by Susan Matthews
The issue that the High Court had to consider in the Bell v. the Tavistock Judicial Review was whether (or at what age) children can give informed consent for puberty blockers. The 2016 documentary ‘Kids on the Edge: the Gender Clinic’ provides a remarkably detailed account of the work of the Gender Identity Development Service (GIDS) as it follows the stories of two young patients, 11-year-old Matt and 8-year-old Ash.
Although the film can only show brief snippets of their assessment, we can be sure that the service stands by the documentary as a record of the way in which they seek informed consent. Not only is ‘The Gender Clinic’ linked on the GIDS website but the Tavistock and Portman website features ‘The service director’s view – Dr Polly Carmichael on ‘The Gender Clinic’. Carmichael writes that: ‘We all feel proud to have been involved in the process and that we could not have wished for more in the way that they approached and conducted the whole process.’
The Gender Clinic: 2016 and the rise of the transgender child
When ‘The Gender Clinic’ aired in November 2016, the GIDS had been offering puberty blockers as an early intervention for five years. Over the same period they had also witnessed an unprecedented increase in referrals, especially of teenage girls. Transgender issues were regularly covered in the media and Time Magazine had announced ‘The Transgender Tipping Point’ with a cover story on Laverne Cox in 2014. Interest in transgender children seems to have peaked in the UK in April 2015 when Louis Theroux’s documentary Transgender Kids was shown:
Presciently, Stephanie Davies-Arai had already posted an article on her parenting website called ‘Is My Child Transgender?’ in March 2015 in which she recalled her own gender non-conforming childhood. ‘I am a heterosexual woman who lived most of my childhood wanting to be a boy’, Stephanie wrote: ‘for a few years my sister and I would answer to nothing except our ‘real’ names: Bill and Mike. I entered puberty kicking and screaming.’
She reassured parents that:
“Most gender non-conforming children (about 80%) turn out to be lesbian or gay, or they grow into society’s gender roles at puberty”, adding the wry comment “girls typically start losing their confidence, boys grow in stature as they recognize their place in the world, and we all breathe a sigh of relief.”
That year, Stephanie founded Transgender Trend to provide evidence-based advice in response to what she realised was a real and growing need. The GIDS figures for referrals proved Stephanie right: 2015-16 saw the sharpest increase in referrals, especially of girls, in any year.
In April 2016, Bernadette Wren, consultant psychologist at GIDS joined Polly Carmichael on a Woman’s Hour discussion of the latest figures. Wren’s position was laissez-faire:
‘We live in a world where people alter their bodies, surgically or otherwise, and this freedom is available for people as they get older.’
‘Maybe we just have to be acknowledging that that is a liberty that people have, that these things are possible, technologically, and people will avail themselves of those things.’
Tavistock clinicians, Wren thought, were witnessing a ‘social revolution’ and they just had to ‘see how it transpires.’ In this context, it was difficult to persuade young people to get on with their lives, Wren said, ‘without necessarily jumping into physical intervention in ways that we might feel is a bit premature given the state of their thinking.’ Wren also wondered whether there was some sense in which it was easier or more attractive to be male or to have a male body in 2016.
Time did not offer enlightenment. In 2018, a group of Tavistock clinicians thought that ‘The reasons are not fully explicable and a number of questions arise. Is this increase due mostly to the greater tolerance of gender-diverse expression in westernised society? Is male status still regarded as preferable?’ (Butler et al, 2018). And in 2020, the Tavistock had no hypotheses to offer to the Judicial Review. The judgement notes: ‘The defendant [GIDS] did not put forward any clinical explanation as to why there had been this significant change in the patient group over a relatively short time.’ (Bell v Tavistock Judgment, 1 Dec 2020, para 30-31.)
