Gender clinic bid to overturn ruling over puberty-blocking treatments

NHS gender clinic WNS bid to overturn landmark High Court ruling over the use of life-changing puberty-blocking treatments for children with gender dysphoria

  • The Tavistock and Portman NHS Foundation Trust won a bid to overturn a ruling
  • It was ruled it was ‘unlikely’ 13-year-old could consent to puberty-blocking drugs
  • But the NHS Trust brought an appeal against last year’s High Court ruling in June
  • Now, Court of Appeal said it was inappropriate for High Court to give guidance

An NHS gender clinic has won a Court of Appeal bid to overturn a landmark ruling over the use of puberty-blocking drugs for children with gender dysphoria.

The High Court previously ruled that children under 16 with gender dysphoria can only consent to the use of hormone-blocking treatments if they can understand the ‘immediate and long-term consequences’. 

The judges said it was ‘highly unlikely’ that a child aged 13 or under would be able to consent to the treatment, and that it was ‘doubtful’ that a child of 14 or 15 would understand the consequences. 

But the Tavistock and Portman NHS Foundation Trust, which runs the UK’s only gender identity development service for children, brought an appeal against the ruling in June.

In a judgment on Friday, the Court of Appeal said it was inappropriate for the High Court to give the guidance, finding doctors should instead exercise judgment about whether their patients can properly consent.

The original case was brought by Keira Bell – a 24-year-old woman who began taking puberty blockers when she was 16 before later ‘detransitioning’ – against the Tavistock and Portman NHS Foundation Trust, which runs the UK’s only gender identity development service for children.

High Court ruled it was ‘unlikely’ a child aged 13 or under could consent to puberty-blocking treatment. But the Tavistock and Portman NHS Foundation Trust (pictured) brought an appeal

A mother of an autistic teenager who is on the waiting list for treatment, only known as Mrs A, supported Ms Bell in their successful legal challenge. 

Hormone, or ‘puberty’, blockers pause the physical changes of puberty, such as breast development or facial hair.

In Friday’s ruling, the Lord Chief Justice Lord Burnett, with Sir Geoffrey Vos and Lady Justice King, said: ‘The court was not in a position to generalise about the capability of persons of different ages to understand what is necessary for them to be competent to consent to the administration of puberty blockers.’

They added: ‘It placed patients, parents and clinicians in a very difficult position.’

During the two-day appeal earlier this year, Tavistock’s lawyers argued the ruling was ‘inconsistent’ with a long-standing concept that young people may be able to consent to their own medical treatment, following an appeal over access to the contraceptive pill for under 16s in the 1980s.

But Jeremy Hyam QC, representing Ms Bell and Mrs A, argued procedures at the Tavistock ‘as a whole failed to ensure, or were insufficient to ensure, proper consent was being given by children who commenced on puberty blockers’.

The chief executive of LGBT charity Stonewall has welcomed the Court of Appeal’s ruling.

The case was brought by Keira Bell (pictured), a woman who began taking puberty blockers when she was 16 before ‘de-transitioning’, and mother of a teenager who is on the waiting list

Nancy Kelley said: ‘We’re extremely pleased to hear that the Tavistock has won its appeal in the Bell v Tavistock case. 

‘Today’s outcome will be a huge relief for trans young people and their families, as well as the wider trans community. 

‘This deeply unsettling case has caused many trans young people and their families enormous distress by adding to waiting lists that were already out of control and leaving young people in limbo without vital healthcare support. 

‘Now the NHS must publish updated guidance for young people relying on these services with as much urgency as they suspended treatment access after the previous ruling. 

What are puberty blockers and how can children transition gender? 

If a child is under 18 and may have gender dysphoria, they’ll usually be referred to the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust.

GIDS has 2 main clinics in London and Leeds.

The team will carry out a detailed assessment, usually over 3 to 6 appointments over a period of several months.

Young people with lasting signs of gender dysphoria may be referred to a hormone specialist (consultant endocrinologist) to see if they can take hormone blockers as they reach puberty. 

These hormone, or ‘puberty’ blockers (gonadotrophin-releasing hormone analogues) pause the physical changes of puberty, such as breast development or facial hair.

Little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria.

Although the Gender Identity Development Service (GIDS) advises this is a physically reversible treatment if stopped, it is not known what the psychological effects may be.

It’s also not known whether hormone blockers affect the development of the teenage brain or children’s bones. Side effects may also include hot flushes, fatigue and mood alterations.

From the age of 16, teenagers who’ve been on hormone blockers for at least 12 months may be given cross-sex hormones, also known as gender-affirming hormones.

These hormones cause some irreversible changes, such as breast development and breaking or deepening of the voice.

Long-term cross-sex hormone treatment may cause temporary or even permanent infertility.

