On 1 December, the Service Specifications for GIDS have updated following the Tavistock v Bell and Mrs A ruling.
The key changes are as follows:
- New patients who have been assessed as being appropriate for puberty blockers must not be referred to the medical team at UCLH until they have a court order to support this need.
- GIDS must review every patient under 16 who is currently on puberty blockers. If the decision is that the blocker should continue, then they must be referred to a court for their decision. If the decision is made not to refer to a court then the blocker will be ‘safely’ withdrawn.
- GIDS must make sure that psychological support is available to anyone whose blocker is withdrawn.
- For 16 and 17 year olds, they may be referred for a court decision if there is any doubt about the best interests of the child.
On 14 December, GIDS wrote to all patients under their care.
Their key points were:
- Medication will not be automatically withdrawn.
- Cases will be reviewed in early 2021 and if it is decided that continuing treatment is in the best interests, a court application will be made.
- Medication may continue until the court decision is made.
- If the patient is 16 or 17 and there is any doubt that continuing care is in their best interest, then they will be referred to the court.
Some support groups were listed, this included neither GenderGP (who can provide continuation of care) nor Mermaids (the only UK children’s charity specialising in the support of trans youth).
While this letter was no doubt sent with the aim of answering questions and minimising concerns for patients and their loved ones, the following questions remain:
- How many young people need to be reviewed?
- Will they all need to attend an appointment? More than one appointment? Or will the review be done by telephone or by reviewing the individual’s records?
- What is the time scale? How long will it take for the case to be reviewed? How long does it take to apply for a court decision?
- Who pays for the court decision?
- What about GPs who feel unsafe in continuing prescriptions without a court order? GIDS do not currently prescribe, what happens to the care of that individual if a GP refuses to prescribe?
- GIDS are not allowed to refer any patients to the prescribing doctors at UCLH, so what happens to those who are waiting to start treatment?
- Will priority be given to any group of patients? Those who still have time to prevent the lifelong changes of puberty? Those who are at risk of self harm or suicide? Those who are unable to engage with education? Those whose GPs feel unable to offer support?
- What will happen to the patients whose needs were specifically raised by the court? Those on the autistic spectrum, those without parental support?
- What compensation will be made available to those young people who will experience lifelong, significant physical or mental changes because of extreme delays or being denied access to this treatment?
- How is it possible that GIDS considered someone eligible for gender affirming medication one day and changed its mind the next? If the clinicians were confident that the patient had the capacity to be able to give informed consent to this treatment before the case, what has changed?
In response to the ruling, the WPATH, EPATH, USPATH, AsiaPATH, CPATH, AusPath and PATHA released a statement opposing the ruling, urging that it be appealed and overturned.
Their key points are:
- The signatories to the statement all have serious concerns about this ruling.
- Withholding treatment with puberty blockers is harmful and carries potential life-long social, psychological, and medical consequences.
- Treatment of transgender adolescents involving gender affirming medical interventions (puberty suppression and subsequent gender affirming hormones) is the most widely accepted and preferred clinical approach in health services for transgender people around the world.
- To be effective, this treatment must commence early in the puberty process, not at the age of 16.
- When treatment is needed, its effectiveness will be diminished while waiting to be seen by a court of law.
- Research has demonstrated that many minors possess the cognitive and emotional abilities to understand the consequences of their decisions, including decisions concerning healthcare.
- WPATH, EPATH, USPATH, AsiaPATH, CPATH, AusPATH, and PATHA recommend that capacity to consent is evaluated on a case-by-case basis by the treating clinician and not by a court of law.
On 18 January it was confirmed that an appeal against the verdict has been granted. It will be heard before 22 March 2021.
- Will the defendants, Polly Carmichael and Gary Butler be prepared with the information that was requested but not made available, even though it existed?
- Will the defendants’ case be better prepared to explain how patients can have the ability to consent to puberty blockers?
- Will the case as to the harm that is caused by delaying access to treatment be presented clearly?
- If delaying treatment is acknowledged as causing harm, what is the defense to the harm caused by the current GIDS long waiting times and drawn out assessment processes?
- Will the GIDS Service Specifications be updated to reflect current International Best Practice which would then have the weight to reassure the courts?
- Should the current commissioning for GIDS to provide gender services to UK transgender youth be withdrawn in light of the failings of their current service specifications and their inability to keep patients safe and if so who will step into the breach?
- If there are doctors who feel that their young trans patient has the capacity to consent to treatment with blockers in a harm-reduction approach, are they ‘allowed’ to treat?
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