Development of best practice guidelines for clinical and community service providers to prevent suicide in LGBTQA+ young people: A Delphi expert consensus study.

OBJECTIVE: The aim of this study was to develop best practice guidelines for preventing suicide and reducing suicidal thoughts and behaviours in LGBTQA+ young people (lesbian, gay, bisexual, trans, queer/questioning, asexual, and those of other diverse sexualities and genders) within clinical and community service settings in Australia. METHODS: We conducted a Delphi expert consensus study. A systematic literature search and interviews with key informants informed an initial 270-item questionnaire. Two expert panels completed the questionnaire, delivered over two rounds: (1) Australian professionals with expertise in LGBTQA+ mental health/suicide prevention and (2) Australian LGBTQA+ young people aged 14-25 with lived experience of suicidal thoughts and/or behaviours. Items endorsed as 'essential' or 'important' by >80% of both expert panels were included in the guidelines. RESULTS: A total of 115 people participated in the Delphi process; n = 52 professionals completed Round 1, and n = 42 completed Round 2; n = 63 LGBTQA+ young people completed Round 1, and n = 50 completed Round 2. A total of 290 items were included in the guidelines and grouped into: (1) general principles for creating an affirming and inclusive environment for LGBTQA+ young people; (2) assessing suicide risk and working with suicidal LGBTQA+ young people; (3) considerations for specific LGBTQA+ populations; and (4) advocating for LGBTQA+ young people. CONCLUSION: These guidelines are the first of their kind in Australia. They provide practical support to service providers regardless of prior training in LGBTQ+ identities or mental health, with the aim of reducing suicidal thoughts and behaviours, and preventing suicide, in LGBTQA+ young people.

Gender non-conformity in childhood and adolescence and mental health through to adulthood: a longitudinal cohort study, 1995-2018.

BACKGROUND: Few studies have examined associations between gender non-conformity (GNC) in childhood or adolescence and mental health outcomes later in life. This study examined associations between (1) GNC and mental health over multiple time points in childhood and adolescence, and (2) GNC in childhood and/or adolescence and mental health in adulthood. METHOD: Second generation participants from the Raine Study, a longitudinal cohort from Perth, Western Australia. Data were collected between 1995 and 2018, comprising seven waves: ages 5 (N = 2236), 8 (N = 2140), 10 (N = 2048), 14 (N = 1864), 17 (N = 1726), 22 (N = 1236) and 27 (N = 1190) years. History of GNC, v. absence of this history, was based on responses to item 110 from the Child Behaviour Checklist (CBCL)/Youth Self Report (YSR) ('wishes to be of opposite sex'). The CBCL/YSR were used to measure internalising and externalising symptoms. Items 18 ('deliberate self-harm [DSH] or attempts suicide') and 91 ('talks/thinks about killing self') were used as measures of suicidal ideation (SI) and DSH. For adults, Depression, Anxiety and Stress Subscales and Kessler Psychological Distress Scale assessed mental health. RESULTS: Child and adolescent GNC was associated with elevated internalising and externalising behaviours and increased odds of DSH. A history of GNC was also associated with vulnerability for severe psychological distress in adulthood in some symptom scales. CONCLUSION: GNC over the child and adolescent period is associated with significant emotional and behavioural difficulties, and psychological distress. A history of GNC in childhood and/or adolescence also predicts poorer mental health in adulthood on multiple symptom domains.

Botulinum Toxin A Injection and Perianesthesia Neuromuscular Monitoring: Case Report and Review.

The popularity of looking younger has been facilitated by the availability of botulinum toxin (BoNT) injection. In 2019, over 7.7 million injections of BoNT occurred, making it the number one minimally invasive cosmetic procedure in the United States. With the ease of patients obtaining BoNT in an outpatient setting, coupled with the fact that it is considered a minimally invasive procedure, most patients do not disclose the use of BoNT during the preoperative anesthesia evaluation. This case report involves a female whose recent BoNT injections interfered with neuromuscular (NM) monitoring during anesthesia. Neuromuscular monitoring was performed using the orbicularis oculi muscle with repeated train-of-four (TOF) 0/4. It was not until completion of procedure when the arms were accessible that the adductor pollicis muscle was assessed with a TOF of 2/4. During postoperative follow up, the patient revealed she had received BoNT injections prior to surgery. A review of BoNT pharmacology, barriers to NM monitoring and use of sugammadex are discussed. This case demonstrates the importance of ascertaining BoNT injection history in any case in which access to the ulnar nerve or tibial nerve is not available.

