On Tuesday, the High Court ruled that under-16s are unlikely to be able to give informed consent to puberty blockers, which are prescribed in order to halt puberty in children suffering with gender dysphoria. The case was brought against Tavistock and Portman NHS Trust, which runs the UK’s only gender identity development service (GIDS).
In their decision, the High Court specifically did not express an opinion as to the effectiveness of puberty blockers to treat gender dysphoria. The High Court did, however, conclude that under-16s cannot understand, weigh-up and retain the perceived smörgåsbord of negative consequences of medical transition. Following the judgment, Tavistock has suspended all referrals for under-16s, to which puberty blockers may have been prescribed.
One of the claimants, Keira Bell, is a ‘detransitioner’. While detransitioners are rare, it would be extremely difficult to read a story like Bell’s without sympathy or to conclude that she does not deserve a voice in the conversation around trans healthcare. Detransitioners may complicate the narrative around trans people, but healthcare practitioners should welcome this complication: stories of where a medical pathway to transition has gone wrong, while devastating, provide an opportunity to push the standard of trans healthcare forward. It is a reminder that the approach to alleviating the often debilitating symptoms of gender dysphoria should be individualised.
Therefore, rather than asking whether the judgment is right or wrong, it might be better to ask: will it go toward improving the standards of trans healthcare? My thoughts are: no, not really, which is why I fail to see how the judgment could really be a victory for anyone. The idea that the judgment will protect children is naive: a medical Saint George and the Dragon, whereby the judgment represents the destruction of the seat of the “trans taliban”.
This narrative forgets that, even though there are clear flaws with the data collection and research carried out at GIDS, there are also a number of under-16s who were waiting for treatment, possibly already for years, now left without the prospect of receiving care from the only NHS-funded body of its kind. Those celebrating the High Court judgment as a meaningful victory forget that those children still need some form of help.
Even if the argument is that no medical intervention is allowable, child and adolescent mental health service (CAMHS) waiting times are above government targets, and not all therapists are equipped to deal with children battling with gender dysphoria. And many of these children will likely need help in one form or another (research of “desistance” – the idea that trans kids will grow out of being trans – overestimates its prevalence).
This is precisely why celebrating the High Court’s decision is strange: there is no broader policy or healthcare framework to take its place, other than to wait and see. It is clear that what fits for one child might not work for all, but why should restricting access to healthcare be substitutable for what is necessary: more holistic healthcare which attends to the specific needs of the individual?
Sadly, the development of a healthcare framework which meaningfully serves both under-16s who would benefit from transition and those who would not, and is in line with international medical standards, feels unlikely. This would ultimately be a question of policy, funding (for both care and research) and a forward-looking government, but in a climate of growing hostility toward trans people – the recent shelving of GRA (Gender Recognition Act) reform being one example – things probably won’t change.
The vacuum left by the judgment will also disproportionately affect trans youth from poorer families. As the story goes, trans youth from wealthier families will probably be fine, with the option to go abroad still remaining. However, a chasmic wealth gap, growing worse due to COVID-19, exposes another way in which capital secures drastically different and unfair health outcomes and quality of life for trans people.
I can’t help but ask why the absence of healthcare is acceptable to anyone, or why anyone would celebrate allowing trans kids who may benefit from early intervention to fall to the wayside – even if it means protecting future Keira Bells. I think the answer is that this isn’t about the celebration of protecting children from healthcare that does not serve them specifically, but rather, this is about protecting children from transitioning. As if, somehow, it is not a problem of deciding who should transition and who shouldn’t, but a problem of transness itself.
I suppose it’s fundamentally unsurprising. Trans people, including myself, have an intimate understanding of the pejorative language used to describe their transitions: castration as a byword for becoming infertile; butchering and mutilation for affirming surgeries; and becoming a lifelong medical patient (aren’t we all?) for hormone treatments. Those who might prefer a non-medical pathway, and even those who do pursue a medical pathway, are often shamed for nonconformity, ironically often by the same people who use words like castration and mutilation.
I’d encourage anyone celebrating the judgment to think carefully about an NHS they want. Is it one that wholesale rejects treatments without regard to variable treatment outcomes, or is it one that serves the individual? I know which I’d prefer.
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