Hello. It's Dr Beth Colby from Talk Mental Health, and I'm a psychiatrist in London. As promised,
this is the third of my talks regarding Keira Bell taking the Tavistock and Portman NHS
Trust to Court regarding their Gender Identity Development Service.
Keira Bell - or Quincy Bell as she was known when she started the Court proceedings - requested a
judicial review of the practice of the Tavistock and Portman NHS Foundation Trust and other Trusts
through its Gender Identity Development Service of prescribing Puberty-Blocking Drugs to people under
the age of 18 years of age. In the introduction and background to the Court case, Gender Dysphoria
was explained as a condition where people experience distress because of mismatch between
their perceived identity and the sex they were born with, and that people with this condition
wish to live according to their perceived identity and not the sex that they were born with. People
with Gender Dysphoria could be referred to the Gender Identity Development Service and may
receive Gonadotrophin Releasing Hormone Agonists, which are hormone or Puberty-Blocking Drugs.
It was stated that Puberty-Blocking Drugs had been prescribed for children as young as 10,
and the children and young people who received these drugs had to give their informed consent.
The issue at the heart of the case was whether children and young people can give truly informed
consent to Puberty-Blocking Drugs. Keira Bell claimed that the information given to those
under 18 by the Gender Identity Development Service was misleading and insufficient to
ensure that children and young people are able to give informed consent. She went further to
state the inadequacy of the information given and the absence of procedural safeguards led to
an infringement of the rights of children and young people under Article 8 of the European
Convention of Human Rights. What the Court was going to consider first was whether a young
person between the age of 16 and 18, or a child, are able to give informed consent to receiving
Puberty- Blocking Drugs, and then if their decision was that they are able to give consent,
then whether the information given by the Gender Identity Development Service was adequate for
achieving informed consent. The Court stated that their remit was not to discuss or make a judgment
about whether Puberty-blocking drugs were good or bad or their long-term positive or adverse
effects for a child or young person but to make a judgment about whether a child or young person
is competent to give consent to treatment in law, and the process by which the consent to treatment
is obtained. There was a long definition of what Gender Dysphoria is; I have mentioned the short
definition at the beginning of this talk. In the background also there was a lot of information
about the Tavistock and Portland's Gender Identity Development Service and how long it's been going,
what it does, and the 3 stages of physical intervention that can be carried out for
children and young people with Gender dysphoria; which is first of all Puberty-Blocking Drugs,
then the administration of Cross-Sex Hormones, and finally Gender Reassignment Surgery, which is only
available in Adult Services. Then went on to state where the referrals came from, the waiting time,
the procedures of assessing a young person or child with Gender Dysphoria, and what happens next
if the child or young person fulfills the criteria for treatment with the Gender Identity Development
Service. Then went on to outline the age and patient group for Puberty-Blockers, the ages of
the children and young people who were referred to the Gender Identity Development Service for
the year 2019-2020, and the gender split, which is 50:50 for girls and boys, and then went on
to outline the process of obtaining consent for Puberty-Blocking Drugs - and there were 3 pages
on this. The effect of Puberty-Blocking Drugs was outlined, and it was noted that there's
been some dispute as to the purpose of prescribing Puberty-Blocking Drugs. According to a doctor from
the Trust, the primary purpose is to give a young person time to think about their gender identity.
Then Professor Butler said that Puberty Blockers ''May have some help or advantage in the support
of Transgender adolescents in some aspects of Mental Health functioning, in particular
with reducing the risk of reduction of Suicidal Ideation and actual suicidal actions themselves.''
It was then stated that the other purpose of giving Puberty-Blocking Drugs is to stop the
development of the physical effects of puberty - and this obviously varies depending on the age
and stage in pubertal development the Puberty-Blocking Drugs are commenced;
because slowing or preventing the early development of Secondary Sexual Characteristics
during puberty can make a later transition, both medical and social, to living as the opposite sex
easier. Then stated that the Gender Identity Development Service and the Trust
were completely clear that Puberty Blocking Drugs and then Cross-Sex Hormones are treated as totally
separate, and that it is possible for a young person to come off Puberty Blockers at any point,
and not proceed to taking Cross-Sex Hormones. However, the evidence has been shown that
practically all children or young people who start Puberty-Blocking Drugs go on then
to receive Cross-Sex Hormones, and the information that they had was from the Netherlands.
The impact of Puberty Blockers and their reversibility was then discussed,
and it was noted that Professor Butler had said, ''We do not know everything about the Blocker,
and as far as we know it is a safe, reversible treatment with a well-established history.''
It was then noted that apart from the Amsterdam study, the history of the use of Puberty Blockers
was from the treatment of Precocious Puberty, which is a different condition to Gender
Dysphoria, and where Puberty Blockers are used in a very different way. Precocious Puberty is when
children go through puberty at a very young age. Dr Devries said that Puberty-Blocking Drug
Treatment is fully reversible, and also said that ethical dilemmas continue to exist around
the uncertainty of apparent long-term physical consequences of Puberty-Blocking on Bone Density,
Fertility, Brain Development and surgical options. Then the Gender Identity Development Services
Information Sheet was outlined. The claimants then went on to discuss a number of aspects
of the asserted reversibility. The claimants asserted that Neurological and Psychological
changes occurring in puberty are less well understood than physiological changes. I'll quote,
''Further, the degree to which neurological differences are caused by biological factors,
like hormones and genes are a matter of debate.'' Professor Levine set out evidence on the degree to
which young people mature through adolescence, through both social and personal experiences.
For young people on Puberty Blockers, that maturing process is stopped or delayed,
with potential social and psychological impacts which could be described as non-reversible.
So the central point of the claimants was that although most of the physical consequences of
taking Puberty Blockers may be reversible if the treatment is stopped, the child or young person
will have missed a period, however long, of normal biological, psychological and social
experience through adolescence; and that missed development and experience during adolescence
can never truly be recovered or reversed. They then went on to repeat that little is known about
the long-term side effects of Hormone or Puberty Blockers in children with Gender Dysphoria,
and that although the Gender Identity Development Service advises that it's a physically reversible
treatment, it is not known what the psychological effects may be. And it's not known whether Hormone
Blockers affect the development of the teenage brain or children's bones, and side effects
may also include hot flushes, fatigue and mood alterations. They then went on to state whether
taking Puberty Blockers will definitely lead to a child or young person receiving Cross-Sex
Hormones, and stated that in statistical terms, if a child or young person receives Puberty Blockers,
they are on a very clear clinical pathway to taking Cross-Sex Hormones. They then went on
to the evidence base to support the use of Puberty Blockers for Gender Dysphoria, and it was stated
that the lack of a firm evidence base for their use is evident from the very limited published
material as to the effectiveness of the treatment however it is measured, and they stated that Paul
Jenkins, the Chief Executive of the Tavistock and Portman NHS Foundation Trust said, ''It is correct
that in recent years some clinicians at the Trust have raised their concerns about the use of
GNRHA for young people presenting with Gender Dysphoria. Indeed, some have called for the
Trust to alter its practices, and have done so in a variety of ways. We are keenly aware that
subject of Gender Dysphoria raises complex issues, and that many have strong opinions on it.''