind parts of Europe and the United States particularly in regional areas where we should be aiming to have more publicly funded services to sit alongside private ecologists, GPs, etc but that's about all I'll say from my perspective of really being in a regional area I'm happy to talk more about it later Thanks so much Darren and I know that many of our questions that came in before the webinar really asked about rural services so it's good that we've had you there to cover that and hopefully we'll come back to that in a little bit when we get to question time I know we've got Campbell back on the line again now so hopefully we might be able to switch back to Cameron I'm just popping back his slide and hopefully Campbell might be able to take us through his last two slides before we move on to question time Sure, my apologies for that I'm not sure what happened I got lost, a bit disconnected What I was saying I think was that we've got a delicate process of helping the child feel confident to share in a trusting way with someone who respects them in this case the GP and the psychologist the dilemma that they face I think the dilemma is both an internal one and an external one as I mentioned many young children feel the need to keep their identity a secret before they are eventually able to share it with their parents and we do know there's no role for conversion therapy for forcing a child to change their experience of their gender their expression of gender and if we can help parents safely encourage the child to feel confident to let them know in the first instance to let their peers know that an extended family and then later the school know who they are how they feel about themselves that's really important These steps in affirmation include helping the child with their name clothing appearance how their hair is cut gender pronouns school enrolment identity documents all of these things step by step parents will help the child Meanwhile emphasizing that the parents love their child whether they are expressing themselves with a boy or a girl or somewhere in between and I think it's useful to raise that possibility with the young child the world does seem binary but you can be your own person one of the kids we saw had a name for herself a category for herself she called herself a male fee and we're between male and female before she eventually was more confident to call herself a girl So I've already alluded to these dimensions of gender this is from Peggy Cohen in Amsterdam and these are important concepts although they do tend to reflect a binary approach and I think again with kids we're trying to help them see that the world isn't just black and white male and female but there are dimensions of gender and self and expression that can be undertaken there I've just listed some of the components of the assessment and I won't detail those I think they're self explanatory there and the process of assessing the young person towards medical treatment some of those steps are included in the last slide here just to conclude it's important that we provide an opportunity for the child to feel respected and trusted and to be able to safely work out internally and externally in their relationships who they are in a way that their identity is accepted and respected and that's where I'd like to leave my presentation thanks very much and sorry for dipping out Thanks so much Campbell it's fantastic we could have you back on the line again So now we've come to the time hopefully we've all been looking forward to which is question time and we've got about half an hour or a bit under half an hour for questions and we were very lucky that you all who registered for the webinar sent us through lots and lots of questions and we were very thankful for them and we were able to go through and identify some key themes that seem to repeat across many of the people registered for the webinar so we're going to go through some of those now with the time that we have remaining and I'll be directing those to each of our speakers who will take a turn having a bit more to say to think about what how they might respond to these questions and certainly we might all chip in in this question time The first question I have is directed to Elizabeth and it's someone asked how do you work with the parents that are not open to their child transitioning in any way shape or form and I know that in the general chat lots of people have been asking how do you respond to really religious parents who are just not going to accept gender diversity Thanks Damien I think look firstly really listen to their perspective and have them feel that they've been taken seriously because if we give the people permission to have their own perspective on this then they're more likely to listen to us when we want to give them more information and education so I aim to engage them through educating them on the facts You know I provide evidence of the child's story that indicates a genuine identity or indicators of gender dysphoria and I want to say clear to them you know that I know that they want to do what's in their child's best interest and I want to help to support them to do that It can take time but from the families that I've worked with which is many now in the hundreds I do know that if there's one parent that's really not supportive they usually come around but they have to do it in their own time and they need to be supported through that It's important that they know that there's nothing they've done that there's nothing that they've done to cause this and that as Campbell mentioned that conversion therapy doesn't work So I want to help them with strategies Sometimes it'll be about what's my church going to think or what's my family going to think I mean we in ourselves feel that we'd be able to handle this but around us it won't So it's important that they understand what it is and how it's separate and different to other conditions and the truth is