The ruling in Bell v Tavistock, on 1st December 2020 was that children under 16 were unlikely to be able to consent to taking puberty blockers and cross sex hormones and that these cases should be brought before the court for a decision. In response The Good Law Project launched it’s ‘Trans Defence Fund’ to bring legal action to challenge this ruling. Today, March 26th we have the first results. Was it worth the money?
I have added this part after having some very useful discussions via social media and attempting to refine my points in an accessible summary. Although social media is largely responsible for the toxic mess we are now in, ironically it continues to afford me access to people and views I might otherwise never get to see – so for that I am grateful. I will summarise my views below, highlight some of the particular points of controversy or difficulty and then offer a neutral precis of the decision itself.
For a very specific cohort of children, such as XY who had already started on PB and wanted to continue, I can see that it was worth exploring these issues for them. As far as I can make out from the judgment, its dealing with the very narrow point of how to reassure GPs already prescribing PBs that it is lawful for them to continue. This judgment makes it clear that parents can consent to this, provided the child wants it to go ahead. This scenario was not covered in Bell as the Tavistock were clear they would never authorise treatment for a child without being satisfied about the child’s consent.
If you are interested in a more general overview of children’s capacity to consent, I deal with it in this post.
But the court did not know if XY was Gillick competent. No independent assessment of XY’s views was carried out. It’s difficult to see what role CAFCASS were playing here. Keira Bell’s lawyers were not invited to intervene. The case carried on with all parties apparently aligned in what they wanted, as court explicitly noted. I think it would have been far better to have simply made a very discrete ruling here that applied to XY alone. I appreciate that on what we know about XY that this child appears to have been consistent and persistent in gender dysphoria and the parents were not rushing into treatment.
But what we have instead is a ruling that goes beyond the individual case and makes general comments about parental consent which do seem to undermine Bell, despite explicit assertion that nothing in this judgment changes Bell. And I think the problem is this – comments are made about the centrality and importance of parental rights to make decisions, with which I agree. But the context in which those decisions are being made is one of extreme polarised positions, lack of proper evidence and very serious long term consequences for a child. That is the elephant in the room. Parents can be ‘loving’ and do all the research they wish – but if the tree is poisoned, so is its fruit. Also the court is silent to the troubling concern highlighted by a number of Tavistock clinicians, that some parents appeared to be motivated to seek treatment because they did not want to raise a gay child.
These are the issues that urgently need attention. We can all, even parents, do terrible things in the name of ‘love’. I agree that the court is not the best arena for all of this. But while necessary discussion remains censored on the grounds of ‘transphobia’, even within the medical profession, then the courts are all we have.
PARTICULARY CONCERNING EDIT 28th March 2021
I had not realised until discussions with a parent via Twitter this morning, that parents had been refused permission to intervene in the Court of Appeal decision on the issue of parental consent. Given that the Tavistock had said – quite rightly – it could conceive of no circumstances in which it would proceed without the child’s consent, presumably that issue was felt to be irrelevant. We now know that isn’t true. And that the parents can apparently give consent – across the board? – as long as the child doesn’t explicitly object. A silent child will be assumed to be simply an ‘overwhelmed’ child who wants mum and dad to make the hard decisions. All of this is given the narrative of ‘loving parents’ – so presumably those parents who don’t consent are ‘unloving’ and hence abusive. There was no discussion in this judgment about the concerns of Tavistock clinicians about those parents – many – who were expressing homophobia as a motivation for their child’s transition. No mention that Sonia Appleby is taking the Tavistock to court for their failure to refer children to her as former head of safeguarding. No more than a few paragraphs at the peculiar atmosphere now enveloping us all – whereby even mild criticism or challenge to the ‘path of affirmation’ is met with cries of ‘transphobia’ or even (I am not joking) ‘genocide’. We are really in a very serious mess. The Court of Appeal will have much work to do.
Some particular points of difficulty
I am not sure that this decision represents the victory that the Good Law Project appear to be celebrating or the coherent decision that we all need. In no particular order of importance, these are the issues that immediately caught my eye.
- It is clear that the court wanted to be firm that the judgment in Bell remains undisturbed. But I still don’t feel confident I understand how these two judgments sit together.
- The court raised an eyebrow at the process whereby XY (a child aged then 13) was sufficient to explore If XY was really Gillick competent to consent
- The court noted that the safeguards provided by a regulatory framework had to be real – and that at no time had the respondents ever sought court approval despite the ‘intense difficulties’ of these kind of cases. The fact that the Tavistock’s previous head of safeguarding is also taking them to court was not touched upon in this judgment but presumably is very relevant to the extent to which we can trust the regulatory framework in place. It is clear from the court’s closing remarks that they thought the difficult issues around PBs are better left to a regulatory and academic setting, not litigation. Which is all well and good – provided we can be confident that neither setting has been ‘captured’ to a greater or lesser extent by any prevailing ideology. The court does touch on the dangers here, by commenting that parents may find it difficult to access an independent ‘second opinion’ but is clearly wary of that process being lead by the courts rather than the regulatory framework itself.
