NHS gender clinic argues ban on puberty blockers 'undermines' rights

NHS child gender clinic argues ban on puberty blockers ‘undermines’ young people’s rights as it battles to overturn landmark decision that ruled under 16-year-olds can’t grasp the ‘long-term consequences’ of treatment

  • High Court ruled that under 16s can’t understand puberty blocker consequences
  • Tavistock and Portman NHS Trust, UK’s only child gender clinic, appealed ruling
  • It told court today that December’s ruling ‘undermined’ rights of young people 
  • Keira Bell began taking puberty blockers when she was 16 before detransitioning
  • 23-year-old brought legal action against the Tavistock and Portman NHS Trust  

A landmark ruling on the use of puberty-blocking drugs for children ‘undermined’ their rights dating back decades, the NHS’s child gender clinic argued at the Court of Appeal today.

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

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

The 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 Trust, which runs the UK’s only gender identity development service for children.

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

Tavistock began its appeal against the ruling on Wednesday and Fenella Morris QC, for the trust, said the decision ‘reset almost half a century of established law’ and caused ‘serious distress to many young people and their families’.

The Tavistock and Portman NHS Trust (file picture) runs the UK’s first gender clinic in London

Keira Bell outside the Royal Courts of Justice in central London after December’s ruling. The 23-year-old, who began taking puberty blockers when she was 16 before ‘detransitioning’, brought legal action against the Tavistock and Portman NHS Trust

In written arguments, she said: ‘The effect of the court’s judgment is to deny trans children and young people access to treatment which they desperately want and need. It is unclear what ‘benefit’ there is to be gained from this.’

She continued: ‘It undermined the entitlement of children under the age of 16 to make decisions for themselves when they have been assessed individually as competent to do so by their treating clinicians. 

‘It intruded into the realm of decisions agreed upon by doctors, patients and their parents where the court had not previously gone.’ 

In the wake of December’s judgment, the Tavistock paused new referrals to endocrinology services.

The barrister told the Court of Appeal that the ruling challenged the established rights of children and young people to make informed decisions regarding their medical treatment.

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 

She said: ‘The courts have recognised since the 1950s that a child who is capable of appreciating fully the nature and consequences of a particular operation or of particular treatment can give an effective consent.’ 

LGBT campaigners raised concerns about all young people’s access to other forms of healthcare, including contraception, after the judgment.

The Tavistock’s lawyers said 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.

Ms Morris said: ‘It will be appreciated that there were in 1986 both known and unknown risks inherent in the use of the contraceptive pill, far greater than any physical risks that are known to be inherent in the prescription of puberty blockers which have been in use for a far longer period of time.’

The three High Court judges also said in December that children and young people wishing to start puberty blockers would also have to understand the implications of taking cross-sex hormones.

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’.

However, the Court of Appeal heard that it was not inevitable that a young person would 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 argued the judgment ‘saw fit to prescribe a one-size-fits-all checklist of relevant information that the child or young person would have to understand. This was wrong’.

She continued that there is no clinical evidence that puberty blockers have irreversible effects on fertility or sexual functioning.

In the previous judgment, the High Court said the use of hormone blockers was ‘innovative and experimental’.

This was rejected by Ms Morris, who said the treatment had been in ‘mainstream usage for decades’, including to treat early puberty.

She added: ‘The use of puberty blockers in precocious puberty and in the treatment of gender dysphoria is the same. The conditions which the drugs are used to treat are different, but the way in which the drugs are used and their purpose is identical.’  

She also told the court that puberty blockers were prescribed ‘to reduce distress’ for children with gender dysphoria, allowing them to make decisions in the future.

She continued: ‘Then, having reduced that distress, it creates the possibility to take time to consider options … it allows the child to make the choice.’

She added: ‘Not providing treatment means that the child remains in a position of distress and difficulties in making choices about what to do next.’

Ms Morris said that puberty blockers are deemed fully reversible in international guidelines.

She later told the Court of Appeal that children or young people who may go onto puberty blockers are told about the potential implications on their fertility from later stages of transition.

Miss Bell (pictured as a five-year-old) had treatment which began at the Tavistock in London

Miss Bell (pictured left, and right as a man), took testosterone, which left her with a deep voice and possibly infertile, and had a double mastectomy – but later realised she had ‘gone down the wrong path’. Right, She changed her name and sex on her driving licence and birth certificate, calling herself Quincy (after musician Quincy Jones)

The barrister said that while puberty blockers are reversible and that it is not inevitable that a young person will go onto cross sex hormones at a later stage, they are still advised at the early stage.

She said: ‘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.’

Jeremy Hyam QC, for Ms Bell and Mrs A, argued the appeal should fail as it did not find any ‘material errors’ in the original ruling.

In written arguments, he said: ‘There is no proper basis for overturning these findings, which were reached by a highly experienced court after careful consideration of a significant body of evidence.’

He added: ‘The need for a child to understand, retain and weigh up the salient facts is all the more important because, unlike life-saving cancer treatment, there is much uncertainty as to what the benefits of puberty blockers actually are.’

