Puberty blockers and parental consent

The decision of the High Court in Bell v & anor v The Tavistock & Portman NHS Foundation Trust & ors [2020] EWHC 3274 (Admin) has given rise to both jubilation and outrage. Detransitioners and their gender critical allies feel vindicated by judicial recognition that treatment of children with puberty blockers is experimental and dangerous; trans activists characterise the decision as an attack on the fundamental rights of all trans people.  

The Court’s decision

On the face of it, given the scope of the decision, both reactions are surprising. The court didn’t actually decide that Keira Bell had been rushed into treatment that she wasn’t able to understand, or order the Tavistock to pay her compensation for the permanent damage to her body caused by the treatment she received. It didn’t even order the Gender Identity Development Service (GIDS) at the Tavistock to stop treating children with puberty-blockers, or to change the information it gave them before it started treatment. What it decided was that teenagers under 16 will very rarely have capacity to give informed consent to treatment with puberty blockers, and children of 13 and under almost never. And that even in the case of young persons of 16 or 17, it may be necessary to seek court authorisation to proceed with treatment. 

But children often receive medical treatment for which they lack capacity to give their own informed consent. An infant needing an operation can’t consent: its parents typically consent on its behalf. A child of primary school age may be able to argue more fluently than its parents would always wish, but still may not be equipped to weigh up the pros and cons of serious medical treatments. So what’s the big deal, if children lack capacity to consent to puberty blockers? Why can’t their parents just consent on their behalf, in the usual way?

The Tavistock’s policy

Paragraph 47 of the judgment quotes from a letter sent by the Tavistock’s lawyers in response to the initial threat of litigation: 

Although the general law would permit parent(s) to consent on behalf of their child, GIDS has never administered, nor can it conceive of any situation where it would be appropriate to administer blockers on a patient without their consent.

In context, it is clear that they are not saying merely they wouldn’t administer blockers to a child who didn’t want them: but that they wouldn’t administer blockers except to a child who had capacity to consent on his or her own behalf to the treatment. In other words, the Tavistock’s own policy was (and is) that parental consent isn’t enough: the informed, effective consent of the child patient is required. That’s why the court’s decision that children will very rarely be able to give such consent matters so much: if the Tavistock won’t act on the basis of parental consent alone, then children won’t be treated unless either they can themselves validly consent, or a court decides that the treatment is in their best interests. 

What’s special about treatment with puberty blockers?

The question I find interesting here isn’t really a legal question. It is this: what is it that’s special about treatment with puberty blockers that makes the Tavistock think that parental consent isn’t good enough? If a child needs a vaccination to reduce the risk of a potentially serious childhood disease, parental consent is good enough. If a child needs a filling to deal with tooth decay, or an extraction to deal with an overcrowded mouth, the same. If a child needs surgery to pin a broken bone, the same again. 

Parental consent is good enough for most medical treatment because its necessity or desirability can be established by objective evidence. Tooth decay and broken bones can be seen with an x-ray; the risks of mumps, measles etc. (and the benefits of vaccination) are well-established by epidemiology. But if a child with the body of a girl says she is so sure that she is really a boy that she wants to be treated with puberty blockers to ensure that she doesn’t mature physically as a woman, there no blood test, no visible symptom, no scan, no x-ray that can confirm her condition. How are parents, teachers, therapists and doctors to know whether she is truly trans (assuming for the purposes of argument that there is such a thing – or if even if there isn’t, at least so intractably dysphoric that radical body modification offers her the best hope of a flourishing life); or temporarily caught up in a teenage craze; or expressing distress in response to childhood abuse, homophobic bullying at school, or a traumatic bereavement or abandonment, or the pervasive sexism and misogyny of the society in which she is growing up?

One might think that these were the kinds of difficult questions with which clinicians would grapple earnestly before agreeing to set children on a path to medical transition and lifelong patienthood. What’s going on here? What are the causes of this child’s dysphoria? What are her chances of growing out of it with natural puberty? If treated, what are the chances that she will later regret the treatment? 

Astonishingly, one would be wrong. Even more astonishingly, it seems that the clinicians who have guided the development of the GIDS would not even regard these as valid questions. Bernadette Wren, Consultant Clinical Psychologist at the GIDS until her retirement in 2020, posed herself these questions in a 2014 paper:   

Can ‘postmodern’ ideas about the non-fixity and instability of gender serve the perplexed clinician? Can we forego the grounding of our ideas in demonstrable certainties? Operating with a postmodern notion of gender, can the clinician justify irreversible physical intervention?

Thinking postmodern and practising in the enlightenment: Managing uncertainty in the treatment of children and adolescents, Feminism & Psychology 2014, Vol. 24(2) 271–291

In the abstract of the same paper, she writes: 

In particular, how do we justify supporting trans youngsters to move towards treatment involving irreversible physical change, while ascribing to a highly tentative and provisional account of how we come to identify and live as gendered? I conclude that the meaning of trans rests on no demonstrable foundational truths but is constantly being shaped and re-shaped in our social world.  

[emphasis supplied

This is consistent with Wren’s understanding of postmodernism, of which she says: 

It argues that we cannot properly speak of objective and universal truths because it recognises that we can never stand outside the conceptual frameworks we are trying to explain.

In a later article Debate: You can’t take politics out of the debate on gender-diverse children, Wren candidly admits that there is little reliable evidence to draw on when making decisions about the treatment of gender dysphoric children: 

In this field of practice… studies are still few and limited in scope, at times contradictory or inconclusive on key questions. Professionals and families must navigate the options with limited reassurance about how to proceed in the face of changing and challengeable clinical evidence. 

Child and Adolescent Mental Health 25, No.1, 2020, pp.40-42

But that does not seem to her to be a reason not to give young people what they ask for: 

[U]nder UK law, we have increasingly come to think that enabling young people to experience some forms of self-determining freedom is a social good (Alderson, 2017), an idea interlinked with the thesis that a measure of authentic self-knowledge can be achieved, even by children and adolescents. This is the permissive culture in which young people – including those who are gender diverse – may be allowed considerable freedom to make their own mistakes. Besides, young people today are entering an era of medical care when intervention on and into the body becomes increasingly commonplace. Twenty-first century medicine offers treatments that are supportive of identity projects as well as responsive to pathology

[emphasis supplied

Alarming though this is, it does at least make perfect sense of the GIDS’ unwillingness to accept parental consent as a substitute for the young person’s consent when treating children or adolescents with puberty-blockers: to do so would be fundamentally at odds with the philosophical underpinnings of the service. Parental consent would be rendered acceptable by a firm evidence base for the treatment proposed. But puberty blockers are not provided because there is convincing clinical evidence that they are needed (or even likely) to alleviate distressing symptoms or effect a full or partial cure for a pathology: on the contrary, it is admitted that the evidence base for treatment is thin tending to non-existent. The conclusion to the 2014 article that “the meaning of trans rests on no demonstrable foundational truths” goes further, suggesting that even a search for such evidence would be misconceived.  Instead, treatment is provided because children and young people – who should be enabled to experience self-determining freedom, including the freedom to make their own mistakes – ask for it. 

No evidence of benefit

It makes an alarming kind of sense of something else, too. The court in Bell repeatedly expressed surprise at the Tavistock’s inability to provide evidence about the effects and outcomes of treatment with puberty blockers, noting – in particular – at paragraphs 23 and 24 that it hadn’t been provided with the results of a research study started some nine years earlier at the Tavistock, which it had requested but been told was unavailable because one of its authors had yet to respond to issues raised in the peer review process. On the face of things, that was quite extraordinary: the study was centrally relevant to the matters discussed in the judicial review, and even if it was still going through the lengthy process of peer-review and hadn’t been finalised for publication, it undoubtedly existed in a near-final form which could have been provided to the court had the Tavistock chosen to provide it.  (It was finally published on the day the High Court’s judgment was handed down.)

But if the service was run by postmodernist-leaning clinicians who regarded “truth claims” with suspicion and saw their task not as relieving the suffering of patients with distressing pathologies, but instead as facilitating their young clients in the pursuit of identity projects, what use would they have for clinical evidence? 

Friendly fire from the Good Law Project

The Good Law Project on its crowd-funding page Legal Defence Fund for Transgender Lives announces a proposed challenge to the Tavistock’s policy:

The Tavistock will be invited – or sought to be compelled – to review its position in relation to whether to accept parental consent. In practice success on this action would remove, in many or most cases, the practical barrier to reatment posed by the Bell decision.

If the Good Law Project gets the High Court’s permission to pursue this, the likely result will be that the Tavistock is forced to explain – in detail, and in public – the reasons why it “cannot conceive of any situation in which it would be appropriate to to administer blockers on a patient without their consent.” That will shine further light on the absence of any convincing evidential basis for these treatments, and on the startling philosophical underpinnings of the GIDS’ practice. It promises to be a bruising encounter for both parties.

With thanks to Heather Brunskell-Evans’ Transgender and Body Politics, Spinifex 2020 for alerting me to Bernadette Wren’s writing.

44 thoughts on “Puberty blockers and parental consent”

  1. Well written and explained. Thank you. I take the view that the more sunlight is shone on the work of the Tavistock the better.

  2. Concur.

    The full name of Tavistock is the Tavistock and Portman Trust of the NHS.
    This has had a checkered past regarding attitudes towards Trans children. It established a specialist clinic in 1989, and merged with Portman in 1994.
    Trans children and rapists were streamed together until 2004.

    From the Frontispiece of ‘Lectures on Violence Perversion and Delinquency’, part of the Portman Papers, containing articles by staff at the Portman Clinic, selected and edited by staff at the Portman Clinic, and peer-reviewed by staff at the Portman Clinic. :

    “The Portman Clinic has been applying a psychoanalytic framework to the understanding and treatment of violent, perverse, criminal and delinquent patients since its foundations in the early 1930s. All Portman Clinic patients have crossed the boundary from fantasy and impulse to action – action that defies legal and moral boundaries but that also breaches the body boundary of the victims. Ultimately, the violence underlying most of such violent, perverse and delinquent action also attacks and disturbs the mind of both the victim, be that an individual or society and that of the perpetrator. In this volume, contemporary staff describe their thinking and clinical work. Theoretical underpinnings for the understanding of perversion and violence, questions of risk and ethics and the institutional difficulties which emerge during the care of these patients are presented alongside chapters on clinical work with adults and adolescents, including chapters on pedophilia, the compulsive use of internet pornography and transsexuality. ”

    Oddly enough, they’ve not published any record of the results of their “talking cure” in long-term follow-up. Neither has anyone else.

    The issue here is the PoMo snake oil. The labelling of GID as a “psychosis” when it meets none of the diagnostic criteria for that – like calling Clostridium Botulinum a “virus”, or the Fibula a Tibia.

    The a priori assumption is that Transsexuality is a pathological, dangerous and violent form of delusional insanity.

    That these are “violent, perverse, criminal and delinquent patients”.

    Making no exceptions, the lectures state that “ALL Portman Clinic patients have crossed the boundary from fantasy and impulse to action – action that defies legal and moral boundaries but that also breaches the body boundary of the victims.”

    So who are the victims here? The patients themselves? No, that’s made clear in the distinction between “victim” and “perpetrator”. Society is the victim. Society gets disturbed, just as Society was disturbed by “Sluggish Schizophrenia with Delusions of Democracy”.

    “Ultimately, the violence underlying most of such violent, perverse and delinquent action also attacks and disturbs the mind of both the victim, be that an individual OR SOCIETY and that of the perpetrator”

    It is a classical case of political or ideological diagnosis. The “violence”, as with the “hooliganism” of the Russian Dissidents, is only to socially and politically acceptable beliefs. The same as with the previous diagnoses of “drapetomania” – the psychosis of slaves desiring emancipation – and “suffragette hysteria” – the psychosis of women wanting to vote.

    With the introduction of evidence based medicine, rather than ideology, this changed. However, it is still some 20 years behind the times, desperately playing catchup without having had the opportunity to collect evidence in the UK before 2016.

    For evidence supporting the therapeutic regime practiced by Tavistock since 2016, but not in the UK so not considered persuasive by the learned judges, see:

    The treatment of adolescent transsexuals: changing insights. Cohen-Ketternis et al, J Sex Med. 2008 Aug;5(8):1892-7.

    Professionals who take responsibility for these youth and are willing to help should yet be fully aware of the impact of their interventions. In this article, the pros and cons of the various approaches to youngsters with GID are presented, hopefully inciting a sound scientific discussion of the issue.

    http://ai.eecs.umich.edu/people/conway/TS/News/Europe/Cohen-Kettenis%20JSM2008.pdf

    It has been many years since the old Portman attitudes prevailed, by all accounts. While there are many horrific accounts of the experiences of Trans kids there before 2007, they now appear to be getting their act together. Most of the dinosaurs have long since retired.

