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The Observer view on the high court's ruling on puberty-blocking drugs for children
The court was correct to halt a disturbing trend among clinicians to assume those as young as 10 were fit to make life-altering decisions about gender identity
Observer Editorial, 6 Dec 2020
Can a child consent to life-altering and irreversible medical treatment as part of transitioning their gender? This was the fraught question at the heart of the case that Keira Bell took against the Tavistock and Portman NHS Trust, which runs the Gender Identity Development Service (GIDS) for children with gender dysphoria. The high court’s landmark ruling clearly sets out that in referring children as young as 10 for puberty-blocking drugs, GIDS has been misinterpreting the law on child consent. It will ensure that children will now receive the protection to which they are legally entitled.
Bell’s story is distressing. From the age of four or five, she started to prefer clothes and games society associates with boys. As a teenager, she felt disgusted by her body and became depressed; then, at 14, she started to question her gender identity and researched transitioning online. At 15, she was referred to GIDS. She started taking puberty blockers when she was 16 and testosterone at 17, then had a double mastectomy when she was 20, three years ago. She has since decided to stop taking testosterone and has transitioned back to being a woman. “I made a brash decision as a teenager… trying to find confidence and happiness, except now the rest of my life will be negatively affected,” she said in her court submission.
There are undoubtedly transgender adults who began taking puberty blockers as children who, unlike Bell and other young people who have questioned their treatment, feel this was the right decision. But this was not the question before the court: it was whether children are able to meaningfully consent.
The law says children under 16 can only consent to their own treatment if they are believed to have the intelligence, competence and understanding to fully appreciate what it involves. The high court set out why it was highly unlikely a child under 13 would be competent to give consent to taking puberty blockers and doubtful in the case of a child of 14 or 15.
First, puberty blockers are an experimental treatment for gender dysphoria, whose long-term health impacts are potentially serious, but unknown. Second, practically all children who start puberty blockers progress to cross-sex hormones, which have profound lifelong consequences, including on fertility and sexual function. Third, gender dysphoria may resolve itself in some teenagers and the high court considers that puberty blockers may support the persistence of gender dysphoria. The court ruled that the highly experimental nature of the treatment and its complex and lifelong consequences make it unlikely children can consent to it.
There are serious questions about the way in which GIDS has been discharging its duty of care. It was unable to supply the most basic of data that the court asked for, including the age profile of children referred for puberty blockers, how many had a mental health diagnosis and data on their treatment pathway. And the judgment casts doubt on the gender-affirming model of treatment for children who present with gender dysphoria. The idea that a child as young as 10 can come to a fixed view about their gender identity that sets them on a path to irreversible medical treatment is alarming, yet has become embedded in clinical practice. As we have reported, longstanding concerns raised by clinicians at the Tavistock have been shut down, with one whistleblower facing disciplinary action.
Any questioning of the gender-affirming model – and the role that trauma, internalised hostility to same-sex attraction or misleading online material may play in gender dysphoria in teenagers – is dismissed as transphobic. This is a chilling state of affairs that is detrimental to child safety. There are children who will find last week’s judgment distressing and it is imperative they receive the professional support they need. Children are not pawns to be deployed in adult debates about identity. Bell’s bravery has paved the way for a child-centred judgment that gives them the protection they deserve.
Trans women retain 12% edge in tests two years after transitioning, study finds
IOC adjustment period for trans women may be too short
Running times better as testosterone levels remain higher
Sean Ingle, 7 Dec 2020
A groundbreaking new study on transgender athletes has found trans women retain a 12% advantage in running tests even after taking hormones for two years to suppress their testosterone. The results, researchers suggest, indicate the current International Olympic Committee guidelines may give trans women an “unfair competitive advantage” over biological women.
Trans women face potential women’s rugby ban over safety concerns
World Rugby recently became the first sports federation to ban trans women from women’s rugby, citing “significant” safety risks and fairness concerns. But most sports still follow IOC guidelines from 2015, which permit trans women to play against biological women providing their testosterone remains below 10 nanomoles per litre – a figure higher than average biological female levels, which range from 0.12 to 1.79nmol/L.
However the new study, based on the fitness test results and medical records of 29 trans men and 46 trans women who started gender affirming hormones while in the United States Air Force, appears to challenge the IOC’s scientific position.
The research, published in the British Journal of Sports Medicine, found that before starting their hormone treatment trans women performed 31% more push-ups and 15% more sit-ups in one minute on average than a biological women younger than 30 in the air force – and ran 1.5 miles 21% faster.
Yet after suppressing their testosterone for two years – a year longer than IOC guidelines – they were still 12% faster on average than biological females.
The trans women also retained a 10% advantage in push-ups and a 6% advantage in sit-ups for the first two years after taking hormones, before their advantage disappeared. But the researchers say they “may underestimate the advantage in strength that trans women have over cis women … because trans women will have a higher power output than cis women when performing an equivalent number of push-ups”.
The scientists conclude by saying “more than 12 months of testosterone suppression may be needed to ensure that transgender women do not have an unfair competitive advantage when participating in elite level athletic competition”.
When it initially published its transgender guidelines five years ago, the IOC said its “overriding sporting objective is and remains the guarantee of fair competition”. However, its plans to lower the testosterone limit to 5nmol/L came to nothing because the issue was so contentious. Instead the IOC indicated it wanted sports to implement their own transgender policies.
Teen runners sue to block trans athletes from girls' sports
When asked for its response to the new research the IOC said it was now working on a “a framework for voluntary guidelines on the basis of gender identity and sex characteristics”, adding: “Overall, the discussions to date have confirmed considerable tension between the notions of fairness and inclusion, and the desire and need to protect the women’s category, all of which will need to be reconciled. The IOC aims to release this framework in 2021.”
The academic research also highlighted the benefits of testosterone for trans men. Before taking the hormone, they performed 43% fewer push-ups and ran 1.5 miles 15% slower than their male peers. But after one year there was no longer any difference in push-ups or run time, and the number of sit-ups performed by trans men exceeded the average performance of their male peers.