Options and realities for trans and gender diverse young people receiving care in Australia's mental health system: findings from Trans Pathways.

OBJECTIVE: Trans and gender diverse young people experience mental health difficulties self-harm and suicidality at markedly higher rates than the general population, yet they often feel isolated from mental health services. There is little qualitative research on the experiences of trans and gender diverse young people accessing mental health support in Australia. The objective of this study was to comprehensively explore the experiences of trans and gender diverse young people in Australia who have sought mental health support from therapists, counsellors, psychiatrists and/or inpatient care providers. METHODS: We report on findings from the Trans Pathways study, which was a mixed-methods study to evaluate the experiences of trans and gender diverse young people accessing mental health services: specifically, therapy and counselling services, psychiatric services and mental health inpatient services. RESULTS: A total of 859 trans and gender diverse young people aged 14-25 years across Australia completed an anonymous online questionnaire. Therapy and/or counselling services (64.4%) were most frequently sought by trans and gender diverse young people in this study, followed by psychiatric services (43.0%) and mental health inpatient services (12.3%). The findings demonstrated that many mental health professionals lacked expertise in gender diversity, and that trans and gender diverse young people found it difficult to locate mental health professionals who were able to meet their needs in a timely manner. CONCLUSION: These findings indicate that training is necessary for all mental health professionals to improve their knowledge of gender diversity, enhance the support provided to trans and gender diverse young people and help to address the high rates of poor mental health. The findings outlined here provide insight into the areas in which clinicians could optimise their care of trans and gender diverse young people.

Associations between negative life experiences and the mental health of trans and gender diverse young people in Australia: findings from Trans Pathways.

BACKGROUND: Trans and gender diverse (TGD) young people worldwide experience high rates of poor mental health; however, these rates were unknown in Australia. In addition, how negative life events affect the mental health of TGD young people has been largely unexplored. METHODS: This paper reports on novel mental health findings of Trans Pathways, the largest study ever conducted in Australia with trans (transgender) and gender diverse young people (N = 859; aged 14-25 years). The study was an anonymous online cross-sectional survey undertaken in 2016. Logistic and linear regression models were used to test associations between mental health outcomes and negative life experiences. RESULTS: TGD young people in Australia experience high levels of mental distress, including self-harming (79.7%), suicidal thoughts (82.4%), and attempting suicide (48.1%). Three in four participants had been diagnosed with depression and/or anxiety (74.6% and 72.2%, respectively). Many TGD young people had been exposed to negative experiences such as peer rejection (89.0%), precarious accommodation (22.0%), bullying (74.0%), and discrimination (68.9%). Most poor mental health outcomes were associated with negative experiences. The strongest associations were found for precarious accommodation and issues within educational settings. For example, participants with a prior suicide attempt were almost six times more likely to have experienced issues with accommodation, including homelessness. CONCLUSIONS: The current results highlight the urgent need for better mental health care and provide insight into areas for targeted mental health interventions. These findings are pertinent for clinicians working with trans young people and wider society.

Feasibility of a commercial smartphone application for dietary assessment in epidemiological research and comparison with 24-h dietary recalls.

BACKGROUND: Dietary assessment methods that can provide high quality data while limiting participant burden and resource requirements in epidemiological research are highly sought after and continue to evolve. The use of mobile phone technology in research has increased rapidly over the last decade and offers multiple advantages to the researcher over traditional data collection methods. This study tested the acceptability and relative validity of a commercial smart phone application (app) for use as an epidemiological dietary assessment tool, compared with a traditional dietary assessment method. METHODS: Study participants completed a 4-d food diary using a modified version of the Easy Diet Diary app and two 24-h dietary recalls during the same week, for comparison. At the end of data collection, participants completed a questionnaire on their experience with both methods. Average proportions of energy from macronutrients and fibre, iron, and calcium densities from the app and 24-h recalls were compared after log transformation, by calculating mean agreement, limits of agreement (LOA), and Pearson's correlations. The prevalence of dietary under-reporting was compared in each method using the Goldberg method. RESULTS: A total of 50 adults (82% women) provided data for analysis (mean age, 31 y; mean BMI, 22.4 kg/m2; 14% overweight or obese). Participant feedback showed high levels of acceptance of the app; 83% preferred using the app to completing 24-h dietary recalls. The average difference in energy intake (mean agreement) between methods was 268 kJ/d. For all intakes except alcohol, the average difference between methods was not significantly different from zero. Most limits of agreement were within an acceptable range. The prevalence of dietary misreporting was similar in both methods. CONCLUSIONS: These findings demonstrate good feasibility for applying this commercially-developed smartphone app in epidemiological research.