    The problem is that the replacements apparently lack experience. This needs looking at. As does the 2 year waiting list for a first appointment (NHS requirement is no more than 18 weeks), the 5,500 waiting list, and the lack of funding for any follow up studies.

    On the other hand, they no longer put pedophiles and trans kids in the same waiting room, nor do they consider mere gender nonconformity to be transsexuality.

    1. Thank you Zoe – this is a fascinating bit of history, of which I was completely unaware. Will read and digest.

      1. Food for thought. The article mentions the plaintiff. I think you will find it as disquieting as I do, though for different reasons.

        https://kyschevers.medium.com/moving-between-worlds-deciding-what-to-do-next-6a148f269af5

        People are individuals. This stuff is hard. The thing is not to be cruel, do no harm.

        Every single detransitioner has been wronged. Mistakes were made, about half should never have transitioned. The other half have also been wronged, they should never have had to retransition because the pressure to detransition was too great.

        3%. Our best estimate of regret is 3%. That means several hundred in the UK. We cannot ignore them. We can’t harm the 97% either in order to reduce that rate. Again, This stuff is hard. The thing is not to be cruel, do no harm.

        We also have to be careful not to infantilise and deny agency to others. While taking responsibility for the majority of situations where we screwed up, sometimes it’s not us. To repeat once more, this stuff is hard. The thing is not to be cruel, do no harm.

        Sometimes the strict binary model of Gender gets in the way, as here. Yet how do we prevent the objective historical harms of Patriarchy without it?

        Human Rights – Freedom – includes the Freedom to make mistakes. Only those who voluntarily take upon themselves a Duty of Care have given up that Freedom.

        Now I’m going to go back to my numbers, my figures, my facts. My refuge from these fraught issues.

        1. It’s so refreshing to do friendly battle on these fraught and difficult questions with someone who admits that they are fraught and difficult! Thank you Zoe.

          I agree the article you link to is disquieting. The author has clearly been through various kinds of hell, and you’d have to be made of stone for your heart not to go out to them.

          But I’m troubled by the author’s repeated treatment of the gender critical position as necessarily transphobic. I am not transphobic, and – though I know a lot of gender critical feminists – I don’t know anyone who is. I don’t believe the same things about trans people that they (commonly – not invariably) believe about themselves; but that doesn’t mean I hate or fear them, or wish them ill. On the contrary: I wish them happy and flourishing lives.

          You say “We also have to be careful not to infantilise and deny agency to others. While taking responsibility for the majority of situations where we screwed up, sometimes it’s not us. To repeat once more, this stuff is hard. The thing is not to be cruel, do no harm.”

          I agree with you on all that – with this proviso. We do have to deny agency to children and adolescents in many circumstances – in order to preserve them from harms they would inflict on themselves. Do you agree, for instance, that we should deny agency to the 14-year-old girl who has a crush on her 21-year-old teacher and wants to have an affair with him?

          Would you agree with me that if a child presents with gender dysphoria, the best possible outcome for them is to desist? That is to say, to come to be happy in the body they were born with, and to cease to be tormented by feelings that it is wrong? And that medical and/or surgical transition should be a last resort, only when it is clear that that “best outcome” can’t be achieved? Or do you think it is necessarily transphobic of me to say that?

        2. I do not understand how you use the word gender. Do you mean sex? Sex is binary. Gender, to the extent one believes in gender identity (I do not) is said to be mutable and multiple. Intervening surgically to adapt sex to this ever changing gender identity is not only cruel, but also pointless. By their own definition of gender, gender ideologists deny the possibility of binary. And yet, they clamor for a strictly binary surgical intervention. Defeated by their own arguments.

      2. @Naomi

        ” Thank you Zoe – this is a fascinating bit of history, of which I was completely unaware. Will read and digest.”

        Until comparatively recently, in the UK the Portland attitudes were standard, default.

        There is a well founded fear that Bell v Tavistock will definitely lead to financial ruin of all parents of Trans children who wish to obtain “Best Practice” care for their offspring.

        There is also a perception – which may be completely inaccurate – of far worse consequences if the wrong Judge is involved.

        https://www.pinknews.co.uk/2020/11/13/transgender-children-parents-crowdfund-legal-battle-fees-family-court-fox-fisher/

        I know personally of only one apparently similar case in the US. Appearances may be completely deceptive, or wholly accurate, the UK records are sealed. A family split was involved, so obtaining an objective view is probably impossible anyway. It is entirely possible, even probable, that the learned judge made a wise decision, rather than a Portland one.

        In the US case, the Jewish family lost custody of their child for causing her “emotional distress” for supporting her social transition, the judge using words very similar to those used in the UK case.

        The US child was fostered to a “Good Christian Family”. In correspondence with her, she stated she obtained emancipation as an adult at age 16, 8 years later, and completed her transition despite significant obstacles.

        Are UK judges of the Family Court occasionally antedeluvian in their attitudes? Perhaps best not to answer that one.

    2. Use of the word ‘dinosaurs’ is neither analytical or descriptive; rather it is pejorative.

      So I will therefore take your comment with a pinch of salt.

      1. @Jones
        A fair comment. “Antedeluvian ” is also not exactly complimentary.
        An accurate description though, in my opinion, and with evidence to back that up.
        Feel free to make a well evidenced counterargument why I am mistaken.

  3. ” before agreeing to set children on a path to medical transition and lifelong patienthood”

    I suspect Naomi Cunningham and I would not agree on feminist or LGBT issues, but I recognise this post as a genuinely interesting legal analysis of the High Court decision, if not for this shocker of a false statement.

    Cunningham has a right to comment on a legal decision, agree or disagree, and I recognise her expertise in legal analysis. I’d be happy to promote this for wider debate – but I can’t do it without this hugely false and substantively misleading statement just … sitting there.

    As anyone who is cisgender and who has been prescribed puberty blockers could have informed you or Cunningham, being prescribed puberty blockers doesn’t make a kid trans. Under international standards of healthcare supported by endocrinologists, a kid who is lucky enough to get as far as a gender-identity NHS clinic will get puberty blockers if, and only if, they meet the international health standard for gender dysphoria. As a recent Newsnight programme illustrated, the Tavistock is very, very good at not prescribing puberty blockers unless a kid really is going to grow up trans.

    Their failure rate – the boys not prescribed puberty blockers who have go to through puberty as a girl and transition as an adult, the girls not prescribed puberty blockers who have go to through puberty as a boy and transition as an adult – is not recorded. But their success rate in almost eliminating false positives is as close to a hundred percent as you can get without being perfect – and this was national news, not so long ago. If Naomi Cunningham missed it, and I concede it’s possible she did, there’s no excuse for the blog collectively to have missed it.

    1. There is a difference of definition that you seem to have overlooked about what constitutes a “failure rate” by the Tavistock. You have implied that if a child takes puberty blockers then chooses to take cross sex hormones later, that proves that the initial decision was correct. By your definition, Keira Bell’s treatment was a success, which seems strange given the consequences and regret that she faces.
      However, many of us, and the court, considered that if a child takes puberty blockers, then hormones, then within a few years desists and regrets the physical changes they have wrought, this is also a failure of treatment. Remarkably, the Tavistock does not track these cases, and cannot provide the data on how common it is. We know anecdotally that this is not rare because of how many detransitioners exist, but we do not know how widespread it is. The court’s decision that children probably could not consent was based in significant part on this lack of data.

      1. “You have implied that if a child takes puberty blockers then chooses to take cross sex hormones later, that proves that the initial decision was correct.”

        Why do you think an adult who isn’t transgender, would want to take hormones for the purpose of medical gender transition? That is a serious question. Why do you think a cisgender adult would want to take “cross-sex hormones”? As a cisgender adult myself, I can’t think of any reason. What reason do you think they would have?

        “Cross-sex hormones” are never prescribed to children in the UK, so your implication that children get to choose cross-sex hormones is inaccurate.

        “However, many of us, and the court, considered that if a child takes puberty blockers, then hormones, then within a few years desists and regrets the physical changes they have wrought, this is also a failure of treatment”

        Yes indeed. But it’s also very, very unusual.

        Keira Bell and her co-plaintiff, the mother who couldn’t stand the idea that her offspring would get to choose transition in adulthood, are neither of them typical cases. And de-transitioners are very unusual – and still more unusual if they don’t re-transition in later life: often de-transitioners report the reason they decided to try to be cisgender is because of the lack of health and social support in their lives for being trans. Medical and surgical treatment for gender dysphoria is very hard to access, and the people who achieve this treatment report post-treatment satisfaction and happiness at a higher rate even than people who get abortions.

        Do you also feel that when an adult chooses to have an abortion, and later regrets it, this would mean abortion on demand ought to be denied all adults as any might come to regret it?

        1. The Tavistocks own long-delayed research into early intervention with puberty blockers was finally published on the day the judgement was handed down. It showed that:-

          1. Virtually all children who took puberty blockers went on to Cross Sex Hormones
          2. Puberty blockers did not improve the childs psychological wellbeing or lessen feelings of dysphoria
          3. Puberty blockers did result in lower bone density and reduced height relative to peers

          There was no control group, hence it is impossible to know what would have happened to children with a similar diagnosis who were not put onto puberty blockers. Children on puberty blockers are in suspended animation – as their peers grow in height and develop secondary sex characteristics they remain with the bodies, and minds of a child. This will make them feel even more different from their peers.

          The numbers given for regret come from a study done at Charing Cross Hospital where researchers took clinical records at random from patients seen over a 1 year period and looked for evidence of regret. The researchers themselves acknowledged the limitations of this approach. Current patients, some of whom may have only just started their treatment, are unlikely to regret their choice. Detransistioners tend not to go back to the clinic that treated them and hence could be expected to drop out of the records. Regret is something that may grow over time. The Tavistock does not keep records of children as they go into adult life, and hence cannot say if these children regret their choices 3, 5, 10 years later. Reddit groups and the Detransistioners Advoacy Network have many individuals that have detransistioned. But the reality there is no robust long term studies.

          What is therefore known is that puberty blockers almost always lead to cross sex hormones with irreversible effects, affect physical development adversely and do not improve mental wellbeing. Going from puberty blockers to cross sex hormones means missing an important stage of development. As the NHS says, we don’t know the long term effect of this.

    2. I’m sorry but I think you are quite simply wrong. The Court very much *did* find that “puberty blocking” was the beginning of a lifetime of medicalisation, because that is what the evidence presented to them (including by GIDS) showed. It is not a “shocker of a false statement” at all, quite the reverse; it is an entirely accurate report of that part of the Court’s reasoning.

      See for example paras 136-138, though it would be better still to read the whole judgment to see how it all hangs together.

      I think you owe the writer of the article an apology to be honest. As I say, she has very much *not* made a “shocker of a false statement … [a] hugely false and substantively misleading statement” – quite the reverse, she has accurately reported the Court’s finding.

      1. ” The Court very much *did* find that “puberty blocking” was the beginning of a lifetime of medicalisation, because that is what the evidence presented to them (including by GIDS) showed.”

        In what way? The court found that GIDs was very, very good at only prescribing puberty blockers to children who, as adults, realised they were transgender.

        To define “being trans” as a “lifetime ofmedicalisation” is a shocking piece of bigotry on your part, not only against trans people, but against anyone who may need lifelong, consistent treatment from the NHS to lead an ordinary life. For example, I need to take anti-histamines every day because I am allergic to dust/dust-mites: I need to wear corrective glasses every waking hour because my vision is so bad: and since I entered peri-menopause, I need to take hormone pills every day to ensure I don’t experience the effects of an out-of-control aging ovary. I have no issues with my “lifetime of medicalisation”, believe me – I like being able to see and to breathe. Why do you have a problem with that?

    3. I said in the original post:

      “One might think that these were the kinds of difficult questions with which clinicians would grapple earnestly before agreeing to set children on a path to medical transition and lifelong patienthood.”

      I think that’s justified by ¶136 of the judgment in the case, of which the final sentence reads: “The evidence shows that the vast majority of children who take PBs move on to take cross-sex hormones, that Stages 1 and 2 are two stages of one clinical pathway and once on that pathway it is extremely rare for a child to get off it.”

      You may disagree with that conclusion, but I don’t think you can fairly reproach me – in analysing the judgment as a lawyer – for treating it as factual.

