Legal feminist gets to the core of it, as good legal minds are so skilled at doing.

The question I find interesting here isn’t really a legal question. It is this: what is it that’s special about treatment with puberty blockers that makes the Tavistock think that parental consent isn’t good enough? If a child needs a vaccination to reduce the risk of a potentially serious childhood disease, parental consent is good enough. If a child needs a filling to deal with tooth decay, or an extraction to deal with an overcrowded mouth, the same. If a child needs surgery to pin a broken bone, the same again. 

I remember strongly dissenting to treatments of that kind as a small child, and failing to get my way. (I was terrified of shots as a child, to a degree that baffles me now. The “pain” is so small and brief that my horror then seems just weird. My best guess is that knowing the little owie is going to happen magnifies it out of all proportion in an undeveloped brain.)

Parental consent is good enough for most medical treatment because its necessity or desirability can be established by objective evidence. Tooth decay and broken bones can be seen with an x-ray; the risks of mumps, measles etc. (and the benefits of vaccination) are well-established by epidemiology. But if a child with the body of a girl says she is so sure that she is really a boy that she wants to be treated with puberty blockers to ensure that she doesn’t mature physically as a woman, there [is] no blood test, no visible symptom, no scan, no x-ray that can confirm her condition. How are parents, teachers, therapists and doctors to know whether she is truly trans (assuming for the purposes of argument that there is such a thing – or if even if there isn’t, at least so intractably dysphoric that radical body modification offers her the best hope of a flourishing life); or temporarily caught up in a teenage craze; or expressing distress in response to childhood abuse, homophobic bullying at school, or a traumatic bereavement or abandonment, or the pervasive sexism and misogyny of the society in which she is growing up?

Emphasis mine.

The whole thing is in the realm of saying, thinking, feeling, saying one thinks or feels. It’s all notional – it’s notional twice over, or even more.

The issue isn’t that that realm doesn’t matter, or that it’s trivial; of course it matters and of course it’s extremely far from trivial. Without it we might as well be bots. But mattering is one thing and being reliable evidence of a material condition is another.

One might think that these were the kinds of difficult questions with which clinicians would grapple earnestly before agreeing to set children on a path to medical transition and lifelong patienthood. What’s going on here? What are the causes of this child’s dysphoria? What are her chances of growing out of it with natural puberty? If treated, what are the chances that she will later regret the treatment? 

Also what do we mean by gender dysphoria? Is there really such a thing? Is it an idea created by people and made popular by social contagion? Is this child confusing the political or sociological or psychological with the biological? Might political involvement (i.e. feminism) or psychological investigation work better than physical intervention? There are a lot of relevant questions.

Astonishingly, one would be wrong. Even more astonishingly, it seems that the clinicians who have guided the development of the GIDS would not even regard these as valid questions. Bernadette Wren, Consultant Clinical Psychologist at the GIDS until her retirement in 2020, posed herself these questions in a 2014 paper:   

Can ‘postmodern’ ideas about the non-fixity and instability of gender serve the perplexed clinician? Can we forego the grounding of our ideas in demonstrable certainties? Operating with a postmodern notion of gender, can the clinician justify irreversible physical intervention?

In other words is it copacetic to just make it all up? The answer of course is “Yeah pretty much.”

Alarming though this is, it does at least make perfect sense of the GIDS’ unwillingness to accept parental consent as a substitute for the young person’s consent when treating children or adolescents with puberty-blockers: to do so would be fundamentally at odds with the philosophical underpinnings of the service. Parental consent would be rendered acceptable by a firm evidence base for the treatment proposed. But puberty blockers are not provided because there is convincing clinical evidence that they are needed (or even likely) to alleviate distressing symptoms or effect a full or partial cure for a pathology: on the contrary, it is admitted that the evidence base for treatment is thin tending to non-existent. The conclusion to the 2014 article that “the meaning of trans rests on no demonstrable foundational truths” goes further, suggesting that even a search for such evidence would be misconceived.  Instead, treatment is provided because children and young people – who should be enabled to experience self-determining freedom, including the freedom to make their own mistakes – ask for it. 

Yes, including the freedom to ruin their own bodies at age 17, 16, 15.

It makes an alarming kind of sense of something else, too. The court in Bell repeatedly expressed surprise at the Tavistock’s inability to provide evidence about the effects and outcomes of treatment with puberty blockers, noting – in particular – at paragraphs 23 and 24 that it hadn’t been provided with the results of a research study started some nine years earlier at the Tavistock, which it had requested but been told was unavailable because one of its authors had yet to respond to issues raised in the peer review process. On the face of things, that was quite extraordinary: the study was centrally relevant to the matters discussed in the judicial review, and even if it was still going through the lengthy process of peer-review and hadn’t been finalised for publication, it undoubtedly existed in a near-final form which could have been provided to the court had the Tavistock chosen to provide it.  (It was finally published on the day the High Court’s judgment was handed down.)

But if the service was run by postmodernist-leaning clinicians who regarded “truth claims” with suspicion and saw their task not as relieving the suffering of patients with distressing pathologies, but instead as facilitating their young clients in the pursuit of identity projects, what use would they have for clinical evidence? 

That’s tragic in the obvious way (people left with ruined bodies) but also in a less obvious way, which is that “identity projects” are the last thing adolescents need. The best way to form an identity is to look away from the self and engage with the world instead. Dive into politics or science or the arts or engineering or conservation or climate issues or any of a thousand things. Don’t be like “Rachel” McKinnon/Veronica Ivy, be like Greta Thunberg or the young John Lewis.