News Review
from previous page stories relayed, there is no double blind study that shows children are doing better. It’ s just strong opinion, and that’ s not evidence.
“ Under the law, it is also deemed essential to protect children from sincere but misguided members of the medical profession. However, no one is questioning the motivations of protagonists for‘ affirmative care’ when managing gender dysphoria.”
He refers to a 2011 PLOS One study conducted in Sweden, which found rates of suicide were nearly 20 times greater among adults who used cross-sex hormones and underwent sex reassignment surgery compared with the general population. 1
The advocates As is probably obvious, Professor Whitehall’ s perspective is not shared by everyone, not least those clinicians, who unlike Professor Whitehall, have experience treating young people for gender dysphoria.
Last month saw the release of the Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents. They offer a very clear view of the risks of stage 2 treatment, the physical effects and what can and cannot be reversed once the decision to treat is made. But they also highlight the importance of‘ gender-affirming care’,
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A 30 min application of Zatamil Hydrogel achieves a similar skin response over 24 hours compared to a 70 min application of mometasone furoate ointment. 1, 3 which is based on claims of the significant mental health benefits of transitioning for those with gender dysphoria. 2
The guidelines have been drawn up by clinicians from Melbourne’ s Royal Children’ s Hospital Gender Service, one
ZATAMIL HYDROGEL FAST ACTING
1
0.1 % hydrogel
Mometasone furoate 0.1 % w / w gel
G1 G
Australia’ s only mometasone hydrogel 2 for rapid action. 1 * For eczema & psoriasis.
PBS Information: Zatamil Lotion and Zatamil Ointment 15g: Restricted benefits. Corticosteroid-responsive dermatoses. Authority Required( Streamlined). Refer to PBS Schedule for full authority information. Zatamil Hydrogel and Zatamil Ointment 45g: These products are not listed on the PBS.
Zatamil( mometasone furoate) Hydrogel, Ointment, Lotion – Minimum Product Information Indications: Short term( up to four continuous weeks) relief of inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses, such as psoriasis and atopic dermatitis. Zatamil Lotion is suitable for use in scalp psoriasis and application to other areas of the body. Contraindications: Hypersensitivity; tuberculosis; fungal or viral skin infections; acne rosacea; perioral dermatitis; ulcerative conditions. Precautions: Irritation or sensitisation; infection; infants and children; prolonged or extensive use; occlusion; eye contact; pregnancy( Category B3); lactation. Adverse Reactions: Itching; burning; stinging; skin atrophy; acneform reactions. Dosage and Administration: A thin film of Zatamil Hydrogel or Ointment should be applied to the affected skin area once daily. A few drops of Zatamil Lotion should be applied to affected skin areas including scalp sites once daily; massage gently and thoroughly until the medication disappears. Based on TGA approved PI dated 10 / 5 / 2012.
Before prescribing please review the full Product Information. Full Product Information is available on request from Ego Pharmaceuticals Pty Ltd and be accessed at www. ebs. tga. gov. au / ebs / picmi / picmirepository. nsf / pdf? OpenAgent & id = CP-2012-PI-01934-3 & d = 2017090816114622483
References: 1. Zatamil hydrogel bioequivalence study C11 – 019 – LBB( ZPS-456). Data on File, Ego Pharmaceuticals Pty Ltd. 2. Department of Health, Therapeutic Goods Administration. Search conducted on 11 / 09 / 2017. Search term used‘ mometasone hydrogel’ on website: www. ebs. tga. gov. au. 3. Mometasome furoate ointment bioequivalence study C11 – 009 – LBB [ ZPS – 454). Ego Pharmaceuticals Pty Ltd. Data on file, Ego Pharmaceuticals Pty Ltd, 21 – 31 Malcolm Road, Braeside VIC 3195, Australia. Ph: + 61 3 9586 8800, Toll free 1800 033 706.‘ Ego’ and‘ Zatamil’ are trademarks of Ego Pharmaceuticals Pty Ltd. © 2017 Ego. Prepared October 2017.
‘ WHILE THERE MAY BE MANY HAPPY STORIES RELAYED, THERE IS NO DOUBLE BLIND STUDY THAT SHOWS CHILDREN ARE DOING BETTER. IT’ S JUST STRONG OPINION, AND THAT’ S NOT EVIDENCE.’
— Professor John Whitehall professor of paediatrics at the University of Western Sydney
of the few clinics caring for transgender children and adolescents. Its caseload has risen significantly over the past 15 years, and this year alone it has received 126 patient referrals, compared with around 600 between 2003 and 2016.
While it claims that no patient who has transitioned has ever decided to go back to their original gender, the service declined to speak to Australian Doctor after being told Professor Whitehall was being interviewed.
Other front-line health professionals are more forthcoming, adamant that transitioning transforms lives for the better. Psychiatrist Dr Yolandie Goodyear, from NewStart Psychologists in Newcastle, NSW, has treated dozens of children with gender dysphoria over the past three years. She admits there is still not enough research on the appropriate treatment of gender dysphoria in the young, with most of the research looking at adults.
But she cites a 2017 review published in the Journal of Child Psychology and Psychiatry that shows“ affirmative treatment protocols” can address mental health difficulties in children. 3 These protocols involve allowing children to adopt different pronouns or ways of dressing consistent with the opposite sex in a process known as social transitioning.
The review also cites evidence from a 2014 study in Paediatrics that cross-sex hormone therapy, so-called stage 2 treatment, along with puberty blockers, could improve mental wellbeing. 4
“ For some kids, they are so unhappy with their secondary sexual characteristics that it alone causes immense distress,” she says.“ So the treatment for that is to change their skin to make them feel more comfortable.”
Dr Goodyear says she has seen how hormone blockers have succeeded in helping transgender adolescents back to school and reduced or stopped self-harm episodes, and that’ s what matters even if the evidence remains sketchy on long-term effects.
“ It’ s about doing the best with what you’ ve got. It improves their mood and reduces the risk of suicide. Parents have corroborated this at every step of the way.”
It is worth pointing out that, while Professor Whitehall refers to the 2011 PLOS One study on suicide rates among adults who have transitioned, with its apparently shocking statistical results, it turns out the authors don’ t share the same interpretation of the data.
Study co-author Mikael Landen, from the department of clinical neuroscience at Stockholm’ s Karolinksa Institutet medical university, told the Conversation last year:“[ It ] may sound as if sex reassignment increased suicide risk 20 times. That is not the case. The risk of suicide was increased 19 times compared with the general population, but that is because gender dysphoria is a distressing condition in itself.
“ Our study does not inform us whether sex reassignment decreases [ which is likely ] or increases [ which is unlikely ] that risk.”
What next? The Family Court’ s decision regarding its role in approving stage 2 treatment is expected soon, and all sides are keen to know the ruling given it could end the roadblocks to treatment faced by many youngsters.
But it is also clear that the debate about appropriate treatment for gender dysphoria, which contains that combustible mix of medicine and politics, will continue.
The stakes are extremely high. Trans Pathways, the largest study ever conducted on the mental health of trans and gender diverse young people in Australia, found that 48 % of those who took part had attempted suicide at some point in their lives. 5
There is therefore a desperate need for care, support and effective, safe treatment. ● References on request.
12 | Australian Doctor | 24 November 2017 www. australiandoctor. com. au