High Court ruling that children should not be given puberty blockers: SSAUK statement

We welcome today’s landmark ruling on the case of Keira Bell and Mrs A versus The Tavistock and Portman NHS Foundation Trust, regarding whether or not children are able to give informed consent to “puberty blockers”.

The court found that “There will be enormous difficulties in a child under 16… deciding whether to consent to the use of puberty blocking medication”, and that “In respect of young persons aged 16 and over… we recognise that clinicians may well regard these as cases where the authorisation of the court should be sought.”

This has had an immediate effect, as the guidance used by GIDS (the Gender Identity Development Service at the Tavistock) now says “Patients under 16 years must not be referred… for puberty blockers unless a ‘best interests’ order has been made by the court.”

This is an excellent judgement. It is very thorough, sensitive and well thought through and we thank all the judges. We recommend it as essential reading for school leaders and all who work with children. Policies must now be revisited.

It is an important safeguarding principle that children must be protected and that there are some things they are unable to consent to. We hope that this judgement leads to a renewed focus on effectively safeguarding all children. Political ideology must never be allowed to override safeguarding in any of our institutions, particularly the NHS and Schools. We trust that this will now see the end to experimental use of puberty blockers on under 16’s and under 18’s without court oversight.

We agree wholeheartedly with the below findings of the court:

“It follows that to achieve Gillick competence the child or young person would have to understand not simply the implications of taking PBs (puberty blockers) but those of progressing to cross- sex hormones. The relevant information therefore that a child would have to understand, retain and weigh up in order to have the requisite competence in relation to PBs, would be as follows: (i) the immediate consequences of the treatment in physical and psychological terms; (ii) the fact that the vast majority of patients taking PBs go on to CSH (cross sex hormones) and therefore that s/he is on a pathway to much greater medical interventions; (iii) the relationship between taking CSH and subsequent surgery, with the implications of such surgery; (iv) the fact that CSH may well lead to a loss of fertility; (v) the impact of CSH on sexual function; (vi) the impact that taking this step on this treatment pathway may have on future and life-long relationships; (vii) the unknown physical consequences of taking PBs; and (viii) the fact that the evidence base for this treatment is as yet highly uncertain.

It will obviously be difficult for a child under 16 to understand and weigh up such information. Although a child may understand the concept of the loss of fertility for example, this is not the same as understanding how this will affect their adult life. A child’s attitude to having biological children and their understanding of what this really means, is likely to change between childhood and adulthood. For many children, certainly younger children, and some as young as 10 and just entering puberty, it will not be possible to conceptualise what not being able to give birth to children (or conceive children with their own sperm) would mean in adult life. Similarly, the meaning of sexual fulfilment, and what the implications of treatment may be for this in the future, will be impossible for many children to comprehend.”

Safe Schools Alliance believe it is totally unacceptable that puberty blockers have ever been prescribed to 10-year-olds. It clearly would never have been possible for any child of this age to give informed consent to the potential loss of fertility, to decide whether they did or didn’t want to attempt any “fertility preservation” and to evaluate “unknown risks associated with GnRHa treatment” such as “how hormone blockers will affect bone strength, the development of your sexual organs, body shape or your final adult height [or] other long-term effects of hormone blockers in early puberty that we don’t yet know about.” Contrary to the stated criteria for prescribing PBs used by the Trust, they certainly wouldn’t have been able to understand the implications of being “unable to have the typical sexual relationship of their identified gender with another person on account of their biological sex organ development” or to evaluate whether the fact that “the thought of sex disgusted them” as an child was a reliable indicator of how they would feel about it as adults.
If children of this age were to have enough knowledge of orgasm and sexual function to be Gillick competent in this respect, this would be a serious safeguarding concern.

Evidence was presented from trans-identified young people in support of giving puberty blockers to children, which we believe demonstrates that it is just not possible for children to make these type of lifelong decisions.

“It was a difficult decision to make because I did not know whether I would want biological children in adulthood, but I was certain I would never want to carry a child and give birth. Ultimately, I made the decision because I had a poor quality of life and without immediate treatment I did not feel I had a future at all… We discussed sex and I told them the idea of it disgusted me. I knew I would be unable to consider having a sexual relationship as an adult with my body so wrongly formed.”

‘J’, who received puberty blockers at the age of 12

“I haven’t really thought about parenthood – I have been asked about it by the gender identity specialist I have mentioned but I just have no idea what me in the future is going to think. I haven’t had a romantic relationship and it’s just not a thing that is really on my radar at the moment.”

‘S’, a 13-year-old treated by a GP at GenderGP who has since been removed from the professional register

We agree with all that Professor Scott (Director of University College London’s Institute of Cognitive Neuroscience) has said in this judgment about the ability of under 18’s to consent to this type of “treatment”.

We are disturbed by the comment that “GIDS takes referrals from across England and Wales and from a wide range of professionals in the health, social services and education sectors, and the voluntary sectors.” We do not believe referrals should have been made by people acting on political ideology and not medical training.

