Re: Emery
[2016] FamCA 240
•15 April 2016
FAMILY COURT OF AUSTRALIA
| RE: EMERY | [2016] FamCA 240 |
| FAMILY LAW – CHILDREN – SPECIAL MEDICAL PROCEDURE – Where the applicants are the parents of a child diagnosed with Gender Dysphoria – where the applicants seek a finding that the child is Gillick competent to consent to Stage Two treatment for Gender Dysphoria – where the child’s treating medical experts and parents support the child commencing Stage Two treatment – assessment of whether 16-year-old child is Gillick competent to consent to medical treatment – finding that the child is competent to consent and authorised to make his own decision about Stage Two treatment. |
Evidence Act 1995 (Cth), s 140
Family Law Act 1975 (Cth), ss 60CB, 60CG, 67ZC, 68L, 69H(1), 97(2) and 100B(2)
Family Law Rules 2004 (Cth), r 4.10
| Gillick v West Norfolk and Wisbech Area Health Authority [1986] AC 112 Secretary Department of Health and Community Services v JWB and SMB (1992) 175 CLR 218 |
| FIRST APPLICANT: | The Mother |
| SECOND APPLICANT: | The Father |
FILE NUMBER: By Court Order File Number is suppressed
| DATE DELIVERED: | 15 April 2016 |
| JUDGMENT OF: | Thornton J |
| HEARING DATE: | 8 April 2016 |
REPRESENTATION
By Court Order the names of solicitors have been suppressed
Orders made 8 April 2016
These proceedings be known by and referred to as ‘Re: Emery’.
Leave be granted for the proceedings to be heard ‘in camera’.
The full name of the child born … 1999 – now known and referred to as ‘Emery’ – Emery’s family members and their occupations, any medical practitioner and hospitals, Emery’s school and any staff at the school, the court file number, the State of Australia in which the proceedings were initiated, the names of the applicants’ legal representatives, any witnesses, and any other fact or matter that may identify Emery shall not be published in any way and only anonymised reasons for judgment and orders (with cover sheets excluding the Registry, file number, lawyers’ names and details, as well as the parties’ real names) shall be released by the Court to non-parties without further contrary order of a Judge.
Notwithstanding paragraph 3 of these orders each of the parties to these proceedings shall be at liberty to collect by hand a full copy of the orders and any reasons for judgment published thereunder with all of the identifying details which are otherwise excluded by paragraph 3 of these orders and such documents may be provided to the treating medical practitioners.
No person shall be permitted to search the court file in this matter without first obtaining the leave of a Judge of the Court.
Until further order pursuant to s 100B(2) of the Family Law Act 1975 (Cth), Emery born … 1999 be permitted to be present and remain in court during the hearing of the application filed 4 April 2016.
The applicants be granted leave to withdraw paragraphs 1, 2 and 4 of the Initiating Application filed 4 April 2016 and such paragraphs hereby stand withdrawn.
Pursuant to rule 4.10 of the Family Law Rules 2004 (Cth), the applicants’ legal representatives forthwith serve upon the relevant Government Authorities copies of the following documents:
(a) Initiating Application filed 4 April 2016;
(b) Affidavit of the Mother filed 4 April 2016;
(c) Affidavit of the Father filed 4 April 2016;
(d) Affidavit of Dr F filed 4 April 2016;
(e) Affidavit of Associate Professor P filed 4 April 2016; and
(f) a copy of this Order.
Following compliance with Order 8 herein, the applicants are to forthwith file an Affidavit of Service and provide to the Court any letter of response received from the relevant Government Authorities.
The matter be otherwise adjourned to Justice Thornton on 15 April 2016 at 12.00 noon for determination and delivery of judgment.
NOTATION
A.The Court notes that in the event that responses are not received from the relevant Government Authorities prior to the adjourned date or their responses indicate that they do not seek to be heard or participate in the proceedings, the parties and their legal representatives will not be required to attend Court on the adjourned date.
Orders made 15 April 2016
Upon the Court being satisfied that Emery born … 1999 ("the child") is competent to consent to the medical treatment described in the Initiating Application filed 4 April 2016, the Court authorises the child to make his own decision in relation to that treatment.
The treatment described in the Initiating Application filed 4 April 2016 is the administration of testosterone for the treatment of Gender Dysphoria (“Stage Two Treatment”) in such dose, in such manner and with such frequency as determined by and under the guidance of the child’s treating medical practitioners from time to time.