Source: NHS 

‘This judgment must be a turning point for NHS and the Government in addressing trans people’s healthcare. 

‘It is time that the NHS and Department for Health take urgent action to address the unacceptable waiting lists facing trans young people, and ensure that all trans and questioning young people can get high-quality care, when they need it.’ 

Following the ruling on puberty-blocking drugs for children with gender dysphoria, Keira Bell, said she was ‘surprised and disappointed’ in the decision but said she had no regrets in bringing the case.

Adding that she believed the medical service had become ‘politicised’, Ms Bell said she will be seeking permission to appeal to the Supreme Court.

She said: ‘I am obviously disappointed with the ruling of the court today and especially that it did not grapple with the significant risk of harm that children are exposed to by being given powerful experimental drugs. 

‘I am surprised and disappointed that the court was not concerned that children as young as 10 have been put on a pathway to sterilisation.’ 

‘It has shone a light into the dark corners of a medical scandal that is harming children and harmed me,’ she continued. 

Ms Bell also said: ‘A global conversation has begun and has been shaped by this case. There is more to be done. 

‘It is a fantasy and deeply concerning that any doctor could believe a 10-year-old could consent to the loss of their fertility.’ 

Adding that she believed the medical service had become ‘politicised’, Ms Bell said she will be seeking permission to appeal to the Supreme Court.

After the ruling, a Tavistock and Portman NHS Foundation Trust spokesperson said: ‘We welcome the Court of Appeal’s judgment on behalf of the young people who require the GIDS (Gender Identity Development Service), and our dedicated staff.

‘We recognise the work we do is complex and, working with our partners, we are committed to continue to improve the quality of care and decision making for our patients and to strengthen the evidence base in this developing area of care.’ 

An NHS spokesperson said: ‘The NHS commissioned Dr Hilary Cass to review gender identity services prior to the original High Court ruling to ensure the best model of safe and effective care is delivered – this will set out wide-ranging recommendations, including on the use of puberty blockers and the many contested clinical issues identified by the court.

‘An independent multi-professional review group will continue to confirm whether clinical decision making has followed a robust consent process now that the endocrine pathway has been reopened by the Tavistock.’

Human rights group Liberty, which intervened in the appeal, said the High Court had imposed a serious restriction on the rights of transgender children and young people to ‘essential treatment’.

Liberty director Gracie Bradley said: ‘This ruling is a positive step forwards for trans rights in the UK and around the world.

‘As the court has recognised, trans children should be able to choose and receive the healthcare they need on the same basis as all other children. 

‘Access to treatment is life-affirming for trans children and young people – without it the risk of serious, long-term harm dramatically increases. 

In a judgment on Friday, the Court of Appeal said it was inappropriate for the High Court to give the guidance. Pictured: Supporters of Gendered Intelligence at the Royal Court of Justice

‘This case has implications for trans children not just in the UK, but also all over the world. Other countries had already started using the UK ruling to restrict trans rights – now they must take note of this judgment, too. 

‘Liberty has a long and proud history of standing up for trans rights and we will keep working with others to build a society where trans rights are recognised as human rights.’ 

The Court of Appeal heard the Tavistock does not provide puberty blockers itself but instead makes referrals to two other NHS trusts – University College London Hospitals and Leeds Teaching Hospitals – who then prescribe the treatments.

John McKendrick QC, for the other trusts, told the court the median age for consenting to puberty blockers is 14.6 for UCL and 15.9 for Leeds. 

According to the World Professional Association for Transgender Health (WPATH) guidelines, very few people regret treatment of their gender dysphoria, the court heard. 

‘They refer to satisfaction rates across studies ranging from 87% in male to female patients and 97% of female to male patients and regrets were extremely rare,’ Fenella Morris QC, for the trust previously said in court.

Ms Bell’s lawyers previously argued there is ‘a very high likelihood’ that children who start taking hormone blockers will later begin taking cross-sex hormones, which they say cause ‘irreversible changes’.

But the Court of Appeal previously heard it is not inevitable that a young person will move from puberty blockers to cross-sex hormones – which will only be prescribed to those over 16 – with even fewer going on to have surgery.

Ms Morris later said that puberty blockers are said to be ‘fully reversible’ in international guidelines relied upon by the trust.

She added that children or young people who are considering going on to puberty blockers are told about the effects on their fertility that may be caused by later stages of transition.

Highlighting that it is not inevitable that a young person will continue on to cross-sex hormones after puberty blockers, she added: ‘The question is whether a child is counselled about fertility implications at the next stage and you can see from the material … all of that is explained at the initial stage.

‘There is no suggestion anywhere that this is one pathway … there is no shying away from explaining to children and young people what the possibilities are.’

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