AusPATH Statement on Bell v. Tavistock

The Australian Professional Association for Trans Health (AusPATH) was established in 2009 and is Australia’s peak body for professionals involved in the health, rights and well-being of all trans people, including those who are gender diverse and non-binary. The AusPATH membership comprises approximately 250 experienced  professionals working across Australia.

AusPATH has serious concerns regarding the ramifications of the ruling handed down in the London High Court on December 1 st , 2020 in Bell v. Tavistock  (https://www.judiciary.uk/wp-content/uploads/2020/12/Bell-v-Tavistock-Judgment.pdf). The judgment stated that anyone under the age of 16 is unable to consent to starting puberty blockers as a gender affirming medical intervention and must instead apply to the court for permission. The consequences of this are extremely harmful for trans youth. Given that many of the irreversible physical changes of puberty are well under way by the age of 16, this decision effectively removes the option of puberty suppression for most trans and gender diverse young people in the UK.

The court was concerned with what they believed to be limited efficacy and lack of safety data regarding the use of puberty blockers, referring to them as “experimental”. They further went on to state that consenting to puberty blockers would automatically lead to gender affirming hormone therapy (GAHT), and that therefore any child would need to understand the permanent and lifelong consequences of hormone therapy before they could consent to puberty blockers. The court took the view that no child under 16 could fully comprehend these consequences, and that therefore it would not be possible for them to consent to puberty suppression. AusPATH states emphatically that puberty suppression and GAHT are two separate treatment options, and one does not always lead to the other. Puberty blockers have effects that are reversible, effectively pausing the changes of puberty. No permanent physical changes occur to an individual’s body until gender-affirming hormones are introduced. However, since puberty blockers are offered, after careful assessment, to those who are consistently and persistently experiencing gender incongruence, and this is the same cohort who are most likely to persist with gender incongruence, it is unsurprising that most people on blockers do progress to GAHT. Starting gender-affirming hormones involves a separate consent process altogether. Consenting to puberty blockers is not the same as consenting to GAHT, and the readiness of an individual to begin GAHT is assessed regardless of whether they have already been on puberty blockers. The court also stated that puberty blockers consolidate a feeling of being transgender, but there is no evidence to support this statement (for instance, there are no reports of puberty blockers inducing gender incongruence in individuals prescribed them for other indications such as precocious puberty).

Puberty blockers have been used as a medical intervention for trans youth for over 2 decades, and although there is limited long-term data, there are several studies pointing to their safety (e.g. Mahfouda, Moore, Siafarikas, Zepf, & Lin, 2017) . They are not an experimental treatment, but rather a reliable tool to assist in the medical management of those who require it. The court was also concerned about the possibility of regret, and quoted a “desistance” rate of 85%, which is at odds with the very low regret rates that are seen in practice. The methodologies of those reporting such high rates have been discredited (Newhook et al, 2018). Studies have found very high rates of persisting stable identity in older children and adolescents, especially those with more severe gender dysphoria (Steensma, 2013). The court did not address the fact that forcing trans young people to experience a puberty that does not align with their internal gender would cause great suffering and increases in suicidality, as has been demonstrated with recent research (Turban, King, Carswell, & Keuroghlian, 2020). Withholding puberty blockers is not a neutral option. Not only do puberty blockers provide immediate relief of distress, but they also prevent the permanent physical changes which are at odds with a young person’s gender identity. Developing such bodily characteristics is distressing for the young person, and they are expensive, painful, difficult and sometimes impossible to change later in life. The court made little mention of the peer-reviewed evidence base that exists, and the expert clinical consensus of people who work with gender diverse children and their families.
The court took pains to point out that the issue they were deciding was about capacity to consent, however AusPATH believes that the court made an enormous leap in conflating “capacity to consent to largely reversible puberty suppression treatment” with “capacity to consent to all possible future gender affirming medical and surgical treatments which they may or may not wish to have as an older adolescent and adult”. This this has set the bar too high for children to ever be able to consent. Capacity assessment is already carried out by expert clinicians prior to each stage of treatment for trans youth, and it is unreasonable to take this assessment and place it in the hands of a judge.

Puberty blockers have been used for over two decades in the treatment of trans youth, and they are reversible, safe and very effective. Capacity is best assessed by expert clinicians, and informed consent for each stage of treatment should be carried out separately.

Removing the ability to prescribe puberty blockers for trans youth who are in early puberty will result in significant distress and loss of bodily autonomy, leading to negative long-term consequences, and is a grave transgression of their human rights.

AusPATH firmly believes that all young people who desire puberty suppression should be able to access such care in a timely manner under appropriate supervision and assessment by a multidisciplinary team in accordance with the current Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents. (Telfer, Tollit, Pace, & Pang, 2018).

References

Mahfouda, S., Moore, J. K., Siafarikas, A., Zepf, F. D., & Lin, A. (2017). Puberty suppression in transgender children and adolescents. The Lancet Diabetes & Endocrinology, 5(10), 816-826. doi:  10.1016/S2213-8587(17)30099-2

Newhook, J.T., Pyne, J., Winters, K., Feder, S., Holmes, C., Tosh, J., Sinnott, M-L. Jamieson, A., Pickett, S. (2018). A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children. International Journal of Transgenderism, 19:2, 212-224, doi: 10.1080/15532739.2018.1456390

Steensma, T.D. et al, Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child & Adolescent Psychiatry, 52(6) 582-590, doi:
10.1016/j.jaac.2013.03.016

Telfer, M. M., Tollit, M. A., Pace, C. C., & Pang, K. C. (2018). Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents. The Medical Journal of Australia, 209(3), 1, doi: 10.5694/mja17.01044

Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics, 145(2), e20191725. doi: 10.1542/peds.2019-1725

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