      Let’s grapple with the substance, briefly, though. I’m not a scientist, so I’ll keep it pretty broad and general.

      You say “the Tavistock is very, very good at not prescribing puberty blockers unless a kid really is going to grow up trans,” but this is really just a different way of looking at the same statistics that the court looked at. If I choose 4 eggs from a box of a dozen, break them into a saucepan containing a little milk and a knob of melted butter, break the yolks and then and stir over a low heat for 10 minutes or so (being careful not to bring the mixture to the boil), those four eggs will turn into scrambled eggs. I am on that measure very, very good at not taking those steps in relation to an egg unless the particular egg really is going to end up scrambled.

      But am I diagnosing the inherent scrambledness of particular eggs, even while they’re still in their shells? Or am I choosing ordinary eggs, and taking steps that have a very strong prospect (tending to certainty, in my experience so far) of scrambling them? The answer is obvious in the case of the eggs on my kitchen counter.

      Suppose there’s a patient population of a number of children – let’s call the number ‘p’ – presenting at the clinic with gender dysphoria. Suppose the clinic diagnoses some number (‘q’) of those as very likely to grow up trans, and prescribes puberty blockers. And suppose they then note that 98.1% of those patients then progress to cross-sex hormones. What have they proved? That they are very good at predicting which children will grow up sufficiently dysphoric to want cross-sex hormones? Or that giving dysphoric children puberty blockers is very likely to confirm their dysphoria to the extent that they will later want cross-sex hormones?

      The answer is “neither.” Despite having been treating children with puberty blockers for many years, the Tavistock repeatedly surprised the court with its inability to provide basic data about treatment and outcomes: it was unable to answer the court’s question about the age distribution of patients referred for puberty blockers (¶¶27-28); nor the proportion who had a diagnosis of autistic spectrum disorder; nor the proportion who progress to cross-sex hormones (¶58 – the figure of 1.9% who did not proceed to cross-sex hormones came from a Dutch study, in the absence of figures from the Tavistock itself).

      The court described treatment with puberty blockers as “experimental” (¶134), because of the degree of uncertainty about its short and long-term consequences, its efficacy, and even what it is seeking to achieve. But a usefully experimental treatment would involve a randomised controlled trial – or if for some reason that proved impracticable, at the very least diligent collection and collation of all available data from the treatment, including long-term follow-up. The Tavistock did neither. In truth, to describe its treatment regime as experimental was to accord it more respect than it merited.

      It is true that the court was left to do the best it could in drawing its factual conclusions on the basis of highly imperfect evidence. That was the fault of the Tavistock, which to a large extent seems not to have bothered to collect the relevant evidence – or (in the case of the research study referred to at ¶24) even to have been reluctant to share with the court such evidence as it had.

      1. “Despite having been treating children with puberty blockers for many years…”

        Less than 5 for those under 16.

        “When the law is on your side, argue the law. When the facts are on your side, argue the facts. When neither is on your side, pound the table”

        If I may crave the Court’s indulgence, and despite the facts being on my side, engage in a little table pounding…. from 2013, an article from the Netherlands arguing that Tavistock should change its policy of not prescribing Puberty Blockers to those not deemed Gillick Competent.

        “Cemeteries can be pretty bleak places, but when it is on the outskirts of a faceless Dutch suburb under a grey January sky, it feel about as about as desolate as you can possibly get. When you are visiting the grave of a child who killed herself in her early teens, the feeling of despair, especially when accompanied by her mother, gives way to an urge to weep bitterly. It is an urge which I am unable to resist as I do the maths subtracting the date of death from the day she was born. It is one thing to be told Juliaantje* was only 14, but to see it carved in marble was too much to bear. Holding her photograph her mother sobs uncontrollably as I hug her while she in turn hugs a precious photograph.

        The picture is of a sunny, smiling, apparently bubbly teenager, with long hair and a grey T-shirt. There is nothing in the picture to suggest that she was transgender, but that is the reason she took her life.

        When she was 12 her mother tried to have her put onto hormone blockers to delay puberty. She didn’t want to develop body hair, a deep voice or have wet dreams. She had already self-harmed when young, trying to slice her penis off with a pair of scissors. However, in what was clearly a borderline decision, the psychologists decided to that she should not be given these drugs. She should be given counselling instead. In despair her mother, a single parent, tried to take her to the United States, but the air fare and the £200 a month cost of these drugs was way beyond her means. Her father had no money either and both sets of grandparents didn’t want to know.

        Two years later the talking therapy failed. Juliaantje took a massive overdose and died, having self-harmed, abused alcohol and other substances for more than a year before that.

        “She was an intelligent and lively girl.” Her mother tells me through the tears and a large glass of Genever in a nearby café, probably the only thing that can deaden the pain of losing her only child. “She had a great future ahead of her, she could have done anything, been a doctor, a lawyer her teachers said…” Her voice breaks. Her happy nature had disappeared when male puberty really hit. “Her voice broke and she started to get facial hair and hair on her chest. She wore make up and turtle-neck jumpers to hide it all, but she simply couldn’t deal with the way her body was developing…”

        Did she blame the psychiatrists? No. Psychiatry is never going to be an exact science, there will always be people who don’t fit into their categories. She does however, feel that they could have given her the benefit of the doubt. “The effects of hormone blockers are easy to reverse, you just stop taking them…” There would have been no risk to her daughter if, at any time she decided that she did not want to be a girl she could simply have stopped, and male puberty would have started.

        Hormone Blockers are essentially a way for young trans people and children to leave their options open. They open an extended open window of choice, which gives them time to think about their future, a time during which young people can decide whether they wish to remain the sex they were assigned at birth, whether that be male or female, or whether they need gender reassignment surgery after the age of 18. Talking to mothers of transgender children in the UK who have been prescribed hormone blockers, usually at great cost (£200 a month plus the cost of a consultation in and flight to the United States) one thing comes across loudly and clearly; “I would rather have a live daughter than a dead son.” One of them told me. One mother had remortgaged her house to pay the cost of these drugs knowing what her child was like, she realised that this would probably be the only way to keep her alive.

        Another mother talked of how her young child had been prescribed a cocktail of a dozen drugs, including Ritalin, because of behaviour problems at home and at school. Yet when her child was recognised as transgender everything changed. As soon as she was treated as a girl, the tantrums, the bedwetting, the crying, the screaming, the hyperactivity, the violence, just stopped, as did the need for any of the drugs. “She became happy and contented almost overnight, just because we treated her like a girl! The psychologist who spotted this probably saved her life.”

        Predictably the accusation of “child abuse” has been levelled at those who advocate prescribing hormone blockers to children between the ages of 12 and 15 (they already are prescribed to those over the age of 16) in the UK. This flies in the face of the evidence in both the United States and Holland, where these drugs have been successfully, and harmlessly prescribed for many years. It also flies in the face of the experience of parents of transgender children, who have lived a day-to-day existence, hoping that their child is still alive and in one piece. Until her daughter was prescribed hormone blockers at age 16 one mother told me of the anguish she and her husband felt when their child had gone missing for a few days when she was 14. “We really thought we would never see her again. Every time the phone rang we thought it would be the police wanting us to identify a body.”

        Now that this technology has been developed, not making it available to all those children who need it is child abuse. Three years ago the trans community was shocked by the suicide of a transgender child who was only 10 years old. The allegation of “child abuse” has been levelled at parents who permit their transgender child to express the gender they prefer and who let them have hormone blockers. Yet this is effectively child abuse in reverse. Not to allow trans children to express their gender identities is actually child abuse. Those who throw accusations of child abuse around without knowing the facts are the ones who are child abusers by proxy; putting pressure on parents to force their children to conform to the gender they were assigned at birth no matter what the consequences.”

        As a scientist, I have to consign that to the box marked “single data point… mere anecdote”. Moreover, slanted to a particular viewpoint, and a little careless of some of the finer points of detail. You have to be caref Cemeteries can be pretty bleak places, but when it is on the outskirts of a faceless Dutch suburb under a grey January sky, it feel about as about as desolate as you can possibly get. When you are visiting the grave of a child who killed herself in her early teens, the feeling of despair, especially when accompanied by her mother, gives way to an urge to weep bitterly. It is an urge which I am unable to resist as I do the maths subtracting the date of death from the day she was born. It is one thing to be told Juliaantje* was only 14, but to see it carved in marble was too much to bear. Holding her photograph her mother sobs uncontrollably as I hug her while she in turn hugs a precious photograph.

        The picture is of a sunny, smiling, apparently bubbly teenager, with long hair and a grey T-shirt. There is nothing in the picture to suggest that she was transgender, but that is the reason she took her life.

        When she was 12 her mother tried to have her put onto hormone blockers to delay puberty. She didn’t want to develop body hair, a deep voice or have wet dreams. She had already self-harmed when young, trying to slice her penis off with a pair of scissors. However, in what was clearly a borderline decision, the psychologists decided to that she should not be given these drugs. She should be given counselling instead. In despair her mother, a single parent, tried to take her to the United States, but the air fare and the £200 a month cost of these drugs was way beyond her means. Her father had no money either and both sets of grandparents didn’t want to know.

        Two years later the talking therapy failed. Juliaantje took a massive overdose and died, having self-harmed, abused alcohol and other substances for more than a year before that.

        “She was an intelligent and lively girl.” Her mother tells me through the tears and a large glass of Genever in a nearby café, probably the only thing that can deaden the pain of losing her only child. “She had a great future ahead of her, she could have done anything, been a doctor, a lawyer her teachers said…” Her voice breaks. Her happy nature had disappeared when male puberty really hit. “Her voice broke and she started to get facial hair and hair on her chest. She wore make up and turtle-neck jumpers to hide it all, but she simply couldn’t deal with the way her body was developing…”

        Did she blame the psychiatrists? No. Psychiatry is never going to be an exact science, there will always be people who don’t fit into their categories. She does however, feel that they could have given her the benefit of the doubt. “The effects of hormone blockers are easy to reverse, you just stop taking them…” There would have been no risk to her daughter if, at any time she decided that she did not want to be a girl she could simply have stopped, and male puberty would have started.

        Hormone Blockers are essentially a way for young trans people and children to leave their options open. They open an extended open window of choice, which gives them time to think about their future, a time during which young people can decide whether they wish to remain the sex they were assigned at birth, whether that be male or female, or whether they need gender reassignment surgery after the age of 18. Talking to mothers of transgender children in the UK who have been prescribed hormone blockers, usually at great cost (£200 a month plus the cost of a consultation in and flight to the United States) one thing comes across loudly and clearly; “I would rather have a live daughter than a dead son.” One of them told me. One mother had remortgaged her house to pay the cost of these drugs knowing what her child was like, she realised that this would probably be the only way to keep her alive.

        Another mother talked of how her young child had been prescribed a cocktail of a dozen drugs, including Ritalin, because of behaviour problems at home and at school. Yet when her child was recognised as transgender everything changed. As soon as she was treated as a girl, the tantrums, the bedwetting, the crying, the screaming, the hyperactivity, the violence, just stopped, as did the need for any of the drugs. “She became happy and contented almost overnight, just because we treated her like a girl! The psychologist who spotted this probably saved her life.”

        Predictably the accusation of “child abuse” has been levelled at those who advocate prescribing hormone blockers to children between the ages of 12 and 15 (they already are prescribed to those over the age of 16) in the UK. This flies in the face of the evidence in both the United States and Holland, where these drugs have been successfully, and harmlessly prescribed for many years. It also flies in the face of the experience of parents of transgender children, who have lived a day-to-day existence, hoping that their child is still alive and in one piece. Until her daughter was prescribed hormone blockers at age 16 one mother told me of the anguish she and her husband felt when their child had gone missing for a few days when she was 14. “We really thought we would never see her again. Every time the phone rang we thought it would be the police wanting us to identify a body.”

        Now that this technology has been developed, not making it available to all those children who need it is child abuse. Three years ago the trans community was shocked by the suicide of a transgender child who was only 10 years old. The allegation of “child abuse” has been levelled at parents who permit their transgender child to express the gender they prefer and who let them have hormone blockers. Yet this is effectively child abuse in reverse. Not to allow trans children to express their gender identities is actually child abuse. Those who throw accusations of child abuse around without knowing the facts are the ones who are child abusers by proxy; putting pressure on parents to force their children to conform to the gender they were assigned at birth no matter what the consequencesul in monitoring bone density for example, Puberty Blockers are powerful JuJu. See the Australian Standards for warnings and data there. Safe? With simple precautions. Reversible? Almost completely, completely if monitored carefully. Read the cited evidence.