Early Rehydration in Surgical Patients With Prolonged Fasting Decreases Postoperative Nausea and Vomiting.

PURPOSE: The purpose of the project was to reduce the incidence of postoperative nausea and vomiting (PONV) in adult surgical patients who fasted for more than 12 hours with the administration of a preinduction intravenous fluid (IVF) bolus. DESIGN: This interdisciplinary project used the Plan-Do-Study-Act model for quality improvement. METHODS: After institutional approval, 381 consecutive adult surgical patients were evaluated for participation; 148 patients fasted more than 12 hours and met inclusion criteria to receive a 1 liter, IV fluid bolus before anesthesia induction. All patients received general inhalational anesthesia and prophylactic doses of dexamethasone and ondansetron, along with peripheral nerve blocks appropriate for surgical case type. FINDINGS: Only 96 (64%) qualified patients received the complete bolus before anesthesia induction. In this group, the incidence of PONV was 4.25%. CONCLUSION: The use of a simple rehydration protocol reduced the incidence of PONV in patients with prolonged fasting times. Time and personnel constraints were identified as barriers that prevented full compliance with the protocol.

Perianesthesia implications of obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a complex medical condition that affects not only the airway but also the cardiopulmonary, endocrine, and central nervous systems. Obstructive sleep apnea can usually be identified with a focused history and physical examination and is commonly associated with obese, middle-aged men with hypertension and glucose intolerance. A high index of suspicion for OSA should arise when reports of loud snoring, nighttime arousal, and acid reflux accompanied by a history of stroke, atrial fibrillation, or congestive heart failure are elicited during a perianesthesia evaluation. Perianesthesia risk in OSA patients includes the potential for difficult airway management, cardiovascular instability, and abnormal sensitivity to sedation and analgesia. Typical doses of respiratory depressants may cause profound hypoventilation, apnea, or cardiopulmonary arrest in OSA patients. Central axial opioids and continuous intravenous opioid infusions should be avoided while nonopioid and non-centrally acting analgesics are recommended. Careful postoperative monitoring is important to preventing serious morbidity. Early identification of OSA and its comorbidities is key to developing a safe anesthesia and postoperative treatment plan.

Experiences of parents of trans young people accessing Australian health services for their child: Findings from Trans Pathways.

Background: Many trans young people seek mental health support and gender-affirming medical interventions including puberty suppression, gender-affirming hormones and/or surgeries. Trans young people and their parents face multiple barriers in accessing gender-affirming care and mental health support, however little is known about the parent perspective on accessing services for their trans child. Aims: This study aimed to understand the experiences of parents accessing medical and mental health services with and for their trans children within Australia. Methods: Using data from Trans Pathways, a large mixed-methods cross-sectional study, we examined the experiences of parents (N = 194) in Australia accessing primary care, psychiatry, therapy/counseling, mental health inpatient, and gender-affirming medical services with/for their trans children (aged 25 years or younger). Qualitative data on service experiences were thematically analyzed. Quantitative analyses included frequency of access to services, wait times, service satisfaction, and mental health diagnoses of the parents' trans child. Results: Services were mostly first accessed when the young person was between 12 and 17 years of age, with primary care physicians being the most accessed service. Parents reported that some practitioners were respectful and knowledgeable about gender-affirming care, and others lacked experience in trans health. Across all services, common barriers included long wait times, complicated pathways to navigate to access support, as well as systemic barriers such as sparsity of gender speciality services. Across services, parents reported feeling as though they do not have the necessary tools to best support their child in their gender affirmation. Discussion: This study highlights the crucial need for systemic changes in the processes of accessing gender-affirming care and mental health support to enable access to appropriate and timely care. These findings also indicate the importance of improving individual practitioner knowledge around trans health, to enhance the support provided to trans young people and their parents.

Retrospective Examination of Peripubertal Return for Patients of Western Australia's Gender Diversity Service.

