British High Court Rules on Puberty Blockers in Trans Kids

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In a landmark legal decision today, the United Kingdom’s High Court ruled that British children under the age of sixteen are unable to consent to treatment with puberty blocking medications. This case was brought by an individual, Keira Bell, and the mother of a teenager with autism. Keira had undergone treatment at Tavistock and Portman NHS Trust, a facility in Britain which provided treatment to children and adolescents who presented with gender dysphoria.

This ruling is likely to trigger substantial controversy and have complex impact on the treatment of children and adolescents with gender dysphoria. I expect that we will see very challenging exploration of the ruling over coming months. The ruling is long, and contains a great many substantial findings which will be unpacked in the future. For instance, the Court raised great concern over the fact that the clinic had failed to publish any data or research on their treatments, in the nine years they’ve been providing puberty blocking medications to children. Further, the Court’s ruling noted that there was substantially little attention given to the tremendous shift in the number of female children versus male children who presented for treatment (worldwide, there has been a shift, where far more females are now identifying as experiencing gender dysphoria, compared to males). The Court also expressed dismay that remarkably little attention given to the special needs and circumstances of children and adolescents with autism who sought treatment for gender dysphoria. Given the potential impact of autism on a minor’s ability to consent to medical treatment, the Court implied that there was concern that it appeared that all children who sought puberty blocking medication were automatically deemed competent to consent.

The Court’s ruling on the competence of minors under sixteen to consent to puberty blocker medication treatment hinged on a few sophisticated and insightful points. First, while puberty blocking medications have historically been presented as “totally reversible” treatment, the Court noted that this view is based on the use of these medications in children as young as 7 or 8, who experience “precocious puberty,” and NOT on children as old as 10 or 13, who might be on these medications for as long as five years. Thus, these medications may have lifelong impact (to bone density, future fertility and brain development) that is not reversible, when administered over a long period during the adolescent years.

Secondly, the Court pointed out that while puberty blocking medications were presented as a means to allow young people to have the time to “figure out” their gender preferences, that these medications were actually being used in a different manner. Puberty blockers were also used as an intentional means to prevent the child’s body from becoming feminized or masculinized from the effects of puberty, such that when the child reached the age to consent to hormone and/or surgical treatments, that their body would not have gone through physiological transitions that would hinder such treatments. In other words, the Court’s ruling suggests that puberty blockers were being used as Stage One of a multi-stage treatment process for gender transition, not merely as a means to “buy time.” In support of this view, the Court noted that essentially all children who were started on puberty blockers went on to later pursue further hormonal treatments, and the Court suggested that puberty blocking medications may actually be serving to create persistence of gender dysphoria, in contrast to the oft-uttered claims that these medications allow children the time to best decide their future courses.

The Court was appropriately careful not to step into questions of whether gender dysphoria in children and adolescents is real, or the relation of it to gender dysphoria in adults. They also did not rule on whether these treatments were medically appropriate. But, they did rule that because puberty blocking medications are being used in a manner that does appear to have lifelong impact, that children under sixteen are likely unable to fully understand how starting puberty blockers would impact their later decision to begin further treatments. Because such medications appear highly likely to have substantial impact on a child’s future ability to have children of their own, the Court expressed that it was almost impossible for a child to consent to such treatment, based on their limited understanding of their future adult desire to have children or not.

The future impact this ruling will have on legal and clinical matters in other parts of the world is unclear. It seems likely that this ruling will reverberate, and raise a great many very real and complex questions for the treatment of children and adolescents with gender dysphoria. However, it’s my opinion that the Court’s clarification of how puberty blocking medications actually are being used, and what the impact of them is, may have the greatest impact on future treatment and informed consent. Children and adolescents who experience gender dysphoria absolutely deserve the highest levels of compassion, acceptance and effective, evidence-based support. I fear that this ruling may lead to trans-identified children, adolescents and adults experiencing that it is harder for them to get the response that they want and deserve.

Over recent years, the use of puberty blockers has become an accepted, low-bar initial treatment intervention. As a result, parents and young people now expect and request them. Unfortunately, therapists, endocrinologists and physicians must now wrestle with the fact that puberty blocker medications do more than just buy time, but actually do have very significant long-term influence on future decisions and future lives. These long-term effects must be explained to patients. This is the essence of informed consent, an ethical requirement for all clinicians. Unfortunately, the High Court suggested that just "giving more information" to these children was unlikely to truly reach informed consent, due to developmental abilities to make decisions about far future possibilities. The playing field for informed consent for treating children with gender dysphoria just changed radically, and it remains to be seen how this will be incorporated into treatment protocols.