Tag Archives: puberty blockers

Good news from Down Under re medical transition of children

Commentary

The decision of Strum J on 9th April 2025 is a very welcome indication that the Australian Family Court is moving away from the notion that medical transition of children should be seen as automatically ‘therapeutic treatment’, in a meticulous and lengthy judgment which unpicks the mother’s case and her expert witnesses with care.

It is both disturbing and alarming to see how the mother was ‘affirmed’ by various experts in a ‘fixed and rigid’ view that her son wanted to be female, but heartening to see a Family Court Judge who was very aware of what was going on and was having none of it. There are clear echoes of Re J [2016] here and a very welcome indication that we are returning to a strict focus on the welfare of the child, rather than a continued pandering to an unevidenced and ideological perspective about the benefits of medical transition for children.

Para 92 is for me particularly interesting. The Judge in this case rejected criticisms by a fellow Judge of the Cass Review as politically motivated calling such remarks ‘speculative’. It is clear that this Judge found the Cass Review authoritative and helpful, relying on its developmental considerations for children and adolescents and citing at length its conclusions about the efficacy and impacts of puberty blockers.

I cheered internally when reading the Judge’s firm rejection at para 106 of any ’emotive suggestion’ that the Cass Review should be seen as part of a ‘third wave’ of transgender oppression, akin to Nazi book burning. Such suggestion had ‘no place whatsoever’ in independent expert evidence and demonstrates ignorance of the true evils of Nazism.

The Judge was clear that earlier decisions of the Australian courts that treatment by way of puberty blockers is ‘therapeutic’ would need to be reconsidered on the better evidence that he had before him (para 194).

It is a relief to see recognition that the mother derived ‘benefit’ from being the parent of a trans gender child (para 203) and the court had grave reservations about her operating sole parental responsibility.

While the judgments meticulous and clear eyed unpicking of the partial and misleading positions of the mother’s experts is very welcome, it remains a matter of great sadness that for so many years, the Family Courts, in a variety of jurisdictions, have been willing to abandon evidence and sense to support an ideology that has the potential to cause irreversible and significant harm to children.

Let us hope this judgment heralds the return of Family Courts all over the world to their fundamental values; to identify and protect the welfare of the child as its paramount concern.

The Judgment

Re: Devin [2025] FedCFamC1F211

This case involved a 12 year old boy. His parents separated when he was 4 years old. Final parenting orders were made in 2018 which provided for the parents to have equally shared parental responsibility. By 2019 the mother had concerns about Devin’s wellbeing and wished him to undertake therapeutic counselling with an organisation dedicated to the well being of LGBTIQ+ community. Devin’s mother said he was suffering from gender incongruence/dysphoria and should be medically transitioned by way of puberty blockers as he had an ‘enduring female gender identity’. This wish to block his puberty was first expressed in 2021 when he was 8 years old and already significantly socially transitioned.

Devin’s father disagreed, asserting that he was rather ‘gender expansive’ and presented with some stereotypically feminine interests/preferences. The hearing took place over 20 days with a significant volume of evidence.

The ‘Reasons for Judgment’ begin with a quote from Maria Montessori

A child has a body which grows and a mind which develops. Both his physiological and psychic development have a single source, life. We should not corrupt or suffocate his mysterious potentialities but wait for their successive manifestations.

The Judge noted that this illustrated the central issue for determination in this case; there are restrictions on the activities and choices of children because their wishes and feelings, while potentially deep seated and genuinely felt, have ‘potentially grave ramifications for their future lives’ and may not be wishes that survive into adulthood.

It is troubling that the Judge comments at para 10

Despite my repeated exhortations to the parents and, to some extent, the experts who supported their respective cases, as well as the lawyers who represented them, to recall that the Court was deciding a case involving the best interests of the child and not the cause of transgender people, that occasionally seemed to fall on deaf ears.

The mother’s experts strayed from their obligations to give objective and unbiased opinion, such as Professor L who described herself essentially as an activist for the transgender cause and who gave misleading responses that omitted findings/material that detracted from her opinion (para 101). She went even further, suggesting that ‘we are currently living through the third wave of transgender oppression’ similar to Nazi book burning (para 105). The Judge was aghast (para 106)

The emotive suggestion, by an expert witness, that the Cass Report forms part of a “third wave of transgender oppression” commencing with the Nazis has no place whatsoever in the independent evidence that should be expected of such an expert. It demonstrates ignorance of the true evils of Nazism and cheapens the sufferings – and mass murder – of the millions of the victims thereof, which included, but were most certainly not limited to, transgender people, as well as gay and lesbian people, amongst other groups of people. I consider there to be no comparison whatsoever.