        It’s like about 40 other similar anecdotes I have heard, or had personal experience with. When you experience situations like that yourself, when you observe them, retaining objectivity and only relying on numbers, studies, reliable scientific evidence is hard. But utterly necessary. The kind of evidence Tavistock apparently did not provide to the Court.

        Because we are being intellectually honest with each other, this post is to help you judge my own (lack of) objectivity, the kind of bias I would be susceptible to without realising it. Where I should recuse myself from judgment.

        You on the other hand are not constrained in the same way. To be objective, yes, because you can’t do best by your clients unless you are. Ethically constrained too, if only as a matter of professional pride (like me). But not forced to ignore anecdote and witness testimony, as I am.

      2. Naomi,

        ““The evidence shows that the vast majority of children who take PBs move on to take cross-sex hormones, that Stages 1 and 2 are two stages of one clinical pathway and once on that pathway it is extremely rare for a child to get off it.”

        You may disagree with that conclusion, but I don’t think you can fairly reproach me – in analysing the judgment as a lawyer – for treating it as factual. ”

        You should certainly treat as factual that the international standards of care for gender dysphoria are very, very thorough about ensuring that only children who are definitely going to be adult trans people, get puberty blockers and thus choose to take “cross-sex hormones” in adulthood.

        It is counter-factual for you to assume that it is taking the puberty blockers that “makes” a cisgender child become transgender. As Zoe has pointed out in her comments, it is far more common for trans kids to be denied puberty blockers because they are deemed not gender-dysphoric enough, than for a cisgender kid to be prescribed puberty-blockers when they grow up not-trans (and stop taking them and do not go on “cross-sex hormones”.)

        As I note in my comment to Jennifer above, still awaiting approval, it is also a shocking piece of bigotry against anyone who requires life-long medical care to assume that life-long medicalisation is a bad thing and it’s always better to make people do without medications, as well as a shockingly bigoted language choice to define trans people as “life-long medicalised”.

        1. “You should certainly treat as factual that the international standards of care for gender dysphoria are very, very thorough about ensuring that only children who are definitely going to be adult trans people, get puberty blockers and thus choose to take “cross-sex hormones” in adulthood.”

          Why? What international standards of care are you referring to? What is the evidence that anyone has found a way of identifying children who are definitely going to be adult trans people before prescribing PBs for them? If the best evidence is “the overwhelming majority of children who receive PBs go on to cross-sex hormones,” I’m not going to buy that – it no more proves that anyone has found a way of identifying children who are going to be trans adults than my high success rate in making scrambled eggs proves that I’ve found a way of identifying eggs that are destined to be scrambled.

          1. ” What is the evidence that anyone has found a way of identifying children who are definitely going to be adult trans people before prescribing PBs for them? ”

            For that I refer you once more to

            The treatment of adolescent transsexuals: changing insights. Cohen-Ketternis et al, J Sex Med. 2008 Aug;5(8):1892-7.

            Sorry about assigning so much reading material.

            Research on post mortem
            brains of male-to-female transsexuals (MtFs) and
            one female-to-male transsexual (FtM) has dem-
            onstrated that one of the sex-dimorphic brain
            nuclei, the central part of the bed nucleus of
            the stria terminalis, shows all characteristics of
            opposite—sex differentiation [6,7]. Unfortu-
            nately, these brain structures are too small in size
            to visualize with presently available imaging tech-
            niques of the brain, and the (temporal) relation-
            ship between the development and size of these
            brain structures and the development of a GID is
            far from clear. This implies that the diagnosis of
            GID still relies on a subjective report of a person
            verified by a mental health professional using
            diagnostic criteria as spelled out in the widely
            used psychiatric classification system Diagnostic
            and Statistical Manual of Mental Disorders
            IV-TR [8]. Because of the far-reaching nature of
            the interventions, professionals largely follow the
            Standards of Care [9] of the World Professional
            Association for Transgender Health, formerly
            called the Harry Benjamin International Gender
            Dysphoria Association. For adolescents, specific
            guidelines also exist of the British Royal College
            of Psychiatrists [10]. In both guidelines, the diag-
            nostic process is lengthy and takes place in
            several stages. This is important because 80–95%
            of the prepubertal children with GID will no
            longer experience a GID in adolescence [11–13].
            First, there is a diagnostic phase in which the
            actual diagnosis of GID is made, and an estima-
            tion is made of potential risk factors for post-
            treatment regret. Then, during a phase called the
            “real life test” or “real life experience,” both cli-
            nician and patient check whether the applicant is
            able to live satisfactorily in the desired gender
            role. Only if the real life experience had been
            successful, the applicant will be eligible for sex
            reassignment surgery (SRS).
            Some find a diagnostic process as described,
            especially for young applicants, a less than solid
            foundation for a medical intervention impinging
            on the physical integrity of the body [2]. They
            refer to classical medical ethical adages such as “in
            dubio abstine” (when in doubt, abstain from inter-
            vention) and “primum non nocere” (first, do no
            harm). For a long time, health professionals have
            waited till their patients have reached young adult-
            hood, or, in general, the age of legal consent to
            medical treatment, even though these adolescents
            make very clear that they find their pubertal physi-
            cal changes unbearable.
            Besides the professional consideration that the
            condition can only be diagnosed with certainty in
            adulthood (see also below), some health care pro-
            viders might also fear disapproval of the peer
            group, reactions of the correctional medical
            boards, or litigation.
            Changes in Policy
            The Amsterdam VU university medical center
            treats 98% of the Dutch transsexuals. About
            20 years ago, when a few adolescents with an over-
            whelming and clear-cut GID came to the attention
            of clinicians [14], the decision was taken to start
            the sex reassignment (SR) procedure before adult-
            hood. Despite many years of psychotherapy,
            gender dysphoria had not abated in these young-
            sters. Many of the problems they were struggling
            with seemed to be the consequence rather than the
            cause of their GID. They were very lucid about
            their situation, had no psychopathology that
            would obtrude their self-assessment, and were able
            to cope with the process of transitioning to the
            other sex. There was also strong parental support
            for the treatment decision. This convinced us to
            make a change in policy and we decided to treat
            subjects younger than 18 years hormonally. Males
            were treated with anti-androgens first and with
            estrogens a few months later provided they
            appeared to do well; females were treated first with
            progesterone to stop menstrual bleeding and
            androgens later [15]. The minimum age set then
            for this treatment was 16 years. Although, in the
            Netherlands, adolescents are from the age of
            16 years on legally competent to make decisions
            on their medical treatment, parents were required
            to endorse the request for treatment, which always
            was the case. Parents had been involved in the
            earlier diagnostic process and were of the convic-
            tion that hormonal and subsequent surgical treat-
            ment was the only acceptable solution to alleviate
            the suffering of their child.
            In several studies this protocol has been evalu-
            ated [16–18]. From these studies it appeared that
            the youth who were selected for early hormone
            treatment (starting between 16 and 18 years) no
            longer suffered from gender dysphoria, and that
            1–5 years after surgery, they were socially and psy-
            chologically functioning not very different from
            their peers. Their scores on various psychological
            instruments, such as a shortened Dutch form of
            the Minnesota Multiphasic Personality Inventory
            and the Symptom Check List-90 [19], were con-
            siderably more favorable than scores of a group of
            subjects who had been treated in adulthood in the
            Amsterdam clinic, and scores were in the normal
            range as compared to normative samples. By con-
            trast, there was also a cohort of adolescents
            presenting with gender dysphoria, who after long-
            term assessment (which, depending on the degree
            of gender dysphoria and nonrelated pathology,
            could take a year or even longer) were not deemed
            eligible for early treatment, and they did not
            pursue SR at later ages. So, the burden of the
            GID, the unabating pursuit of SR, and clinical
            assessment provided by our clinic appeared to
            provide acceptable selection criteria for good can-
            didates for SR before adulthood. Over the last
            5–6 years the age of adolescents applying for SR
            has dropped considerably. It is no longer unusual
            to have 12-year-olds presenting at gender identity
            clinics with the wish to undergo SR. Most are
            accompanied and supported by their parents.
            These youngsters are no longer willing to wait for
            many years, knowing that the alienating experi-
            ence of development of the secondary sex charac-
            teristics of their biological sex by then will have
            been completed and can only be incompletely
            reversed at a high price of medical interventions.
            Clinics with a good deal of experience with gender
            dysphoric juveniles such as in Gent, Boston, Oslo,
            and Toronto recently started to offer (or refer for)
            medical interventions before the age of 16 years
            provided hormonal puberty has started, and has
            progressed to at least Tanner stage 2. Other crite-
            ria for a start with gonadotropin-releasing
            hormone (GnRH) analogs are: (i) a presence of
            gender dysphoria from early childhood on; (ii) an
            increase of the gender dysphoria after the first
            pubertal changes; (iii) an absence of psychiatric
            comorbidity that interferes with the diagnostic
            work-up or treatment; (iv) adequate psychological
            and social support during treatment; and (v) a
            demonstration of knowledge and understanding of
            the effects of GnRH, cross-sex hormone treat-
            ment, surgery, and the social consequences of sex
            reassignment. Treatment consists of administra-
            tion of GnRH analogs blocking the hormonal
            puberty of their biological sex. No cross-sex hor-
            mones are administered at this stage. In our view,
            these early hormonal interventions should not
            be considered as sex reassignment per se. Their
            effects are reversible. By blocking, delaying or
            “freezing” puberty by means of GnRH analogs
            time is “bought” [20]. The peace of mind of the
            adolescent provides more opportunity to explore
            with the mental health professional the applicant’s
            wish for SR thoroughly. The prospect of the
            alienating experience of developing sex character-
            istics, which they do not regard as their own, will
            not occur. It is also proof of solidarity of the health
            professional with the plight of the applicant. Yet
            many professionals are reluctant to treat youth
            with GID with GnRH analogs. They reason that
            before a GID can be regarded as unremitting, the
            brain must have been fully exposed to the hor-
            mones of puberty of the sex one is born in. There
            is, however, no evidence from brain research to
            support this contention.
            Arguments Pro-Pubertal Delay
            There are a number of reasons for allowing ado-
            lescents to start with the GnRH analogs.
            First, delaying the start of treatment (even
            under 16 years) has its psychological drawbacks.
            Some individuals who have shown a pattern of
            extreme cross-sex identification from toddlerhood
            onwards develop psychological problems, such as
            depression, suicidality, anorexia, or social phobias,
            which are consequences of the agony about the
            pubertal physical development rather than comor-
            bidity unrelated to the GID. This burden can
            adversely affect social and intellectual develop-
            ment. Patients and their parents often report that
            halting the physical features of puberty is an
            immediate relief of the patients’ suffering.
            Second, pubertal suppression may give adoles-
            cents, together with the attending health profes-
            sional, more time to explore their gender identity,
            without the distress of the developing secondary
            sex characteristics. The precision of the diagnosis
            may thus be improved.
            Third, the child who will live permanently in
            the desired gender role as an adult may be spared
            the torment of (full) pubescent development of the
            “wrong” secondary sex characteristics (e.g., a low
            voice and male facial features for the ones who will
            live as women, and breasts and a short stature
            [males are on average 12 cm taller than women]
            for the ones who will live as men). This is obvi-
            ously an enormous and life-long disadvantage.
            Ross and Need [21] found that postoperative psy-
            chopathology was primarily associated with factors
            that made it difficult for transsexuals to pass post-
            operatively successfully as members of their new
            sex. If the adolescents would make a social gender
            change without receiving hormone treatment,
            they may fail to be perceived by others as a
            member of the desired sex and be easy targets for
            harassment or violence.
            Fourth, early treatment will likely make certain
            forms of surgery redundant or less invasive (e.g.,
            breast reduction in FtMs and maxillo-facial
            surgery in MtFs).
            Fifth, follow-up studies among adult transsexu-
            als show that unfavorable postoperative outcome
            seems to be related to a late rather than an early
            start of the sex reassignment procedure (for re-
            views, see [22–24]). Age at time of assessment also
            emerged as a factor differentiating two groups of
            MtFs with and without postoperative regrets [25].
            Sixth, youth who have no access to regular
            treatment may try to find illicit sources of medi-
            cation (Internet and older peers) and turn away
            from any professional health care all together.
            There is increasing evidence that GID is not a
            matter of choice or caused (solely) by environmen-
            tal factors, such as poor parenting. We are still far
            from understanding which factors are necessary or
            sufficient for an atypical gender identity develop-
            ment [26]. Biological factors do seem to play a role
            [6,7,27–29] and may contribute to persistent GID
            (see below).
            Arguments Against Pubertal Delay
            Some assume that it is not possible to make a
            definitive diagnosis of GID in adolescence,
            because in this developmental phase gender iden-
            tity is still fluctuating; others fear that preventing
            secondary sex characteristics to develop will
            inhibit a “spontaneous formation of a consistent
            gender identity, which sometimes develops
            through the ‘crisis of gender’” (see also [30]).
            These points raise the question of what is actually
            known about the persistence of GID in juveniles.
            If childhood GID does not persist over time it
            would be less than desirable to provide early
            somatic treatment. As mentioned earlier, symp-
            toms of GID at prepubertal ages decrease or even
            disappear in a considerable percentage of children
            (estimates range from 80–95%) [11,13]. There-
            fore, any intervention in childhood would seem
            premature and inappropriate. However, GID per-
            sisting into early puberty appears to be highly per-
            sistent [31]: at the Amsterdam gender identity
            clinic for adolescents, none of the patients who
            were diagnosed with a GID and considered eli-
            gible for SR dropped out of the diagnostic or treat-
            ment procedures or regretted SR [16–18]. Even
            some of those who were not eligible to start
            treatment before the age of 18 years because of
            serious psychiatric comorbidity, extremely adverse
            living circumstances, or a combination of both,
            persisted in their wish for SR. Because their other
            problems had to be addressed before they were
            regarded eligible to start SR successfully, their
            treatment was usually delayed until after 18 years
            of age.
            Another potential risk of blocking pubertal
            development relates to the development of bone
            mass and growth, both typical events of hormonal
            puberty, and of brain development. In theory, peak
            bone mass may not be achieved and/or there might
            be body segment disproportion. However, the first
            data of a Dutch cohort of adolescents who have
            been treated with GnRH analogs suggest that,
            after an initial slowing in bone maturation, it sig-
            nificantly caught up after the commencement
            of cross-sex steroid hormone treatment [32]. A
            parallel may be drawn with children with a (con-
            stitutionally) delayed puberty who are similarly
            exposed to sex steroids beyond the normal age of
            puberty. There are indications that these children
            develop a lower bone mineral density than chil-
            dren who go through puberty at a normal age but
            the differences are not large [33]. It has also been
            reported that these differences might be attributed
            to the methods of measuring properties of bone
            [33,34]. Body proportions, as measured by sitting
            height and sitting-height/height ratio, remained in
            the normal range [32]. Early treatment may result
            in a final height for MtFs that is in the normal
            female range. For FtMs, a timely administration of
            oxandrolone may result in acceptable male height
            [32]. Effects of suppression of the hormones
            of puberty on brain development are currently
            studied, and not known yet. Clinically, there seem
            to be no effects on social, emotional, and school
            functioning, but potential effects may be too subtle
            to observe during the follow-up sessions by clinical
            assessment alone.
            Finally, for the MtFs a non-normal pubertal
            phallic growth, the genital tissue available for vagi-
            noplasty may be less than optimal. However,
            appropriate adjusted techniques exist to deal with
            the shortage of tissue [35].
            Ethical and Legal Aspects
            Are adolescents able to make their own decisions
            when it comes to medical treatment? According
            to Dutch law, adolescents from 16 years on are
            legally competent to make a treatment choice,
            even without parental consent, because it is
            assumed that they are able to fully understand the
            pros and cons of a treatment. These, and possible
            alternative treatments, should have been explained
            completely and repeatedly to the patient in the
            course of the diagnostic procedure. Under Dutch
            law, if children are between 12 and 16, they can
            also make treatment decisions, but at this age they
            still need the consent of their parents.
            Some argue that it is not possible to give valid
            informed consent to hormonal suppression of
            puberty, because the risks of it are partially un-
            predictable. Giordano [30] points out that if it
            were impossible to consent to interventions whose
            outcome is uncertain, much medical research
            involving human beings would be unethical.
            Indeed, much research is done because the outcome
            is not known. Naturally, in order to give valid
            consent, the applicant must receive as complete as
            possible information about treatment, and has to
            be informed about the unknown risks of each stage
            of therapy. The person will then consider and
            weigh the unknown risks of treatment and the
            potential benefits on one side, and all the known
            psychological and physical effects of nontreatment
            on the other. It will be clear that in the case of a
            complex treatment such as SR, informed consent is
            not given at a single point in time. Rather, it is a
            process during which the adolescent is progres-
            sively more able to understand what the decision is
            all about.
            Finally, in judging the desirability of hormonal
            pubertal suppression as a first but reversible phase
            in the sex reassignment procedure, one should not
            only take consequences of the intervention into
            account. Rather, one should also consider the con-
            sequences of nontreatment. Nonintervention is
            not a neutral option, but has clear negative life-
            long consequences for the quality of life of those
            individuals who had to wait for treatment until
            after puberty. It may lead to irresponsible and
            risky, unhealthy actions of the patient in order to
            get access to the desired medication, distrust
            against professionals, with negative consequences
            for other aspects of their health care. It may lead to
            developmental arrest, and a psychological func-
            tioning forever hampered by shame about one’s
            appearance. This implies that “in dubio abstine”
            may actually be harmful. Not different from other
            endeavors in medicine, the care for gender dys-
            phoric juveniles must be open to peer review and
            scientific scrutiny, which has always featured high
            on the agenda of the Dutch health care for trans-
            gendered subjects.
            Realizing the potential harmfulness of nonin-
            tervention, one may wonder whether not provid-
            ing treatment may not only be doubtful on ethical
            grounds, but also have legal implications [36].
            In the field of treatment of young adolescents, it
            may be that the adage “in dubio abstine” needs to
            be reconsidered. Particularly when there are
            research opportunities to lessen this “dubium”
            to the benefit of those who suffer from gender
            dysphoria.

