'Treat Youth With Gender Dysphoria as Individuals'

Becky McCall

June 27, 2021

Young people with gender dysphoria should be considered as individuals rather than fall into an age-defined bracket when assessing their understanding to consent to hormone treatment, according to the Tavistock and Portman NHS Foundation Trust, as it awaits the verdict of its appeal last week in London against a High Court ruling. 

The High Court ruling, made in December 2020 as reported by Medscape Medical News, stated that adolescents with gender dysphoria were unlikely to fully understand the consequences of hormone treatment for gender reassignment and was the result of a case brought by 24-year-old Keira Bell, who transitioned from female to male at the Gender Identity Development Service (GIDS), starting at the age of 16, but later "detransitioned".

Along with changes made to rules around prescribing puberty blockers and cross-sex hormones to minors with gender dysphoria in countries such as Finland and Sweden, the English ruling signals a more cautious approach to any medical treatment for such children, as detailed in a feature published in April by Medscape Medical News.

However, during last week's appeal, The Trust argued once more that puberty blockers give children time to "consider options" about their bodies and that the decision (the December ruling) was inconsistent with the law that "entitles children under the age of 16 to make decisions for themselves after being assessed as competent to do so by their doctor."

Alongside other organizations, the US-based Endocrine Society submitted written evidence in support of the Tavistock. "The High Court's decision, if it is allowed to stand, would set a harmful precedent preventing physicians from providing transgender and gender diverse youth with high-quality medical care," it noted in a statement.

Defending the High Court's ruling, the lawyer for Bell said its conclusion was that puberty blockers for gender dysphoria are an "experimental" treatment with a very limited evidence base.

"The judgment of the [High Court] is entirely correct and there is no proper basis for overturning it," he asserted.

The 2-day appeal hearing ended on June 24 and a ruling will be made at a later date.

Do Children Understand the Consequences of Hormone Treatment?

One central aspect of the overall case is the fact that Bell regrets her decision at age 16 to transition, saying she only received three counseling sessions prior to endocrinology referral. And she consequently had a mastectomy at age 20, which she also bitterly regrets.

So a key concern is whether young people fully understand the consequences of taking puberty blockers and therapies that may follow, including cross-sex hormones.

Witness for the appeal Gary Butler, MD, consultant in pediatric and adolescent endocrinology at University College Hospital, London, UK, where children are referred to from GIDS for hormone treatment, said the number of children that go on to cross-sex hormones from puberty blockers is "over 80%." 

But the actual number of children who are referred to endocrinology services (where puberty blockers are initiated) from GIDS is low, at approximately 16%, according to 2019-2020 data, said a GIDS spokesperson in conversation with Medscape Medical News

"Once at the endocrinology service, young people either participate in a group education session, or if under 15 years, an individualized session between the clinician and the patient and family members," she added. The Trust also maintained that initiation of cross-sex hormones "is separate from the prescription of puberty blockers."

And since the December ruling, The Trust has put in place multidisciplinary clinical reviews (MDCR) of cases, and in July, NHS England will start implementing an independent multidisciplinary professional review (MDPR) to check that the GIDS has followed due process with each case.

Slow the Process Down, Give Appropriate Psychotherapy

Stella O'Malley is a psychotherapist who works with transitioners and detransitioners and is a founding member of the International Association of Therapists for Desisters and Detransitioners (IATDD).

Whatever the outcome of the appeal process, O'Malley said she would like to see the Tavistock slow down and take a broader approach to counseling children before referral to endocrinology services. 

In discussing therapy prior to transition, O'Malley told Medscape Medical News her clients often say they did not explore their inner motivations or other possible reasons for their distress, and that the therapy was focused more on when they transition, rather than being sure it was something they wanted to do.

"We need to learn from the mistakes made with people like Keira Bell. Clinicians need to realize that fast-tracking counseling doesn't work, especially when [children are]...young and especially when they're traumatized," O'Malley said.

"Had they received a more conventional therapy, they might have thought about their decision from different perspectives and in the process acquired more self-awareness, which would have been more beneficial." 

"The 'affirmative' approach to gender therapy is too narrow, we need to look at the whole individual. Therapy in other areas would never disregard other, nongender issues such as attention deficit hyperactivity disorder or anxiety [which often co-exist with gender dysphoria] — issues bleed into each other," O'Malley pointed out. "We need a more exploratory approach."  

"I'd also like to see other therapists all over the country [UK] who are perfectly qualified and capable of working with gender actually start working with gender issues," she said, noting that such an approach might also help reduce the long waiting list at the Tavistock.

The latter had been overwhelmed and this led to a speeding up of the assessment process, which led to a number of professionals resigning from the service in recent years, saying children were being "fast-tracked" to medical transition.  

Fertility and Sexual Function Are Complex Issues for Kids

Also asked to comment was Claire Graham, from Genspect, a group that describes itself as a voice for parents of gender-questioning kids.

She told Medscape Medical News: "Parents are rightly concerned about their children's ability to consent to treatments that may lead to infertility and issues surrounding sexual function." She added that other countries in Europe were changing their approach. "Look to Sweden and Finland who have both rowed back on puberty blockers and no longer recommend them."

Graham, who has worked with children with differences in sexual development, added that it was very difficult for children and young people to understand the life-long implications of decisions made at an early age.

"How can children understand what it is to live with impaired sexual functioning if they have never had sex? Likewise, fertility is a complex issue. Most people do not want to become parents as teenagers, but we understand that this will often change as they grow," said Graham.

"Many parents worry that their child is not being considered in the whole [and] that their child's ability to consent to medical interventions for gender dysphoria is impacted by comorbidities, such as a diagnosis of autism, or a history of mental health issues. These children are particularly vulnerable."

"At Genspect, we hope that the decision from the...court is upheld," Graham concluded.

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