- when determining that there is no ‘special category’ of cases regarding medical treatment that must come before the court, its interesting that the line of authorities around deprivation of liberty were not discussed. When considering a DoL, iit is clear that parents may not consent to deprive a child of their liberty once the child is old enough to be beyond the ‘zone of parental authority’ which is certainly by 16 years, even if the child lacks mental capacity to consent to such deprivation.
- Although the court commented that cases where the clinicians disagree should come to court, it was silent as to whether the same applied when parents disagree – I assume that it must but it would be good to see this set out, rather than the assumption (as clearly exists in Canada!) that a parent who does not support this treatment must nevertheless be compelled to affirm it.
- It’s interesting that the only cases that seemed to come close to a ‘special category’ which must always come to court were cases involving the sterilisation of young children. As this is exactly what PB and CSH lead to, I would have hoped to see a little more discussion of that comparison.
- The court commented on the ‘research’ done by the mother and the frequent consultations between staff and parents. But if PB are the ‘experimental’ treatment that Bell found, and if the evidence to support the treatment is as poor as Bell found – then what is the point of such extensive research and clinical consultation? Zero plus zero is still zero.
- At some point the divergence between the Australian approach and English approach will have to be resolved. What exactly is the evidence that allows the Australian courts to confidently assert that both PB and CSH are ‘therapeutic’ treatment, and thus viewed more sympathetically by the court?
- If XY at 13 would be highly unlikely to be able to provide valid consent – as Bell held – why was the court now prepared to proceed on the basis that parental consent was ok? Either the child’s consent is necessary and important or it isn’t. It seems odd to make a distinction between a child who has started and not started treatment. If the consent isn’t valid, the treatment isn’t lawful, no matter how far down the line you have gone. I can see a potential difference in levels of distress for a child who has to stop in the middle of treatment, but that’s the only distinction I can see.
Live issues which may require further consideration by the Court of Appeal was the argument raised that considering this kind of treatment differently could be discrimination under the Equality Act. The Court did not feel that it should deal with this issue in this case, but it may merit resolution in the Court of Appeal. I also hope the Court of Appeal will finally knock on the head the continuing and irritating assertion from the Good Law Project that the decision in Bell is somehow an ‘attack’ on Gillick competence. This is simply untrue. It is also perplexing that the Good Law Project appears on the one hand to place great stock in Gillick, while on the other it argues for ‘loving parents’ to be able to offer consent on behalf of children. That position appears to me at least to be incoherent, if not utterly inconsistent. We shall see what the Court of Appeal makes of it all.
This judgment however only makes sense if it is restricted to that specific cohort of children who have already started taking PB and wish to continue and their parents and doctors agree but require clarity as to who is actually giving consent so that GPs outside the framework of NHS England can have the confidence to lawfully prescribe.
Background to the application
The application was bought by parents of the child XY to seek a declaration that they could consent to XY taking puberty blockers and that this decision should not come before the court as either a matter of legal requirement or good practice. The respondents were the Tavistock and Portman NHS Trust and the University College London Hospital NHS Trust. CAFCASS also appeared to assist the court.
After the judgment in Bell, NHS England amended the Service Specification for GIDS so that every patient currently receiving treatment should be assessed and a ‘best interests’ application made to the court if the review determined that PBs should continue. It was clear that it would take a considerable time to carry out these reviews; at least 3 months for XY. The clinicians, parents and XY were all of the view that XY should continue treatment and it should not stop pending review as that would lead to XY developing irreversible secondary sex characteristics which XY did not want and would find very distressing.
The background to the services provided at GIDS were all set out in judgment in Bell. No one wanted the court to adjourn to wait for the Court of Appeal decision in that case (hopefully by June 2021). What is different in this case is that Bell explicitly did not deal with the issue of whether or not parents could consent to such treatment continuing when it had already started.
After Bell some GPs agreed to continue to prescribe PBs as they are not parties to the contract between NHSE and the NHS Trusts. But it was not clear whose consent was being relied upon to make the prescription of PBs by GPs lawful post Bell. In light of that uncertainty, XY’s mother applied to court.
Therefore, the court was concerned with a specific cohort of children – those who are currently receiving treatment with PBs. It was argued that these children would suffer if treatment did not continue – therefore it should continue on the basis of parental consent alone, as long as the patient continues to want the treatment.
