She may have been Gillick Competant but she was not given sufficient information to make informed consent.
Exactly. Consider this consultation with an 11 year old. I’ve chosen male just for simplicity regarding describing physical changes.
Scenario One: TRA Model
Male Child: I want puberty blockers and “HRT”.
Doctor: Do you understand this will mean you won’t get any puberty and you’ll get breast tissue that will grow?
Male Child: yes! That’s awesome! I want that.
Doctor: great! You clearly understand and are therefore Gillick competent.
Scenario Two: Proper Consent (as determined by the judges in the Bell case)
Male Child: I want puberty blockers and “HRT”.
Non-captured doctor: Okay. Do you understand that this might make you feel happier immediately but won’t necessarily make you happier in the long run because we don’t have any evidence of long term psychological benefit? [i) the immediate consequences of the treatment in physical and psychological terms;]
Male Child: okay but I’ll be happier, right?
Doctor: to start with maybe, but not forever.
Male Child: but as long as I don’t have to do puberty.
Doctor: okay…do you understand that if we start these blockers, you will end up on oestrogen? [(ii) the fact that the vast majority of patients taking puberty blocking drugs proceed to taking cross-sex hormones and are, therefore, a pathway to much greater medical interventions;]
Male Child: yes! That’s what I want!
Doctor: But it also means you will be seeing doctors regularly for the rest of your life because of the health problems we will be inducing as a result of this. Your body will never mature past the point it is now.
Male Child: I don’t care, that’s ages away. And I don’t want my body to mature, that will be horrible.
Doctor: And if you stop puberty and your penis and scrotum don’t grow, it means it will be very difficult for anyone to do surgery, it will require the surgeons to use bowel to create any form of vagina. [(iii) the relationship between taking cross-sex hormones and subsequent surgery, with the implications of such surgery;]
Male Child: I don’t really want to think about surgery, I’ll think about that when I’m older.
Doctor: And if we do this, you won’t be able to ever have children or your own because you won’t have developed any sperm. [(iv) the fact that cross-sex hormones may well lead to a loss of fertility;]
Male Child: I don’t mind that, I don’t really want children.
Doctor: But you’re only 11, so you think you’re sure at this age?
Male Child: Oh I’m sure! I don’t even want to think about having kids!
Doctor: And what about sex. What do you know about sex so far? [(v) the impact of cross-sex hormones on sexual function;]
Male Child: Well I kind of know what it is from PSE at school.
Doctor: Do you think you might have sex when you’re older?
Male Child: I guess, maybe 😳 But I think I might be asexual.
Doctor: Do you know what erections are and have you had one?
Male Child: not really 😳😳
Doctor: because if we do this you won’t ever be able to have proper erections and sex when you’re older. This is something you might want to do if you meet someone you like when you’re older. [(vi) the impact that taking this step on this treatment pathway may have on future and life-long relationships;]
Male Child: I don’t really want to think about that right now, I just don’t want my body to change.
Doctor: Okay…finally, do you understand that if we start this, we can’t tell you or your parents what this will lead to in the long term? That there might be serious problems we don’t know about and we don’t really know if it will help you? We do know if we support you through puberty there’s a good chance you’ll be happy with that as an adult. [(vii) the unknown physical consequences of taking puberty blocking drugs; and (viii) the fact that the evidence base for this treatment is as yet highly uncertain]
Male Child: that’s okay, I’m sure this will be right for me 🤞, everyone tells me it’s the best thing to do otherwise I might get suicidal.
Doctor:…..
And this scenario imagines a child who can talk reasonably, might be a bit precocious. I have seen children who don’t talk, can’t verbalise their concerns, some with ASD, intellectually impaired, children with trauma, children in care, all put on puberty blockers. How many children who have been placed on puberty blockers around the world have had even half of such a conversation prior to their first injection?
Show me a child who is at Tanner stage 2, aged 11, 12, 13, who can provide good solid answers to these questions to remove any doubt about Gillick competence for this treatment pathway and I’ll show you a unicorn.
Keira’s case put this out there. Doctors now need to show the child understands those implications. The successful appeal against Keira didn’t remove those implications, it just changed the responsibility of who makes sure the child understands back from the courts to the doctors. So as well as showing me a child who understands those things, show me a doctor who thinks they have a child competent enough to understand those things and I’ll show you a doctor who should be in front of a competency assessment.
Children just cannot consent.