This study shows that the commissioning of professional services makes the implementation of an assessment process linked to appraisal feasible. However, trust-based assessment requires significant development: developmental appraisal needs protection; new instruments are needed for non-clinical specialties; PR requires specific administrative support, and guidance is required over concern thresholds and demographic effects. Disaggregated assessment data may help identify doctors with potential performance problems.

IntroductionBeing transgender is frequently accompanied by gender dysphoria, which often coexists with mental health concerns. Increased referrals of transgender and gender diverse (TGD) youth to gender clinics have been observed in many countries. Nevertheless, there are limited empirical data on the presentation and outcomes of these patients, and there is an urgent need for more evidence to ensure optimal medical and psychosocial interventions. Here, we describe Trans20, a longitudinal study of TGD patients attending a multidisciplinary paediatric gender service in Melbourne, Australia. Trans20 aims to understand the demographic and clinical characteristics of these patients, to document the natural history of gender diversity presenting in childhood and to investigate long-term outcomes for those receiving interventions.Methods and analysisTrans20 is a prospective cohort study based on children and adolescents first seen at the Royal Children’s Hospital Gender Service (RCHGS) between February 2017 and February 2020. Current estimates indicate the final sample size will be approximately 600. Patients and their parents complete online questionnaires prior to the first appointment with RCHGS and regularly thereafter as part of routine clinical care. On discharge from RCHGS, patients are invited to continue undertaking questionnaires biennially. In this way, a naturally forming cohort study has been created. The primary outcomes include gender dysphoria, physical and mental health, schooling, family functioning and quality of life. Subgroup analyses based on factors such as gender identity, birth-assigned sex and treatment received will be performed using bivariate and multivariate modelling as appropriate, and relevant statistical methods will be applied for the repeated measures over time.Ethics and disseminationThe Royal Children's Hospital Human Research Ethics Committee approved this study (#36323). Findings from Trans20 will have translational impact by informing future treatment guidelines and gender affirming healthcare practices and will be disseminated through conferences and peer reviewed journals.

Introduction Young people use social media to communicate about self-harm and suicide and this is associated with both potential risks and protective effects. The #chatsafe guidelines were originally developed in 2018 to equip young people to communicate safely online about suicide. They were shown to be safe, acceptable, and beneficial; however, they do not provide guidance on self-harm, and social media is constantly evolving. This study aimed to update the #chatsafe guidelines to reflect new evidence and current social media affordances, and to include guidance on self-harm. Methods A Delphi expert consensus study was conducted, comprising six stages: 1) A systematic search of peer-reviewed and grey literature; 2) A series of roundtables with key stakeholders including social media companies, policymakers, and young people; 3) Questionnaire development; 4) Expert panel formation; 5) Data collection and analysis; and 6) Guideline development. Results A total of 191 items were included in the new #chatsafe guidelines. These were organised into eight themes, which became the overarching sections of the guidelines: 1) General tips; 2) Creating self-harm and suicide content; 3) Consuming self-harm and suicide content; 4) Livestreams of self-harm and suicide acts; 4) Self-harm and suicide games, pacts, and hoaxes; 6) Self-harm and suicide communities; 7) Bereavement and communicating about someone who has died by suicide; and 8) Guidance for influencers. Discussion The new guidelines include updated and new information on online communication about self-harm, livestreams, games, pacts, and hoaxes, as well as guidance for influencers. They will be disseminated via a national social media campaign and supported by a series of adult-facing resources. Given the acceptability of the original guidelines and the ubiquitous use of social media by young people, it is hoped that the new guidelines will be a useful resource for young people and adults alike, both in Australia and worldwide.

ObjectiveFertility counselling for trans and gender diverse (TGD) adolescents has many complexities, but there is currently little guidance for clinicians working in this area. This study aimed to identify effective strategies for—and qualities of—fertility counselling for TGD adolescents based on clinicians’ experiences.DesignWe conducted qualitative semi-structured individual interviews in 2019 which explored clinician experiences and fertility counselling practices, perspectives of the young person’s experience and barriers and facilitators to fertility preservation access. Data were analysed using thematic analysis.SettingThis qualitative study examined experiences of clinicians at the Royal Children’s Hospital—a tertiary, hospital-based, referral centre and the main provider of paediatric TGD healthcare in Victoria, Australia.ParticipantsWe interviewed 12 clinicians from a range of disciplines (paediatrics, psychology, psychiatry and gynaecology), all of whom were involved with fertility counselling for TGD adolescents.ResultsBased on clinician experiences, we identified five elements that can contribute to an effective approach for fertility counselling for TGD adolescents: a multidisciplinary team approach; shared decision-making between adolescents, their parents and clinicians; specific efforts to facilitate patient engagement; flexible personalised care; and reflective practice.ConclusionsIdentification of these different elements can inform and hopefully improve future fertility counselling practices for TGD adolescents, but further studies examining TGD adolescents’ experiences of fertility counselling are also required.