Everyone agreed the court was bound by the findings in Bell, most relevantly here the treatment’s “experimental nature, the issues around reversibility, and the lifelong and life-changing nature of the treatment pathway that the child has entered upon“. Indeed it would have been very odd if anything else had been said given that Mrs Justice Lieven who delivered this judgment was one of the three judges deciding Bell.
The court was very clear that:
Kiera Bell’s lawyers had asked to be kept informed about this application but the court did not order this at an earlier stage. Clearly the case involved very personal details about a child and the court wished to limit the involvement of third parties. The court further rejected a suggestion that a ‘best interest’ analysis should be carried out for XY IF the court found parents could not consent – there was no independent evidence from CAFCASS who had not been invited to act as XY’s guardian.
Who is XY?
XY was born a boy and is now aged 15. XY ‘came out’ as transgender aged 10. When attempting to conform to a ‘male’ stereotype, XY became ‘utterly miserable’ and ‘very withdrawn’. XY does not have unresolved mental health issues and is not on the Autistic Spectrum. XY was referred to GIDS in 2016. The parents wanted to wait before starting PBs until puberty commenced and the mother carried out ‘extensive research’ before hand. XY was seen in April 2019 aged 13 where XY was declared ‘competent to consent’. The court raised some concern that the form offered to XY to sign did not test if the child understood the issues set out at para 138 of Bell, but made no further comment about how this process tested out Gillick competence. XY then started PB in July 2019. XY did not want to consider any fertility preservation treatment as stopping PBs would entail developing male secondary sex characteristics which XY would find ‘devastating’. The court set out the number of appointments the parents had to discuss XY’s treatment.
The questions for the court
- Do the parents retain a legal right to consent to the treatment?
- Is it the kind of treatment where an application must be made to the court, or should be made to the court as a matter of good practice?
The court noted that the role of parents in making decisions about their children’s lives was ‘central, fundamental and critical’. Parental responsibility clearly extends to granting consent to medical treatment. In the vast majority of situations, the courts should respect and uphold the decisions parents make. The court referred to a number of authorities, as well as article 5 of the UNCRC and article 8 of the ECHR.
Do the parents retain a legal right to consent – yes.
The issue here was whether the parents had a continuing right to consent even if XY was Gillick competent. The court in Bell set out at myriad issues a child would need to grapple with to be deemed competent to consent to this treatment. There had been no fresh assessment of XY’s competence. Therefore the court considered the case on the two alternatives – whether XY is or is not Gillick competent. But it remained relevant if the parents could also give operative consent as the clinicians, GPs and parents were very uncertain as to the current lawful basis on which PB’s can continue to be prescribed. So the court needed to examine the degree to which the parental right to consent to treatment continued even when the child was Gillick competent.
The court rejected a suggestion that a parent retains the right to consent to treatment which a Gillick competent child has refused. This is simply unsustainable when looking at article 8 ECHR. The parent has a ‘dwindling right’ to consent on behalf of a child whose autonomy increases in line with their age and understanding.
In this case, the parents and child agreed. So, does the parent’s ability to consent disappear once the child achieves Gillick competence? The court decided it did not. The parent cannot ‘trump’ a child’s decision but if the child fails to make a decision, then the parent’s ability to do so continues. An obvious example of where a parent has a continuing duty to make decisions, is if the child is unconscious. But it could also arise if a child declines to make a decision as the situation is too overwhelming and she would rather her parents decided.
Therefore, if XY was Gillick competent, XY did not object to the parents making the decision to carry on with the PB. If XY was NOT Gillick competent, the parents could consent on XY’s behalf. Such an approach protects the rights of both the child and the parents.
Is PB a special category of treatment which must come before the court? – NO
In essence, cases should come to court if there was disagreement between clinicians (or presumably parents?) or there was evidence that a child was pressuring parents into making a decision.
The court was not troubled by the distinction between ‘legal requirement’ or ‘good practice’ – if a doctor failed to have regard to good practice then he or she risks considerable criticism so the impact of the two is similar. But if such a ‘special category’ of treatment exists it is extremely limited. Cases which have considered this have looked at the issue of sterilisation of girls, some under 16. The request of a mother to sterilise her 11 year old girl who had ‘impairment of mental function’ and ‘certain aggressive tendencies’ was treated with great concern in Re D (A Minor) (Wardship Sterilisation)  1 All ER 326 and the court certainly wished there to ‘throw some care around this child’ given that sterilisation involved the deprivation of a basic human right. The case of F v West Berkshire Health Authority  2 AC 1 set out six factors to assist a decision about whether or not a case should come to court, including the irreversibility of the decision and the extent to which it involved a fundamental human right.
However, as the court noted, this case involved an adult without capacity and not a child with parents who were capable of and entitled to exercise PR. Further authorities were examined which explored the distinction between ‘therapeutic’ and ‘non therapeutic’ treatment.
