Topic: Healthy Young Breast Tissue Saved

[Blumf]

Hummmm......

https://www.bbc.co.uk/news/uk-england-cambridgeshire-55144148

Children under 16 with gender dysphoria are unlikely to be able to give informed consent to undergo treatment with puberty-blocking drugs, three High Court judges have ruled.

The case had been brought against Tavistock and Portman NHS Trust.

One of the claimants, Keira Bell, said she was "delighted" by the ruling.

The trust said it was "disappointed by today's judgment and we understand that the outcome is likely to cause anxiety for patients and their families".

...

The judges said their decision was only on the informed consent of a child or a young person, not whether puberty blockers were appropriate themselves.

The ruling said: "The court is not deciding on the benefits or disbenefits of treating children with GD (gender dysphoria) with PBs, whether in the long or short term."

[Jumblegraws]

Seems more accurate to say that the Tavistock lost than that the claimants won. The decision fetters the GIDS significantly, but, from what I can tell, it’s not a remote possibility that Bell would’ve gotten the same treatment if she had sought to transition with an equivalent piece of case law on the books at the time.

A lot of trans people and relatives of trans kids on Twitter really upset by the decision, whilst the people cheering it on are the usual Prosecco Stormfront and overgrown school bully set.

[Zetetic]

Waiting times presumably make this largely irrelevant anyway.

[Jumblegraws]

No, it means the waiting time is even longer and that even less people will be able to afford to join the queue in the first place. Not like you to be that flippant.

[Zetetic]

T&P is seeing people referred in late 2017. Cardiff is seeing people referred in March 2018.

More relevant for primary care prescribers, I guess?

[dissolute ocelot]

I'm hoping to see (a summary of) the full judgment. The BBC made it seem like the main argument was "if you get hormone blockers you'll automatically go onto actual sex hormones, and sex hormones are dangerous, so we won't let you get hormone blockers." Which makes no sense.

[GoblinAhFuckScary]

#IShitOnKeiraBell

[Pingers]

Seems more accurate to say that the Tavistock lost than that the claimants won. The decision fetters the GIDS significantly, but from what I can tell it’s not a remote possibility that Bell would’ve gotten the same treatment if she had sought to transition even if an equivalent piece of case law on the books at the time.

A lot of trans people and relatives of trans kids on Twitter really upset by the decision, whilst the people cheering it on are the usual Prosecco Stormfront and overgrown school bully set.

My reading of this is that it's primarily a ruling on mental capacity and that the issue of transitioning is secondary.

[Blumf]

I'm hoping to see (a summary of) the full judgment. The BBC made it seem like the main argument was "if you get hormone blockers you'll automatically go onto actual sex hormones, and sex hormones are dangerous, so we won't let you get hormone blockers." Which makes no sense.

Yeah, that line of reasoning seemed odd to me, almost like saying chemotherapy causes cancer.

At a High Court hearing in October, lawyers representing the claimants said there was "a very high likelihood" children who start taking hormone blockers will later begin taking cross-sex hormones

Well, yeah, they wouldn't be on the blockers if they didn't have some, fairly high, level of gender dysphoria in the first place.

[Pingers]

I'd be interested to hear Zetetic's thoughts on the parallels with the caution exercised around giving psychiatric diagnoses to children, on the basis that it can be very hard to unpick what is a psychiatric "disorder" (let's assume for a moment that term has validity) and what is being a teenager. The risks of rushing into giving a diagnosis being significant in terms of life chances and being able to get the right support.

[Buelligan]

My reading of this is that it's primarily a ruling on mental capacity and that the issue of transitioning is secondary.

I'm unsure what the ruling actually means though.  There are other health areas, I'm sure, where interventions are time-sensitive and, for whatever reason, the "patient" is not viewed as competent to make an informed choice.  If the intention is to deny these people agency over their own lives and bodies, to impose the will of others on them, even simply through delay, that's clearly not a good thing at all.  I hope there's enough wisdom in the world to safeguard these individuals and make sure that they get to determine their own futures.

[Zetetic]

That's an interesting comparison, Pingers because I don't get the impression that reticence to diagnose children and teenagers is much driven by fears of iatrogenic harm as by services attempting to protect their capacity.[1]

(Since you've asked, I will try harder to piece together some more considered, if not actually useful or knowledgeable, thoughts.)