The mother’s case outline referenced the Change or Suppression (Conversion) Practices Prohibition Act 2021, which the Judge determined was irrelevant to these proceedings, but the Judge noted the ‘chilling effect’ of this Act in the difficulties faced by the father in obtaining expert evidence and alternative treatment proposals for Devin, as there was evidence to suggest that many shyed away from treatment that was not ‘affirming’ in case they fell foul of the Act, which creates criminal offences attracting up to 10 years imprisonment.

One expert stated

Anecdotally, I have heard practitioners express concern that if they do not automatically affirm a child’s declared gender identity they would find themselves accused of “conversion therapy” as per the legislation. This is despite social transition not being beneficial or harmful, exploratory therapy being an acceptable approach worldwide, and the fact that there would be no need nor intention to “convert” [the child] to have a “cis” identity, just merely not blinding affirming and medicalising.

The Judge was blunt. Para 24

I made it clear … that the Court was not concerned “in what the community thinks” or ideologies, but only what, on the evidence, is in the child’s best interests. Ideology has no place in the application by courts of the law, and certainly not in the determination by courts exercising jurisdiction under the FLA of what is in a child’s best interests.

It is heartening to see the Judge pay careful attention to the Cass Review final report (note para 51) and the considerable variation in international guidelines regarding criteria for starting puberty blockers. The experts disagreed with whether or not Devin had gender dysphoria/incongruence and on the likelihood of Devin persisting with either. The Judge was particularly critical of the mother’s expert Dr N and how cross examination revealed ‘significant issues’ with her diagnostic process. She failed to undertake a ‘biopsychosocial’ assessment of Devin (a broad framework that takes into account the full range of interacting factors) and her notes did not support a ‘consistent, persistent female identity’.

Dr L was similarly treated with caution, as she relied on her own work in drafting the Australian Standards of Care and Treatment Guidelines as ‘best practice’, making her ‘judge, jury and executioner’. The Guidance is strongly ‘affirming’ and relies on statistics about suicide attempts if affirming does not occur. The Judge was particularly concerned to note the Guidance does not consider failure to affirm a ‘neutral’ option, commenting at para 74

it is concerning that an oddly binary approach is adopted in relation to children, especially of the age of the child the subject of these proceedings; that is, to affirm unreservedly those who present with concerns regarding their gender, brooking no questioning thereof. The case of the mother, supported by the evidence of Dr N, is that because the child says so, the child is, and must unquestioningly be affirmed as being, female in gender identity. However, that overlooks the obvious, namely, that the child is still a child and not even, if it matters, a teenager.

The Judge notes at para 75 that the child has lived in a gender affirming home environment and has a social circle dominated by transgender young people. Devin was introduced to a transgender ‘support’ group at the age of 6. The possibility of contextual/environmental influence was accepted, even by Dr N. The mother chose ‘gender affirming underwear’ for her son, to pressure and flatten the penile area, without seeking any medical advice as to its potential adverse impacts.

With echoes of the English case Re J [2016] the mother further asserted that Devin wanted to cut his penis off and tried to self harm aged 6. But she made no mention of any of this in an affidavit of August 2020 and the Judge considered this issue had ‘gathered momentum with the passage of time’ and he rejected the mother’s evidence about this noting her ‘rigid, fixed’ views.

Although the mother’s experts opined that ‘gender identity’ is ‘internal and immutable’ and thus not subject to external influence, neither could point to any empirical or substantive basis for their opinion, but offered only anecdotes (para 88). The Judge was concerned by the mother’s team’s dismissal of any other relevant factor such as maternal influence or underlying neurodivergence (para 90). Again the Cass Review is given favourable mention and the mother’s experts criticised for being ‘at odds’ with it (para 91). Bizarrely it was the mother who put the Cass Review in evidence, even thought it did not support her case.

Interestingly, the Judge dismissed the criticism of the Cass Review offered by a brother Judge in the case of Re Ash (No 4) [2024] FedCFamC1F 777, (para 92). To suggest that because the Cass Review was undertaken in a ‘vexed environment’ means that it was driven by ‘political imperative’ was a rejected by this Judge as ‘speculative’. The Judge goes on to quote at length from Chapters 6 and 8 of the Cass Review, that examine developmental considerations for children and adolescents, and the possible factors influencing the ‘very altered profile of the children and young people who are now being seen in NHS gender services’.