Kids on the Edge: The Gender Clinic which aired in November 2016 seems designed to answer some of the questions raised by the Woman’s Hour interview earlier that year. The first time we see Polly Carmichael in the film we hear a clip from the April programme as presenter Jane Garvey says that the latest figures from the Tavistock are ‘interesting, some might even say, astonishing…. What is happening?’ (4.27)
A child with ASD
The film follows 11-year-old child, Matt, as she confronts the decision whether to take puberty blockers. ‘There’s no verbal reasoning’, says her mother Rachel as Matt draws a ring round a drawing labelled ‘boy’ on a board. Matt hates speaking but expresses herself vividly in writing, in books, on the wall. The clinicians wonder whether Matt’s male identity is part of her rich imaginative internal life, a story she’s created about herself. (16.20) As one clinician puts it: ‘She has this very imaginative fantasy world and I sometimes think it’s almost as even in talking to someone you might destroy that.’ Polly Carmichael wonders ‘How do you know that the gender dysphoria isn’t like other obsessions they might have?’ The documentary tells us that ‘Around half of all children seen by the Gender Identity Development Service show autistic traits – a link no one can explain.’ (14.38)
It’s worth reading what we said when ‘the Gender Clinic’ first aired in November 2016:
The programme was devastating and heartbreaking in equal measure, not least because of the statistic that half the number of children being referred to the Tavistock show autistic traits. Is this alarming statistic being investigated? There was no indication that it was, or will be. Is that it then, for ASD kids, no further investigation needed?
In 2020 the High Court asked for figures on rates of autism at GIDS. But the Tavistock couldn’t provide them:
‘The court asked for statistics on the number or proportion of young people referred by GIDS for PBs who had a diagnosis of ASD. Ms Morris said that such data was not available, although it would have been recorded on individual patient records. We therefore do not know the proportion of those who were found by GIDS to be Gillick competent who had ASD, or indeed a mental health diagnosis.
Again, we have found this lack of data analysis – and the apparent lack of investigation of this issue – surprising.’ (Bell v Tavistock Judgment, 1 Dec 2020, para 34-35)
The Impact of Bullying
Rachel explains that Matt wants to be called ‘he’ at school or when around other people but is happy to be ‘she’ at home. (11.18) She has recorded Matt explaining that pupils were asking her daily ‘Are you a boy or a girl?’ Rachel says that she’s been called ‘weirdo, loser, has had a brick chucked in her face.’ In a notebook, Matt has drawn pictures of this bullying behaviour, including the brick being thrown at her.
But no one suggests that the male identity, insisted on at school but not at home, might be a means for Matt to resist bullying, to assert her own strength. A 2015 research study – which must have been known to the GIDS staff – had found ‘persistent experiences of bullying before the onset of gender dysphoria’ (my emphasis) in a group of natal girls with gender identity problems. It noted that ‘autism spectrum problems were very common’ and cautioned that gender dysphoria ‘in adults and in adolescence may not be the same issue in general.’ A 2018 study found that homophobic name calling can contribute to a change in a child’s gender identity:
homophobic name calling at the onset of middle school emerged as a form of peer influence that predicted change in early adolescent gender identity from the fall to the spring of the 6th grade academic year. (Delay et al, 2018)
A decision for the parent?
The Tavistock submission to the Judicial Review insisted that the child, not the parent, must provide informed consent:
“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.” (Para 47)
But the 2016 documentary presents this as a decision for the parent. The narrator comments: ‘Rachel has another big decision to make. Whether she will let Matilda enter puberty and develop into a woman or use hormone blocking drugs to pause the process.’ (12.06) Rachel is clearly unwilling to medicate her child: ‘the whole blocker thing is worrying me’, she says, ‘because I guess we haven’t got major studies. I worry about what am I putting into my child.’ (11.47) Tavistock clinician Dr Charlie Beaumont suggests that Rachel is worried about the approach of puberty: ‘I think with puberty there’s always a huge amount of anxiety, often from the parent. I think it’s really difficult for them to know what to do. To sort of think, ‘If I allow this person go through puberty, are they going to end up doing something really awful to themselves?’ (12.27) Will Rachel ‘let’ Matilda enter puberty? Will she ‘allow’ her to go through this process?
