A landmark Supreme Court ruling has highlighted the work of the Gender Identity Development Service for Children and Adolescents (GIDS) in the Tavistock and Portman NHS trust in London.
The long-awaited ruling on Tuesday concerned 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, argued that she was too young to consent to medical treatment under the supervision of the GIDS that began her transition from female to male as a teenager.
In a 36-page ruling, the court concluded that it is unlikely that children under 16 years of age considering gender reassignment are unlikely to be mature enough to give informed consent to prescribe puberty-suppressing drugs, thus reducing medical intervention for under 16s. with gender dysphoria is in fact limited. .
“It will pose enormous difficulties for a child under 16 years of age to understand and weigh this information and decide whether to consent to the use of puberty inhibitors,” the ruling said.
“It is highly unlikely that a child aged 13 or under would be able to consent to the administration of puberty blockers. It is doubtful whether a 14 or 15 year old child can understand and weigh the long-term risks and consequences of the administration of puberty blockers. “
The decision was hailed by some as a victory for sanity and protection, and condemned by others for having a chilling effect on the rights of young transgender people.
NHS England said any future medical intervention for under-16s would only be allowed “if a court specifically allows it”.
The GIDS has been scrutinizing heavily in recent years, with some former staff and campaigners voicing 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 the Sandyford clinic in Glasgow, Scotland’s only provider of gender services for children and young people, clinicians have provided The Guardian with insight into treatment pathways, while former staff members shared their own experiences.
The Supreme Court ruling raised particular concerns about the use of puberty blockers, which it says “can be correctly described as an experimental treatment” with “limited evidence of efficacy or long-term effects.”
Between March 4, 2019 and March 1, 2020, the GIDS referred 171 young people to endocrinology, the first step for any medical intervention. Of these, 60 were men and 111 women, their mean age was over 15 years, and they had an average of 10 appointments before this happened.
The GIDS emphasizes that the whole process is aimed at giving young people time for reflection. It says that while some young people will arrive with a specific medical intervention in mind, others will be much more insecure and will benefit from exploratory sessions conducted with and without parents.
A care plan is then drawn up, which for the majority involves further investigation, perhaps with a request to local services or the school for help. Before the Supreme Court ruling, a minority of adolescents were recommended hormone blockers, which halt puberty, often a source of great distress for transgender teens.
A separate assessment and consent process was required before a patient transitioned to cross-sex hormones, which aim to better match secondary sexual characteristics with gender identity, and which were available around the age of 16 and after one year of blockers. The GIDS does not offer surgery.
Both the GIDS and Sandyford Clinics have seen an increase in teenage girl referrals over the past decade – a trend that is reflected across Europe and worldwide.
GIDS specialists say that the increase must be kept in perspective – only one in 10,000 young people is referred to the highly specialized service – and that an overrepresentation of girls could just as well be an underrepresentation of boys, for whom gender nonconformity is usually controlled more aggressively by colleagues.
For some girls – who enter puberty earlier and are more sexualized by society and more aware of the pressures to have “the perfect body” – the service is helping them explore ways to become more accepting of their changing bodies.
Only a small proportion of those seen at the GIDS have access to medical treatment while on duty.
But critics argue that this amounts to the medicalization of what is essentially a crisis at the beginning of female puberty.
Those critics believe there is evidence that vulnerable young people – many of whom are gay and have homophobic parents or are bullied in school, who have autism or have undergone child abuse – are convinced that changing gender will solve their problems, and that professionals also fear disapproval if they challenge this.
The Supreme Court itself was critical of what it characterized as the Tavistock’s “surprising” lack of research into the increase in referrals of girls and people with autistic spectrum disorder.
Sources at Sandyford insist they see no overrepresentation of lesbian and gay youth, nor a large proportion of girls who have been sexually abused or those with homophobic parents who are trying to “correct” their child’s sexuality.
They say there is an overrepresentation of young people in the autistic spectrum, but warn that within that population there are already high rates of sexuality problems, caused by very rigid thinking in terms of self-definition.
There are individual stories of girls in need trying to escape their abuse by identifying as boys, or parents pushing their children the trans route because of fear or misunderstanding, but these are the exception.
One doctor suggests that a reference to the Sandyford often gives very confused young people and anxious parents a chance to ponder with a variety of professionals about what is really bothering them.
Those professionals can often inject ‘a sense of reality’ into theories and ideas that patients have read about online that they believe appear to be a quick fix to their problems.
A former consultant psychiatrist and psychotherapist, who worked with the Tavistock Adult Service and with the GIDS, expressed concern that the ‘very affirmative’ approach there risked medicalizing behaviors that might otherwise be understood as a young person’s normal need to move away from parents to divorce and express. their individuality, perhaps through membership of a subculture.
He reported that in his current private work with older teens and young adults showing similar concerns, it was possible to help them through their gender conflicts through exploratory therapy that was neither “affirmative” nor attempted to be “corrective”.
The transgender teens to whom The Guardian was introduced by Mermaids – a charity that provides support to transgender or non-gender-conforming children, including those undergoing medical interventions – report overwhelming frustration with long waiting times for first appointments (mean 18 months according to GIDS); some turned to private practitioners in the meantime. Last month, the Good Law Project launched legal action against NHS England over these waiting times.
“People who say the process is going too fast just don’t understand. Medical intervention is like winning the lottery, ”said 18-year-old Dylan, adding that he was“ deeply saddened ”by the Bell judgment.
“It is very important that people realize that this is not a choice. The media is talking about children being ‘brainwashed’ or ‘accelerated’, or that young people want to be trans because it is a trend. Yes, there are some kids who don’t know their gender or use those labels, but if you experience dysphoria that’s different. “
It’s an opinion shared by Alex, also 18, who says he is “terrified that this judgment will condemn trans teens to years of excruciating puberty, leading to uncontrollable levels of dysphoria and anxiety.”
Alex was referred to the GIDS six years ago and had regular sessions there for 18 months before being prescribed hormone blockers. Describing this wait as “the worst” of his treatment so far, he added, “It’s a thorough process, and I accept it should be. They break up what you say, but that’s a good one. therapy. “
He started taking testosterone two years ago and said, “I’ve usually gotten to a point where being trans doesn’t matter anymore – I finally feel like the real me, and now I feel normal, which is the goal. I’m happy.”
The Tavistock is seeking permission to appeal Tuesday’s verdict.