Children Cannot Consent: Puberty Blockers, Gender Eugenics and Keira Bell

Today, the verdict of a judicial review ruled that is ‘highly unlikely’ that 13 year old children can give informed consent to puberty blockers and that it is ‘doubtful’ that 14 and 15 year old children can ‘understand and weigh the long term risks and consequences’ of such medication. The ruling also recognised that, even though 16-18 year olds generally can give informed consent for medical treatment, due to the ‘experimental’ nature of puberty blocking medication, a court order should be sought in order to start treatment.

Given that the majority of children being referred for puberty blocking treatment are female, and female puberty begins between 8 and 14 years old, this ruling effectively safeguards them from unknown long-term medical harm. Also, as the majority of children who take puberty blocking medication do (almost invariably) go on to take irreversible hormone replacement therapy and seek irreversible surgeries (such as masectomies and hysterectomies), the High Court’s intervention regarding puberty blockers will also prevent children from taking a life-changing medical pathway which they are ill-equipped to understand. 

The legal challenge was brought by Susan Evans, a former clinician at the Tavistock gender identity clinic who left her post after whistleblowing on the dangerous practice of prescribing puberty blockers to children. Alongside her was Keira Bell, a detransitioned 23 year old woman woman who was put on this treatment pathway at age 16. Also bringing the challenge was Mrs A, the mother of a 15-year-old autistic child with several mental health conditions. Mrs A’s autistic daughter is currently being referred to the gender identity clinic and the mother fears that her daughter will be put on puberty blockers — drugs that block hormone receptors and stop children from growing and developing physically to sexual maturity.  

Although these are described as ‘puberty blockers’, an off-label term for drugs such as Lupron and Decapeptyl (brand name, known generically as Triptorelin). The manufacturers do not approve them for purposes of suppressing puberty and the treatment is highly experimental. So far, the evidence suggests puberty blockers in combination with cross-sex hormones in children lead to bone density problems, sexual dysfunction, cardiovascular problems and sterility.  

Sexual dysfunction was central to Keira Bell’s and Mrs A’s court battle against the Tavistock. Alarmingly, the Gender Identity Clinic’s defence team argued that because some 12 year olds are sexually active, they can also ‘consent’ to puberty blockers and that they do so in full knowledge of the risks of later sexual dysfunction. Firstly, this willingness to accept that 12 year old children can give informed consent to sexual activity is a huge safeguarding red flag. Furthermore, the premise that because some 12 year old children are sexually active is evidence that they possess adult maturity in is absolutely ridiculous. The other argument put by the Tavistock’s defence team is that some children grow up to be adults who are disinterested in sex anyway. Despite a small proportion of children who grow up to be disinterested in sexual activity, every child deserves the chance to make these decisions themselves when they are sexually mature enough to do so — rather than being permanently denied access to a fulfilling adult sex life by experimental child medical treatment.

Jazz Jennings is a 20 year old American reality TV star who given his own television show as a child to document his ‘transition’ for entertainment. Jazz was famously captured on camera asking his father what an orgasm is like after doctors told Jazz he will never experience one. Jazz’ sexual dysfunction was a result of being given puberty blockers age 11. It is gender non-conforming children like Jazz, or other children seen as ‘different’ that are often viewed as having a problem in need of ‘solving’. Those so-called irregularities or abnormalities, supposedly in need of a cure, such as autism, have been over medicalised and problematised for centuries. 

Mrs A’s child is not an unusual case. Autistic people are hugely overrepresented in referrals to gender identity clinics. The Tavistock’s own figures show that, although people with an autism spectrum condition (ASC) make up only 1.6% of the population, 35% of child referrals have moderate to severe ASC traits, and a further 13% have mild ASC traits.

As an autistic woman myself, I find the efforts to pathologise and medicalise us depressingly familiar. Stonewall,  Mermaids and GIRES have all claimed that autistic traits may actually be evidence that a child is ‘really’ trans, and these traits may disappear with medical intervention. Stonewall and Mermaids both attempted to give evidence at the court case against the Tavistock. They were both were disallowed by the judge — presumably because of their lack of expertise in health. The material and financial existence of these organisations wholly relies on the continued existence of trans children. Mermaids (a self-proclaimed ‘trans kids charity’) needs gender nonconforming children to continue to buy into the notion that there is something fundamentally ‘wrong’ with them. For Stonewall, the need to categorise gender nonconforming children is more existential; for trans adults to exist there must theoretically be trans children.

Diane Ehrensaft, a child gender therapist in the United States, describes pre-verbal and non-verbal children tearing off uncomfortable clothing, or getting upset at uncomfortable hairstyles, as somehow reflecting an internal conflict and declares it to be a symptom of gender dysphoria. According to Ehrensaft, it is not external, material reality that causes the problem – uncomfortable clothing and uncomfortable hairstyles – but an internal essential problem. It is consistently female children who are forced into less practical, more uncomfortable clothing — as well as having our long hair tied up in decorative styles. Is it any wonder little girls reject the straight jacket of femininity? Beyond general discomfort, every autistic person I know (myself included) remembers having a ‘meltdown’ at being put into clothing that set off our sensory issues, or strongly reacting to having someone invade our personal space to style our hair. These are known autistic traits; yet they are being declared evidence for irreversible experimental medical treatment on children. Tony Attwood, an autism expert in Australia, where up to 50% of child gender clinic patients are autistic, recently called for “extreme caution” in this area.