that we all live in a world that oppresses gender diversity and their child has been dealing with gender policing and pressure their whole life which we know is also damaging to them and so I want to inform them of the prevalence that there's nothing they can do about the gender identity that the child isn't making a decision about it that they don't have any choice and really highlight the importance of family support offer them the resources and let them know that it is a process and stay with them stay working with them stay having them feel that you know I'm an ally for them as well I think that's enough I think that's such an important point because of course our focus is the child but our focus is also the family and children are violent because of gender norms but so are family members and I think often as you said if the parents are feeling perhaps incorrectly that the church members might judge them or may not include them or may reject them they have no way of testing that either so that stays through that silencing as well so it's so important as you said to speak through those things with people so they can work through what's holding them back our next question is going to go to Michelle and someone has asked us one of our webinar that has been asked when clandering so Michelle how do we minimise stigma attached to a gender dysphoria diagnosis Thanks Damien I think there are a number of different ways to answer this question at an individual and family level young people often come to us knowing that they are gender diverse especially from an adolescent perspective and sometimes have thought about this for many many years have come to terms with things and felt comfortable enough over time to disclose their identity and aren't in any way surprised for a doctor when hearing our conclusions that concur with their thoughts and really with their two thermal supports their senses where they are the parents have often not had that same amount of time to come to terms with things and there is often a sense of shock and worry and concern about the stigma and how this will be viewed by gendered family and schools and community more generally and I think when talking about the diagnosis and we help to get normalised gendered diversity to put them in touch with other families and provide support at that level both professionally and through the peer group to help them deal with some of their peers around descriptions of others in reality I think many children experience more acceptance than they're expecting certainly with extended family members that is often the case as well that the fear of disclosure and the stigma way of fear will be associated with the diagnosis is not necessarily realised in that disclosure as much at a community and society a societal level is more complicated and often I feel that we take a few steps forward and then a step back but it's to me about advocacy about positive stories come publicly and to have young people and adults coming out and telling others who they are and expressing the wonderful things that they're doing and hopefully it will over time be accepted as we believe it is a normal expression of one sense of self I think it's spot on about the importance of those groups that where people can get together and talk about those experiences I know in South Australia we have a number of parent run groups that I know they exist in other states and I think it's amazing the work that can do to reduce stigma when children see other children parents see other parents and really understand as everyone's been saying all the panel members have been saying today this is just a part of human variation it may have been seemed exceptional to us you know a decade or so ago but we really know now it's not and we know that about the normalisation is part of the key to combating stigma So the next question which I know a lot of people have written in questions about webinar participants had asked about and I'm going to direct this one to Campbell is does dysphoria, gender dysphoria always come with anxiety? You know a very good question too I think the short answer for me is probably yes but it's a lot more complicated than that I think if you're talking about the young person in a sense of stress and confusion trying to work out who they are and anxiety that might come with that I think that's probably a universal thing but for the kids whose families are tuned and receptive and able to support them through that I think anxiety is not one that reaches sort of clinical extent if you like We know from and if we're able to provide over the course of development appropriate mental health and particularly medical care and treatment kids develop the same strength of emotional social cognitive development as the broader community and material from the DAPT study from Amsterdam demonstrates that young children who've entered the program there met with mental health clinicians met with the endocrinologist for pediatricians moved through to have when a progress puberty suppression and later affirming sex hormone treatment and maybe surgical intervention later on they have the same emotional profile of the broader Dutch young persons community although in addition they're actually performing better in terms of their participation in school and work So we know that good support, good treatment makes the likelihood of anxiety as a clinical problem much diminished we know that if it's not there parent support's not there kids get really very stressed, lonely, isolated and frightened, depression and self-harm suicidal ideations are a common consequence in that circumstance I think it's amazing like there's certain things I think as clinicians other than providing hormone blockers for example that we sometimes can't really do anything in the place of in regards to anxiety around puberty but I know from the work we all do that often some of the other anxieties around not being accepted or being