Purpose: Children far in advance of pubertal development may be deferred from further assessment for gender-affirming medical treatment until nearer puberty. It is vital that returning peripubertal patients are seen promptly to ensure time-sensitive assessment and provision of puberty suppression treatment where appropriate. This study investigates (1) how many referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children's Hospital are deferred due to prepubertal status; and (2) how many deferred patients return peripubertally. Methods: A retrospective review of all closed referrals to the service was conducted to determine the frequency of prepubertal deferral and peripubertal re-referral. Results: Of 995 referrals received (2014 to 2020), 552 were closed. The reason for closure was determined for 548 referrals (99.3%). Prepubertal status was the second-most frequent reason for closure, and the most frequent for birth-registered males. Twenty-five percent of all deferred prepubertal patients returned peripubertally, before audit closure. A greater return frequency (55.6%) was estimated for those older than 13 years at audit closure. Conclusion: High rates of prepubertal referral indicate the importance of pediatric gender services in providing information, advice, and reassurance to concerned families. With increasing service demand, high rates of return peripubertally have implications for service planning to ensure that returning peripubertal patients are seen promptly for time-sensitive care. Frequency of peripubertal re-referral cannot, however, speak to the stability of trans identity or gender incongruence from childhood to adolescence. Clinics advising prepubertal deferral must proactively plan to ensure that sufficient clinical resources are reserved for this purpose.

Reidentification With Birth-Registered Sex in a Western Australian Pediatric Gender Clinic Cohort.

Importance: Some young people who identify as transgender and seek gender-affirming medical care subsequently reidentify with their sex registered at birth. Evidence regarding the frequency and characteristics of this experience is lacking. Objective: To determine the frequency of reidentification and explore associated characteristics in a pediatric gender clinic setting. Design, Setting, and Participants: This retrospective cohort study examined all referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children's Hospital between January 1, 2014, and December 31, 2020. The Gender Diversity Service is the sole statewide specialist service in Western Australia that provides children and adolescents up to age 18 years with multidisciplinary assessment, information, support, and gender-affirming medical care. All closed referrals for this study were audited between May 1, 2021, and August 8, 2022. Exposure: Reidentification with birth-registered sex. Main Outcomes and Measures: The number of referrals closed due to reported reidentification with birth-registered sex was determined, as well as descriptives and frequencies of patient demographics (age, birth-registered sex), informant source, International Statistical Classification of Diseases, Tenth Revision gender-related diagnoses, pubertal status, any gender-affirming medical treatment received, and whether subsequent re-referrals were received. Results: Of 552 closed referrals during the study period, a reason for closure could be determined for 548 patients, including 211 birth-registered males (mean [SD] age, 13.88 [2.00] years) and 337 birth-registered females (mean [SD] age, 15.81 [2.22] years). Patients who reidentified with their birth-registered sex comprised 5.3% (29 of 548; 95% CI, 3.6%-7.5%) of all referral closures. Except for 2 patients, reidentification occurred before or during early stages of assessment (93.1%; 95% CI, 77.2%-99.2%). Two patients who reidentified with their birth-registered sex did so following initiation of puberty suppression or gender-affirming hormone treatment (1.0% of 196 patients who initiated any gender-affirming medical treatment; 95% CI, 0.1%-3.6%). Conclusions and Relevance: These findings from a pediatric gender clinic audit indicate that a small proportion of patients, and a very small proportion of those who initiated medical gender-affirming treatment, reidentified with their birth-registered sex during the study period. Longitudinal follow-up studies, including qualitative self-report, are required to understand different pathways of gender identity experience.

Twelve Tips for Inclusive Practice in Healthcare Settings.

This paper outlines practical tips for inclusive healthcare practice and service delivery, covering diversity aspects and intersectionality. A team with wide-ranging lived experiences from a national public health association's diversity, equity, and inclusion group compiled the tips, which were reiteratively discussed and refined. The final twelve tips were selected for practical and broad applicability. The twelve chosen tips are: (a) beware of assumptions and stereotypes, (b) replace labels with appropriate terminology, (c) use inclusive language, (d) ensure inclusivity in physical space, (e) use inclusive signage, (f) ensure appropriate communication methods, (g) adopt a strength-based approach, (h) ensure inclusivity in research, (i) expand the scope of inclusive healthcare delivery, (j) advocate for inclusivity, (k) self-educate on diversity in all its forms, and (l) build individual and institutional commitments. The twelve tips are applicable across many aspects of diversity, providing a practical guide for all healthcare workers (HCWs) and students to improve practices. These tips guide healthcare facilities and HCWs in improving patient-centered care, especially for those who are often overlooked in mainstream service provision.

Perspectives of trans and gender diverse young people accessing primary care and gender-affirming medical services: Findings from Trans Pathways.