This misconstrued link between autism and transgenderism also plays into the popular ‘extreme male brain’ theory proposed by Simon Baron-Cohen. Starting from an assumption that men and women have fundamentally different brain structures, Baron-Cohen argues that autistic people’s brains are much more ‘male’. This, of course, lends some credence to the ‘born in the wrong body’ essentialist description of gender identity which is currently being imposed on children. However, sexed brain differences have been debunked by neuroscientists such as Cordelia Fine in her book Delusions of Gender, and Gina Rippon’s The Gendered Brain.

This is not the first time autistic people have encountered movements claiming to ‘cure’ us, or attempting to sterilise us — but it is unusual to see both in one. The eugenics movement has a long history of trying to eradicate autistic people. In 1910, then home secretary Winston Churchill recommended sterilisation of ‘feebleminds’ for ‘the improvement of the British breed’. In the 1940s, Hans Asperger, a paediatrician and autism researcher, collaborated with German Nazi authorities by referring his child patients for execution under Aktion-T4, the programme that aimed to eradicate disabled people. My own diagnosis, Asperger Syndrome, is still named after Hans Asperger, with little mention of his barbaric views and murderous actions towards autistic people during his collaboration with the Nazis (Steve Silberman’s book Neurotribes covers this history thoroughly).

In the late 2000s, groups like Autism Speaks (which has no autistic board members) began to appear. Autism Speaks has been accused of pathologising autism and demonising autistic people and their families, which in turn led to the rise of autism acceptance, autism pride and autism self-advocacy movements. Autism Speaks and other such groups focused on genetic testing and screening for autism, which combined with their established attitudes to the condition became a cause for concern.

Today’s use of drugs and operations to impede sexual development is not the first-time disabled children have been given treatments similar to those used to ‘transition’ children. Ashley X, a severely disabled American child with static encephalopathy, was given hormone treatments to stunt her growth, and a hysterectomy and double mastectomy. The justification for this radical treatment was that if Ashley’s growth were restricted, her carers would find it easier to move her than if she were adult-sized, and after a hysterectomy they would not have to clean her menses, and breast amputation would make it more comfortable for her to be strapped into her wheelchair, and less vulnerable to sexual abuse.

When the case became known to the public, Arthur Caplan described this as ‘a pharmacological solution for a social failure’. This phrase is a perfect summary of all of the treatments directed at children who do not fit society’s mould. If Ashley, and all disabled people, were kept safe from sexual predators through proper safeguarding; if care work was properly valued and adequately provided to disabled adults; and if equipment for disabled people were more comfortable and suited to their owners, the question of the ‘Ashley Treatment’ would never have arisen.

Similarly, if there were no profit motive in medicine, there would be no material drive to pathologise neurodiverse people, gay men or lesbians, and otherwise gender nonconforming children in order to sell them the ‘cure’. Puberty blockers such as Lupron and Decapeptyl are sold off-label so the manufacturers can deny any legal responsibility for harm, while still making the sale.

Puberty blockers are a marked change from the ‘watchful waiting’ approach previously supported for gender dysphoric children. It is no coincidence this change arrived at a time of severe cuts to NHS mental health services, including child and adolescent mental health services, and a backlog of ever-growing waiting lists. The push to fast-track children onto dangerous medication without regard for safeguarding, as the Tavistock whistleblowers described, is a cost-saving exercise derived from a profit driven model. Rather than take the necessary time to support children with psychotherapy in order to treat any comorbid mental health conditions, private sector interests’ sector have seeped in, representing a wider neoliberalisation of the NHS.

The medicalisation of disabled, neurodiverse, and gender nonconforming children is driven by economic and political motives — not by consideration as to what is in their best interests. A Marxist approach to healthcare, that would entail the socialisation of caring for disabled people, and pharmaceutical manufacturing untethered from the market, would do away with the profit motive, remove any conflict of interest between the private and the public sector, and put patient need and interests first.

A material analysis of the restrictive gender stereotypes pushed onto children, inscribed early in childhood by sex-roles inside the family, as framed in Engels’ Origin of the Family, Private Property and the State, would lead to recognition of sex stereotypes as a form of social control. This control is designed to secure the sexual and social reproduction inside the heterosexual nuclear family, an institution which relies on gender norms being upheld. Its survival is tied to sexual normativity and therefore gender non-conformism is a threat to its existence. As Marxists we must clearly interrogate and oppose the ideological forces that pathologise children who, for whatever reason, don’t conform to dominant gender ideology. In fact, gender non-conformity should be actively encouraged and we would do well to do with the gender straight jacket altogether.

I hope for a return to the brief period in the late 2000s and early 2010s of autism acceptance, when the positives of our condition, and our gender nonconformity, was celebrated, rather than viewed as a disease to be fixed. We, the autistic community, are a proud that within our membership is so many great and accomplished people. We will not be eradicated. 

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