In January 2020, Mr Justice Hayden, Vice President of the Court of Protection, produced guidance as to when applications for medical treatment should be made to the court, for example those cases that were finely balanced, or involved disagreement between the parties.
Arguments were made about the extent to which parents can give consent even to experimental treatment but the court did not find the case law advanced particularly helpful – if a child has a condition that would otherwise be fatal then its easy to see that experimental treatment would generally not require Court approval. But the factual, clinical and ethical issues surrounding PBs are different. The child is not facing a terminal illness and the treatment has life-changing and life-long consequences, the implications of which are not fully understood.
Interestingly the court commented upon some of the Australian authorities which deemed even CSH ‘therapeutic treatment’ but noted that this approach was very different to Bell.
The Respondents relied on the ‘extensive regulatory and oversight framework’ within which the clinical decision to prescribe PBs are made and that this broad framework was the more appropriate mechanism to ensure best practice and child safeguarding, rather than placing PBs into a special category which requires Court authorisation and thus removes the power of parents to consent. The court agreed that the framework gave ‘the opportunity’ for significant safeguards to be put in place and noted also that the Cass Review is reporting this year. Further, the Tavistock and UCL are subject to regulatory oversight by the Care Quality Commission (CQC) which reported regarding GIDS and set out various improvements it needed to make. Further, all the clinical professionals are subject to regulation and oversight by their own professional bodies.
The court did note that the safeguards did not appear to have worked ‘on the ground’ given that despite the ‘intensely difficult issues’ raised, the Tavistock had never felt it necessary to apply to the court for the approval of the prescription of PBs, even when the children were below the age of 16. There was clearly a risk of ‘unanimity of view’ within the clinical group that would mean referrals were never made.
The analysis of the case law showed that in terms of a ‘special category’ of cases that must come before the court, only the ‘non -therapeutic’ sterilisation of a child seemed to come close. Other cases that came before the court were fact specific – where there is clinical disagreement or possible alternative treatments.
The court concluded
It might be argued that in the light of the Divisional Court’s analysis in Bell, PBs are sufficiently different from other forms of treatment to be treated differently. I accept that I am somewhat hampered by the fact that no party was putting this argument. The factors from Bell which would be relied upon in this regard would, I assume, be the poor evidence base for PBs; the lack of full and long term testing; the fact their use is highly controversial, including within the medical community; and the lifelong and life-changing consequences of the treatment, which in some ways are irreversible. The ratio of Bell is that a child is very unlikely to be in a position to understand and weigh up these factors.
However, the key difference from Bell is that parents are, in general, in a position to understand and weigh up these matters and consider what is in the long and short term best interests of their child. They are adults with full capacity and as the people who know their child best, and care for them the most, will be in a position to reach a fully informed decision. The evidence strongly suggests that XY’s parents have fully considered these matters and come to a careful and informed decision.
In my view, the factors identified in Bell, which I fully agree with, do not justify removing the parental right to consent. The gravity of the decision to consent to PBs is very great, but it is no more enormous than consenting to a child being allowed to die. Equally, the essentially experimental nature of PBs should give any parent pause for thought, but parents can and do routinely consent on their child’s behalf to experimental treatment, sometimes with considerable, including life-changing, potential side-effects. It is apparent from Bell that PBs raise unique ethical issues. However, adopting Lady Black in NHS v Y, I am wary of the Court becoming too involved in highly complex moral and ethical issues on a generalised, rather than case specific, basis.
The court went on to note two points of ‘particular concern’ around parents giving consent for PBs for children with Gender Dysphoria. This raises ‘unique and highly controversial ethical issues’ and the division has become ‘highly polarised’. Therefore there isa real risk that clinical disagreement and difference will not necessarily be fully exposed and the early adoption of ‘fixed positions’ may deny parents access to a truly independent opinion. However, again the court stressed that this was a matter for the various regulatory bodies when imposing standards and good practice. The second concern was that of ‘reverse pressure’ where a child is desperate to have PBs and it may be hard for the parents to refuse given the inevitable tensions that would then arise in a family setting.
I have a great deal of sympathy for the court in wanting to bat this back to the ‘regulatory frameworks’. But we have to have faith that the regulatory frameworks will do what they are supposed to do, to protect everyone involved in this process, but of course and most particularly the children who are going to have to live with the consequences. It maybe that the Cass Review will help to break down the enormous harm that has been done by the unquestioning adoption of ‘affirmation’ . However, given the moves to make ‘conversion therapy’ (i.e. talking to a child about their gender identity distress) unlawful, I am not wholly confident that we are out of the woods yet, or certainly that we are out of the court arena. But let’s see what the Court of Appeal says in June.