            Going through the various cited papers giving the evidence justifying the conclusions therein shouldn’t take more than a few weeks, and the citations they in turn reference , the experimental results, methodology and statistical analysis no more than another few months.

            Of course much more work has been done since then, but this is a good start for an informed layperson.

  4. ” How are parents, teachers, therapists and doctors to know whether she is truly trans (assuming for the purposes of argument that there is such a thing – or if even if there isn’t, at least so intractably dysphoric that radical body modification offers her the best hope of a flourishing life); or temporarily caught up in a teenage craze; or expressing distress in response to childhood abuse, homophobic bullying at school, or a traumatic bereavement or abandonment, or the pervasive sexism and misogyny of the society in which she is growing up?”

    Excellent question, getting to the heart of the matter. (Of course it is, she’s a lawyer with 25 years experience, this is what she *does* for a living)

    The short answer is – years and years and years of psychiatric and psychological observation and testing. Two years in the most simple textbook cases, but often ten or more.

    The long answer I am most familar with, in an Australian context:

    https://www.mja.com.au/journal/2018/209/3/australian-standards-care-and-treatment-guidelines-transgender-and-gender#panel-article

    Abstract

    Introduction: The Australian standards of care and treatment guidelines aim to maximise quality care provision to transgender and gender diverse (TGD) children and adolescents across Australia, while recognising the unique circumstances of providing such care to this population. Recommendations are made based on available empirical evidence and clinician consensus, and have been developed in consultation with Australian professionals from multiple disciplines working with the TGD population, TGD support organisations, as well as TGD children and adolescents and their families.

    Main recommendations: Recommendations include general principles for supporting TGD children and adolescents using an affirmative approach, separate guidelines for the care of pre-pubertal children and TGD adolescents, as well as discipline-based recommendations for mental health care, medical and surgical interventions, fertility preservation, and speech therapy.

    Changes in management as a result of this statement:
    Although published international treatment guidelines currently exist, challenges in accessing and providing TGD health care specific to Australia have not been addressed to date. In response to this, these are the first guidelines to be developed for TGD children and adolescents in Australia. These guidelines also move away from treatment recommendations based on chronological age, with recommended timing of medical transition and surgical interventions dependent on the adolescent’s capacity and competence to make informed decisions, duration of time on puberty suppression, coexisting mental health and medical issues, and existing family support.

    Note ” Although published international treatment guidelines currently exist…”. They have done for decades, and are constantly being updated, either because of an increased evidence base, or to work within newly established legal limits.

    I refer you to WPATH (World Professional Association for Transgender Health) Standards of Care, version 7, section VI, dealing with Assessment and Treatment of Children and Adolescents with Gender Dysphoria


    Phenomenology in Adolescents
    In most children, gender dysphoria will disappear before or early in puberty. However, in some children these feelings will intensify and body aversion will develop or increase as they become adolescents and their secondary sex characteristics develop (Cohen-Kettenis, 2001; Cohen-Kettenis & Pfäfflin, 2003; Drummond et al., 2008; Wallien & Cohen-Kettenis, 2008; Zucker & Bradley, 1995).
    Data from one study suggest that more extreme gender nonconformity in childhood is associated with persistence of gender dysphoria into late adolescence and early adulthood (Wallien & Cohen-Kettenis, 2008). Yet many adolescents and adults presenting with gender dysphoria do not report a history of childhood gender nonconforming behaviors (Docter, 1988; Landén, Wålinder, &
    Lundström, 1998). Therefore, it may come as a surprise to others (parents, other family members, friends, and community members) when a youth’s gender dysphoria first becomes evident in adolescence.
    Adolescents who experience their primary and/or secondary sex characteristics and their sex assigned at birth as inconsistent with their gender identity may be intensely distressed about it.
    Many, but not all, gender dysphoric adolescents have a strong wish for hormones and surgery.
    Increasing numbers of adolescents have already started living in their desired gender role upon entering high school (Cohen-Kettenis & Pfäfflin, 2003).

    It is a long book, chock full of substantiating references justifying the statements therein, based on scientific and medical research over the last 60 years. I can’t quote it all. Here are just a few more snippets.


    Phenomenology in Adolescents

    Among adolescents who are referred to gender identity clinics, the number considered eligible for early medical treatment – starting with GnRH analogues to suppress puberty in the first Tanner stages – differs among countries and centers. Not all clinics offer puberty suppression. If such treatment is offered, the pubertal stage at which adolescents are allowed to start varies from Tanner stage 2 to stage 4 (Delemarre-van de Waal & Cohen-Kettenis, 2006; Zucker et al., in press). The percentages of treated adolescents are likely influenced by the organization of health care, insurance
    aspects, cultural differences, opinions of health professionals, and diagnostic procedures offered in different settings.

    Roles of Mental Health Professionals Working with Children and Adolescents with Gender Dysphoria

    The roles of mental health professionals working with gender dysphoric children and adolescents may include the following:
    1. Directly assess gender dysphoria in children and adolescents (see general guidelines for assessment, below).
    2. Provide family counseling and supportive psychotherapy to assist children and adolescents with exploring their gender identity, alleviating distress related to their gender dysphoria, and ameliorating any other psychosocial difficulties.
    3. Assess and treat any co-existing mental health concerns of children or adolescents (or refer to another mental health professional for treatment). Such concerns should be addressed as part of the overall treatment plan.
    4. Refer adolescents for additional physical interventions (such as puberty suppressing hormones) to alleviate gender dysphoria. The referral should include documentation of an assessment of gender dysphoria and mental health, the adolescent’s eligibility for physical interventions (outlined below), the mental health professional’s relevant expertise, and any other information pertinent to the youth’s health and referral for specific treatments

    Psychotherapy should focus on reducing a child’s or adolescent’s distress related to the gender dysphoria and on ameliorating any other psychosocial difficulties. For youth pursuing sex reassignment, psychotherapy may focus on supporting them before, during, and after reassignment. Formal evaluations of different psychotherapeutic approaches for this situation have not been published, but several counseling methods have been described (Cohen-Kettenis, 2006; de Vries, Cohen-Kettenis, & Delemarre-van de Waal, 2006; Di Ceglie & Thümmel, 2006; Hill, Menvielle, Sica, & Johnson, 2010; Malpas, in press; Menvielle & Tuerk, 2002; Rosenberg, 2002; Vanderburgh, 2009; Zucker, 2006).

    Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success (Gelder & Marks, 1969; Greenson, 1964), particularly in the long term (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965). Such treatment is no longer considered ethical.

    Mental health professionals should not impose a binary view of gender. They should give
    ample room for clients to explore different options for gender expression. Hormonal or surgical interventions are appropriate for some adolescents, but not for others.