The Judge comments at para 98

Importantly, the Cass Report states that “[s]implistic explanations of either kind (‘all trans people are born that way’ or ‘it’s all social contagion’) do not consider the wide range of factors that can lead young people to present with gender-related distress and undervalues their experiences” (at paragraph 8.25) and that, rather, “gender incongruence is a result of a complex interplay between biological, psychological and social factors” (at paragraph 8.52). Those statements accord with much of the evidence in this case, as well as with commonsense, and I place significant weight on them.

The Judge was clear that Dr N had allowed herself to be influenced by the mother and failed to take into account the father’s views or parenting style (para 111). The imminence of the trial was conceded by Dr N as causative of a diagnosis of Devin as incongruent/dysphoric and in this ‘rush’ to provide evidence the mother at least distorted some of Devin’s symptoms.

At para 123 the Judge confirmed that the opinion of Dr M was not, as the mother alleged either transphobic or ideologically extreme. Dr M had said

Humans cannot change sex. It is not possible for [the child] to be a girl, a woman when he’s [sic] older, or a female. He [sic] can only ever be a male, or a male whose body has been medicalised. It should be celebrated that [the child] is a male who refuses to be constrained by current society’s expectations of his sex, while at the same time maintaining the reality of that sex. [The child] should be prepared for puberty in that it brings changes and while these changes can be confronting and distressing for many of the human race, it will give him [sic] benefits when he [sic] is older. It is important that the adults in [the child’s] life remember that puberty is not a disease, it is a normal developmental stage of humans that brings sexual and reproductive maturity. Avoiding this means [the child] will never reach this stage of maturity.

Taking into account all the concerns about the mother’s evidence, the court was not willing to find the mother had proved on the balance of probabilities that Devin is gender incongruent or had gender dysphoria. IF Devin were either, should puberty blockers be administered? (para 134). The Judge was not impressed with Professor L’s opinion that ‘trans people’ are best placed to know what is in their best interests, given the complexity of the medical evidence adduced in this case (para 143). The Judge accepted the evidence of Dr O (para 151) that there was a lack of evidence and expert consensus regarding gender affirming treatment and an alternative avenue is developmentally informed and holistic psychotherapeutic approaches.

The Judge examined the therapeutic approach at length and expressed concerns that the CHGS clinicians overstated the certainty of the evidence and dismissed the possibility of alternative treatment. He cites the Cass Review to note the surprise that the novel use of puberty blockers did not require a more rigorous trial (para 158) and the concern about the impacts of blocking puberty in general.

The impacts on Devin of puberty blockers, given that almost all children who take puberty blockers progress to cross sex hormones, would be to arrest his physical development at Tanner Stage 2. His penis would never grow. He will be sterile. He will have no sexual function. He will likely develop bone thinning. The effects on his brain are unknown. He will be a medical patient for the rest of his life.

The Judge was therefore not satisfied that even if Devin was gender dysphoric, the purported benefits of puberty blockers outweighed the identified risks (para 187). He accepted the opinion of Dr M (para 191)

the most likely best strategy for [the child] would be to give him [sic] time to breathe, to allow life to settle in his [sic] visitation pattern, to not push nor deny any expression, to not seek treatment or information on a condition/state that [the child] may or may not have that may or may not eventuate into something more formative. Both parents should avoid [the child] being “boxed in” to any identity. It is possible that ongoing engagement with [City K Children’s Hospital] Gender Clinic and its affirmative nature could serve to concrete [the child’s] alternate gender identity that might otherwise desist if left to live life without influence of gender affirmation.

The Judge made it clear that treatment by way of puberty blockers is qualitatively different to childhood vaccinations or surgery to mend broken bones. Earlier decisions of the Australian courts would need to reconsider its categorisations of puberty blockers as reversible.

It is also very refreshing to see the Judge note that the mother derived a personal benefit from being the parent of a transgender child; this had influenced her actions.

Children’s Consent to Medical Transition

The Court of Appeal decision in the Bell v Tavistock case.

