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A landmark high court ruling has focused the spotlight on the work of the Gender Identity Development Service for Children and Adolescents (GIDS) at the Tavistock and Portman NHS Trust in London.
The highly anticipated ruling on Tuesday involved legal action taken by 23-year-old Keira Bell against the service, the only one of its kind for England and Wales.
Bell, a former patient, said she was too young to consent to GIDS-supervised medical treatment which began her transition from woman to man as a teenager.
In a 36-page ruling, the court concluded that children under the age of 16 considering gender change are unlikely to be mature enough to give informed consent for prescribing drugs to block puberty, effectively limiting medical intervention for children under 16 with gender dysphoria.
“There will be enormous difficulty for a child under 16 to understand and evaluate this information and decide whether to consent to the use of drugs that stop puberty,” the ruling said.
“It is highly unlikely that a child 13 years of age or younger will be competent to consent to the administration of puberty blockers. It is doubtful that a 14 or 15-year-old child can understand and evaluate the risks and long-term consequences of administering puberty blockers. “
The decision was hailed by some as a victory for common sense and safeguarding, and by others condemned because it has a chilling effect on the rights of trans youth.
The UK National Health Service said any future medical intervention for children under 16 would only be permitted “if specifically authorized by a court”.
In recent years, GIDS has come under extensive scrutiny, with some former staff members and activists raising concerns about the “overdiagnosis” of gender dysphoria, the consequences of early medical interventions, and the significant increase in referrals of girls who question their gender identity.
In a series of interviews with GIDS and Glasgow’s Sandyford Clinic, Scotland’s only provider of gendered services for children and young people, doctors gave the Guardian an overview of treatment pathways, while former staff shared their experiences.
The high court ruling found particular concerns about the use of puberty blockers, which he believes could be “adequately described as an experimental treatment” with “limited evidence of efficacy or long-term effects”.
Between March 4, 2019 and March 1, 2020, GIDS referred 171 young people to endocrinology, the first step before any medical intervention. Of these, 60 were male and 111 female, their average age was over 15, and they had an average of 10 appointments before this happened.
GIDS emphasizes that its entire process is geared towards giving young people time for reflection. He says that while some young people will arrive with a specific medical intervention in mind, others will be much more uncertain, benefiting from exploratory sessions, conducted with and without parents.
A care plan is then produced, which for the most part will involve further evaluation, perhaps with a request for help from local services or the school. Prior to the high court ruling, a minority who had started puberty were recommended hormone blockers, which arrest puberty, often a source of great distress for transgender teens.
A separate evaluation and consent process was required before any patient switched to cross sex hormones, which aim to more closely align secondary sexual characteristics with gender identity and which were available around 16 years of age and after a year with blockers. GIDS does not offer surgery.
Both GIDS and the Sandyford Clinic have seen an increase in referrals of teenage girls over the past decade, a trend reflected in Europe and around the world.
GIDS specialists say the increase should be kept in perspective – only one in 10,000 young people go to the highly skilled service – and that an over-representation of girls could equally well be an under-representation of boys, for whom compliance tends to be monitored more aggressively by peers.
For some girls – who enter puberty earlier and are more sexualized by society and more aware of the pressure to have “the perfect body” – the service helps them explore ways to become more acceptable to their changing body.
Only a small percentage of those seen at GIDS access medical care while on duty.
But critics believe this amounts to medicalizing what is essentially a crisis at the onset of female puberty.
These critics believe there is evidence that vulnerable young people – many of whom are gay and have homophobic parents or are bullied in school, have autism or have experienced childhood abuse – are convinced that changing sex will solve their problems and that children professionals are afraid of censorship if they challenge it.
The Supreme Court itself has been critical of what it called the Tavistock’s “surprising” lack of investigation into the rise in referrals of girls and those with autism spectrum disorder.
Sources in Sandyford insist that they do not see an over-representation of young lesbians and gays, nor a large percentage of girls who have been sexually abused or people with homophobic parents who try to “correct” their children’s sexuality.
They say there is an over-representation of young people on the autism spectrum, but beware that there are already high rates of sexuality concerns within that population, caused by very rigid thinking in terms of self-definition.
There are individual stories of troubled girls trying to escape their abuse by identifying as boys, or parents pushing their children down the transitional path due to anxiety or misunderstanding, but these are the exception.
One doctor suggests that a referral to Sandyford often allows very confused youngsters and anxious parents a chance to consider what truly worries them with a variety of professionals.
These professionals can often “inject a sense of reality” into the theories and ideas that patients have read about online that seem to them to be a quick fix to their problems.
A former psychiatrist and psychotherapist consultant who has worked with the Tavistock Adult Service and GIDS expressed concern that the “very affirmative” approach risked medicalizing behavior that might otherwise be understood as a young person’s normal need. to separate from their parents and express their individuality, perhaps through belonging to a subculture.
He reported that in his current private work with older teens and young adults who express similar concerns, it was possible to help them overcome their gender conflict through exploratory therapy that was neither “affirmative” nor attempting to be “corrective” .
Transgender teens introduced to the Guardian by Mermaids – a charity that provides support to transgender or gender-nonconforming children, including those undergoing medical interventions – overwhelmingly report frustration with long waiting times for initial appointments (an average of 18 months according to GIDS); some have turned to private professionals in the meantime. Last month, the Good Law Project filed a lawsuit against NHS England for these waiting times.
“People who say the process is too fast just don’t understand. Getting medical attention is like winning the lottery, ”said 18-year-old Dylan, who added that he was“ deeply saddened ”by the Bell ruling.
“It is really important that people realize that this is not a choice. The media talks about children being “brainwashed” or “accelerated”, or that young people want to be trans because it’s a trend. Yes, there are some guys who are confused about the gender or get into the labels, but if dysphoria occurs it’s different. “
It is an opinion shared by Alex, also 18, who says he is “terrified that this judgment will condemn young trans girls to years of excruciating puberty, causing unmanageable levels of dysphoria and distress.”
Alex was referred to GIDS six years ago and had 18 months of regular sessions before he was prescribed hormone blockers. While she described this waiting as “the worst part” of her treatment so far, she added, “It’s a complete process, and I accept it has to be. They separate what you say, but it’s good therapy.”
He started taking testosterone two years ago and said, “I’m mostly at a point where being trans doesn’t matter – I finally feel like the real me, and I feel normal now that’s the goal. happy.”
The Tavistock asks for permission to appeal against Tuesday’s ruling.
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