The applicants be at liberty to provide a copy of the unanonymised orders and the unanonymised reasons for judgment to all persons involved with the child’s treatment.
The applicants’ Initiating Application filed 4 April 2016 be otherwise dismissed and the matter be removed from the list of cases awaiting hearing.
IT IS NOTED that publication of this judgment by this Court under the pseudonym Re: Emery has been approved by the Chief Justice pursuant to s 121(9)(g) of the Family Law Act 1975 (Cth).
| FAMILY COURT OF AUSTRALIA |
FILE NUMBER: By Court Order File Number is suppressed
| The Mother |
First Applicant
And
| The Father |
Second Applicant
REASONS FOR JUDGMENT
Introduction
These are my reasons for making an order finding that Emery, aged 16 years 11 months, is competent to consent to his own medical treatment, commonly known as Stage Two treatment for Gender Dysphoria, in the form of testosterone hormone treatment.
Emery (formerly H) was born a female but now identifies as a male. He revealed to his parents that he had known for a long time that he did not fit his body and that he is a boy. This was in or about June 2014 and Emery subsequently changed his name. He has been diagnosed with Gender Dysphoria and wishes to undergo Stage Two treatment.
Emery’s parents brought an urgent application for a finding that Emery is competent pursuant to the decision in Gillick v West Norfolk and Wisbech Area Health Authority [1986] AC 112 (“Gillick competent”) to consent to his own Stage Two treatment. As the parents of Emery, the applicants have standing to make this application.[1]
[1] Family Law Rules 2004 (Cth), r 4.08(a).
Due to the sensitive nature of the subject matter of these proceedings, I made an order that the proceedings be conducted in camera pursuant to s 97(2) of the Family Law Act 1975 (Cth) (“the Act”). I also made the usual orders preserving Emery’s anonymity, which include not only protecting his given and chosen names, but also other information such as the names of the medical practitioners, lawyers and other professionals and entities involved.
There is no controversy about Emery’s diagnosis, his wishes or his competence to provide informed consent for his own medical treatment. Emery’s parents and his treating professionals, Associate Professor P and Dr F, support the application.
The application is essentially an application for determination by the Court as to whether Emery is competent to consent to his own Stage Two medical treatment for Gender Dysphoria.
The Law: “Gillick” Competence
The term “Gillick” refers to the English case of Gillick v West Norfolk and Wisbech Area Health Authority [1986] AC 112 (“the Gillick case”).
In Secretary Department of Health and Community Services v JWB and SMB (1992) 175 CLR 218 (“Marion’s case”) the High Court said that the view of the House of Lords in the Gillick case represented the common law in Australia.
In the Gillick case, Lord Scarman recognised the underlying principle in the case law that parental right yields to the child’s right to make his/her own decisions when he/she reaches a sufficient understanding and intelligence to be capable of making up his/her own mind on the matter requiring decision. Lord Scarman referred to the spirit and principle of the law captured by Lord Denning MR when he said that:
The common law can, and should, keep pace with the times. It should declare … that the legal right of a parent to the custody of a child ends at the 18th birthday; and even up till then, it is a dwindling right which the courts will hesitate to enforce against the wishes of the child, and the more so the older he is. It starts with a right of control and ends with little more than advice.[2]
[2] Gillick v West Norfolk and Wisbech Area Health Authority [1986] AC 112, 129 (Lord Scarman), quoting Hewer v Bryant [1969] 3 All ER 578, 582 (Lord Denning MR).
In the Gillick case Lord Scarman said at 188-189:
… I would hold that as a matter of law the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed. It will be a question of fact whether a child seeking advice has sufficient understanding of what is involved to give a consent valid in law.
In Marion’s case, Mason CJ, Dawson, Toohey and Gaudron JJ, in discussing the Gillick principle enunciated by Lord Scarman, said as follows at 237-238:
A minor is, according to [the Gillick] principle, capable of giving informed consent when he or she “achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed”.
This approach, though lacking the certainty of a fixed age rule, accords with experience and with psychology. It should be followed in this country as part of the common law.
(References omitted).
In Re: Jamie [2013] FamCAFC 110; 50 Fam LR 369 (“Re: Jamie”) the Full Court held that stage two treatment of gender dysphoria (administration of testosterone or oestrogen) was a medical procedure that required court authorisation, unless the Court found that the child was Gillick competent and thus able to fully understand and give informed consent to stage two treatment at the time it was to commence. The Full Court found that it was the Court’s responsibility to assess whether or not a particular child was Gillick competent.