A decision for the clinician?
Given Rachel’s unwillingness to medicate her child, it seems plausible that her anxiety is generated in part by the focus of the clinical team on the issue of puberty blockers. At a case conference we see plenty of doubts expressed: ‘There’s a lack of consistency of gender presentation and its very unclear whether Matilda particularly wants to pursue a transition’ says one of Matt’s case coordinators. ‘The child in a way is a bit unclear where they are in the world.’ But a decision is approaching. One clinician reports: ‘She is now apparently sort of starting to show very small signs of her chest developing. And um Mum is feeling a real sense of responsibility but almost pressure to kind of like she has to make decisions now’.
The answer, all agree, is to educate Rachel about the medical options: ‘Giving mum a chance to become more informed about the medical process might relieve some of her concerns.’ Gary Butler, the UCLH endocrinologist who prescribes hormone blockers for the Tavistock agrees that meeting with Rachel might help by ‘demystifying puberty a little bit.’ When he does so, he addresses the question that High Court decided this year: what does constitute informed consent in the case of an autistic 11-year-old? Butler explains to Rachel:
‘If a young person is expressing extreme disquiet there can be a choice made to start blocker treatment as long as puberty has begun. But they have to get their head around the whole process of what it means which is quite a hard concept in any case for an 11/12 year old to take. But particularly if there are other distresses around.’
What does this mean in practice? Butler says:
‘If someone is 11 going on 12 they really need to understand the process to the level of maturity that you would expect for an almost 12 year old. At the same time you need to understand that it’s going on a journey which might end up changing their body permanently.’ (25.44, emphasis added)
This matches what Butler told the Judicial Review:
“it is an absolute requirement before starting any treatment that a young person can fully understand this effect on fertility and sexual functioning according to their age and level of maturation.” (Para.42, emphasis added)
The judges disagreed. They decided that informed consent requires the child to understand issues ‘which objectively ought to be given weight in the future although the child might be unconcerned about them now’.
The meeting with Gary Butler recorded in 2016 clearly sways Rachel, despite her instinctive antipathy towards medication: ‘You see the more you talk about it the more I’m going towards saying I have to go home and have a talk, a conversation with Matt and say, you know, this is the issue’, she tells him. And yet she is no closer to extracting an answer from Matt: ‘every time you broach the subject, Matt just completely dismisses it. It’s like, I’m not going to speak about it.’ As Matt continues to refuse to talk to her mother about gender, Rachel becomes desperate and asks: ‘Do you want them to make you a real boy?’ (23.50)
Keira Bell told the Judicial Review that when she was referred to the adult Gender Identity clinic to discuss surgery, she “was visualising myself becoming a tall, physically strong young man where there was virtually no difference between me and a biological boy.” (para 80). Keira began to have serious doubts about her transition aged 20 when she began to notice ‘how physically different I am to men as a biological female, despite having testosterone running through my body.’ But no one in the documentary questions whether Matt can turn into a ‘real boy’. This is surely a failure on the part of the gender clinic who bear the responsibility to be honest about the limited efficacy of the medical pathway they offer. The High Court was clear that the child needs to understand ‘the impact on fertility and on future sexual functioning.’ (para 132.)
Communicating with a child
With Rachel briefed about the urgency of the puberty blocker decision, the focus shifts to Matt. What we see is a pincer movement as both parent and child are set up to extract agreement from the other. Rachel is told by endocrinologist Gary Butler that she needs to talk to Matt about puberty blockers; Matt is told by clinician Charlie Beaumont that she has to get Rachel on board: ‘You can agree to this, but you have to make sure that your mum agrees.’ (40.55) Given that Matt won’t talk and Rachel doesn’t want blockers, it’s puzzling to locate the source of the urgency.