This is a post by Sarah Phillimore. I will be discussing these issues at a webinar organised by EBSWA on September 30th. Please join us.

https://m.facebook.com/chegender/photos/a.933845336653629/3805107706194030/?type=3&source=54

Summary

Over recent years, considerable debate has arisen over the consequences of medical intervention which aims to allow ‘gender dysphoric’ children to ‘transition’ from the body into which they were born, to better reflect their perceived ‘gender identity’.  There are serious concerns that this kind of intervention is experimental, with no clear evidence base and carries significant risks for the child.

The debate culminated in 2020 with the challenge of Keira Bell by judicial review, against the lawfulness of the decision by the Tavistock and Portman NHS Foundation Trust (‘the Tavistock’) to agree that she could offer valid consent to medical transition, aged 16. The High Court determined that such cases should be brought to court for a ‘best interests’ decision, emphasising how unlikely it was for children under 16 to be ‘Gillick competent’ and therefore able to offer informed consent to medical transition, by way of puberty blockers and cross sex hormones.

The Tavistock appealed in June 2021 and the judgment was published today, September 17th 2021.

In brief, the Court of Appeal allowed the appeal, considering that the High Court had made findings on controversial and disputed facts, which was not the purpose of a judicial review and which is was not entitled to make. The court noted the real danger in situations involving ethical questions coming before the court on disputed evidence which is not capable of resolution in this arena. The court may attempt “to enunciate propositions of principle without full appreciation of the implications that these will have in practice, throwing into confusion those who feel obliged to attempt to apply those principles in practice.” (para 77). The decision about treatment must be made by the clinicians, child and parents. However, the Court of Appeal sounded a clear note of warning at paras 92 and 93 – clinicians must be aware of their ethical duties when determining a child’s informed consent and failure to do so will carry regulatory or even criminal consequences.

So where do we go from here?

The necessary debate about the implications of medical transition for children – particularly as the huge recent surge in referrals of teenage girls strongly suggests some kind of social contagion rather than pressing medical need – has been gravely hampered by a toxic and polarised atmosphere, whereby legitimate concerns about the welfare of children have been actively rejected as ‘bigotry’ or ‘transphobia’. However, in the run up to the first hearing in Bell and immediately afterwards, consideration of the welfare issues for children began to get more serious exposure.

Current NHS advice with regard to puberty blockers and cross sex hormones states that little is known about the long-term side effects of either treatment. Although some claim that puberty blockers are a physically reversible treatment, the psychological effects are not known. There are concerns about potential impact on the brain  or bones. For boys, ‘pausing’ puberty may mean they do not develop enough penile or scrotal tissue to undergo later construction of a neo-vagina. Cross sex hormones may cause irreversible changes to the body – such as breast growth or deepening of the voice and temporary or permanent sterility. 

The National Institute for Health and Care Excellence (NICE) (see ‘further reading’ below) has concluded that any potential benefits of gender-affirming hormones must be weighed against the largely unknown long-term safety profile of these treatments in children and adolescents with gender dysphoria. Other jurisdictions, such as Sweden, Finland and Australia are also raising concerns about the quality of the available evidence. 

The High Court decision

The High Court held  that in order for a child to be competent to give informed consent to puberty blockers, the child would have to understand, retain and weigh the following information:

  • the immediate consequences of the treatment in physical and psychological terms;
  • the fact that the vast majority of patients taking puberty blocking drugs proceed to taking cross-sex hormones and are, therefore, on a pathway to much greater medical interventions;
  • the relationship between taking cross-sex hormones and subsequent surgery, with the implications of such surgery;
  • the fact that cross-sex hormones may well lead to a loss of fertility;
  • the impact of cross-sex hormones on sexual function;
  • the impact that taking this step on this treatment pathway may have on future and life-long relationships;
  • the unknown physical consequences of taking puberty blocking drugs; and
  • the fact that the evidence base for this treatment is as yet highly uncertain.

The Court considered that it was ‘highly unlikely’ that a child of 13 years or younger could give informed consent (the youngest patient referred to the Tavistock for puberty blockers was aged 10 years) and ‘doubtful’ whether a child aged 14 or 15 could. Clinicians were advised to consider seeking court authorisation before treating any child, but that position was clarified in AB v CD & Ors [2021] EWHC 741 (Fam). If child, their parents and the clinician all agreed that treatment was the best course of action then court authorisation was not required. 

The response of the Court of Appeal

The Court of Appeal, comprised of Lord Burnett of Maldon, Sir Geoffrey Vos and Lady Justice King, handed down its judgment on 17th September 2021.