In summarising her conclusion in Re: Jamie Bryant CJ relevantly said (inter alia) at [140]:
…
c)In relation to stage two treatment, as it is presently described, court authorisation for parental consent will remain appropriate unless the child concerned is Gillick competent.
d)If the child is Gillick competent, then the child can consent to the treatment and no court authorisation is required, absent any controversy.
e)The question of whether a child is Gillick competent, even where the treating doctors and the parents agree, is a matter to be determined by the court.
(Original emphasis).
In that same case Finn J, whilst expressing reluctance to impose upon the child and his/her parents the costs and stress of further court proceedings, particularly when the Court may ultimately reach the same decision which the child and his/her parents had already reached with the child’s doctors, stated at [186]:
Nevertheless, I have concluded that at least the question of the child’s capacity to consent to treatment which has the irreversible effects of stage two treatment must remain a question for the court. I have reached this conclusion because of the requirement by the High Court majority in Marion’s case for court authorisation for irreversible medical treatment in circumstances where there is a significant risk of the wrong decision being made as to the child’s capacity to consent to the treatment and where the consequences of such a wrong decision are particularly grave, as they would be in this case.
Her Honour, in reaching that conclusion, took into account “the persuasive submissions” made on behalf of the Australian Human Rights Commission and the public authority “which support continued court involvement in decisions concerning stage two treatment”.[3]
[3] Re: Jamie [2013] FamCAFC 110; 50 Fam LR 369, [187].
In the same case Strickland J agreed with the outcomes proposed by both the Chief Justice and Finn J and generally for the reasons set out by each of them. He stated at [196] :
Whether the child is able to fully understand and give informed consent to stage two treatment… is a threshold issue that the court must decide. This is because of the requirement by the High Court majority in Marion’s case that it is for the court to authorise medical treatment that is irreversible where there is a significant risk of the wrong decision being made as to the child’s capacity to consent to the treatment, and where the consequences of such a wrong decision are particularly grave.
Jurisdiction
This application is brought under Part VII of the Act.
Section 69H(1) of the Act provides that jurisdiction is conferred on the Family Court in relation to matters arising under this part.
Section 67ZC of the Act provides additional jurisdiction under Part VII of the Act to make orders relating to the welfare of children. It was inserted by an amendment to the Act in 1995 and reads:
(1)In addition to the jurisdiction that a court has under this Part in relation to children, the court also has jurisdiction to make orders relating to the welfare of children.
(2)In deciding whether to make an order under subsection (1) in relation to a child, a court must regard the best interests of the child as the paramount consideration.
Subdivision BA of Part VII of the Act deals with how the Court determines a child’s best interests.
The Court has power to make an order under s 67ZC of the Act to authorise medical treatment. In the circumstances of this case it is not necessary to do so because, for reasons set out below, I am satisfied that Emery is Gillick competent.
Procedure
Counsel for the parents submitted that the appointment of an Independent Children’s Lawyer was unnecessary in the circumstances of the case. Section 68L of the Act allows for the appointment of an Independent Children’s Lawyer in proceedings under the Act in which a child’s best interests are, or a child’s welfare is, the paramount, or a relevant consideration. It is a discretionary matter for the Court as to whether a child’s interests in the proceedings ought to be independently represented by a lawyer.
Having regard to all the circumstances of this case, including Emery’s age and the urgency of the proceedings, I agree with the submissions of counsel for the parents and am satisfied that the appointment of an Independent Children’s Lawyer is unnecessary. In Re K (1994) FLC 92-461 at 80,773 the Full Court issued guidelines as to the circumstances in which an Independent Children’s Lawyer should usually be appointed. One of the categories referred to in those guidelines were applications in the Court’s welfare jurisdiction relating in particular to the medical treatment of children where the child’s interests are not adequately represented by one of the parties. In the circumstances of this case, I am satisfied that the child’s interests are adequately represented by the parents who are the applicants. I am fortified in that view by the evidence of the expert witnesses.
Service of the Application
At the time of the hearing, the relevant Government authorities had not yet been served with this application in accordance with Rule 4.10 of the Family Law Rules 2004 (Cth). At the hearing on 8 April 2016, I made an order for the applicants’ legal representative to forthwith serve upon the authorities copies of the application and supporting affidavits, together with a copy of the orders made that day. I also made an order that thereafter they file an affidavit of service. Two affidavits of service in respect of the relevant Government authorities were filed later that day on 8 April 2016.
