Bell v. Tavistock
The following is a summary overview of the holdings and findings of the High Court’s Judicial Review Hearing of the practices of the GIDS Tavistock Pediatric Gender Clinic with respect to the administration of puberty blockers to minors. The central question before the Court was whether minors may consent to the use of puberty blockers. The issue as to whether the minor’s parent may consent on their behalf was not before the Court and not adjudicated.
COURT’S CENTRAL HOLDING
Minors under 16 years of age are unlikely to be competent to consent to the use of puberty blockers.
The High Court based its holding on finding the following:
Treatment with Puberty Blockers is experimental due to a lack of evidence as to:
Short and long term consequences of taking them during normal puberty (PARA 71.)
Lack of effectiveness in treating Gender Dysphoria (PARA 73.)
Lack of clarity over the purpose of treatment to which the minor is supposedly consent.
(a) Is it a “pause to think” or
(b) A treatment to limit the effects of puberty
A. The use of puberty blockers is not neutral or a “pause.” Rather, they are part of a single seamless pathway of medical transition that involve significant and, in part, potentially irreversible long-term physical and psychological consequences beyond the competency of young people to comprehend and weigh.
98% of children put on puberty blockers go one to cross sex hormones and surgeries that significantly impact fertility and sexual function. (PARA 57.) The representation that puberty blockers are merely a safe and efficient means of pausing puberty while the minor assesses either their gender identity and/or medicalized transition is misleading and insufficient as to the nature of the treatment or its medical risks.
In 2009, 97 minors were referred to the clinic. In 2018, the number was 2519. In 2019 50% of children referred for puberty blockers were under the age of 16, with 17% being 13 years or younger. (The youngest being 10 years old.) In 2011, the gender split was 50/50. In 2019, 76% of referrals were females. A significant portion have a diagnosis of Autistic Spectrum Disorder.
There were no records of the proportion of referrals for puberty blockers with ASD or other mental health diagnosis. There were no records of minors who were found not competent to consent.
Tavistock obtained consent for the referral to an endocrinologist and the endocrinologist then obtained consent for the prescription. 98% of those referred for puberty blockers went onto cross sex hormones. (PARA 57.) This treatment must be maintained for the duration of the patient’s life.
B. LACK OF EVIDENCE – SAFETY AND EFFICACY
The representation that puberty blockers is a “safe reversible treatment with a well -established history” is misleading. There is only one study of the use puberty blockers during normally timed puberty, all others were for the treatment of precocious puberty which is completely different. (PARA 60). Further, there is genuine medical concern with respect to their long term impact on bone density, brain development and fertility. (PARA 62-63.) Further, the psychological and social effects of interrupting normally time puberty are not known. (PARA 64-67.)
C. LACK OF CLEAR PURPOSE FOR THEIR USE
In the late 1990s, puberty blockers were first used as part of what is referred to as the “Dutch Protocol” under which puberty suppression was to begin at age 12 after a diagnosis of Gender Dysphoria with cross sex hormones beginning at age 16 which induces something like the process of normal puberty for members of the opposite sex. This protocol was first published in 2006.
The stated purpose for the use of puberty blockers was to give the young person time to think about their identity in a “sex-hormone neutral environment” versus allowing subsequent cross-sex hormones without the need for surgeries to remove the unwanted effects of puberty in the birth gender.
D. PUBERTY BLOCKERS MAY INCREASE PERSISTENCE
In light of the ratio of 98% of minors who take puberty blockers go onto cross sex hormones (in contrast to the 60%- 90% who desist when no intervention undertaken), the question arises as to whether their use increases persistence. While the High Court recognized that the prior persistence ratios may be attributed to age and diagnosis differences, it noted that the lack of clarity demonstrates “the highly complex and unusual nature of this treatment and the great difficulty there is in fully understanding its implication for the individual young person.” (PARA 77.)
In other words, diagnosis and treatment with puberty blockers may solidify cross sex identification and lead a minor “to commit to cross sex reassignment more strongly than they would have done if there had been a different diagnosis and treatment.” (PARA 76.) “In short, the treatment may be supporting the persistence of GD in circumstances in which it is at least possible that without the treatment the GD would resolve itself.” (PARA 77.)
A. PUBERTY BLOCKERS ARE UNIQUE
Administration of puberty blockers to young people going through puberty is “unique”as a medical treatment. The clinical intervention of a treatment effecting the physical body to treat a condition that has no direct physical manifestation is different in kind to other treatments. In other cases, medical treatment is used to remedy, or alleviate the symptoms of, as diagnosed, a physical or mental condition and the effects of that treatment are direct and usually apparent.” (PARA 135.) Consequently, consenting to puberty blockers is unlike other situations where minors may consent to complex long lasting medical treatment.
B. USE OF PUBERTY BLOCKERS IS NOT NEUTRAL OR PAUSE
The use of puberty blockers is not a neutral process, but a confirmation of the child’s chosen gender identity and a stepping stone to cross sex hormones. Because 98% go onto use cross sex hormones, competency to consent to “reversible puberty blocker” is not adequate. In reality, puberty blockers are part of one clinical pathway and once on that pathway it is extremely rare for a child to get off it.
C. TREATMENT WITH PUBERTY BLOCKERS IS COMPLEX WITH PROFOUND PERMANENT EFFECTS
The purpose for the use of puberty blockers is not clear and leads to significant lifelong and life changing consequences in the “most fundamental way imaginable.” (PARA 134.) Treatment with them “goes to the heart of the individual’s identity.” (PARA 134.) “Apart perhaps from life-saving treatment, there will be no more profound medical decision for children than whether to start this treatment pathway.” (PARA 149.)
D. MOST YOUNG PEOPLE CARE NOT COMPETENT TO UNDERSTAND AND WEIGH THEIR RISKS AND IMPLICATIONS
The Court found that the risks and implications of using puberty blockers were too profound and complex for young people to understand and weigh. “You can not explain to many of these children what losing their fertility or full sexual function may mean to them in their later years.” (PARA144.) The problem is not the information given but the ability of young people to understand and weigh up the information. (PARA 150.)