The hearing before the Lord Chief Justice Lord Burnett – sitting with Sir Geoffrey Vos and Lady Justice King – is expected to last two days with judgment at a later date. 

Speaking outside the Royal Courts of Justice at the start of the NHS trust’s appeal on Wednesday, Ms Bell said: ‘I’m always hopeful, but the result could go any way.’

She added: ‘It’s a global case … it’s definitely had a big impact.’

Discussing the previous judgment, Ms Bell said: ‘It makes me feel very positive because it has been recognised around the world and people are becoming more and more aware of what’s going on.’

Later asked about puberty blockers, she added: ‘Children can’t consent to it … it has complex repercussions that children can’t understand.’ 

Nine organisations or individuals – including human rights group Liberty and professional body The Endocrine Society – have intervened in the case.

Liberty director Gracie Bradley said: ‘Liberty has a long and proud history of standing up for trans rights – and today is no different. This case has implications for trans children not just in the UK, but also all over the world.

‘Other countries have already started using the UK ruling to restrict trans rights – we now have a chance to stop that.

‘This case could also impact the ability of all children and young people to choose and receive healthcare – something which would be a regressive step that any rights’ respecting society should be loudly and fiercely rejecting.’ 

Why did the NHS let me change sex? Keira Bell tells her story in the hope that it will ‘serve as a warning to others’

IT engineer Miss Bell is pictured outside the Royal Courts of Justice in London in January

In an interview earlier this year, Keira told the Daily Mail what happened to her, in order to highlight her plight and, she says, serve as a warning to others. 

Keira was brought up in Hertfordshire, with two younger sisters, by her single mother, as her parents had divorced. Her father, who served in the U.S. military in Britain and has since settled here, lived a few miles away.

She was always a tomboy, she said. She did not like wearing skirts, and can still vividly remember two occasions when she was forced by her family to go out in a dress.

She told the Daily Mail: ‘At 14, I was pitched a question by my mother, about me being such a tomboy. She asked me if I was a lesbian, so I said no. She asked me if I wanted to be a boy and I said no, too.’

But the question set Keira thinking that she might be what was then called transsexual, and today is known as transgender.

‘The idea was disgusting to me,’ she tells me. ‘Wanting to change sex was not glorified as it is now. It was still relatively unknown. Yet the idea stuck in my mind and it didn’t go away.’

Keira’s road to the invasive treatment she blames for blighting her life, began after she started to persistently play truant at school. An odd one out, she insisted on wearing trousers — most female pupils there chose skirts — and rarely had friends of either sex.

When she continually refused to turn up at class as a result of bullying, she was referred to a therapist.

She told him of her thoughts that she wanted to be a boy.

Very soon, she was referred to her local doctor who, in turn, sent her to the child and adolescent mental health service (CAMHS) near her home. From there, because of her belief that she was born in the wrong body, she was given treatment at the Tavistock 

Keira had entered puberty and her periods had begun. ‘The Tavistock gave me hormone blockers to stop my female development. It was like turning off a tap,’ she says.

‘I had symptoms similar to the menopause when a woman’s hormones drop. I had hot flushes, I found it difficult to sleep, my sex drive disappeared. I was given calcium tablets because my bones weakened.’

Keira claims she was not warned by the Tavistock therapists of the dreadful symptoms ahead.

Her breasts, which she had been binding with a cloth she bought from a transgender internet site, did not instantly disappear. ‘I was in nowhere land,’ she says.

Yet back she went to the Tavistock, where tests were run to see if she was ready for the next stage of her treatment after nearly a year on blockers. 

A few months later, she noticed the first wispy hairs growing on her chin. At last something was happening. Keira was pleased.

She was referred to the Gender Identity Clinic in West London, which treats adults planning to change sex.

After getting two ‘opinions’ from experts there, she was sent to a hospital in Brighton, East Sussex, for a double mastectomy, aged 20. 

By now, she had a full beard, her sex drive returned, and her voice was deep.

After her breasts were removed, she began to have doubts about becoming a boy.

Despite her doubts, she pressed on. She changed her name and sex on her driving licence and birth certificate, calling herself Quincy (after musician Quincy Jones) as she liked the sound of it. She also altered her name by deed poll, and got a government-authorised Gender Recognition Certificate making her officially male. 

In January last year, soon after her 22nd birthday, she had her final testosterone injection. 

But, after years of having hormones pumped into your body, the clock is not easily turned back. It is true that her periods returned and she slowly began to regain a more feminine figure around her hips. Yet her beard still grows.

‘I don’t know if I will ever really look like a woman again,’ she said. ‘I feel I was a guinea pig at the Tavistock, and I don’t think anyone knows what will happen to my body in the future.’ 

Even the question of whether she will be able to have children is in doubt.

She has started buying women’s clothes and using female toilets again, but says: ‘I worry about it every time in case women think I am a man. I get nervous. I have short hair but I am growing it and, perhaps, that will make a difference.’ 

By law she is male, and she faces the bureaucratic nightmare of changing official paperwork back to say she is female.

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