signified really do respond very positively which to affirmation from us as clinicians and working with parents to be affirming as well And also schools and broader social social networks like with families where religion is an important issue to speak to the parish priest to speak with Aynon we've had a number of young kids who have come from Muslim background and their parents have been positive and affirming anxious about what doctrinal view would be but if we as a little bit of saying engage with the religious advisors for parents in a respectful way I think we can go a long way to helping that anxiety for the family and then for the young person to diminish but I do think like young children in particular I think can struggle with things internally and I know when we've worked with families and the kids and they've moved into a social transition behavioural learning problems and sometimes quite severe mental health problems seem to have melted away in the face of the child being able to be who they want to be be who they are at call and parents often remark on that and we can see it ourselves that there are many things we can do to diminish that anxiety Yes I believe The next question actually I must move down my order in very well I'm also going to go to Campbell and this is one that I know a lot of people asked about and I just saw in the general chat earlier a lot of discussion going on around the co-occurrence of gender dysphoria and autism spectrum disorders or developmental delays amongst young people Yeah we've certainly seen quite a number of kids with autism spectrum problems in the clinic may be up to a quarter we're currently researching that and it depends where you draw the boundary around things such as autism spectrum disorder autism etc but it's something that is recognised universally in the clinic and others around the country and internationally as well could be a significantly increased co-occurrence What it means, we don't know yet Some people say oh well autistic kids you know they get a fix on something you know they're interested in buff timetables well maybe it's just the same thing they're interested in gender but I don't believe that's the case from our clinical work with the kids we see I think they experience the same level of intensity, persistence, strong identity statements that go beyond just a narrow interest Of course there might be some kids with autism where that's the case that you know they become obsessed with a particular character or personality but the young people we see in our context have very similar the same sort of pervasive and intense internal courtence of being of the other gender and we've certainly seen that with young people with intellectual disability as well although interestingly some of the kids when they've been able to talk about that to share it with their parents and with others transition and not to start medical treatment their cognitive impairment seems to be much diminished and they get involved in school where learning that looks like their intellectual difficulties are resolving to some degree so the fact that one might have an autistic if you like perspective on the world doesn't mean that gender disorder can also be part of your experience and it's our job to support these young kids as well as others and also incidentally we're at a meeting recently where Georgie Stone and I were talking to a public forum the first question was from a young gender diverse person who said why can't we get the same support and I think that's a very important question that there's a significant number of young kids we see who might not fit into a more stereotypic male stereotypic female but are really exploring gender and we need to provide the same level of mental health and as appropriate medical intervention for gender diverse young kids often there are ones where they're not feeling as some sort of autistic dimension as well but they each deserve the same level of assessment support and treatment thank you very much for those insights Campbell I'm going to turn to Jaron now and ask a question of him and this is a difficult question because there's an amazing turnout of people on the webinar tonight an amazing number of people registered so it seems like so much interest in this area and understanding more about working with children experiencing gender dysphoria but we also know some clinicians may not feel that they know enough or may feel uncomfortable and so what do you think Jaron about the idea if a clinician is feeling uncomfortable or feel like they lack knowledge and perhaps particularly in a regional or remote area do you think they should be referring on or do you think there's another pathway they might take thanks Damian that's a very difficult question to answer I think one of the one of the more difficult ones it has to do with the autonomy for the clinician as along with the welfare of the child and the family and this is a balancing act most clinicians will not have I suppose personal qualms about working with with kids like this but they may feel they lack the skills to do so if they've never met transgender kids or adults before they may really feel very inadequate when they're faced with this and you've heard from some amazing experts tonight who have a lot of knowledge but if you're working by yourself as a practitioner and you're a third one of these kids it's hard to know where to start and so the immediate knee jerk reaction is probably to say I don't feel comfortable here with a problem I don't think I know what to do I'll refer them on and I think that is not the best thing to do although it is a somewhat specialist field if you're used to working with children or adolescents or families then the issues that are raised often a lot of common sense stuff and a lot of things that you really can work with from your basic principles it's also worth thinking about asking an expert there are experts in the country who will