The judgment begins by making it clear that the only issue before the court was the question of whether or not the sanction of the court was needed before puberty blockers or cross sex hormones were prescribed – not whether the treatment itself was lawful. The claimants argued that those under 18 were not capable in law of giving valid consent.

The court notes at para 5 an ‘odd feature’ of the claim – it was not actually the Tavistock who prescribed puberty blockers. It referred children on to either UCH or Leeds which then independently made its own clinical assessment and obtaining valid consent from the child. Neither hospital trust was joined as a party to these proceedings but intervened as it was their prescribing of puberty blockers that was ‘under attack’. In reality therefore, the claim was a challenge to the NHS policy of providing treatment for gender dysphoric children – the gender identity service at the Tavistock (GIDS) is provided as part of the NHS Standard Contract and commissioned by the NHS Commissioning Board in accordance with a service specification.

The High Court did not find any illegality in the policy or practice of the Tavistock, UCH or Leeds. Nor did it agree that the information given to children was ‘inadequate’ – but did express concern about the ability of children to understand and weigh it [para 150]. The claim for JR was not however dismissed; the High Court went on to declare precisely what was required by ‘informed consent’.

The Tavistock appealed on 8 grounds (para 12)

  • Grounds 1 and 2 – the court misapplied the law in Gillick.
  • Ground 3 – the court’s conclusions were inconsistent with the 1969 Family Law Reform Act.
  • Grounds 4 and 5 challenge the conclusion that prescription of puberty blockers for gender dysphoria is “experimental” and that their effects are “lifelong” and “life-changing”.
  • Grounds 6 and 7 – challenge the court’s reliance on expert evidence adduced by the claimants and relying on it to resolve clinical differences of opinion.
  • Ground 8 – that that the approach of the court discriminates against children with gender dysphoria which cannot be justified

From para 15, the Court of Appeal examined the factual background in more detail. From para 24 it sets out the history of the use of puberty blockers.

How did the High Court deal with the law?

The Court of Appeal examined this from para 39. The High Court had concluded that apart from ‘life saving’ treatment, there could be no more profound intervention in a child’s life and therefore it was appropriate for the court to sanction this type of treatment. But the Court of Appeal responded to remind itself that it should be wary of “becoming too involved in highly complex moral and ethical issues on a generalised, rather than case specific basis.” Neither the service specifications nor the standard operating procedures of the Tavistock were unlawful. The House of Lords in Gillick had been very clear that it was for the clinician to decide if a child under 16 could give informed consent to medical treatment. It was unwise for the courts to attempt to put judicial limits on this – the rights of the patients were better protected by the professional standards of the treating clinicians.

How did the High Court deal with the evidence?

The Court of Appeal were unhappy with how the High Court dealt with disputed evidence.

Even from within the evidence filed on behalf of Tavistock, there is an apparent disconnect between the international experience that 1.6% of children who started puberty blockers did not go on to cross-sex hormones and the figures which arose from the random sample, namely that of 49 referred to the Trusts only 27 were approved for or accessed cross-sex hormones. This is one example of the difficulty in drawing conclusions from statistics which are not fully explained or explored in an evidential context where they were peripheral to the legal dispute before the Divisional Court and where any apparent differences were not capable of being tested forensically.

The Court of Appeal agreed with the stated approach of the High Court that a judicial review was not the correct arena for making findings of fact (para 31) or attempting to choose between disputed expert evidence but considered that despite these statements of intent, the High Court had made some factual determinations. See from para 33:

  • It was unusual for a child to be refused puberty blockers because s/he could not consent; instead ‘more information’ was offered.
  • Once a child started puberty blockers they were on a clear pathway to cross sex hormones
  • This treatment was rightly described as ‘experimental’
  • This treatment may support the persistence of gender dysphoria, which would otherwise have resolved

The Court of Appeal were unhappy that the status of the claimant’s evidence had not been resolved by the High Court- it had been adduced without permission and some of it was ‘argumentative and controversial’. A judicial review is simply not the arena to resolved disputed expert evidence and normally the defendant’s evidence would be taken at face value.

There was further discussion of this from para 61. The High Court found the treatment was ‘experimental’ on the basis that there was ‘real uncertainty over the short and long-term consequences of the treatment with very limited evidence as to its efficacy’ – but the Court of Appeal found it would have been better to avoid those kind of ‘controversial’ findings. The same criticisms were levelled at the finding that the overwhelming majority of children would move from puberty blockers to cross sex hormones. The declaration “turns expressions of judicial opinion into a statement of law itself. In addition, it states facts as law which are both controversial and capable of change” (para 80).

