Returning a bit to the ideas of capacity to consent and the Tavistock / GIDS process ... (This is loooong, sorry)
Butterfly I haven't read all of your most recent posts in detail, but what I hear is that your experience of puberty blockers and transition was a relatively smooth one that perhaps represents a best case scenario:
- you were ?mid-teens when you started on blockers
- your transition was MtF, so blockers stopped you experiencing the irreversible effects of testosterone, which was the original intention of the Dutch protocol
- you were part of a small initial cohort, so you were given a lot of information about the long term impact of early transition and had the time to ask questions and come to weigh up the different options and come to a decision that worked for you
- You were seen as relatively 'stable' compared to other clients by the clinicians you saw - so presumably you didn't have other serious mental health difficulties / a significant history of trauma or abuse (or were able to work through that alongside your gender identity issues); you had a supportive, accepting family background and are roughly neurotypical.
For you, that meant that you were able to make an informed decision about transition that you were comfortable with at the time, and that has worked out well for you in the long-term although you have had some (small) health problems as a result of transition.
I think in clinical terms you were able to show that you were Gillick competent - that you had the capacity to make that decision about your health at that time.
However, I think a lot of things have changed in the 20 years since then.
Firstly, the number of referrals GIDS deals with has increased enormously. The yearly referral rate was about 30x higher in 2019 than in 2010 (www.transgendertrend.com/surge-referral-rates-girls-tavistock-continues-rise/). The size of the GIDS team has not increased by nearly that much. That partly means longer waiting times, but it also means less time for clinicians to really work in depth with the young people they see to help them find the best option for them. Kiera Bell said that her assessment sessions were perfunctory; and there are reports of patients being referred for treatment after just a couple of sessions despite concern from other clinicians.
Whilst you may have had the capacity to consent to a treatment that was presented as highly experimental, it really doesn't seem that today's cohorts are afforded the same level of care. That's very concerning, particularly when it is clear that much younger children are now being put on blockers.
Secondly, a lot of the young people referred to GIDS today have very complex backgrounds. About 40% have diagnosed autism or score highly on autism screenings. Others have experienced sexual abuse and other childhood traumas that have affected their sense of self and their feelings of dysphoria. If you read the judgement from the Sonia Appleby tribunal (www.gov.uk/employment-tribunal-decisions/mrs-s-appleby-v-the-tavistock-and-portman-nhs-foundation-trust-2204772-2019), it is clear that GIDS discouraged and impeded their clinicians from getting support and making safeguarding referrals when they had concerns about a child's wellbeing. That's really bad. It's probably partly the result of being overwhelmed with work already (making safeguarding referrals is quite time consuming), but it shows that there is a general culture in which the needs of vulnerable children are not being recognised.
There is also a thread throughout the Appleby judgement about children in homophobic environments who may be same-sex attracted identifying as trans, in some cases in a way that seemed parent driven. It's clear that clinicians were concerned about these types of referrals, but that they were shut down by senior staff as "transphobic". That's also really concerning. This and the lack of consideration about trauma, abuse and non-neurotypical clients, especially coupled with the quite cursory assessment process, suggests that there are children and young people being put on this pathway of blockers and transition for whom other pathways could be more suitable. That's not to say that transition is inherently bad. Just that it comes with a heavy medical burden (infertility, loss of sexual sensation/function, lifelong medication, risky operations, reduced bone density, increased cancer and osteoporosis risk), especially if natal puberty is halted very early. So it is very important that other psychological issues are well managed so that a young person is in the best possible place to make a decision about transitioning; that other alternatives to childhood transition are considered, and that any safeguarding concerns about reasons for wanting transition are properly investigated. Based on all the evidence from GIDS, I am not convinced that any of that happens at all, making me very concerned about the harmful and potentially unnecessary treatments being given to children and adolescents.
Thirdly, the demographics of GIDS referrals has changed hugely. The Dutch protocol (blockers followed by hormones) was designed for young people who had experienced (parent documented) gender dysphoria from childhood and tbh who were mostly transitioning MtF. That was the bread and butter of GIDS 20 years ago. Today a lot of the referrals are for people who want to transition FtM and who only started presenting as trans at the onset of puberty. They are being put on the sam pathway but it's a much poorer fit. Blockers that stop masculinisation at puberty are good at helping trans girls to pass better as adult trans women; but blocking the growth spurt at puberty blocks trans boys from even reaching the adult height they would have attained without blockers. Trans boys, because they still remain biologically female, are also at much greater risk of serious osteoporosis in adulthood if they miss out on the bone density increase of their natal puberty.
It's also worth considering that the concept of being trans is much more prominent than it was 20 years ago. (Note - this paragraph is more speculative. I'm basing my argument on ideas from Ethan Watter's book 'Crazy like us' about how people in different times and different cultures have different ways of expressing psychological suffering.) That means that it's very possible that young people are more likely to express distress through the lens of gender dysphoria. Whereas 20 years ago someone might have developed anorexia or used self-harm, similar feelings of distress and alienation may be interpreted by young people today as evidence of being trans, with transition viewed as a concrete solution to their unhappiness. Those young people may interpret steps along a path to transition as proof that their suffering is genuine, valid and understood by others. That's not to say that there can't be more young people for whom transition is genuinely an appropriate pathway, but we need to be very careful to fully explore a young person's understanding of transition (in a way that, as above, I don't think GIDS is doing) before starting them on a pathway to an early medical transition.
Finally, there have never been any proper randomised controlled trials of puberty blockers for trans children. 20 years ago this was a very new idea, so proof of concept trials with no control group are a reasonable first step. However, today we still have no high quality data to say (beyond anecdotes) that puberty blockers have any clinical benefit. Data that we do have (see the NICE review of evidence here www.evidence.nhs.uk/document?id=2334888&returnUrl=search%3fq%3dtransgender%26s%3dDate ) suggests that there might be a small improvement in depression when teens are given blockers, but that there is no significant effect on anxiety, anger, dysphoria or other quality of life measures. At this point, we are beyond asking whether a child can consent to the treatment; we need to ask why the treatment is being offered at all, given that it functions no better than an antidepressant and comes with a much longer list of severe side effects.
At this point, I honestly don't think GIDS is fit for purpose. I am uncomfortable with blockers being prescribed outside of a clinical trial with a control arm (placebo, treatment as usual, waitlist, take your pick ...). I would also want to see wholesale restructuring of their service and preferably much tighter integration with other mental health services before I had any confidence that they were able to practice safely and meet the healthcare needs of the children they support.