gladly give their time to talk with you I do guide sessions occasionally with transgender individuals around the country and I help out families and others by distance and I'm certainly happy to work for clinicians and I'm sure most of the panel here would in some way or other want to help too the more difficult issue is if one that does have a religious or some moral concern about about kind of genderism and working with teachers transitioning and that's a more difficult thing my personal view a bit confrontational it's a controversial because if you're in a public system you don't get that choice you work with whoever comes in but as a private practitioner you do have some control over who you see but as the question states it's far better to try and refer that person on to make sure they you don't abandon them until they get good quality care I think that's such an important point and I always say this to students when I'm teaching about transgender issues is that yes you need to be knowledgeable and if you have a referral and you don't really feel like you know enough you've got one appointment between one and the next to go off and learn some more contact someone ask for some supervision but also as you said Darren a lot of it is about if you have skills for working with children a lot of it is working with the child and the same as working with any child you need to have the knowledge obviously around gender dysphoria but a lot of the time I'm talking with children stuff that isn't specifically about gender it's just about being themselves and coming into their being so as I think you said basic skills can get you a long way and then you have time in between sessions to to bone up on some extra knowledge and touch base with other people so I definitely agree with you that in most cases and certainly public systems referring on is probably not the best response I'm going to go back and ask another perhaps double barrel question of Michelle which as a researcher I shouldn't ask double barrel questions but I think these two sort of sit together neatly is to sort of think about we know that and you're one of the strong advocates for this getting hormones out of the court system but at the moment they're still in the court system so we have this lag time between lockers which starts you know at a particular tennis stage with puberty progression and then at the moment not until 18 for getting hormones so how do we support young people through that time which is often the time when they're most vulnerable and also the double barrel part is how do we how do we support their families to often you know work with children who are adolescents to us getting suicidal who may be self mutilating yes thanks Damien it's a good question there are for the GPs in the audience there are a number of things that we can do medically that can be extremely helpful so for example for the trans males who are puberty virtual who have completed their breast development so usually that's anyone who started menstruation one of the most successful interventions is to actually suppress their periods and we use criminal law which is a progestogen pill that can successfully induce amenorrhea or stop one period and you find that much of the dysphoria around menstruation ceases at that time and there are a number of people our team included who feel that using criminal law is just as effective at this age as using the injectable pubi blockers because you can't undo the breast development authority there for pubi blockers so there are things medically and certainly we have information sheets for GPs that we can send out and psychologists will also often refer the the adolescents to the GPs that simple prescription which is GPs and amenorrhea and safe as well I have said psychologically acknowledging how distressing it is and how unfair with these arbitrary laws that we have that have been created over time by case law I think listening to that distress helping the young person to understand that we understand that it was given and providing the support through the mental health colleagues certainly play a huge role in helping this situation and for families too there's a lot of the questions aiming about how do we help the parents there is a lot of information there out there about if one does want to access the court how you might go about that in most states now certainly families are given access to pro bono legal assistance and can be assisted through that process it does take six to eight months for apologizing distressing horrible process but for some families it's worth pursuing that for others we provide a psychological scaffold I think is probably the best way to help hold the anxiety into one can start the dating sometimes what we do is give the young person uncertainty by booking an appointment on their 18th birthday so for many 17 year olds I see who have finished the assessment and who are due to start we do the birthday appointments and something to look forward to and an end point where they can get on and start their life in the body that they feel is more right then so a few tips there I hope I've answered your question I mean I think what you I love what you said about being honest with young people around this is a system that we don't agree with this is a system we wouldn't have agreed to and sometimes acknowledging that certainly we're not doing sometimes complicit with it but acknowledging that I think sometimes to be really powerful to hear from us as clinicians that we agree this is not okay yeah yeah and I do think it helps people know that we are fighting to change the system yeah yeah now we only have just a couple of minutes left so I'm going to just ask one last question and direct this to Elizabeth and I think this is one that again has been coming up in the general chat how do a young person is aware of their gender they know they've maybe found a way to speak to you and they're struggling to think about