As the Court of Appeal made clear at para 64

The point, however, is that these judicial review proceedings did not provide a forum for the resolution of contested issues of fact, causation and clinical judgement….As will appear from what we say in the next section of this judgment, we have concluded that the declaration implied factual findings that the Divisional Court was not equipped to make.

Was the High Court right to make declarations about the nature of the treatment?

Short answer: No. The Court of Appeal examined this issue from para 66, noting that it was the heart of the appeal: the Tavistock arguing that the court “intruded into the realm of decisions agreed upon by doctors, patients and their parents, where the court had not previously gone.” Nor could the Court of Appeal find any example of declaratory relief being granted in a judicial review where the challenge with regard to the law had failed.

At para 70 the Court of Appeal criticised the High Court’s declarations as attempting an exhaustive list of factual circumstances that must be evaluated in seeking consent from a child. But some of the factors identified beg questions to which different clinicians would give different answers. At para 75 the Court of Appeal said:

The evidence of Tavistock and the Trusts was that the treatment was safe, internationally endorsed, reversible and subject to a rigorous assessment process at each stage. It was supported by the service specification, the WPATH guidelines, the Endrocrine Society Clinical Guidelines and explained in the witness statements of Dr Carmichael and Dr Alvi. As we have seen, and as these proceedings have illuminated, there are strongly held contrary views. The declaration would require the clinicians to suspend or at least to temper their clinical judgement and defer to what amounts to the clinical judgement of the court on which key features should inform an assessment of Gillick competence, influenced by the views of other clinicians who take a different view and in circumstances where Mr Hyam accepts that the service specification, which sets out criteria for referring a child for puberty blockers, is not unlawful. 

Both Lords Scarman and Fraser had in Gillick made detailed observations about what they would expect to see from doctors assessing informed consent. But to have turned these into declarations of law would have been inappropriate (para 81).

Was the High Court right to have given guidance that these matters should come before the court?

Short answer: no. The Court of Appeal noted at para 86 that requiring the decision about this treatment to be sanctioned by the court “placed patients, parents and clinicians in a very difficult position”. The guidance would in practice have the effect of denying treatment as many wouldn’t have the resources to make an application and there would be inevitable delay through court involvement. In addition, where child, parents and clinicians agree treatment is in the best interests of the child, it would be inconsistent with the conclusion of the Supreme Court in An NHS Trust (discussed at [49]) to bring the matter to court.

Having made these decisions, the Court of Appeal did not need to consider the issues around discrimination in the final ground of appeal.

Where next?

I do not doubt that gender dysphoria is a ‘real thing’ and causes great suffering. However, I do very strongly doubt that it is as common as current referal rates or social media activity suggests. The majority of children expressing ‘gender variance’ will not wish to ‘change sex’ if left to go through puberty unmedicated.

The Court of Appeal was clear at para 92 that the pre-Bell landscape has shifted and sounds a warning note for clinicians and their insurers.

We should not finish this judgment without recognising the difficulties and complexities associated with the question of whether children are competent to consent to the prescription of puberty blockers and cross-sex hormones. They raise all the deep issues identified in Gillick, and more. Clinicians will inevitably take great care before recommending treatment to a child and be astute to ensure that the consent obtained from both child and parents is properly informed by the advantages and disadvantages of the proposed course of treatment and in the light of evolving research and understanding of the implications and long-term consequences of such treatment. Great care is needed to ensure that the necessary consents are properly obtained. As Gillick itself made clear, clinicians will be alive to the possibility of regulatory or civil action where, in individual cases, the issue can be tested. 

And at para 93:

But it is for the clinicians to exercise their judgement knowing how important it is that consent is properly obtained according to the particular individual circumstances, as envisaged by Gillick itself, and by reference to developing understanding in this difficult and controversial area. The clinicians are subject to professional regulation and oversight.

Keira Bell’s judicial review has failed but she has performed a great service for not only the welfare of children but also the integrity of the medical and scientific community. The High Court blew the lid off the lack of proper evidence in this field alongside the bizarre cementing of an ‘affirmation path’ which confined children on a route to really serious medical intervention, for the rest of their lives. I hope that the discussion generated by both the High Court and the Court of Appeal will finally bring an end to this dangerous climate of fear, where necessary discussion is shut down as ‘transphobia’.