1.	This is probably a testable claim…

[Zetetic]

Link to judgement:
https://www.judiciary.uk/judgments/r-on-the-application-of-quincy-bell-and-a-v-tavistock-and-portman-nhs-trust-and-others/

[Zetetic]

(As an aside, not surprising that it's basically impossible to get data of GIDS, but still disappointing. I wonder if Cardiff's is any better given it's been setup much more recently and in the one Welsh health board that might ensure that they could answer the sorts of quantitative questions that GIDS struggled to.)

[Pingers]

I'm unsure what the ruling actually means though.  There are other health areas, I'm sure, where interventions are time-sensitive and, for whatever reason, the "patient" is not viewed as competent to make an informed choice.  If the intention is to deny these people agency over their own lives and bodies, to impose the will of others on them, even simply through delay, that's clearly not a good thing at all.  I hope there's enough wisdom in the world to safeguard these individuals and make sure that they get to determine their own futures.

That's the function of the Court of Protection for adults who lack capacity. For children, the choices are mostly with the parents unless those choices are causing 'significant harm', at which point safeguarding under the Children Act comes in.

[Zetetic]

Notably, paragraph 47 of the judgement says:


If a child cannot give consent for treatment because they are not Gillick competent then the normal position in law would be that someone with parental responsibility could consent on their behalf. Mr Hyam sought at one point to argue that a decision as to giving PBs would fall outside the scope of parental responsibility because of the nature of the treatment concerned. However, the GIDS practice in relation to acting on parental consent alone is quite clear. In the response to the pre-action protocol letter the defendant said:

36. There is a fundamental misunderstanding in your letter, which states that parents can consent to pubertal suspension on behalf of a child who is not capable of doing so. This is not the case for this service, as is clear from the above. 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. The Service Specification confirms that this is the case.

It follows that is not necessary for us to consider whether parents could consent to the treatment if the child cannot lawfully do so because this is not the policy or practice of the defendant and such a case could not currently arise on the facts.


Although this seems slightly odd to me, because it seems plausible that T&P GIDS could move to a policy of obtaining parental consent (where UCLH already seek support for under-16s[1]) in law and still require the patient's agreement in fact (even if they aren't considered Gillick competent).

1.	See Butler's comments in paragraph 40.

[Buelligan]

What I find hard to discern from that is - if it's decided a person is not able to give consent, which it has been, then they cannot give consent, whether they consent or not (if you understand).  Surely, this is where the ruling takes us... which means that PBs will no longer be given (I assume).  Am I correct?

[bgmnts]

Can you still use the term man tits or moobs to describe your fatty pectorals?

I think this is one aspect of the Great Trans debate that hasn't been discussed.

[Zetetic]

What I find hard to discern from that is - if it's decided a person is not able to give consent, which it has been, then they cannot give consent, whether they consent or not (if you understand).

The terms "consent in law" and "consent in fact", might be useful here, although they're mostly used in the context of sexual offences as far as I know. Someone who lacks the relevant capacity or competency isn't considered able to consent in law, even if they consent in fact.

Surely, this is where the ruling takes us... which means that PBs will no longer be given (I assume).  Am I correct?

The suggestion seems to be is that this will generally make determining best interests a matter for the Court of Protection (?) in each case, making it harder but not impossible to prescribe PBs for someone under 16.

I suspect Pingers might see if there's a less involved option available than that.

[Pingers]

I've only had time to skim the judgement, but it seems particular to GIDS. Section 47 does indeed look very relevant as highlighted by Zetetic, because it looks like the court has swerved the question of whether a parent could consent against the wishes of a child because GIDS would refuse to prescribe in that situation anyway.

That's not to say that a different service, perhaps a private one, wouldn't have a different policy. In that instance I think it would fall into the area of local authority social care, who, if they aware of parents having that intention, would have to decide whether this would constitute significant harm to the young person. I would be pretty confident that they would think it did, and I could see the family court making an injunction to stop the parents giving consent against the child's wishes, and possibly also holding the child's passport to prevent the parents trying to go abroad for a consultation.

[Zetetic]

I think though, importantly, they've also swerved whether a parent can consent (in law) in place of but in line with the wishes of a child (who lacked Gillick competency[1]) to the prescription of GBs.

