To be transgender is not a lifestyle choice. It is not a fad or a craze. It is not easy, but requires courage and commitment. It is a part of who you are, like being gay, and, as such, denial of it can be annihilating. Denial of the medical treatments that can help trans people can also be devastating.
I offer these views as the father of a trans man, which has caused me to see and reflect on these issues more than I would otherwise have done. Without this experience I might have found myself, like many of my age and outlook, nodding along with the near-unanimous approval by the British press, including this newspaper, of last December’s high court judgment in the case of Bell versus Tavistock. This decision, currently being appealed against, rules that transgender teenagers, acting with their doctors and families, are incapable of consenting to treatment that might help them through their entire lives.
If you are a trans adolescent, you may find puberty unbearable, as your body changes in ways that you don’t want. There is a medical way to help with this - puberty blockers - which have been used to treat young trans people around the world since the 1990s. They slow down puberty, which can relieve your distress, and give you time until you are old enough to consider further forms of treatment – cross-sex hormones, which in this country are allowed from the age of 16, and surgery, which can take place later.
If you don’t take blockers the consequences will last a lifetime. You will develop the physical characteristics – breasts, facial hair, deepening voice, broadening shoulders or widening hips – which will make it harder to pass in your gender identity later in life. These characteristics will entail more extensive surgery to change than if blockers had slowed their growth in the first place. Blockers are largely reversible, though according to the NHS, some of the the side-effects are unknown. If you later decide that transition is not for you, your body will continue to develop the characteristics of your natal sex.
The high court case was brought by Keira Bell, a woman who had believed herself to be a trans boy, and at the age of 16 was prescribed puberty blockers by the Tavistock clinic in London, which runs the UK’s only gender-identity development service for children and young people. At 17, she started taking cross-sex hormones to develop male characteristics and, at 20, she had her breasts surgically removed. She now deeply regrets these actions and feels that she was given insufficient guidance by the clinic.
The court found that the Tavistock tries hard to give adequate information to its patients in an appropriate manner, but that “the problem is not the information given”. It ruled that children under 16 are unlikely to have sufficient understanding to give their informed consent to treatment with blockers and that a court order should therefore be required to proceed. This is a costly, slow and uncertain addition to what is already a tortuously slow process, with waiting times of 18 months and more. Clearly, if you are talking about the onset of puberty in teenagers, time is of the essence.
The practical effect of this judgment will be to deny blockers – life-saving in some cases, life-transforming in most – to many people who would benefit from them. It was based on some tenuous arguments. It relied heavily on the fact that most people who take puberty blockers progress to cross-sex hormones, which the court thought indicated that blockers could act to confirm teenagers’ possibly mistaken perception of their gender. But there is another explanation for this progression: that the patients were correctly diagnosed in the first place and that therefore they naturally would want the next stage of treatment when it is available, that this is a case of correlation and not causation.
The court’s logic led it to assert that the impacts of cross-sex hormones, which can sometimes affect fertility and sexual function, should be fully considered by a child at the time they started on blockers – they would have to contemplate the effects not only of the medication on offer, but also of that which would be on offer in the future. The court decided it would be impossible for them adequately to do this, even if their families and doctors were in full agreement, and that the decision should be passed to a judge.
At the same time, the court paid minimal attention to the consequences for trans people of puberty unhindered by blockers. It thought it more important to protect transgender children from blockers, which are reversible, than from the effects of unwanted puberty, which in many ways are not. Doing nothing is not a neutral option and can be harmful, a point that the court did little to acknowledge.
The choices are truly difficult – there is no risk-free course available, either for the great majority who remain happy with their transition, or those, such as Keira Bell, who come to regret it. Every reasonable step should be taken to ensure correct diagnosis but it is not clear how court orders, or the blanket assertion that under-16s cannot understand the issues at stake, will lead to better outcomes.
Bell’s story should elicit sympathy from everyone, which might be one reason for the widespread approval of the court’s judgment. However, it was the hormones and surgery she chose at 17 and 20 that created her plight, not blockers, unless you accept as certain the theory that the latter channels people into accepting later interventions. It is a misplaced and disproportionate response to her case to deny to many others a form of treatment that commands a high rate of satisfaction among those who take it.
My son came out aged 19, too late for puberty blockers, but the treatment that he has received has been vital for his wellbeing. The Tavistock judgment, in the name of child protection but based on shaky reasoning, will raise impossible barriers to equally vital treatment to teenagers. It is cruel. It will cause misery. It is already causing anxiety and unhappiness to trans children and their families. No one should pretend that the issues around transgender children are easy but it is not a good response to this complexity simply to obstruct treatment.
Rowan Moore is the architecture critic of the Observer