While I am disappointed that there is little reference by the Court of Appeal to the ancient powers of protection that the court exercises over children I can understand the limitations of the judicial review process and the difficulty of trying to determine disputed and controversial evidence within it. I also hope that the medical profession will undertake their duties to properly assess the informed consent of their child patients, without bowing to pressure from political lobby groups.

The signs are hopeful now of more general willingness and openness to discuss these very important issues. The Cass Review was commissioned in 2020 to carry out an independent review into gender identity services for young people. Its terms of reference focus on the assessment, diagnosis and care of children with gender incongruence and will be wide ranging in scope.

I will await the outcome of the Cass Review with great interest. I hope it is going to show that all patients, but particularly children, need services that are insulated from political ideology. ‘Talking therapies’ must assume a greater importance than simply a model of affirmation. This will no doubt place an even greater strain on the existing specialist facilities for ‘gender diverse’ children but the long term impacts on children are too serious to ignore and we must make investment in our children’s mental health a priority. 

First – Do No Harm.

Online comment

The variety and disparity of the online comment immediately generated, underscores for me the need for Parliament to step in and set clear parameters for the age limits for this treatment.

Transgender Trend response

Andrew Tettenborn, Salisbury Review

Court overturns ‘cruel ruling’ Pink News

Gendered Intelligence blog

Further reading

When can a child consent to medical transition? PDF ‘explainer’ from Transgender Trend and EBSWA

How do children consent? The interplay of Gillick competence and parental responsibility’ CPR Jan 2020

Age at which child can access transgender hormone therapy in Europe 2017 https://fra.europa.eu/en/publication/2017/mapping-minimum-age-requirements/transgender-hormone-therapy

‘First Do No Harm’ May 2019 presentation at the House of Lords https://2d3aa506-25d9-4c0d-b140-7d13f9421f96.filesusr.com/ugd/1b54b4_32788a07d22f4fa59e2cab0dfc6971cf.pdf

For discussion about the research in this area of the efficacy of the current treatment regimes, see Jesse Singal “How Science-Based Medicine Botched Its Coverage Of The Youth Gender Medicine Debate”

https://jessesingal.substack.com/p/how-science-based-medicine-botched

For an examination of the history of the drive to increase children’s access to puberty blockers and cross sex hormones, see Michael Biggs investigation in 2019 ‘The Tavistock’s experiment with puberty blockers’ https://users.ox.ac.uk/~sfos0060/Biggs_ExperimentPubertyBlockers.pdf

Professors Lemma and Savulescu essay in July 2021 in “To be, or not to be? The role of the unconscious in transgender transitioning: identity, autonomy and well-being” https://jme.bmj.com/content/early/2021/07/29/medethics-2021-107397

National Centre for Health and Care Excellence [NICE] evidence review of puberty blockers https://www.evidence.nhs.uk/document?id=2334888&returnUrl=search%3fq%3dtransgender%26s%3dDate

NICE Evidence review of Cross Sex Hormones https://www.evidence.nhs.uk/document?id=2334889&returnUrl=search%3ffrom%3d2021-03-10%26q%3dEvidence%2bReview%26to%3d2021-04-01

Gender Affirming hormone in children and adolescents BMJ 2019 https://blogs.bmj.com/bmjebmspotlight/2019/02/25/gender-affirming-hormone-in-children-and-adolescents-evidence-review/

The decline and fall of science based medicine Andy Lewis July 2021 https://www.quackometer.net/blog/2021/07/the-decline-and-fall-of-science-based-medicine.html

Organisations/Podcasts

Gender: A Wider Lens podcast. Therapists Sasha Ayad and Stella O’Malley openly consider gender, identity, and transition, 

https://www.youtube.com/channel/UCP62aWWtlZV1oVnbMhTRBcg

Transgender Trend https://www.transgendertrend.com/

An organisation of parents, professionals and academics based in the UK who are concerned about the current trend to diagnose children as transgender, including the unprecedented number of teenage girls suddenly self-identifying as ‘trans’ (Rapid Onset Gender Dysphoria or ROGD). See discussion of the teenage brain https://www.transgendertrend.com/teenage-brain/

Evidence Based Social Work Alliance https://www.ebswa.org/

A group of social workers committed to evidence-based practice, a process that involves open discussion and professional curiosity.