    Differences between Children and Adolescents with Gender Dysphoria

    An important difference between gender dysphoric children and adolescents is in the proportion for whom dysphoria persists into adulthood. Gender dysphoria during childhood does not inevitably continue into adulthood.
    Rather, in follow-up studies of prepubertal children (mainly boys) who were referred to clinics for assessment of gender dysphoria, the dysphoria persisted into adulthood
    for only 6-23% of children (Cohen-Kettenis, 2001; Zucker & Bradley, 1995). Boys in these studies were more likely to identify as gay in adulthood than as transgender (Green, 1987; Money & Russo, 1979; Zucker & Bradley, 1995; Zuger, 1984). Newer studies, also including girls, showed a 12-27% persistence rate of gender dysphoria into adulthood (Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Wallien & Cohen-Kettenis, 2008).
    In contrast, the persistence of gender dysphoria into adulthood appears to be much higher for adolescents. No formal prospective studies exist. However, in a follow-up study of 70 adolescents who were diagnosed with gender dysphoria and given puberty suppressing hormones, all continued with the actual sex reassignment, beginning with feminizing/masculinizing hormone therapy (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2010).
    Another difference between gender dysphoric children and adolescents is in the sex ratios for each age group. In clinically referred, gender dysphoric children under age 12, the male/female ratio ranges from 6:1 to 3:1 (Zucker, 2004). In clinically referred, gender dysphoric adolescents older than age 12, the male/female ratio is close to 1:1 (Cohen-Kettenis & Pfäfflin, 2003).
    As discussed in section IV and by Zucker and Lawrence (2009), formal epidemiologic studies on gender dysphoria – in children, adolescents, and adults – are lacking. Additional research is needed to refine estimates of its prevalence and persistence in different populations worldwide.

    And much, much more.

    ” One might think that these were the kinds of difficult questions with which clinicians would grapple earnestly before agreeing to set children on a path to medical transition and lifelong patienthood. What’s going on here? What are the causes of this child’s dysphoria? What are her chances of growing out of it with natural puberty? If treated, what are the chances that she will later regret the treatment?

    Astonishingly, one would be wrong. Even more astonishingly, it seems that the clinicians who have guided the development of the GIDS would not even regard these as valid questions. ”

    While I suppose it is possible that the clinicians at Tavistock have gone completely rogue, and are completely out of step with all accepted International guidelines for medical treatment, I submit that it is far more likely that their practice has been misinterpreted by people who were clueless about the decades long history of the study of such considerations posed in the question.

    That assertions of enforcement of an “anti feminist binary model of gender”, and that clinicians don’t bother with psychological assessment of alternative causes are based on uninformed supposition.

    Were any of the readers here aware of the existence of the International Standards?

    Do the words ” These guidelines also move away from treatment recommendations based on chronological age, with recommended timing of medical transition and surgical interventions dependent on the adolescent’s capacity and competence to make informed decisions, duration of time on puberty suppression, coexisting mental health and medical issues, and existing family support.” from the Australian standard come as a complete surprise?

    The forthcoming version of the SOC will have much of the uncertainty removed. “More study needed”…”there are no formal epidemiological studies”.. were both true in 2009, and 2013 when v7 was published. The first is still true to a concerning extent, but the latter not so.

  5. The whole point of science, done properly, is that it enables us to step outside our assumptions and let reality determine what is true or not.

    If you peruse the biological literature from the 2nd half of the 19thC which I have done it is remarkable the number of photographs and photomicrographs which they contain. 19thC scientists looked at photography and recognised the objective reality of it. They then grasped it with both hands, worked out and built microscope camera connections. Started shipping photographic plates around the world.

    The postmodernists say because the camera can be used to lie this invalidates it entirely, except it doesn’t. When other people can check your work you don’t futz your photos. Do and you will be found out. With digital you leave footprints. I have used the photoshop tools to remove bright distracting bubbles or dust motes from the background of photos. That is acceptable since it does not affect the data itself.

    The data from the Tavistock as placed on the Archive server is damning. Of course 90% of those on puberty blockers go on to further treatment. Their brains have been blocked from maturing to the point where an untreated teen would likely have desisted. The other effects are bad enough but it stops mental development. A puberty blocked teen of any age I would argue is not properly competent for that reason.

  6. The number of adolescents placed on puberty blockers for reasons other than the treatment of Gender Dysphoria exceeds the number treated at Tavistock.

    There is as far as I am aware no evidence for the assertion that “Their brains have been blocked from maturing to the point where an untreated teen would likely have desisted. The other effects are bad enough but it stops mental development. ” in those cases.

    The possibility hasn’t even been raised, as standard psychological tests performed as part of Stage I trials for safety showed no anomalies.

    Having said that.. there is compelling evidence that both testosterone and estrogen cause physiological changes in the brain, both in foetu, adolescence and adulthood.

    See

    Changing your sex changes your brain: influences of testosterone and estrogen on adult human brain structure by Pol et al, Europ Jnl Endocrinology, Vol 155, suppl_1, S107-S114 2006

    Objective: Sex hormones are not only involved in the formation of reproductive organs, but also induce sexually-dimorphic brain development and organization. Cross-sex hormone administration to transsexuals provides a unique possibility to study the effects of sex steroids on brain morphology in young adulthood.

    Methods: Magnetic resonance brain images were made prior to, and during, cross-sex hormone treatment to study the influence of anti-androgen + estrogen treatment on brain morphology in eight young adult male-to-female transsexual human subjects and of androgen treatment in six female-to-male transsexuals.

    Results: Compared with controls, anti-androgen + estrogen treatment decreased brain volumes of male-to-female subjects towards female proportions, while androgen treatment in female-to-male subjects increased total brain and hypothalamus volumes towards male proportions.

    Conclusions: The findings suggest that, throughout life, gonadal hormones remain essential for maintaining aspects of sex-specific differences in the human brain

    While there is no evidence, based on non Gender Dysphoric patients, that “mental development is stopped” by the use of Puberty Blockers, and much against, we cannot completely rule out the conjecture that there may be something different in trans brains that causes arrest of mental development, even though there’s no evidence I am aware of of that. Absence of evidence is not evidence of absence. We know that the neurology of trans people is anomalous, that even before any treatment by puberty blockers or hormones, trans girls have feminised brain structures.

    It has been conjectured, with exactly the same lack of evidence, that those with feminised brain structures have arrested mental development, and are incapable of giving informed consent. This is held to be the case in many Islamic countries, notably Saudi Arabia.

    Dr Ashby, may I assume your expertise is in neurology or psychology? Your confident assertions would seem to indicate you know things I don’t (ok, that’s not a particularly high bar to jump). Could you please clue me in on the evidence you have used to form your conclusions?

    1. Children who have puberty blockers to delay precocious puberty or to allow them to grow taller, undergo puberty after they stop using the blockers and their brains and bodies develop normally.

      Children who go onto cross sex hormones after puberty blockers are not experiencing cross sex puberty, so it is unclear if their brain development continues as it should.
      A girl would get more than oestrogen in natural puberty. A boy would get more than testosterone.

      Their secondary sexual characteristics will approximate the opposite sex but other subtle changes, to growth plates, to brain development etc may not happen at all.

      No one actually knows what happens to someone if you go straight from blockers to cross sex hormones. And the Tavistock was not investigating either.

      That’s the whole point.

    2. “We know that the neurology of trans people is anomalous” – do we? If that’s the case, why don’t they just use MRI to determine if a child is transgender or not? Sorry, I am not convinced. There isn’t enough evidence based on scientific research that this is the case. If you think there is enough evidence for that, don’t you think it’s scandalous that the children aren’t tested fot that? Either was it’s a mass. Though, as I said, I honestly don’t believe there is enough evidence to support your claim.

      1. That’s a good point, Catelyn: if there was a robust diagnostic then why isn’t it being used?

        But all the papers I’ve seen about apparent neurological differences in transgender people, the direction of causality was never established and there are usually many confounding factors.

  7. The Gender Critical Position of WoLF

    https://mobile.twitter.com/LisaTMullin/status/1344571301277564928

    “Would you agree with me that if a child presents with gender dysphoria, the best possible outcome for them is to desist? That is to say, to come to be happy in the body they were born with, and to cease to be tormented by feelings that it is wrong? And that medical and/or surgical transition should be a last resort, only when it is clear that that “best outcome” can’t be achieved? Or do you think it is necessarily transphobic of me to say that?”

    My personal view – with our current imperfect state of technology, I agree with you without much cavil.

    In the far future, then it may be different, but that requires a degree of biological engineering we don’t have.

    Why do I agree? Surgery is often required. That is never risk free. A lifetime of hormone supplementation is required, and that costs Neither sex nor gender strict binary models are more than just approximations, often really good ones, but rarely actually harmful.

    In cases where neither surgery nor medical treatment is required, where the issue is purely Gender Role not body, that’s a different matter. For example, 46,XX children with CAH who are really “butch” but identify as girls, should not be compelled or even encouraged to ” frock it up” to meet societal expectations.

    I have issues telling people they should just accept their bodies, and not get a kidney transplant if they are on dialysis. Likewise with prosthetics. I’m a monster of ego and arrogance, but there *are* limits to my arrogance in telling other adults or children what they should do.

    Taking the case of Ms Bell.

    At age 16, was she Gillick Competent? Current law before this case assumed so, but it was an assumption. This was the age she started Puberty Blockers, and it is really unlikely she was only at Tanner Stage 2. For the sake of argument, let us assume she was *not* Gillick Competent. There is after all some evidence for that.

    At age 18, was she Gillick Competent? Current law before this case says yes, certainly, barring proof of mental disability. This was the age she started taking testosterone. For the sake of argument, let us assume she was *not* Gillick competent, due to her taking Puberty Blockers. That calls into question whether the current assumption that those of that age are Gillick Competent, barring obvious mental disability, is true. This has massive implications on, for example, right to vote, right of sexual consent, right to drive, right to consume alcohol and so on as well as right to consent to medical treatment such as contraception (apparently the target here, not that Ms Bell desired that. As a Feminist lawyer, I’m sure you are aware of the political slant of her legal team. Not that that should make any difference, I’m sure you would do your professional best acting for an ultra conservative MCP client trying to close down a women’s refuge, you’d just prefer to be on the opposition, but I digress).

    What other situations would disqualify an 18 year old from Gillck Competence? A Feminist upbringing? Being a rape victim? The latter would likely result in PTSD with brain changes visible on MRI scans, yet be nowhere near the line set for mental incompetence.

    At age 20, was Ms Bell Gillick Competent? This was the age she requested and obtained a bilateral mastectomy. For the sake of argument, let us assume she was *not* Gillick Competent, because… um… Reasons? Not capable of rational decisions? Where do we draw the line here.

    Apparently the learned judges in her case decided that anyone with Gende Dysphoria is by definition mentally incompetent to consent to medical treatment at any age, or do I have it wrong? If not, then exactly what was it that they did decide?

    I can understand the overturning of age 16 Gillick Competence. I don’t agree, but it is arguable. Age 18… much less so. Age 20, nope.

    Taking your example…
    “Do you agree, for instance, that we should deny agency to the 14-year-old girl who has a crush on her 21-year-old teacher and wants to have an affair with him? ”

    Do we deny agency to the teacher? Are they not responsible for their actions? Are they not assumed to be responsible, capable of making informed decisions? What is the age of “Criminal Responsibility” in the UK? (Looks it up – 10, but 12 in Scotland.. typical social construct)

    Or do we use this case to argue that due to the fact that the teacher broke his collarbone at age 16 and was given strong painkillers, that his brain is not fully developed? A conjecture with possibly even more evidentiary support than in Bell v Tavistock given the number of such people who go on to develop opioid addiction?

  8. “What international standards of care are you referring to? ”

    International Standards of Care v7 from the World Professiomal Association for Transgender Health.

    Plus the many commentaries on it . Use Google Scholar to find those.

    One you might find particularly useful.

    https://scholar.google.com.au/scholar?start=10&q=wpath+soc+7&hl=en&as_sdt=0,5&as_vis=1#d=gs_qabs&u=%23p%3Ds1q0HtQlKFcJ

    Gender dysphoria in adolescence
    Scott Leibowitz, Annelou LC de Vries
    International Review of Psychiatry 28 (1), 21-35, 2016
    Adolescents presenting with gender-related concerns are increasingly seeking support from providers from a variety of disciplines within health care settings across the world. For those treating young people who meet the criteria for the DSM 5 diagnosis of gender dysphoria (GD), complex decisions in clinical care are common. Defining best practice with this population with respect to interventions that span mental health, physical, and surgical domains can be challenging, given a relative dearth of empirical data available; yet practice guidelines have emerged from different professional organizations which can aid with this. For this review paper, a broad literature search was performed to identify relevant studies pertaining to the care of adolescents with GD. In addition, an overview of trends in clinical practice, including shifts in conceptualization of how clinicians and patients define care that is considered affirming when working with this population, is described. This paper explores the characteristics of referral patterns to specialized clinics, provides a brief overview of gender identity development in adolescence, and then describes the phenomenology of known aetiological factors and co-occurring psychiatric issues in adolescents with GD. Additionally, clinical management considerations that detail assessment aims and common treatment interventions across disciplines will be explored.

