What are the health outcomes of trans and gender diverse young people in Australia? Study protocol for the Trans20 longitudinal cohort study

Abstract

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.

A Follow-Up Study of Boys With Gender Identity Disorder

“…To date, however, there are no long-term follow-up studies of clinic-referred samples of children who had all socially transitioned prior to puberty. Future follow-up studies should be able to capture a much larger subgroup of such children and compared to those who have not with regard to long-term outcome with regard to persistence and desistance [e.g., ( 154 )]. The persistence-desistance rates found in this study and the ones preceding it can be used as a comparative benchmark for samples in which a social transition took place prior to puberty.…”

Gender identity development in children and young people: A systematic review of longitudinal studies

“…In the US, the Trans Youth Project is investigating trajectories of a community sample of socially transitioned children (Olson & Gülgöz, 2018) and another large scale NIH funded study is investigating medical interventions for transgender youth (Olson-Kennedy et al, 2019). Australia (Tollit et al, 2019), and the UK (LOGIC Study, 2020) also have longitudinal studies in progress, recruiting from gender identity development services. Overall, these studies, which have been established following the rise in referrals to clinics internationally in the last few years, will enhance understanding of outcomes over time and how better to support gender identity development in children and young people.…”

Informed consent and childhood gender dysphoria: emerging complexities in diagnosis and treatment

“…Since 2000, there have been dramatic increases in numbers of children referred to gender clinics both internationally 13 and locally, 14 with the largest gender clinic in Australia at the Royal Children's Hospital (the RCHGS) seeing 250 new referrals per year. Despite the significant knowledge gaps, many gender clinics have adopted treatment protocols based on a gender-affirmation approach to the exclusion of competing models of care, despite limited and poor quality outcome data.…”

“…Prospective cohort studies such as the Trans20 study currently being undertaken at the Royal Children's Hospital Gender Service do not include a treatment control group, or randomisation of individuals to affirmation or non-affirmation interventions. 14 Without the inclusion of a conventional treatment control group, these studies will not be able to determine whether the affirmation approach to GD is superior to the conventional approach, or even better than no treatment. At the moment, children entering affirmation approaches to GD are being exposed to experimental treatments without long-term evidence of efficacy or safety.…”