Background: Increasing numbers of trans young people are seeking medical services worldwide, but there have been few qualitative investigations of the experiences of trans young people attempting to engage with these services to explore in-depth experiences of clinical interactions. Aims: We aimed to explore the experiences of trans young people accessing primary care and gender-affirming medical services in Australia for reasons related to their gender. Methods: Using data from a large mixed methods cross-sectional study, we explored the personal experiences of trans young people aged 14-25 (N = 859) receiving care within primary care services and gender-affirming medical services. Qualitative data on these service experiences were thematically analyzed. Results: Trans young people in Australia reported experiencing difficulties when accessing medical services, especially in relation to gender-affirming medical intervention, referrals to specialist services, and obtaining clinical support in an affordable and timely manner. We found that trans young people were frequently confronted with negative experiences due to clinicians lacking expertise in providing gender-affirming care. Trans young people also reported many positive experiences, including feeling their gender identity was valued and respected by certain services. Although many practitioners attempted to assist their trans patients, they often did not provide satisfactory care and young people were often left to navigate the health care system unsupported. These interactions were often constrained by long waiting times and service cost. Discussion: In general, clinicians require further training to be able to respectfully interact with trans patients and to adequately assist trans young people to obtain necessary medical care. The danger of providing such non-affirmative care to a trans young person is not only invalidating the young person's identity, but also an elevated risk of ill-health due to later avoidance of health care.

They Told Me "This Isn't a Hotel": Young People's Experiences and Perceptions of Care When Presenting to the Emergency Department with Suicide-Related Behaviour.

In Australia, the number of young people presenting to the emergency department with mental health concerns, in particular, suicidal behaviour (defined here as suicidal ideation, thoughts, intent and attempts) is increasing. Little is known about the experiences of Australian young people who present to hospital emergency departments with suicidal behaviour. In this qualitative study, we conducted a series of focus groups with 55 young people aged 16-25 years, with a view to developing a framework for youth suicide prevention for Western Australia. The data were analysed using a general inductive analysis approach. We explored the experiences and perceptions of the care and management of 35 young people presenting to Western Australian hospital emergency departments. Participants described a range of negative experiences relating to the emergency department environment, staff attitudes and their treatment by staff. We argue that adapting ED practices and approaches to young people presenting with suicidal thoughts and behaviours based on these findings will result in lower rates of repeated presentations and admissions to hospital and lower rates of suicide attempts and deaths by suicide.

Reach and perceived effectiveness of a community-led active outreach postvention intervention for people bereaved by suicide.

Background: Postvention is a core component of suicide prevention strategies, internationally. However, the types of supports provided to people impacted by suicide vary widely. This study examines the perceived effectiveness of the Primary Care Navigator (PCN) model for people bereaved by suicide. The PCN model was implemented in response to a suicide cluster. It is an active outreach postvention intervention, initiated by police in response to a suspected suicide and links individuals to support in the immediate aftermath of their loss. Methods: A retrospective cross-sectional mixed methods approach was used to (1) identify the reach of the PCN model, (2) describe the type of support provided to people bereaved by a suspected suicide and (3) identify the perceived effectiveness of the PCN model from the perspective of WA police, postvention stakeholders and individuals bereaved by suicide. Quantitative data was used to examine the characteristics of suicide in the region, the characteristics of people who received bereavement support, and the types of support that were provided. Interviews with police, postvention stakeholders, and people bereaved by a suspected suicide were conducted to identify the perceived effectiveness of the intervention. Results: Between 1 January 2019 and 31 March 2021 there were 80 suspected suicides. Active outreach was provided to 347 bereaved individuals via the PCN model. Just under half of those who were offered outreach accepted further support (N = 164) in the form of suicide bereavement information (98%), mental health or clinical support (49.6%), specialized postvention counseling (38.4%), financial assistance (16%) and assistance with meals (16%), followed by housing assistance (14%) and referral to community services (11%). Police, stakeholders, and people with lived experience of a suspected suicide perceived the PCN model to be effective at connecting them to the community, linking people to support, and preventing suicide. Conclusion: The results provide evidence supporting the perceived effectiveness of an active outreach approach to postvention that provides acute support to people bereaved by suicide. Findings highlight important practical areas of support such as providing referral pathways and information on grief and suicide loss in the immediate aftermath of a suicide loss.

Mental health difficulties among trans and gender diverse young people with an autism spectrum disorder (ASD): Findings from Trans Pathways.