  9. Not ready for prime time.

    £50,000 of functional MRI scans are no more accurate than 5 mins of just asking the child what sex they are at age 9. Accurate, but un necessarily expensive.

    It is confounded because the easy and relatively inexpensive tests by the low voxel (ie low resolution) imagers used in most hospitals rather than research labs are only good for testing gross characteristics such as size of brain structures and static views of blood flow. Distribution of cell types within a structure, and functional (dynamic) imaging of blood flow in response to certain stimuli, not so much, and it’s those subtle tests that are needed, taking many hours or days. Brains of men and women are far more similar than different in most (not all) ways, and exposure to sex hormones is responsible for most (not all ) of the obvious differences that exist.

    See
    Changing your sex changes your brain: influences of testosterone and estrogen on adult human brain structure by Pol et al, Europ Jnl Endocrinology, Vol 155, suppl_1, S107-S114 2006

    Objective: Sex hormones are not only involved in the formation of reproductive organs, but also induce sexually-dimorphic brain development and organization. Cross-sex hormone administration to transsexuals provides a unique possibility to study the effects of sex steroids on brain morphology in young adulthood.

    Methods: Magnetic resonance brain images were made prior to, and during, cross-sex hormone treatment to study the influence of anti-androgen + estrogen treatment on brain morphology in eight young adult male-to-female transsexual human subjects and of androgen treatment in six female-to-male transsexuals.

    Results: Compared with controls, anti-androgen + estrogen treatment decreased brain volumes of male-to-female subjects towards female proportions, while androgen treatment in female-to-male subjects increased total brain and hypothalamus volumes towards male proportions.

    Conclusions: The findings suggest that, throughout life, gonadal hormones remain essential for maintaining aspects of sex-specific differences in the human brainre more accurate and reliable tests, but they require thinly slicing sections of the brain, and examining those under the microscope, so have obvious disadvantages as diagnostic tools.

    If I can make use of an analogy…

    It is not particularly controversial to say that women are shorter than men. By and large. With exceptions. This is not “sexist”, just a matter of demonstrable biological fact.

    If we took a large number random humans of age 20 in the UK, and divided them into 3 groups,
    1)
    those 3″ under average height,
    2)
    those 3″ over average height, and
    3)
    those in the “too hard” basket,

    we could say with a high degree of confidence that those in the first group are very probably female, those in the second group very probably male.

    This would be quite accurate.

    Or.. we could forego the measurement, and ask them. 1 in 60 are Intersex in some say (usally indetectible without subtle lab tests and so of no practical conseauence). 1 in 300 are Trans to a greater or lesser degree (but only 1 in 3000 would require medical treatment, if that) . Asking them would be at least as accurate as measuring their height.

    It would also avoid the issue of arrogantly informing someone only 5ft tall that they “must be female” despite their objections, because “the biological test says so”.

    Some useful papers for those interested in the details:

    First, the binary model of sex is an approximation.

    Sexual differentiation of the human brain in relation to gender identity and sexual orientation D.Swaab & A.Garcia-Fulgaras Functional Neurology, Jan-Mar 2009:

    One person we studied had untreated male gender dysphoria (S7), took no hormones and kept his transsexual feelings under wraps. He appeared to have a large INAH3 volume – in the male range – but a female INAH3 number of neurons (68) and a female BSTc somatostatin neuron number (95). Hence, this individual’s hypothalamic characteristics were mid-way between male and female values.

    If you want certainty, try Religion or Ideology. Science has to be more cautious.

    A sex difference in the hypothalamic uncinate nucleus: relationship to gender identity. by Garcia-Falgueras et al Brain. 2008 Dec;131(Pt 12):3132-46.

    We propose that the sex reversal of the INAH3 in transsexual people is at least partly a marker of an early atypical sexual differentiation of the brain and that the changes in INAH3 and the BSTc may belong to a complex network that may structurally and functionally be related to gender identity.

    White matter microstructure in female to male transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study. – Rametti et al, J Psychiatr Res. 2010 Jun 8.

    CONCLUSIONS: Our results show that the white matter microstructure pattern in untreated FtM transsexuals is closer to the pattern of subjects who share their gender identity (males) than those who share their biological sex (females). Our results provide evidence for an inherent difference in the brain structure of FtM transsexuals.

    Regional cerebral blood flow changes in female to male gender identity disorder. – Tanaka et al, Psychiatry Clin Neurosci. 2010 Apr 1;64(2):157-61.

    RESULTS: GID subjects had a significant decrease in rCBF in the left anterior cingulate cortex (ACC) and a significant increase in the right insula compared to control subjects.
    CONCLUSIONS: The ACC and insula are regions that have been noted as being related to human sexual behavior and consciousness. From these findings, useful insights into the biological basis of GID were suggested.

    I said “differences” rather than “100% complete sex reversal in all aspects” deliberately,

    Regional gray matter variation in male-to-female transsexualism. by Luders et al Neuroimage. 2009 Jul 15;46(4):904-7.

    We analyzed MRI data of 24 male-to-female (MTF) transsexuals not yet treated with cross-sex hormones in order to determine whether gray matter volumes in MTF transsexuals more closely resemble people who share their biological sex (30 control men), or people who share their gender identity (30 control women). Results revealed that regional gray matter variation in MTF transsexuals is more similar to the pattern found in men than in women. However, MTF transsexuals show a significantly larger volume of regional gray matter in the right putamen compared to men. These findings provide new evidence that transsexualism is associated with distinct cerebral pattern, which supports the assumption that brain anatomy plays a role in gender identity.

    Functional MRI allows more sophisticated testing.

    Specific Cerebral Activation due to Visual Erotic Stimuli in Male-to-Female Transsexuals Compared with Male and Female Controls: An fMRI Study by Gizewski et al J Sex Med 2009;6:440–448.

    Results. Significantly enhanced activation for men compared with women was revealed in brain areas involved in erotic processing, i.e., the thalamus, the amygdala, and the orbitofrontal and insular cortex, whereas no specific activation for women was found. When comparing MTF transsexuals with male volunteers, activation patterns similar to female volunteers being compared with male volunteers were revealed. Sexual arousal was assessed using standard rating scales and did not differ significantly for the three groups.

    (Correspondence with the author showed both control and trans groups were not all heterosexual, this is not a matter of sexual orientation, but instinctive sexual behaviour regardless of target)

    Male-to-female transsexuals show sex-atypical hypothalamus activation when smelling odorous steroids. by Berglund et al Cerebral Cortex 2008 18(8):1900-1908;

    …the data implicate that transsexuality may be associated with sex-atypical physiological responses in specific hypothalamic circuits, possibly as a consequence of a variant neuronal differentiation.

    Dichotic Listening, Handedness, Brain Organization and Transsexuality Govier et al International Journal of Transgenderism, 12:144–154, 2010

    This study investigated the functional brain organization of 68 male-to-female (MtF) transwomen and 26 female-to-male (FtM) transmen by comparing their performance with 36 typical male and 28 typical female controls on two indicators of cerebral lateralization: dichotic listening and handedness. A sex-differentiating dichotic test and a handedness questionnaire were administered. It was hypothesized that the MtF participants’ dichotic performance would be significantly different from the control males and resemble the control female pattern. This hypothesis was supported. It was also hypothesized that the FtM dichotic pattern would be significantly different from the control females and would resemble the control male pattern. This hypothesis was not supported. Finally, it was hypothesized that there would be significantly more nonexclusive right-handers in both trans-groups. This hypothesis was supported. Taken together, the dichotic and handedness data reported here indicate that the MtF and FtM conditions are not mirror images in terms of the verbal-auditory aspects of their brain organization and neurobiology plays an important role, particularly in the development of the male-to-female trans-condition.

    And, oh, a couple of thousand other papers.

  10. @Kel R

    ” Children who go onto cross sex hormones after puberty blockers are not experiencing cross sex puberty, so it is unclear if their brain development continues as it should”

    Interesting assertion. What animal experiments would suggest that?

    Apart from 17b estradiol, and the various steroids it aromatises to in the body, and progesterone, and its aromatisation products, what other significant steroids are produced at puberty in females are there that are blocked by GnRH analogues (colloquially, puberty blockers)? Pituitary is affected, parathyroid and thyroid are not affected. Testes, ovotestes and adrenals are indirectly because of pituitary effects.

    Same with males and testosterone, aromatising to DHT (and if over done, estrogen)

    (Yes, I’m greatly simplifying, missing out the roles of 3beta hydroxysteroid dehydrogenase in converting cholesterol to progesterone, etc, steroidogenesis is complex)

    What differences are there between the therapeutic regime recommended by the Endocrine Society and “cross sex puberty” as you would define it? Follicular stimulating hormone (FSH)? Lutinising hormone (LH)? How do these affect “brain development”?

    I’d be very much in your debt if you could point me to some citations on PubMed or elsewhere where I could look this stuff up.

    I’m aware of effects on spatial cognition in sheep, but this is explained by any testosterone blocking, and has not been replicated in goats or mice.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5140006/

    Spatial memory is impaired by peripubertal GnRH agonist treatment and testosterone replacement in sheep,
    Hough et al, Psychoneuroendochrinology Jan 2017

  11. I do not understand how you use the word gender. Do you mean sex? Sex is binary. Gender, to the extent one believes in gender identity (I do not) is said to be mutable and multiple. Intervening surgically to adapt sex to this ever changing gender identity is not only cruel, but also pointless. By their own definition of gender, gender ideologists deny the possibility of binary. And yet, they clamor for a strictly binary surgical intervention. Defeated by their own arguments.

    1. @Allesandra

      Sex is not strictly binary. But that’s a good approximstion.
      Gender Identity is not strictly binary. But that’s a good approximation.
      Gender is hardly binary at all, the approximation is poor.

      Those are 3 different things.

      Sexual orientation is a different thing again.

  12. “The meaning of trans rests on no demonstrable foundational truths.” Nailed it! Like other commenters here, I do not believe in the existence of ‘gender identity’ upon which the whole ‘trans’ narrative is built. These are surreal times, when we witness the medicalisation of healthy bodies; compelled speech; adulteration of the meanings of words; silencing of opinion; new laws; destruction of boundaries and relinquishment of human rights for the ‘normal’ majority – all for something which, as far as we are concerned, is non-existent.
    A gaping flaw in this ideology is the claim that we ALL have a ‘gender identity’ – gaping, because it can be debunked in an instant by all of us who can say, “No. I haven’t got one.” Once that is said, there is no reason to believe anything else about it. I agree with Ms Wren. Why search for ANY truth when one falsehood stares us in the face instantly?
    I also disagree with the notion that competence to reach an informed decision rests solely upon the age of the individual. A 20-year-old female who has had no medical intervention thus far, wishing for a double mastectomy, cannot be compared to a female of the same age who has spent the last quarter of her life believing herself to be a boy. The years from 15 to 20 are especially significant; in my experience, we undergo more changes then than at any other time in our lives. Imagine yourself spending that time as you probably DID; then imagine if you had spent it changing aspects of your body so as to resemble those of the opposite sex, socialising as the opposite sex, convincing yourself and being convinced by others that you were the opposite sex. I doubt very much that you would make the same decisions!
    Irreversible body changes seem to completely overlook the widely accepted notion of neuroplasticity. We don’t spend our lives thinking the same way all the time. For instance, there are people from very religious backgrounds who become adamant atheists; atheists who become ‘born-again Christians’; people who change from one religion to another; people with strong opinions on a given topic who can be swayed by the opinions of others, and even if they don’t change their minds, can see where ‘the other side’ is coming from; people who fall into depression and think only negative thoughts and see ugliness and pointlessness everywhere but who recover an ability to be in awe of the beauty in the world; people with PTSD who constantly relive a trauma, then find that they are remembering rather than reliving it, then find themselves remembering it less; people who are born able-bodied, then become disabled and their brain adapts to compensate. Yet we are told by gender ideologists that, despite the possibility of being ‘gender fluid’ (whatever that is!) paradoxically a ‘gender identity’ is set in stone and the body must be changed to accommodate an immutable ‘feeling’/belief/way of thinking. Factor in those who claim this ‘feeling’ but don’t want to change their bodies, and it becomes all the more incoherent.
    I think that sums up why so many of us are ‘gender sceptics’!

