WPATH, EPATH, USPATH, AsiaPATH, CPATH, AusPATH, PATHA
Response to Bell v. Tavistock Judgment

Statement Regarding Medical Affirming Treatment including Puberty Blockers for Transgender Adolescents

The Boards of Directors of the World Professional Association for Transgender Health (WPATH), the European Association for Transgender Health (EPATH), the United States Professional Association for Transgender health (USPATH), the Asian Association for Transgender Health (AsiaPATH), the Canadian Association for Transgender Health (CPATH), the Australian Professional Association for Trans Health (AusPATH), and the Professional Association for Transgender Health Aotearoa (PATHA) all strongly disagree with the recent judgment of the London High Court in Bell v. Tavistock. We believe this decision will result in significant harm to the affected children and their families. We oppose this ruling and urge that this ruling be appealed and overturned.

The case

On December 1, 2020, the London High Court ruled (Bell v. Tavistock) that children are highly unlikely to be able to consent to taking puberty blockers. The far-reaching result of the judgment is that all applicants for gender affirming medical intervention in the UK under the age of 16 must first seek authorization from a court of law to obtain necessary and effective medical care, with the apparent likelihood that permission will not be given due to the court’s improper practice of medicine.

As professional medical organizations, the European Professional Association for Transgender Health (EPATH), and the World Professional Association for Transgender Health (WPATH), as well as the other signatories to this statement, all have serious concerns about this ruling and wish to express that although treatment for young transgender adolescents involves uncertainties, as is the case in many fields involving young people, several studies demonstrate the clear mental health benefit of gender-affirming medical treatment (including puberty blockers). Withholding such treatment is harmful and carries potential life-long social, psychological, and medical consequences.

Immediate and long-term consequences of puberty blockers

Treatment of transgender adolescents involving gender affirming medical interventions (puberty suppression and subsequent gender affirming hormones) is the most widely accepted and preferred clinical approach in health services for transgender people around the world. The aim of puberty suppression is to prevent the psychological suffering which stems from undesired physical changes that occur during puberty, and to allow the adolescent time to carefully consider whether or not to pursue further transition when they are eligible. It is part of the two main international guidelines: the WPATH’s Standards of Care as well as the Endocrine Society’s Clinical Practice Guidelines. To be effective, this treatment must commence early in the puberty process, not at the age of 16. When treatment is needed, its effectiveness will be diminished while waiting to be seen by a court of law.

Do puberty blockers lead to further gender affirming treatment?

Gender affirming medical interventions for adolescents are usually offered in a stepwise approach from reversible to irreversible treatments. Starting with blockers, which affects pubertal development in a reversible way, young people are provided with ample time to explore their gender. All possible reversible steps are considered before any less reversible steps. It is not the case that one stage invariably leads to the next. Gender affirming hormone treatment is a carefully considered later intervention for which adolescents (and their parents) provide separate informed consent after having received information about the effects, limitations, and potential side effects of this treatment. Not all adolescents seeking gender-affirming care will require hormonal or surgical treatments; treatment is always individualized according to each adolescent’s needs.

The harmfulness of not providing puberty blockers

We have a grave concern that the High Court has overlooked not only the immediate positive effects of puberty suppression, which has been demonstrated to result in decreased psychological suffering and a healthier adolescent development, but also the lifelong benefits of having a physical appearance which is congruent with one’s gender identity. Withholding such treatment until adolescents are 16 years old means they will experience complete puberty incongruent with their gender identity, which has potential life-long harmful consequences such as stigmatization, personal physical discomfort, difficulty with sexual function and social integration.

The age of consent

As noted in the case Bell v. Tavistock, “The sole legal issue in the case is the circumstances in which a child or young person may be competent to give valid consent to treatment in law and the process by which consent to the treatment is obtained.” Even when they do not yet have the legal right to give their own consent to treatment, research has demonstrated that many minors possess the cognitive and emotional abilities to understand the consequences of their decisions, including decisions concerning health care. The determination of the ability of a particular adolescent to give consent should be made by a competent transgender healthcare provider who has evaluated the adolescent, and not by a court of law. Current guidelines already recommend that this competence is assessed prior to the start of treatment.

Conclusion

WPATH, EPATH, USPATH, AsiaPATH, CPATH, AusPATH, and PATHA recommend that capacity to consent is evaluated on a case-by-case basis by the treating clinician and not by a court of law. We do not agree that transgender healthcare is so different in kind to that provided to cisgender people as to warrant separate legal provision. We consider puberty blocking treatment and treatment with gender affirming hormones as two separate treatment steps each requiring informed consent at the time such treatment is to be started.

We support the provision of healthcare to gender diverse people in a timely manner such that they can live their best lives. We are gravely concerned that the ruling will have a significantly adverse impact upon gender diverse youth and their families by imposing barriers to care that are costly, needlessly intimidating, and inherently discriminatory.

References
https://www.judiciary.uk/judgments/r-on-the-application-of-quincy-bell-and-a-v-tavistock-andportman-nhs-trust-and-others/

Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., Rosenthal, S. M., Safer, J. D. Tangpricha, V., & T’Sjoen, G. G. (2017). Endocrine Treatment of GenderDysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The Journal
of clinical endocrinology and metabolism, 102(11), 3869–3903. https://doi.org/10.1210/jc.2017-01658

E. Coleman , W. Bockting , M. Botzer , P. Cohen-Kettenis , G. DeCuypere , J. Feldman , L. Fraser , J. Green , G. Knudson , W. J. Meyer , S. Monstrey , R. K. Adler , G. R. Brown , A. H. Devor , R. Ehrbar , R. Ettner , E. Eyler , R. Garofalo , D. H. Karasic , A. I. Lev , G. Mayer , H. Meyer-Bahlburg , B. P. Hall , F. Pfaefflin , K. Rachlin , B. Robinson , L. S. Schechter , V. Tangpricha , M. van Trotsenburg , A. Vitale , S. Winter , S. Whittle , K. R. Wylie & K. Zucker (2012) Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People, Version 7, International Journal of Transgenderism, 13:4, 165-232, DOI: 10.1080/15532739.2011.700873

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