GIDS clinical psychologist, Dr Aiden Kelly explained in 2018 that the clinic has to put the responsibility on the family: ‘So once we’ve gotten to a point where we think this is the right thing to do, with the family, and really, often we are putting responsibility back on the family because we don’t have the evidence base to say it’s these kids and not these kids, or how we can pick out which kids should go forward and which shouldn’t’. The Tavistock needs Rachel to decide; Rachel wants guidance from the experts; Rachel wants to know what Matt really thinks; Matt doesn’t want to talk.
In a revealing session we witness clips from the interview with Matt in which Charlie Beaumont tries to extract an answer. The camera turns to the clock in the room as the psychologist tries again and again to get Matt to answer (41.00). The clock ticks on. She won’t answer, she shrugs, says ‘Kind of.’
Charlie: I suppose the thing about the blocker is it’ll just pause things. If you don’t take that how do you think you would feel. (41.47)
In 2020, the High Court questioned whether the blocker ‘provides a “pause to think” in a “hormone neutral” state or is a treatment to limit the effects of puberty, and thus the need for greater surgical and chemical intervention later, as referred to in the Health Research Authority report.’ (para 133) The judges concluded that:
‘the use of puberty blockers is not itself a neutral process by which time stands still for the child on PBs, whether physically or psychologically. PBs prevent the child going through puberty in the normal biological process. As a minimum it seems to us that this means that the child is not undergoing the physical and consequential psychological changes which would contribute to the understanding of a person’s identity. There is an argument that for some children at least, this may confirm the child’s chosen gender identity at the time they begin the use of puberty blockers and to that extent, confirm their GD and increase the likelihood of some children moving on to cross-sex hormones. Indeed, the statistical correlation between the use of puberty blockers and cross-sex hormones supports the case that it is appropriate to view PBs as a stepping stone to cross-sex hormones.’ (para 136)
Perhaps Matt does want puberty blockers as ‘a stepping stone to cross-sex hormones’. We see Matt reading something she has written: ‘To be honest I see myself as a real boy, but I really do want to be a real real boy.’ (42.15) ‘I just want the blockers now. I really do. I just don’t like talking about it.’ (42.24)
But the session with Charlie reveals a simpler explanation. Perhaps she just wants to be accepted and understood:
Charlie: ‘If you went through a full puberty you would feel kind of sad.’ Matt nods. (42.42) Charlie: ‘Would you like people to understand you?’ Matt: ‘Yes’ (42.49)
Clinician Charlie tells Gary Butler: ‘I think that Matt was much more aware of the process than he’s ever been before. I think there is some anxiety about puberty and what that means. And how you might develop if you went through puberty and feeling that’s not what he wants. (43.13) I think we’ve got a much clearer picture than we’ve ever done before.’ Butler replies: ‘I think that’s really important.’ To the GIDS, this scene presumably documents the care with which clinicians approach difficult decisions. But it is a flimsy basis for a decision with potentially lifelong consequences.
Rachel now believes that for Matt ‘having breasts would be more damaging than not having them.’ (43.05) We see Matt getting a blocker injection while Rachel holds back her tears. (46.00)
Ash’s story: sexual orientation and gender identity
Eight-year-old Ash is socially transitioned as a girl both at home and school. This has caused problems with bullying and the whole family has been forced to move to try out a new school where Ash presents as a girl, living in stealth. But this only produces a new problem, as her mother Terri reports:
‘After being at the school for about nine days, Ash come home and she said, oh, I’ve got boyfriend. And I think, oh God, ok. And then, that week, she come out and go, ‘He kissed me on the lips.’ And, er, it makes me uneasy when she says things like that because I think of what the other parent would feel if she knew.’ (6.24)
As long ago as 1987, Richard Green’s fifteen-year study of feminine boys, published as The “Sissy Boy Syndrome” and the Development of Homosexuality showed that the most likely outcome for boys who are extremely feminine is adult homosexuality, not a transgender identity. This was the point that Stephanie Davies-Arai made in her 2015 blog. Recent research has supported this finding. (Li, Kung, Hines 2017)
But no one seems to have told Ash’s mother. The documentary captures a revealing discussion at the GIDS, where the mother, Terri, asks Polly Carmichael: ‘Do you think there’s any chance that Ash could have more female hormones now than male. Does that happen? She’s just so feminine.’ Terri is presumably thinking about some kind of intersex condition.