We are shocked to hear that “As at November 2019 the waiting time for a first assessment at GIDS was between 22- 26 months.” This is an unacceptable waiting time for children suffering from gender dysphoria or any other type of mental distress. Timely support and counselling must be made available for these vulnerable children and their families. It is particularly concerning if, during this waiting time, children have been socially transitioned by parents and/or teachers. Affirmation is a form of treatment that parents and teachers are not qualified to prescribe.

The judgment notes that “Dr Carmichael said that during assessments young persons will be asked, for example, about: the onset of their gender dysphoria; the consistency of their feelings about their gender; how they identify (cross-gender, non-binary, etc); their relationships with peers and family members; their social functioning in general, thoughts about or experience of puberty; their relationship to their bodies; their attractions or romantic relationships as appropriate based on their age and maturity; and their hopes and expectations for the future.” This does not strike us as a thorough assessment of what else may be going on in a child’s life. It seems to start from the assumption that the child DOES have gender dysphoria: in particular, there is no indication here that GIDS explore what a child or their family may have been looking at online. We consider this a serious oversight.

The court has noted “we find it surprising that such data was not collated in previous years given the young age of the patient group, the experimental nature of the treatment and the profound impact that it has.”
We view it as nothing short of negligence that children as young as ten years old have been subjected to experimental treatment over a period of nine years and yet there has been insufficient collection of data and no results of this experimentation have been published.

The exponential rise of referrals from 97 in 2009 to 2519 in 2018 is indicative to us of social contagion. We hope that there are answers from the upcoming Cass review. There are many questions to be answered:
How did the experimentation starting in 2011 affect these figures? How did referrals being taken from lay individuals affect these figures? What was Mermaids’ influence here? What was the influence of Stonewall and other organisations producing school materials on ‘gender identity’? What was the influence of social media? Of YouTube? Of the BBC broadcasting ‘I am Leo’ and other programs? What is behind the massive increase in the percentage of girls referred? Has the overwhelming sexism and sexual assault/harassment girls are subjected to in schools and online had any influence here? Why are children with ASD over-represented? Is there enough support for these children and their families in schools and wider society?

The court would appear to share our concerns, noting that “we have found this lack of data analysis – and the apparent lack of investigation of this issue – surprising”.

We find it astonishing that the Tavistock only adopted a standard operating procedure for the taking of consent on 31 January 2020, when they have been carrying out this experimental treatment since at least 2011. This suggests to us that many children have been treated without informed consent being adequately obtained. It is commented that “The court gained the strong impression from the evidence and from those submissions that it was extremely unusual for either GIDS or the Trusts to refuse to give PBs on the ground that the young person was not competent to give consent.”

Professor Butler of University College Hospital (witness for the defence) is recorded as saying that his clinic “has never sought to apply to the Court under its inherent jurisdiction ‘against’ parental opinions because he is concerned that would cause familial frictions” and that “it would also increase the distress suffered by the young people themselves, finding that their right to autonomous decision making had been removed from them.” This demonstrates a shocking lack of understanding of his responsibility to safeguard the children under his care. We have previously heard from whistle-blowers at the Tavistock of their concerns with regards to children who appeared to be transitioning due to parental homophobia, internal homophobia or homophobic bullying, who were on the autistic spectrum and/or suffering from undiagnosed trauma and abuse.

Schools must take heed of this judgement. They cannot continue with policies to affirm a child’s ‘gender identity’. Affirmation puts a child on the path to puberty blockers, and “The evidence shows that the vast majority of children who take PBs move on to take cross-sex hormones, that (these) are two stages of one clinical pathway and once on that pathway it is extremely rare for a child to get off it.” The judgment also notes that “CSH are to a very significant degree not reversible.”

Schools and others who are not qualified psychologists must not start children on this irreversible journey, armed only with misinformation from political lobby groups and a misguided sense of ‘kindness’ and ‘inclusion’. Everybody must remember the principle of ‘First do no harm’.

Finally, we note that the court refers to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in this ruling:
“Gender dysphoria is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) which provides for one overarching diagnosis of gender dysphoria with separate specific criteria for children and for adolescents and adults…In children, gender dysphoria diagnosis involves at least six of the following and an associated significant distress or impairment in function, lasting at least six months:

• 1. A strong desire to be of the other gender or an insistence that one is the other gender.
• 2. A strong preference for wearing clothes typical of the other gender
• 3. A strong preference for cross-gender roles in make-believe play or fantasy play
• 4. A strong preference for toys, games or activities stereotypically used or engaged in by the other gender
• 5. A strong preference for playmates of the other gender
• 6. A strong rejection of toys, games and activities typical of one’s assigned gender
• 7. A strong dislike of one’s sexual anatomy
• 8. A strong desire for the physical sex characteristics that match one’s experienced gender.”

Safe Schools Alliance consider criteria 2 – 6 to be regressive and sexist. They reinforce gender stereotypes, which harm all children, and they conflict with the latest Department for Education guidance. We also believe they will disproportionately impact on those children who will grow up to be Lesbian, Gay or Bisexual.
We would consider point 7 to be a safeguarding flag, potentially indicative of child sexual abuse/exploitation or other trauma.

We suggest that this diagnostic tool should itself be reviewed.