1.	As the judgement suggests almost all under-16s do in the context of the GBs.

[Pingers]

I think though, importantly, they've also swerved whether a parent can consent (in law) in place of but in line with the wishes of a child (who lacked Gillick competency[1]) to the prescription of GBs.

1.	As the judgement suggests almost all under-16s do in the context of the GBs.

Yeah, but I think probably that would be dealt with the same as the scenario I've given above. Essentially, the judgement seems mainly to put some limits on Gillick competency that are likely to be applicable to some other treatments, although I don't know what they are.

[Zetetic]

I would have thought it'd be far less clear cut that a court would seek an injunction in the case where the parents' consent accorded with the child's views.

[Pingers]

I would have thought it'd be far less clear cut that a court would seek an injunction in the case where the parents' consent accorded with the child's views.

Even if the child was not Gillick competent? Family court judges seem to have a lot of leeway, but they will always start from what is in the best interests of the child - so perhaps they could make a ruling that would conflict to a degree with this judgement. If a local authority opposed the parents' plan, I would imagine the family court would hear similar arguments against as in this case.

[Shoulders?-Stomach!]

My reading of this is that it's primarily a ruling on mental capacity and that the issue of transitioning is secondary.

I agree.

I remember encountering trouble on here forwarding my understanding that if we set legal age limits on other activities and choices on the basis of mental capacity then it stands to reason that the same should go for surgery towards transitioning, which is an incredibly more complex choice with profound consequences than most (potentially all of them given it concerns identity, but that's contentious).

There is also no good reason why we should endow a party with a commercial incentive to pursue services that make them money with too much freedom to exploit that. Ethics are already a major issue in private cosmetic surgery (which unlike transitioning people tend to be down about on here but that still contends with serious issues of dysphoria, self-worth and pursuit of identity) and my broad view is that there should always be very high thresholds of safeguarding.

[Zetetic]

Noting that none of this is about surgery (and is very specifically about PBs), and I don't believe that any relevant NHS service will be commissioned on anything other than block contract basis.

If a local authority opposed the parents' plan

I suppose I'm not sure why that would be the default position though, rather than the (usual) assumption in the absence of Gillick competence that the parents are making informed decisions in the best interests of the child.

[Pingers]

Noting that none of this is about surgery (and is very specifically about PBs), and I don't believe that any relevant NHS service will be commissioned on anything other than block contract basis.
I suppose I'm not sure why that would be the default position though, rather than the (usual) assumption in the absence of Gillick competence that the parents are making informed decisions in the best interests of the child.

Like it or not, local authorities are the arbiters of whether parents' decisions need scrutiny. Obviously in terms of the general population they assume that most parents are doing the right thing most of the time, but if they become aware of a possible safeguarding issue (e.g. via a medical professional who has concerns) then they have to investigate. It's up to the judge ultimately though.

[Zetetic]

Apologies, I suspect I'm not being clear and your "become aware of a possible safeguarding issue" clarifies a bit for me.

[Non Stop Dancer]

Ooh I just don't know what to think about any of this.

[Pijlstaart]

Some regard puberty as a deeply aversive act, it is intimately tied to it's impositions, bursting out of shorts in public incredible-hulk style, fluid seeping down legs and an endless din of mating calls keeping good folk awake past bedtime. Channel 4 has been rendered unwatchable by Women's Bum shows, played-out Women's Bum anecdotes that transfix those cursed by pubic stupor. Abstainers should be rewarded with a tax credit, alongside meal vouchers for those who can demonstrably halt an initiated puberty for longer than 3 months. Aren't they just neater? Much neater.

You stop puberty and suddenly the baggage allowance on planes will go up from all the weight saved, we'll stop driving cars and start driving go-karts and we'll never have to worry about banging our head on door-frames again. Medium-sized animals will be able to prey on us, rejuvenating an unhealthy monopolised ecosystem and never again will we live in fear of our unsightly pubic bushes bursting forth like a family of disgruntled hedgehogs during a work meeting. I have suffered the indignity of puberty, the physical manifestation of sin, I have stank and secreted, I am more than I should be, wish nothing more than to be ground down into ready-meal slurry by diminutive men with impeccable skin.