The medical, ethical, and legal complications surrounding the puberty blockers case If Ms Evans and Mrs A’s case wins, a clinical decision to prescribe puberty blockers will soon become a legal one

A former nurse and the mother of a teenager hoping to transition have said they will be launching a legal challenge over the age of consent for puberty blockers in the UK.

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

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

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

How do puberty blockers work?

For those not in the know, puberty blockers – real name gonadotropin-releasing hormone (GnRH) – are a treatment offered to children and young people questioning their gender.

The “blocker”, developed by Dutch clinicians, sends a signal to the brain so it doesn’t send sex hormones to the gonads, producing the chemicals that trigger adolescence.

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

“The puberty blockers put the pause button on puberty,” Dr Caroline Salas-Humara, adolescent paediatrician at Hassenfeld Children’s Hospital at NYU Langone, told i.

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

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

How are puberty blockers prescribed?

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

But for children under 18, there is just one funded clinic in England and Wales, the Gender Identity Development Service, known as GIDS.

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

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

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

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

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

Leo, a young trans man who took puberty blockers for two years, is now taking testosterone. But he had to wait a year to access the blockers at The Tavistock Centre, an experience he describes as “important but frustrating”.

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

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

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

Age of consent for blockers?

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

“We are essentially seeking to say that the provision at the Tavistock for young people up to the age of 18 is illegal because there isn’t valid consent,” said Paul Conrathe, a solicitor with Sinclairslaw, which is representing Evans and the mother.

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

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

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

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

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

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

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

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

“There is an evaluation process, it’s based on maturity, and the capacity to send for these hormones,” said the specialist.

But the medical professional recognises that patients over the age of 18 would tend to be offered cross-sex hormones rather than the blockers, as puberty is very likely to have already taken place.

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

What are the pitfalls?

Puberty blockers, however, are not without their drawbacks. While a BBC investigation into a study into puberty blockers causing mental health issues was classed as moot by the HRA, studies have indicated the drugs could affect bone density, which could lead to patients sustaining a fracture more easily. Bone mineralisation can occur (which can theoretically be reversed with cross-sex hormone treatment) and fertility can be compromised; data on the effects on brain development are still limited. “The biggest consideration is the effect puberty blockers have on bone density,” said Dr Salas-Humara. “Adolescence is this critical window where the human body builds bones and makes them strong. As oestrogen and testosterone production is blocked, which helps build bones. “We don’t have the data to know if it increases risk of fractures, but we do use a close eye on it, using dexa (bone density) scans. We don’t keep the kids on blockers forever for that reason. It’s an interim use.”

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

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

“First of all, it’s important to know that medical bodies across the world follow specific guidelines on administering treatment such as puberty blockers. What people don’t necessarily realise is that this treatment has been safely used on patients for more than 30 years,” said Dr Salas-Humara. “The treatment was first used to treat people with central precocious puberty, to stop children experiencing hormonal changes who had started puberty too early. Because of this, we have been aware of the safety and efficacy of the treatment for children and young adults for a lot longer than people realise.”

Trans children ‘falling by the wayside’

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

“In England we’re married to the welfare of the child through the Children Act. All children’s law is about doing what’s best for the welfare for the child. If you have a young person with a clinical determination, that this is a young person who would benefit, then putting in place for obstacles for that child accessing those seems in contradiction with that ruling,” said the Law lecturer.

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

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

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