Britain’s only NHS gender clinic for children has suspended referrals for hormone therapy after a ruling on the experimental use of puberty blockers.
Judges at the High Court found it was “highly unlikely” that 13-year-olds, and “doubtful” that anyone aged 14 or 15, would understand the full implications of the hormone treatments, and therefore could not give informed consent.
In almost all cases people who take puberty blockers go on to take cross-sex hormones, which may lead to life-changing consequences, such as loss of fertility and impaired sexual function.
Keira Bell, 23, a woman who regrets starting puberty blockers at the age of 16, brought the legal action against the Tavistock and Portman NHS Trust, which runs the country’s only gender identity development service (GIDS) for children.
The clinic, also known as the Tavistock, has been prescribing them to under-16s since 2011. The drugs are not licensed for gender dysphoria in the UK and there is little evidence of their long-term safety in this context.
The High Court also recommended that doctors should not prescribe the drugs to those aged 16 and 17 without first seeking the consent of the courts.
Anyone who continues to prescribe puberty blockers to under-16s without court authorisation now runs a higher risk of pursuit for clinical negligence.
The NHS said: “The Tavistock have immediately suspended new referrals for puberty blockers and cross-sex hormones for the under-16s, which in future will only be permitted where a court specifically authorises it.”
A former GIDS clinician who blew the whistle, with four other colleagues, in a Times investigation last year, said the ruling was a vindication. They had claimed that children seeking to transition were being sent down an irreversible path towards infertility and surgery after as few as three sessions with a therapist, without sufficient investigation of the cause of their distress.
“The Tavistock were given chance after chance to moderate their approach, after staff voiced our concerns, but they essentially called us transphobic,” the clinician said. “The High Court has said no, we weren’t transphobic, and the judges agreed with our concerns.”
Ms Bell said she was “delighted” with the judgment, which she hoped would protect young people from making decisions they may regret.
Speaking outside the Royal Courts of Justice after the ruling, Ms Bell said: “It was a judgment that will protect vulnerable young people. I wish it had been made before I embarked on the devastating experiment of puberty blockers. My life would be very different today.”
She added that the ruling “exposes a complacent and dangerous culture at the heart of the national centre responsible for treating children and young people with gender dysphoria”.
The legal challenge was also brought by Mrs A, the mother of a 16-year-old autistic girl, who is on the waiting list for treatment.
In a statement read out on Mrs A’s behalf, she said: “I hope this judgment will provide a safety net to prevent the unsupervised medical experimentation on children, like my daughter, by an institution charged with helping to alleviate her distress.”
Paul Conrathe, the pair’s solicitor, described the “historic judgment” as “a damning indictment of clinical practice at the Tavistock”.
He said: “Ironically — and as matter of serious concern — despite its international reputation for mental health work, this judgment powerfully shows that a culture of unreality has become embedded in the Tavistock.
“This may have led to hundreds of children receiving this experimental treatment without their properly informed consent.”
The case considered written evidence from a variety of experts on the issue of gender dysphoria and a number of individuals who have been treated or are still being treated with puberty blockers.
The court heard that 26 of the 161 children who were referred to the clinic in 2019/2020 were 13 or younger; 95 of them were under 15. Some had been on puberty blockers for five years, from the age of ten.
In 2009, only 97 children and young people were referred. In 2018 that number was 2,519, a disproportionate amount of girls and young women.
The trust had argued that it would be an intrusion on a young person’s autonomy to restrict access to the drugs. However, the judges rejected this: “In principle, a young person’s autonomy should be protected and supported. However, it is precisely the role of the court to protect children, and particularly vulnerable children’s best interests.”
At a brief hearing yesterday, the court refused the Tavistock and Portman NHS Trust’s application for permission to appeal against the ruling.
But the court gave the trust until December 22 to apply directly to the Court of Appeal and, in a statement after the ruling, a spokesman confirmed that the trust would seek permission to appeal against the judgment.
A spokesman for the trust said it was “disappointed” by the judgment. “Our first duty is to our patients, particularly those currently receiving hormone blocking treatment, and we are working with our partners, University College London Hospitals NHS Foundation Trust and Leeds Teaching Hospitals NHS Trust, to provide support for patients concerned about the impact on their care.”
Susan Evans, who was previously employed by the Tavistock as a psychiatric nurse, said she hoped the ruling would “change their attitude” at the trust.
She said she hoped it would put the brakes on the “at times quick process towards a medicalised treatment” and “allow more time for assessment and psychological treatments for young people”.
The ruling was praised for providing “clarity” by some legal experts.
Sarah Williams, legal director at law firm Payne Hicks Beach, said: “This ruling provides much needed clarity on the capacity of a child to provide valid consent to innovative and experimental medical treatments which could result in infertility or impaired sexual function.
“Today the court has shone the light on a murky area of the law. Not only will parents find this ruling reassuring, but clinicians should too. This will provide a welcome safeguard.”
Nancy Kelley, Stonewall’s chief executive, said that the ruling was shocking and could have “a significant chilling effect on young trans people’s ability to access timely medical support”.
The NHS trust said that it was “working through” the implications of the ruling and would “not be making new referrals to endocrinology until we have more clarity”.
What are puberty blockers?
Puberty blockers do just that; they stop puberty in it tracks, effectively pausing the transition from child to adult. They are only licensed in the UK to delay the onset of puberty for children suffering “precocious puberty” — that is, those who start developing abnormally early before the age of eight or nine.
They are physically reversible, only insofar as puberty will eventually restart once someone stops taking them. But no one knows their long-term impact, for example, on the teenage brain.
Side-effects include insomnia, exhaustion, fatigue, low moods, rapid weight gain leading to stretch marks, and a reduction in bone density, leading to easily broken bones. There is no clear evidence they even help people with gender dysphoria.
In some cases, there is a suggestion that a person’s distress over their body is only exacerbated. In almost all cases, a young person who begins puberty blockers will go on to cross sex hormones and possibly gender reassignment surgery.
This ruling heralds the end of the “Wild West” approach to treating children who are exploring whether they may be transgender (Lucy Bannerman writes).
For years puberty blockers have been described by trans rights charities, such as Mermaids and Stonewall, as a benign and reversible way of giving “time to think”.
In fact, as the High Court has ruled, their use to treat gender dysphoria is highly experimental, with an unknown long-term effect on adolescent brains and bodies. What was certain, the three judges found, was that most children who began puberty blockers went on to take cross-sex hormones. Because one treatment led to the other, informed consent was required for both.
Some young people say that puberty blockers have provided short-term relief by delaying the onset of physical characteristics of an unwanted sex. Others have complained that blockers did nothing to alleviate feelings of dysphoria, and indeed increased a sense of alienation by keeping their bodies childlike.
Dame Victoria Sharp, with Lord Justice Lewis and Mrs Justice Lieven, found that treating gender dysphoria in the young was a “unique” medical treatment, raising specific ethical dilemmas. The judges said the Tavistock clinic “did not put forward any clinical explanation” for the huge rise in referrals. The court also “gained the strong impression . . . that it was extremely unusual for [the clinic] to refuse to give puberty blockers on the ground that the young person was not competent to give consent”.
Over are the days when a child could embark on the biggest decision of their lives after a few conversations with a therapist.
