Those employed at Sydney Children’s Westmead, as with any paediatric healthcare, have a Duty of Care and Child Protection responsibilities. In some cases (as described) children's distress may indicate sexual, emotional abuse and/or neglect.
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5.4.2. The complex relationship between gender dysphoria and sexual abuse
One of the first clinical challenges that emerged via a number of cases was the complex relationship between gender dysphoria and sexual abuse. The two amalgam cases outlined below highlight the core questions that we asked ourselves: were the children’s negative feelings toward their bodies related to gender dysphoria or were they a manifestation of past trauma in the context of past sexual abuse? And how were these factors to be disentangled?
Avery was an adolescent male (XY chromosomes) in the early stages of puberty who experienced substantial feelings of disgust and distress when looking at, touching, or washing the genitals. Avery was clear that he did not want to mature into a man, but he was not clear about his subjective sense of gender. Avery had been sexually abused as a young prepubertal boy, and the abuse had involved inappropriate touching of the genitals.
Jordan was an adolescent female (XX chromosomes) who identified as a boy. Jordan was adamant that he wanted male sex hormones and to surgically remove his breasts. Jordan was not interested in lower surgery. Jordan had experienced puberty early, and as a school-aged child, Jordan had been sexually abused by a neighbor over a long period of time. The touching of Jordan’s breasts had been a key element of the abuse. (continues)
5.4.6. Gender dysphoria and the agendas of parents
... A further potential complication is that the child can be triangulated into marital conflict between the parents, acted out via the issue of gender dysphoria. Understanding such cases within family systems and child protection frameworks, and possibly even calling in protection services, may sometimes be necessary. In yet another scenario, it becomes clear that whatever particular problems or conflicts the child may be experiencing, the motivation for engaging with the Gender Service and seeking medical intervention comes from the parent(s), not the child. In such cases, the multidisciplinary team needs to ensure that the child’s voice is heard and heard clearly. (continues)
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The following is an excerpt from a 2019 letter that Kirsty Entwistle, a clinical psychologist who previously worked at the Gender Identity Development Service (GIDS) in Leeds, wrote to Polly Carmichael, Director of the GIDS at the Tavistock Clinic.
...I also felt that [we were seeing] an overrepresentation of the young people who were living in poverty. I had a young person whose family were living within such extreme financial constraints that he considered it a treat to buy a can of pop. I also had another young person who was living in a very complex and unstable arrangement who arrived to sessions in a poor state of hygiene and said that there wasn’t money for hygiene products. How is it ethical to undertake a gender identity assessment with the view to a medical pathway when there are children and young people do not have their most basic needs met?^ (Entwistle, July 19 2019)