Polly: ‘It’s very very very, really very unlikely, almost never do we find anything such as you’re talking about.’
Terri: ‘I suppose I’d just really like to know why this happens.’
Carmichael is right here: a routine karyotype (or check of the child’s chromosomes) was once a standard procedure at the GIDS but was abandoned because the results showed no abnormalities. (Butler et al 2018) Gender dysphoria has nothing to do with intersex. This was Polly Carmichael’s opportunity to explain to Terri that Ash might grow up to be gay. Instead, she affects ignorance:
Polly, ‘But I mean in the end we don’t know why, we don’t know why people feel the way they feel about who they are. It’s your life, your body.’
Ash: ‘My decisions.’
Polly: ‘Your decisions.’
For Terri, Carmichael is the expert, the one person she can trust. But Carmichael’s answer is political. Ignoring research over five decades she presents transition as a mystery, a question of bodily autonomy that only an eight-year-old can decide: ‘It’s your life, your body,’ she tells Ash. Carmichael’s answer recalls what her colleague Bernadette Wren told Woman’s Hour in April: ‘We live in a world where people alter their bodies, surgically or otherwise, and this freedom is available for people as they get older.’ And so Carmichael asks Ash about hormones: ‘Are you someone at the moment who feels they’d like to have the female hormones.’
Lacking the knowledge that Ash might be gay, Terri – who is keen to support Ash – reinforces the female identification: ‘When you’re not here’, she says, ‘I’m the only girl round here. I’m the only person who doesn’t lift the toilet seat around here.’ (22.00) Ash wants to stay a child because ‘If I stay a child forever, nothing bad will happen.’ When the filmmaker asks: ‘Do you think you’ll be a girl forever?’ Ash replies: ‘Yes.’ But not even girls can stay a girl forever. This is not a child who has realistic expectations of the future.
The Tavistock starts the discussion about puberty blockers years before they will be needed and at Ash’s next visit Polly Carmichael raises the subject again. Terri says that Ash has hardly mentioned blockers since the last meeting. Ash’s new preoccupation is having a baby and she has explored this online. Ash knows that a womb transplant is available if she goes to Sweden. She knows that she would have to have a caesarean though she doesn’t know why. Ash is bright and articulate. But she is also a child, thinking like a child. Carmichael comments: ‘They don’t really get a full understanding of some of those decisions.’ She explains to Ash that ‘womb transplants are quite a new thing and we don’t know for sure that it would be possible for you.’ Kindness conspires to support Ash’s fantasy and the repeated discussion of hormones sets up child and parent for this likely outcome.
Five years after the start of the puberty blocker experiment, the GIDS opened their doors to documentary makers to demonstrate their cautious approach to medical intervention and to win over public support. With hindsight, their pride in ‘The Gender Clinic’ appears to be misplaced. In 2016, Transgender Trend asked how a child could give informed consent to a pathway that will shape their whole life:
To be in the position of having to make this decision is an unenviable one for parents but it’s especially worrying when the decision is handed over to the child. Of course, a child needs to be informed and their view ascertained before any treatment, but really how can a child begin to understand the complexity of this issue, the life-long effects of treatment which even the adults don’t know, and the reality of life as a transsexual adult?
In 2020 the High Court agreed. (Bell v.Tavistock, para 151,152.) Why did the GIDS not listen to the voices of caution over those four years?