Thread by @hannahsbee

WPath guidelines say puberty blockers are not a ‘nice to have’ defendants say.

Defendant says ‘time to think and alleviate distress’ is absolutely accurate way of describing purpose of puberty blockers

Judge quotes HRA investigation. Tavistock disagrees with HRA assessment.

Defendant says consent process robust - “if there’s concern, then they have to be resolved. There’s no proceeding” if concerns are not resolved

Defendant says what claimants submit “does violence to Montgomery.” Back on consent/competency. Defendant says what is material is what reasonable person in patient’s position would attach significance to. Defendants argue that abstract adult (a judge) is not reasonable person

Defendant says that Mr Hyam’s (claimants’ barrister) submission that someone can’t make a decision without relevant experience, undermines most consent decisions.

Defendant says fertility is discussed with YP

Judge questions what would constitute sufficient understanding of sexual functioning, defendant says if 11 year old didn’t know what an erection was, what an orgasm was, then they would not be deemed capable of giving consent

That person would then be helped to improve their understanding and would be reassessed.

Assessment for cross sex hormones - oestrogen and testosterone - involve a whole new process and more discussion, defendant says

Younger ‘clients’ would have more appointments before being referred to endocrinology. Average age of referral though is 15.4 years, Tavistock says

Appointments must also be spaced over a ‘significant period of time’.

Service specification states first appointment should be within four months. At the moment it’s about two years

Judge clarifies referrals figures - over half of those referred to endocrinology for blockers were under 16, over a quarter were under 14

Defendant says On average younger patients had 10 to 11 appointments before being referred

Information provided by GIDS to children and families emphasises it’s entirely up to them whether to go onto puberty blockers. They are presented with benefits and possible disadvantaged and are told, “please think carefully about the advantages & disadvantages before you decide”

Defendant says there are instances where GIDS refer to endocrine clinic, but where endocrine clinic do not think child can give consent and will refer back.

Tavistock client N talked about - understood their options and the impact puberty blockers would have on body, mood, fertility options were discussed with me. ‘I never felt pressured to go on the treatment... the treatment with puberty blockers may very well have saved my life’

Referring to case law, defendant says law should be simple and clear. That one particular treatment - puberty blockers - be carved out, is contradictory. Furthermore, a whole raft of legislation recognises the age of 16 as a threshold. Claimant is arguing under 18s can’t consent

Tavistock emphasises the autonomy of the child, defendant says. Asked about the 11 year old who wants treatment but can’t consent, defendant wants to consult with Tavi team. Currently, Tavi has never taken an application to court when it comes to treatment with blockers

Judge questions defendants understanding of gillick competency. The application of Montgomery does not fit in with the analysis, she says

Defendant argues that what is salient is key and that is person and context specific. Two dimensions to what is salient - for the individual person, and for the treatment. Defendant argues Tavistock process takes these into account and helps recognise whether YP can give consent

Judge asks again about the 11 year old, with little understanding of sexual functioning and don’t have a basis of experience. Defendant says job of clinicians is to help facilitate understanding in process of dialogue. To make sure they understand what is salient...

If they don’t then more time will be given. Judge presses again what about the three 10/11 year olds who were referred for blockers last year. On what basis were they judged as being competent?

Defendant says 10 yo at tanner stage 2, 10 appointments and discussion with child and families, and then decision reached. We don’t have the circumstances of those cases in front of us. They were all properly clinically made decisions.‘Nothing inherently unlawful in that process’

Responding to point raised by claimant yesterday that court can override the decision of a child, defendant says it can only be done in very narrow circumstances: threat to life or grave risk of severe mental or physical harm. Those are not met in this case, they say

Defendant says court cannot declare that process used by Tavistock for referral for hormone blockers is unlawful

To rule that under 18s cannot give consent would run entirely contrary to existing law and precedent

To apply to court of protection in every case where treatment of puberty blockers is wanted, even where all parties are agreed - In these circumstances, defendant argues, court has no jurisdiction. Plus court of protection not right vehicle.

Judge raises question of 10 year old given puberty blockers, then wants to sue aged 19. The YP says ‘you never should have done that to me’ as part of a medical negligence claim.

Barrister for Tavistock has now finished. Now the barrister who represents the hospitals who provide the Endocrinology services to GIDS patients

Barrister: the 10 yo girl who has started periods. She understands her body has changed. She has gender dysphoria, but knows that she can alleviate distress by taking blocker. The issues of fertility don’t need to be discussed at this point. 10yo could begin stage 1 blockers...

Then, say, at 14, she could come off the blocker to have eggs frozen etc. From endocrinologist perspective, stage 1 is reversible. Could pause then have eggs harvested, and then go onto surgery much later if they wanted.

We say a 10 year old does have gillick competency. They understand their bodies. They understand their gender dysphoria and it causes them distress.

‘There is no alternative treatment’ counsel for hospitals says

Very few 10yo have blockers - they’re mostly natal girls - but we do think they can give consent

Judge asks whether experience of being on blocker will effect the later 14yo decision-making process? Barrister says they will have matured and be in a better position to understand

Judge presses whether having puberty suppressed will impact on decision making. Barrister says it’s a long pathway. If you go on blocker at 10, you have to wait 6 years for cross sex hormones

Another judge says what you will not have gained is experience of what it’s like to live in the body you were born with though...

Accepts that aspect but whole purpose of NHS commissioning this service is to alleviate suicidal ideation and gender dysphoria

Endocrinologists at UCLH and a leeds are experienced, the former doing this since 2006. They have treated hundreds of distressed children in stage 1. It’s their view that it can and does alleviate the distress of the dysphoria.

Judge cites the early intervention study which suggests no overall improvement in psychological well-being. Barrister says endocrinologists’ view is that the hormone blockers are alleviating distress.

Judge asks what has happened to the publication of the results of the early intervention study, given it ended in February 2019? Barrister for Tavi says it’s going through peer review process. Judge says, ‘why can’t we see it then?’

There’s no reason in law why parental responsibility is not sufficient. In practice, we take parental consent. If we fail to persuade you that children as young as 10 are Gillick competent then there would need to be a discussion between endocrinologists & Tavistock

But in the eyes of the law, if someone sued my endocrinologists, ‘I would be shouting parental responsibility’ all through the claim.

Barrister says no role whatsoever for the court of protection.

Just to explain there are three judges hearing this case - THE PRESIDENT OF THE QUEENS BENCH DIVISION and LORD JUSTICE LEWIS and MRS JUSTICE LIEVEN DBE - I’m unable to clarify which is questioning on any given occasion. It’s too time consuming for the purposes of tweeting

Some clarifications on earlier points. Of 161 referrals to endocrinology for puberty blockers last year, break down by age is:
10/11 - 3
12 - 13
13 - 10
14 - 24
15 - 45
16 - 51
17/18 - 15

So in fact fewer than a quarter were under 14

The Tavistock have informed me that this number is the average across all ages. They say that recent analysis shows that there were 13.3 appointments on average for young people aged 10 and 11. None received fewer than 9 appointments before referral to endocrinology.