Recent research highlights an overlap of gender diversity and autism spectrum disorders (ASD); however, data on individuals who are trans and also on the autism spectrum are largely from clinical samples and may not be representative of individuals who are trans with ASD in the general population. In addition, there is scant literature on the mental health of these individuals and their experiences in accessing gender-affirming care. We investigated the prevalence of ASD in trans young people, their mental health (psychiatric diagnoses and self-harm and suicidal behaviors) and experiences in accessing gender-affirming care. This is an analysis of data collected in an Australian cross-sectional mixed methods survey (N = 859) of trans young people aged 14-25 years. Overall, 22.5% of participants had ever received a diagnosis of ASD from a health professional. This group was more likely to exhibit current psychopathology, have engaged in self-harming and suicidal behaviors, and was also more likely than the non-ASD diagnosed reference group to have received a psychiatric diagnosis. The ASD-diagnosed group were also more likely to experience barriers in accessing gender-affirming care. This is the first large population-based sample of trans individuals with ASD to report on mental health outcomes and experiences in accessing gender-affirming care. We highlight the necessity for clinicians working with either trans or ASD populations to have awareness of the co-occurrence, and to cultivate skills to work with individuals who are both trans and on the autism spectrum.

Group mindful self-compassion training to improve mental health outcomes for LGBTQIA+ young adults: Rationale and protocol for a randomised controlled trial.

BACKGROUND: Young adults who are lesbian, gay, bisexual, trans, queer or questioning, intersex, asexual and other diverse genders and sexualities (LGBTQIA+) are more likely to experience mental health difficulties and are at significantly elevated risk of substance abuse, self-harm and suicide, relative to their heterosexual, endosex and cisgender peers. There is a need for effective mental health interventions for LGBTQIA+ young adults. Mindful Self-Compassion training is a promising approach; among LGBTQIA+ individuals, self-compassion accounts for more variation in mental health outcomes than bullying, victimization, and adverse childhood experiences combined. Furthermore, LGBTQIA+ individuals with high self-compassion report more positive identity and happiness, less self-stigma, and lower suicidality than those with low self-compassion. METHOD: This paper outlines the rationale and protocol for a single-blind CONSORT-compliant randomised controlled trial, comparing group Mindful Self-Compassion to a delayed-treatment waitlist control group, for improving mental health, decreasing self-criticism and increasing self-compassion in LGBTQIA+ young adults (age 18-25 years). Mindful Self-Compassion training is an 8-week group program that focuses on cultivating self-compassion and mindfulness. While typically delivered as a face-to-face program, the proposed trial will investigate efficacy of the program when provided via videoconferencing. DISCUSSION: Videoconference Mindful Self-Compassion training has the potential to improve the mental health of Australian LGBTQIA+ young adults and provide a possible cost-effective, scalable intervention for this population. The proposed trial will be the first to determine its efficacy for LGBTQIA+ young adults and will provide the first data on the delivery of the program via videoconferencing.

The Perth Gender Picture (PGP): Young people's feedback about acceptability and usefulness of a new pictorial and narrative approach to gender identity assessment and exploration.

BACKGROUND: A number of psychological assessment tools have been developed to describe various dimensions of gender. Some of these tools are restricted to a binary gender concept and are inflexible in reflecting how a young person's gender may change and develop over time. Most are text questionnaires which require a good level of literacy. AIMS: This study aimed to evaluate a newly developed pictorial tool that facilitates a conversation about gender between a child or adolescent (aged 11-18) and their clinician, enabling a diverse understanding and expression of gender identity. METHODS: The Perth Gender Picture (PGP) was co-created between clinicians and young clients between 2016 and 2018. In 2018, the measure was evaluated through a pilot study at the Gender Diversity Service at Perth Children's Hospital in Western Australia. After use of the PGP during a clinical consultation, clients were invited to fill in a feedback questionnaire about their experience of its use. Clinicians participated in unstructured interviews to give their feedback. RESULTS: Most participants rated the PGP as easy to understand, acceptable and useful, and many stated that they found gender easier to describe with the picture rather than words. The results show positive uptake from clients, demonstrating feasible implementation with gender diverse young people. DISCUSSION: This evaluation positions the PGP as a useful tool to facilitate conversations about gender identity between gender diverse children and adolescents and their clinicians, in a nonjudgmental and playful manner. It is well-suited to young people who may have limited literacy or difficulty with complex language. The PGP has potential for use in other age groups and non-clinical contexts.