www.epath.eu

www.wpath.org
www.wpath.org

www.epath.eu

WPATH, EPATH, USPATH, AsiaPATH, CPATH, AusPATH, PATHA
Response to Bell v. Tavistock Judgment
Statement Regarding Medical Affirming Treatment including Puberty Blockers
for Transgender Adolescents
The Boards of Directors of the World Professional Association for Transgender Health(WPATH), the European Association for Transgender Health (EPATH), the United States
Professional Association for Transgender health (USPATH), the Asian Association forTransgender Health (AsiaPATH), the Canadian Association for Transgender Health(CPATH), the Australian Professional Association for Trans Health (AusPATH), and theProfessional Association for Transgender Health Aotearoa (PATHA) all strongly
disagree with the recent judgment of the London High Court in Bell v. Tavistock. We
believe this decision will result in significant harm to the affected children and theirfamilies. We oppose this ruling and urge that this ruling be appealed and overturned.

The case
On December 1, 2020, the London High Court ruled (Bell v. Tavistock) that children are highly unlikely
to be able to consent to taking puberty blockers. The far-reaching result of the judgment is that all
applicants for gender affirming medical intervention in the UK under the age of 16 must first seek
authorization from a court of law to obtain necessary and effective medical care, with the apparent
likelihood that permission will not be given due to the court’s improper practice of medicine.
As professional medical organizations, the European Professional Association for Transgender Health(EPATH), and the World Professional Association for Transgender Health (WPATH), as well as theother signatories to this statement, all have serious concerns about this ruling and wish to express
that although treatment for young transgender adolescents involves uncertainties, as is the case inmany fields involving young people, several studies demonstrate the clear mental health benefit ofgender-affirming medical treatment (including puberty blockers). Withholding such treatment isharmful and carries potential life-long social, psychological, and medical consequences.

Immediate and long-term consequences of puberty blockers
Treatment of transgender adolescents involving gender affirming medical interventions (pubertysuppression and subsequent gender affirming hormones) is the most widely accepted and preferredclinical approach in health services for transgender people around the world. The aim of puberty
suppression is to prevent the psychological suffering which stems from undesired physical changes
that occur during puberty, and to allow the adolescent time to carefully consider whether or not to11

www.wpath.org

www.epath.eu

pursue further transition when they are eligible. It is part of the two main international guidelines:
the WPATH’s Standards of Care as well as the Endocrine Society’s Clinical Practice Guidelines. To beeffective, this treatment must commence early in the puberty process, not at the age of 16. Whentreatment is needed, its effectiveness will be diminished while waiting to be seen by a court of law.

Do puberty blockers lead to further gender affirming treatment?
Gender affirming medical interventions for adolescents are usually offered in a stepwise approachfrom reversible to irreversible treatments. Starting with blockers, which affects pubertal
development in a reversible way, young people are provided with ample time to explore theirgender. All possible reversible steps are considered before any less reversible steps. It is not the casethat one stage invariably leads to the next. Gender affirming hormone treatment is a carefully
considered later intervention for which adolescents (and their parents) provide separate informed
consent after having received information about the effects, limitations, and potential side effects ofthis treatment. Not all adolescents seeking gender-affirming care will require hormonal or surgicaltreatments; treatment is always individualized according to each adolescent’s needs.

The harmfulness of not providing puberty blockers
We have a grave concern that the High Court has overlooked not only the immediate positive effectsof puberty suppression, which has been demonstrated to result in decreased psychological sufferingand a healthier adolescent development, but also the lifelong benefits of having a physicalappearance which is congruent with one’s gender identity. Withholding such treatment until
adolescents are 16 years old means they will experience complete puberty incongruent with theirgender identity, which has potential life-long harmful consequences such as stigmatization, personal
physical discomfort, difficulty with sexual function and social integration.

The age of consent
As noted in the case Bell v. Tavistock, "The sole legal issue in the case is the circumstances in which achild or young person may be competent to give valid consent to treatment in law and the process
by which consent to the treatment is obtained." Even when they do not yet have the legal right togive their own consent to treatment, research has demonstrated that many minors possess thecognitive and emotional abilities to understand the consequences of their decisions, including
decisions concerning health care. The determination of the ability of a particular adolescent to giveconsent should be made by a competent transgender healthcare provider who has evaluated the22

www.wpath.org

www.epath.eu

adolescent, and not by a court of law. Current guidelines already recommend that this competence isassessed prior to the start of treatment.

Conclusion
WPATH, EPATH, USPATH, AsiaPATH, CPATH, AusPATH, and PATHA recommend that capacity toconsent is evaluated on a case-by-case basis by the treating clinician and not by a court of law. We
do not agree that transgender healthcare is so different in kind to that provided to cisgender people
as to warrant separate legal provision. We consider puberty blocking treatment and treatment withgender affirming hormones as two separate treatment steps each requiring informed consent at thetime such treatment is to be started.
We support the provision of healthcare to gender diverse people in a timely manner such that they
can live their best lives. We are gravely concerned that the ruling will have a significantly adverse
impact upon gender diverse youth and their families by imposing barriers to care that are costly,needlessly intimidating, and inherently discriminatory.

Referenceshttps://www.judiciary.uk/judgments/r-on-the-application-of-quincy-bell-and-a-v-tavistock-andportman-nhs-trust-and-others/
Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H.,
Rosenthal, S. M., Safer, J. D. Tangpricha, V., & T'Sjoen, G. G. (2017). Endocrine Treatment of GenderDysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The Journalof clinical endocrinology and metabolism, 102(11), 3869–3903. https://doi.org/10.1210/jc.201701658
E. Coleman , W. Bockting , M. Botzer , P. Cohen-Kettenis , G. DeCuypere , J. Feldman , L. Fraser , J.
Green , G. Knudson , W. J. Meyer , S. Monstrey , R. K. Adler , G. R. Brown , A. H. Devor , R. Ehrbar , R.
Ettner , E. Eyler , R. Garofalo , D. H. Karasic , A. I. Lev , G. Mayer , H. Meyer-Bahlburg , B. P. Hall , F.
Pfaefflin , K. Rachlin , B. Robinson , L. S. Schechter , V. Tangpricha , M. van Trotsenburg , A. Vitale , S.
Winter , S. Whittle , K. R. Wylie & K. Zucker (2012) Standards of Care for the Health of Transsexual,Transgender, and Gender- Nonconforming People, Version 7, International Journal ofTransgenderism, 13:4, 165-232, DOI: 10.1080/15532739.2011.700873

33