So, doctors can ignore children’s wishes on life-saving blood transfusions – but not potentially life-wrecking hormone treatments?

Doctors override the wishes of children if they believe respecting them may ‘restrict their options in future.’ If hormone therapy can render people infertile, surely they should resist prescribing it till they are more mature.

Reports last week that a 15-year old British girl was given a blood transfusion against her wishes added to the debate over consent – and the right to withhold consent – in the medical treatment of children.

The girl is a Jehovah’s witness, a religious sect that believes that the Bible commands them not to “ingest blood.” Her doctors assessed her to be hours from death when the High Court in London judged that she should not be allowed to die.

That case in the UK followed similar incidents in Ireland, Australia and Canada. Each time, courts determined that doctors should determine the best interests of the child, overriding their religious objections – no matter how sincerely held.

But does that give doctors the power of God? The plight of Charlie Gard generated attention far beyond the UK when Charlie’s prognosis was so bleak that Great Ormond Street Children’s Hospital decided his life support should be withdrawn, allowing him to die. After judges at the European Court of Human Rights agreed with the hospital, his parents fought for him to be given an experimental treatment in the US. Despite raising £1.3 million and attracting the interest of both Pope Francis and the US President, Charlie sadly died aged 11 months on July 28 2017.

Doctors may have made the decisions, but they were not playing God. They were practising medicine, and medicine is rooted in science. They also work along clear codes of ethics. When assessing the best interests of a child, the UK General Medical Council insists that “an assessment of best interests will include what is clinically indicated in a particular case.” Doctors are, however, also advised to consider:

1. the views of the child or young person, so far as they can express them, including any previously expressed preferences;

2. the views of parents;

3. the views of others close to the child or young person;

4. the cultural, religious or other beliefs and values of the child or parents;

5. the views of other healthcare professionals involved in providing care to the child or young person, and of any other professionals who have an interest in their welfare; and

6. which choice, if there is more than one, will least restrict the child or young person’s future options.

Quite rightly, the views of the patient, their family and others involved in the case should be taken into account where options are available. But the last point in the list is distinct because it is objective. In the case of the young Jehovah’s witnesses, the blood transfusions were necessary to preserve their future options. Poor Charlie, however, had a terminal condition. The hospital explained that options had been explored but, “the experimental treatment, which is not designed to be curative, would not improve Charlie’s quality of life.” The decisions are therefore consistent, based on medical ethics.

Unfortunately, that code of ethics is not being applied in the same way when children present with gender dysphoria, a sense of unease that a person may have when their biological sex and gender identity do not match. Previously, where watchful waiting was adopted, most young people desisted and were no longer trans by adulthood. But recently there has been a worldwide push to medicate transgender-identified children. The World Professional Association for Transgender Health (WPATH) suggested that hormone therapy was fully or partially reversible, though the NHS in Britain has now taken a more cautious – and arguably honest – stance: “Little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria.” 

However, recklessness persists. Earlier this year in Canada, the British Columbia Court of Appeal reaffirmed a 15-year-old’s right for hormone treatment to develop male secondary sex characteristics. The Gender Clinic at the BC Children’s Hospital in Vancouver recommended the treatment when she was just 14. The case reached the court when her parents disagreed with each other. But, irrespective of anyone’s opinions, hormone therapy has a potentially devastating impact on future fertility. Options as fundamental as the ability to have children are at risk.

Young people do not always know best, and adults have a responsibility to keep children safe from themselves as well as others. So we do not allow them to be tattooed, nor do we allow them to buy cigarettes or alcohol; we insist that they go to school, and we set their bedtimes.

Keira Bell’s case indicates the folly of ignoring good practice where gender dysphoria is cited. Bell – a 23-year--old British woman – is currently taking legal action against the Gender Identity Development Service, the UK's only children's NHS gender clinic, run by the Tavistock and Portman NHS Trust. The clinic prescribed her puberty-blocking hormone treatment when she was 16. Last month, Bell told the High Court that “I made a brash decision as a teenager, as a lot of teenagers do, trying to find confidence and happiness, except now the rest of my life will be negatively affected." She added that “Transition was a very temporary, superficial fix for a very complex identity issue."

Back in Canada there are signs that courts might be becoming aware of the problems that women like Bell now face. Last week the British Columbia Supreme Court blocked a 17-year-old old girl from undergoing a double mastectomy in Vancouver. The case was brought by the girl’s mother who referred to her daughter as “caught up in a fad.”

Whether or not it is a fad, decisions have been made based on personal views – what the child thinks and what their parents think. I am transgender myself so I know the devastating impact that gender dysphoria can have on mental health, but I am not so naïve to think that it is caused by some metaphysical gender identity that cannot be proved nor falsified. It is a psychological condition that needs to be treated as any other.

Youngsters who may be desperate for treatment that may make it impossible for them to have children of their own need to be heard in the same way as those who are trying to refuse the blood that will save their lives. Opinions are important but the child’s best interests are determined by what is clinically indicated and what will least restrict their future options. When they reach adulthood, they may be competent to make those decisions about their own bodies. But while they are still children, adults have a responsibility to keep them safe. 

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