The medical, ethical, and legal complications surrounding the puberty blockers case – inews

News If Ms Evans and Mrs A's case wins, a clinical decision to prescribe puberty blockers will soon become a legal one

Friday, 10th January 2020, 4:39 pm

The high court trial is taking place this week (Photo: PA)

Susan Evans, a former nurse who worked with transgender people, intends to file a legal case with 'Mrs A', the mother of a 15-year-old teenager with autism who wants to take puberty blockers. The duo want to establish a minimum of age of 18 for puberty-blocking treatment.

Ms Evans, a former healthcare worker who has now had her proposal supported by the likes of Transgender Trend, an organisation that sends out information packs to schools saying it's better if teachers don't affirm a child's gender identity, said the treatment should only be offered to those aged 18 and above.

But specialists have stated that raising the age of consent for gender diverse children would pose medical, ethical, and legal complications - some of which could be life-threatening for transgender people.

Those who transition at a younger age are offered puberty blockers to take time to think about whether they want to transition (Photo: Foreign and Commonwealth Office/CC By-SA 2.0)

The treatment, given through injection or implant, is given to children and young adults before the onset of puberty so they can consider whether they'd like to permanently transition through cross-sex hormones, before they develop adult characteristics that can only be altered through surgery.

"The puberty blockers put the pause button on puberty," Dr Caroline Salas-Humara, adolescent paediatrician at Hassenfeld Childrens Hospital at NYU Langone, told i.

"The treatment pauses irreversible changes in their body, such as breast growth, voice deepening, body hair, or an Adam's apple developing, which a young person would need surgery later to change if they transitioned. This way, the blockers can stop irreversible changes while being a fully reversible intervention, and it helps the young person feel like theyre not experiencing the wrong puberty.

"If they started and stopped the treatment, whether they've realised they don't want to transition or they decide they want to take cross-sex hormones, puberty would recommence."

A GP will refer a person suffering from gender dysphoria to a gender identity clinic, with seven specialist practices operating in the UK.

At the clinic, specialists will decide whether puberty blockers are right for their patient. But Ms Evans believes that the treatment is offered with little clinical guidance.

The nurse, who left her job at gender identity clinic The Tavistock Centre in 2004, said: "The alarm bells began ringing for me when a colleague at the weekly team clinical meeting said that they had seen a young person four times and they were now recommending them for a referral to the endocrinology department to commence hormone therapy."

Susan Evans discussed her decision to file the case on BBC's Victoria Derbyshire programme (Photo: BBC)

While her words triggered an internal enquiry, Dr Peter Dunne of University of Bristol Law School, an expert on the law surrounding gender identity and sexual orientation,said that the UK generally has a "conservative approach" to puberty blockers.

"In the UK, it's more common for patients to access puberty blockers once their puberty has already started," he told i.

"If you look globally, transgender and gender diverse people who want to change their gender are offered puberty blockers at the very onset of gender dysphoria. When you administer the treatment early, it saves a child going through a process that can be quite harmful," he explains.

The teenager, who was fourteen at the time, says the delay had more of an impact on his mental health than the medication itself.

"I was thankful, because the process was starting, but I was frustrated at times," he said.

"And it's not an easy ride, because you're assessed by the clinic, and challenged on your ideas of who you are. But I know those waiting times are important, and I know blockers can be great for the people who dont know what they want."

According to the argument put forward by Ms Evans and Mrs A's lawyer, the concern doesn't regard the grievances she brought forward in 2004, but the age in which children can take the blockers.

We are essentially seeking to say that the provision at the Tavistock for young people up to the age of 18 is illegal because there isnt valid consent, said Paul Conrathe, a solicitor with Sinclairslaw, which is representing Evans and the mother.

The allegation is in dispute of a landmark legal case over the age of informed consent for children receiving medical treatment without the permission or knowledge of their parents, known as the Gillick competency test.

The test is based on the case of Roman Catholic mother Victoria Gillick, who challenged the right for children and teenagers under the of 16 to be offered the contraceptive pill in 1984.

She was unsuccessful, with the House of Lords ruling that the medication could be offered to under 16s if the child achieves sufficient understanding and intelligence to fully understand what is proposed."

But Mrs A believes that her teenager, who is 15 and autistic, might not understand the decision, writing on a Crowdfunder page for the legal case that she worried that no one (let alone my daughter) understands the risks and therefore cannot ensure informed consent is obtained".

Dominic Wilson, consultant neonatologist and professor of ethics, at the University of Oxford, told i the decision to supply blockers is all down to a patient's understanding.

"The key ethical principle for decisions about medical treatment for a child or young person who cannot consent is whether the treatment is in their best interests, do the benefits outweigh the risks? It is important for the young person (if they are able) to be involved in the decision, but their consent is not crucial. The consent of the child's parents is important.

"If a young person is mature enough to be able to make a decision by themselves, the ethical question is slightly different. Then the focus is on whether the young person understands the risks and benefits of the treatment, and believes that overall it would be best to proceed. They may receive the treatment if they consent to it, even if their parents do not support the treatment."

It is that competency test that clinicians like Dr Salas-Humara use to determine whether their patients are viable and ready for the treatment.

"There is an evaluation process, its based on maturity, and the capacity to send for these hormones," said the specialist.

"In my own clinical experience, oftentimes, I see smart people who are 9, 10, 11 who understand the risks and benefits. Puberty starts earlier than 18," she added.

Activists and their supporters rally in support of transgender people (Photo: Drew Angerer/Getty Images)

Because of these effects, anti-trans campaigners and beyond have referred to puberty blockers as "experimental treatment," with the treatment in need of further study.

While experts are in agreement that treatments for trans people require significantly more research, Dr Salas-Humara has said the treatment has been successfully used on children who haven't experienced any dysphoria symptoms.

"First of all, it's important to know that medical bodies across the world follow specific guidelines on administering treatment such as puberty blockers. What people don't necessarily realise is that this treatment has been safely used on patients for more than 30 years," said Dr Salas-Humara.

"The treatment was first used to treat people with central precocious puberty, to stop children experiencing hormonal changes who had started puberty too early. Because of this, we have been aware of the safety and efficacy of the treatment for children and young adults for a lot longer than people realise."

If Ms Evans and Mrs A's case wins, a clinical decision to prescribe puberty blockers will soon become a legal one - one Dr Dunne believes will result in treatment for transgender children "falling by the wayside."

"In England were married to the welfare of the child through the Children Act. All childrens law is about doing whats best for the welfare for the child. If you have a young person with a clinical determination, that this is a young person who would benefit, then putting in place for obstacles for that child accessing those seems in contradiction with that ruling," said the Law lecturer.

"Prohibiting access to puberty blockers would not be in the best interest of the child, and if an age cap was put on the treatment, it would be"a blanket ban that doesn't take into account these individual considerations. If this became a judicial process, the real fear would be those that can afford it go to court, with other cases falling by the wayside."

But for trans kids that are currently struggling with gender dysphoria, Dr Salas-Humara insists it is crucial that their concerns are taken seriously.

"Theres data to suggest that those 62 per cent of transgender people have experienced mental health problems when they were refused gender affirming care, and 44.8 per cent have attempted suicide. If a young person comes to me, and they are who they are, and theyre suffering with mental health issues, because of societal implications, it would feel wrong to not use our medicine to help them," the paediatrician said.

Read more:
The medical, ethical, and legal complications surrounding the puberty blockers case - inews