  13. @Alan Henness

    I could refer you to previous comments on previous posts, regarding Intersex. But that on its own would be too much like the intellectually dishonest cop out of demanding that you do your own research. I do urge you to have a look though, as I go into great detail there.

    I will leave you with a few quotes and citations that might help explain. One legal, one theological, one scientific.

    https://www.aclu.org/sites/default/files/field_document/16-273_bsac_interact_advocates_for_intersex_youth.pdf

    Gloucester County School Board v. G.G – interACT: Advocates for Intersex Youth, et al.

    ” This case raises issues central to amici’s mission as advocates for intersex youth. Petitioner maintains that the word “sex” in Title IX must refer only to an Individual’s so-called “physiological” sex, rather than the sex with which an individual identifies and lives every day. This is so, Petitioner argues, because “physiological” sex—purportedly unlike gender identity—is binary, objective, and self-evident. The intersex youth for whom amici advocate are a living refutation of this argument.

    Petitioner’s simplistic view of “physiological” sex is demonstrably inaccurate as a matter of human biology. Moreover, it demeans many thousands of intersex youth by erasing their bodies and lives and placing them outside the recognition of the law. Physicians who treat individuals with intersex traits recognize that the key determinant of how individuals navigate sex designations in their lives is their gender identity—their internal sense of belonging to a particular gender.

    Gender identity, they suggest, is “fuzzy and mercurial,” id. at 8, while “physiological” sex simply is. But the foregoing discussion should make clear that this assertion is similarly flawed. An intersex student’s “physiological” sex may depend entirely on which Physiological trait one chooses to privilege. Indeed, because of the diversity of medical perspectives, trained experts can and do disagree on the “correct” sex to assign to an intersex child.

    Interpreting “sex” to refer to a student’s gender identity would avoid (or at least mitigate) these problems. Unlike “physiological” sex, all parties appear to agree on what gender identity means: it is “[an] individual’s ‘innate sense of being male or female.’” Pet. Br. at 36; cf. Resp. Br. at 2 (similar). It is not subject to competing definitions depending on which expert or court is consulted. Moreover, unlike “physiological” sex, a student’s gender identity by definition cannot be subject to differences in medical opinion: each student is the ultimate arbiter of their own gender identity, as they (and they alone) experience it first-hand.

    Accordingly, when Congress enacted the provision at issue here, it knew—or, at minimum, should have Known—that not all students could be straightforwardly categorized as “male” or “female” based on Their anatomy alone. Congress could not have believed otherwise without ignoring millennia of Western history, science, and law.

    Regarding “Millenia of western history, science and law”: John Boswell’s Christianity, Social Tolerance, and Homosexuality (Appendix Two) has a translation of Peter Cantor’s De vitio sodomitico — or On Sodomy (d. 1192 AD). Here’s the excerpt on hermaphrodites (or as we’d call them now, intersexuals) were viewed historically by a prominent, Catholic Theologian:

    The Lord formed man from the slime of the earth on the plan of Damascus, later fashioning woman from his rib in Eden. Thus in considering the formation of woman, lest any should believe they would be hermaphrodites, he stated, “Male and female created he them,” as if to say, “There will not be intercourse of men with men or women with women, but only of men with women and vice versa.” For this reason the church allows a hermaphrodite — that is, someone with the organs of both sexes, capable of either active or passive functions — to use the organ by which (s)he is most aroused or the one which (s)he is more susceptible.

    If (s)he is more active [literally, “lustful], (s)he may wed as a man, but if (s)he is more passive, (s)he may marry as a woman. If; however, (s)he should fail with one organ, the use of the other can never be permitted, but (s)he must be perpetually celibate to avoid any similarity to the role inversion of sodomy, which is detested by God.

    If you want something a little more recent than 800+ years old, there’s https://www.scientificamerican.com/article/sex-redefined-the-idea-of-2-sexes-is-overly-simplistic1/

    Sex Redefined: The Idea of 2 Sexes Is Overly Simplistic
    Biologists now think there is a larger spectrum than just binary female and male

    As a clinical geneticist, Paul James is accustomed to discussing some of the most delicate issues with his patients. But in early 2010, he found himself having a particularly awkward conversation about sex.

    A 46-year-old pregnant woman had visited his clinic at the Royal Melbourne Hospital in Australia to hear the results of an amniocentesis test to screen her baby’s chromosomes for abnormalities. The baby was fine—but follow-up tests had revealed something astonishing about the mother. Her body was built of cells from two individuals, probably from twin embryos that had merged in her own mother’s womb. And there was more. One set of cells carried two X chromosomes, the complement that typically makes a person female; the other had an X and a Y. Halfway through her fifth decade and pregnant with her third child, the woman learned for the first time that a large part of her body was chromosomally male. “That’s kind of science-fiction material for someone who just came in for an amniocentesis,” says James.

    Sex can be much more complicated than it at first seems. According to the simple scenario, the presence or absence of a Y chromosome is what counts: with it, you are male, and without it, you are female. But doctors have long known that some people straddle the boundary—their sex chromosomes say one thing, but their gonads (ovaries or testes) or sexual anatomy say another. Parents of children with these kinds of conditions—known as intersex conditions, or differences or disorders of sex development (DSDs)—often face difficult decisions about whether to bring up their child as a boy or a girl. Some researchers now say that as many as 1 person in 100 has some form of DSD.

    Intersex people really don’t like to be referred to as “disorders”. Technically, 1 in 60 people don’t match either male or female stereotype in every respect, but if it takes a subtle battery of lab tests to detect the difference, it’s usually inconsequential.

    However, for many Intersex people, the differences from either M or F can be spectacular. Most have either a male or female Gender Identity, but some identify as both, others as neither. And they have the anatomy to prove it.

    Feel free to ask for more elucidation, as you can imagine, like many scientists, I can talk for hours on my subject of research.

    1. Sorry, was that in response to my comment “Can you explain “Sex is not strictly binary”, please?”? If so, your reply has appeared in the wrong place.

      However, I was hoping something other than anecdotes, a US court case or the bible.

      In terms of the Scientific American article, when someone asked the author, Claire Ainsworth, “In your piece ‘Sex Redefined’ are you making the claim there are more than 2 sexes?”, she replied: “No, not at all. Two sexes, with a continuum of variation in anatomy/physiology.”

      Further:

      Humans are sexually dimorphic, with rare intersex conditions being anomalous developments of dimorphic sexual classes. It is not possible to change biological sex.[1]

      And:

      Sex

      Humans are sexually dimorphic: there are only two viable gametes and two sexes, whose primary and secondary sexual characteristics determine what role they play in human reproduction. Sex is determined at fertilisation and revealed at birth or, increasingly, in utero. The existence of rare and well-described ‘disorders (differences) of sexual differentiation’ does not negate the fact that sex is binary. The term ‘assigned at birth’ suggests a possibly arbitrary allocation by a health professional, rather than the observed product of sexual reproduction.[2]

      There are only two gametes and therefore only two sexes: sex is binary.

      __________
      1. Bewley S, Clifford D, McCartney M, et al. Gender incongruence in children, adolescents, and adults. Br J Gen Pract 2019;69:170–1. doi:10.3399/bjgp19X701909 https://bjgp.org/content/69/681/170
      2. Griffin L, Clyde K, Byng R, et al. Sex, gender and gender identity: a re-evaluation of the evidence. BJPsych Bulletin undefined/ed;:1–9. doi:10.1192/bjb.2020.73

      1. Depends how you interpret “strictly”.

        There is a continuum – so if there is a case that is equally M or F, as there has to be if the continuum is continuous and not discrete (as well as being multidimensional) then the strict binary model cannot apply.

        In reality, there are cases of Intersex people being equally both, and others being equally neither. It depends on which physiological characteristics you privilege, but even then, there are halfway points.

        1. You’re referring to what Bewley et al. called “anomalous developments of dimorphic sexual classes” (they are variations around the two sexes) and, as Griffin et al. say, there are just two gametes so there are just two sexes – ‘strictly’ is superfluous. There are no intermediate gametes so no intermediate sexes.

  14. https://www.outinperth.com/court-rules-child-does-not-need-both-parents-permission-to-access-puberty-blockers/

    That news article is exactly on target for the subject of this post. I recommend reading it in full.

    “A Queensland judge has granted permission for a transgender child to access puberty blockers without the consent of both parents.

    The landmark ruling will allow the 13 year old to access puberty blockers, and will overrule a previous ruling that both parents must give permission for the medical treatment to commence.

    The court heard that the teenager requires the treatment as their is concerns for their mental health as they approach puberty. The subject of the case has identified as female since the age of four and has socially transitioned and has lived as female for six years.

    The court heard that the child is autistic but is also an above average student. The teenager lives her mother and is no longer in contact with her father. The court heard the father has not been in contact with the family since 2017 and his whereabouts are unknown. The court head the father also has a history of drug abuse and there had also been previous reports of domestic violence.

    Supreme Court Justice Ann Lyons said delaying the treatment while attempts were made to track down the father were not in the interest of the child.

    Lyle Shelton, the former head of the Australian Christian Lobby, who has campaigned against transgender people under the age of eighteen being able to access medical treatment, has criticised Justice Lyon’s decision describing it as “surprising and shocking”.

    On his social media channels Shelton said Justice Lyons should have paid more attention to the Keira Bell British High Court decision that was delivered in December 2020 which has limited British doctors ability to prescribe puberty blockers and hormone treatments. Admitting that he had not read the judgement, Shelton said he had no idea of what the judges thinking was in the case.

    In her published judgement Justice Lyons outlines Australian case law regarding children’s ability to make decisions, parental rights, and previous decisions relating to children who are transgender. Justice Lyons also said that if the parent and child later wanted to progress to secondary treatment involving hormone treatment the Family Court of Australia would be the most appropriate forum given their previous experience in cases involving the treatment of gender dysphoria.

    Speaking to QNews Australian Transgender Support Association of Queensland (ATSAQ) president Gina Mather commended the judge’s decision as in the child’s best interest.

    “We understand the heartache and desperation of trying to contact an absent parent regarding medical assistance for a child,” she said while highlighting that puberty blockers gave people breathing space to consider the future carefully.”

    Disclaimer – I have in the past worked with Gina and ATSAQ.

    1. You omitted to say why you believe the “news article is exactly on target for the subject of this post” particularly since it’s a different jurisdiction and it concerns whether the consent of both parents is required or whether the consent of only one parent is sufficient for administering treatment to a child. It does not seem to address the issue of informed consent by the child – which is what the Bell v Tavistock case was about – nor whether doctors could simply rely on the consent of the parents instead of the informed consent of the child – as the GLP seems to want.

      1. What is the title of the thread? The subject of the post?
        “Puberty Blockers and Parental Consent”.

        I submit that a news article about puberty blockers and parental consent is exactly on target.

        res ipse loquitur.

        Other, previous articles address the matters you raised.

  15. Zoe,

    The papers you quote about brain differences do not show any significant similarity between the brains of natal woman and men who think they were born in the wrong body. As an evolutionary biologist I have read these papers in detail. I understand the issue of sample size and problem of trying to infer anything from looking at the the brains of corpses. Fraught with error and issues.

    Of all the papers published on trying to show any differences in brain structure of those claiming to be born in the wrong body and any other humans I agree with the post-modern, trans-promoting scientist Anne Sterling Fausto. There is one paper that shows what is called a trend and again the sample size is very small. Men thinking they are born in the wrong body have similarity to those with anorexia nervosa as well as those who take “gym” steroids to change their bodies in one area of the brain. This area of the brain is responsible for body image and how one perceives. None of the papers you paste from have any meaningful data. Even the authors state this none of this is conclusive and much more data is needed.

    Now I know that the culture of “rocket science” is different from biology. In biology because something is published doesn’t mean it is real or significant. I can point you to bad data in many papers. Contrary to what a young person told me recently, one cannot go get a brain MRI and see if they are trans. Pink News is not a scientific source. To date there is no scientific method or test to identify any biological marker that says one is born in the wrong body.

    1. Thank you for this comment. Very useful. Would you please post references, especially to these two points? (behind pay wall sources are ok.)

      Do you think the small sample size in reference to the second quote makes it suggestive – or useless.

      “To date there is no scientific method or test to identify any biological marker that says one is born in the wrong body.”

      “Men thinking they are born in the wrong body have similarity to those with anorexia nervosa as well as those who take “gym” steroids to change their bodies in one area of the brain.”

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