how they might tell their parents how they might tell their friends or their extended family members so what are some of the ways you might assist them to do that disclosing okay so I think the first part of that is helping them to actually define themselves and find their own words around it sometimes they don't actually have the language to talk about how they really feel so firstly checking that they do have that and that they do understand that concept of themselves look sometimes young people are in my room I've had young people who have their parents sitting outside but they actually haven't told them what they hearful and trying to facilitate that process for them in helping them find the words and helping them know that I'm going to support them when their parents come in and can they tell them there and then I think it's probably unfair to the parents to be put on the spot like that but if that's the only safe place for a young person to feel comfortable about speaking up then I think that's the way that it's going to work best for them and just to make the parents realize that they can have support to if they need that one of the things I did a couple of years ago was invite all the parents I was seeing into my backyard so they could safely meet each other and that network now has many many parents in it and they arrange get-togethers and they do all sorts of things with the kids so it's important that they have that peer support from other parents as well you know I find out what what is the young person's concern about telling their parents you know and work with them through their worst fears what's the worst thing that could happen and how realistic is this so that they're prepared for that worst case scenario and of course usually that's just not the case you know I want them also to know what is it that they actually want their parents to know and what is it that they want their parents to do so they have a really clear idea of any request that they might have from their parents so I'll help them with aspects that they've mentioned to me that might help their parents understand the situation so I think there's quite a lot we can do for that and it can take a few sessions to kind of get them to a point where they're ready to broach that subject I think that was a really good question to end on because I think it really highlights what we've all been saying all throughout this evening which is young people who experience gender dysphoria are a diverse group there's no one narrative so we have young people who have all the words and all the language and they have it all in place and they have supportive parents who understand and who are aware and we have young people who don't know all the language who haven't seen Cain and Jenna who are not aware of Chesno and those journeys who have not told their parents and this is what is coming to us in the clinical space is a whole range of diversity that we respond to in the ways that Michelle and Elizabeth and Campbell and Darren have outlined this evening so hopefully that's given everyone online tonight a little bit of a taste of some of the work that we're doing and hopefully that reflects the other work that's being done across the country in terms of supporting young people Obviously there's a lot more to learn and we all keep these conversations going hopefully into the future but I think it really is about acknowledging that diversity and acknowledging that the affirming approach is the way that we go because we know that contributes to positive outcomes Now as I mentioned earlier I'd like to remind you all when we finish in a minute or two that you take a moment to fill out the exit survey we want to know what you like we want to know what you struggle with I know that you're going to say struggle with sound at times but other things that you would have liked us to have covered or aspects of the webinar that you'd like to see done in maybe different ways into the future I would really encourage you to continue to attend the webinars that the mental health professionals network runs Hopefully as you've experienced tonight they're a really useful way to bring together lots of different perspectives We have five clinicians with similar viewpoints because I think we have very similar affirming approaches but different takes on different points and I think that's really important to acknowledge as well There's one I guess unified response which is the affirming response there's lots of nuances in how we take up that affirming response and that's really important to acknowledge as well I'd encourage you to if you haven't already noticed that there's another webinar coming up next week which is on understanding first episode socosis so if you're interested in that please do register for that and also please do consider setting up your own special interest network as part of the MHPN or join ones that exist I know that most states in Australia already have networks around lesbian, gay, bisexual, transgender and intersex issues so becoming a part of that is another way to continue these conversations and to continue to have those peer support and informal ways of discussing issues that you're struggling with in your own work So in closing I'd really like to acknowledge the consumers and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present Thank you to our four wonderful speakers for their time for all the fantastic insights they've given us this evening Thank you to the technical team to Julie and Geoff at MHPN for all of their wonderful work in making this happen for bringing us together as a group and thank you to all of the people that were online this evening We've ended up, we've started off with under 400 We've ended up with over 500 people online tonight There's more than a thousand more people who will watch us at a later date So thank you all for your interest in this area and all the best and you're working to the future Goodnight