Subsequent to the hearing before me, the applicants’ legal representative forwarded to the Court a letter from the one of the Government authorities dated 13 April 2016 in which that authority indicated that it was not necessary for them to be heard or to participate in the proceedings. The applicants’ legal representative also forwarded to the Court email correspondence received from the Legal Services branch of the second Government authority dated 14 April 2016 which stated that they “do not have instructions to respond to the application at this time”. After receiving this response, I caused an email to be sent by my Associate earlier today seeking clarification from the second authority that they do not intend to participate in these proceedings. In a subsequent email received by the Court at 11.39am today, the second authority advised that they would not be participating in the proceedings.
Evidence and Standard of Proof
The rules provide that evidence may be given in the form of an affidavit or orally with the Court’s permission.[4] The documentary evidence relied upon for this hearing is listed in Annexure A to these reasons.
[4] Family Law Rules 2004 (Cth), r 4.09(3)
The standard of proof applicable is on the balance of probabilities under s 140 of the Evidence Act 1995 (Cth).
At [139] of Re: Jamie, Bryant CJ held that for an application with respect to Gillick competence, the material in support would not need to be as extensive as an application for the Court to authorise treatment. Her Honour stated that in the absence of some controversy, she could see no reason why any other party needed to be involved and that it would be an issue of fact to be determined by the Court on the material presented. The other members of the Full Court either did not express a contrary view or expressed implicit agreement with the Chief Justice on this point.
For the purposes of the hearing before me, no witnesses were cross-examined and the case proceeded by way of submissions only.
The Nature of the Proposed Medical Treatment
Emery is currently receiving puberty suppression hormone treatment and has been receiving such treatment since April 2015.
It is now proposed that Emery commence Stage Two treatment in the form of testosterone administration. This is outlined in detail in the evidence of Dr F.
Gillick Competence
The evidence of Emery’s parents and treating doctors, Associate Professor P and Dr F, supports a finding that he is Gillick competent. That evidence is summarised below.
Evidence of the Parents
Both the applicant parents swore and filed affidavits in support of the orders sought.
The father’s affidavit unconditionally adopted and supported the evidence of the mother, and further supported testosterone administration.
I accept the unchallenged evidence of the mother who deposed to the following matters regarding Emery.
Emery was born a female but identifies as male. His birth name was H and he legally changed his name to Emery in November 2015 after he told his parents that he was transgender in June 2014. After this revelation the parents had some difficulty coming to terms with Emery’s identification as male and researched what it meant to be transgender. The parents ultimately began to develop an understanding of some of the issues and were able to discuss them with Emery and support him.
Emery struggled to connect with many of the other students at his previous school and did not feel comfortable or accepted. His enthusiasm for learning began to wane, although he is academically gifted. Emery became more withdrawn, less social and lost interest in school and other activities that he previously enjoyed. He was desperately unhappy and would frequently refuse to go to school. During that difficult time, with the assistance of his parents, Emery sought treatment at the Gender Dysphoria Clinic at the X Hospital. Emery commenced puberty blockers in April 2015. However he was already well into puberty by the time he commenced the puberty blockers and had developed breasts. He now wears a binder around his chest which affects him psychologically and physically.
He currently attends a coeducational school where he is studying year 11. He attends a homestay program which means that rather than staying on campus at the boarding school he stays with a family nearby. Emery prefers not to attend a local school where the community know him as “H”.
Identifying and living as a male has enabled him to feel more settled and confident than he has in some time. He is very self-conscious about his appearance and the fact that his male peers are already shaving and have deeper voices. He desperately wants his body to be like other males in his classes. He is devastated when members of the public assume he is female even though he dresses as a male. Emery intends to continue to wear a binder until he is old enough to have surgery.
Both parents fully support Emery’s desire to be male and have accepted his decision. His mother deposes that they are “in awe of his bravery”.
In terms of the treatment sought, which is stage two hormone (testosterone) treatment for gender dysphoria, both parents consent to Emery being permitted to undergo that treatment. They are concerned that if he does not receive the treatment, his emotional and psychological state is likely to deteriorate. They have observed that he is suffering significant anxiety and they fear for his well-being should his mental state decline further.
The parents are confident that Emery fully understands the nature of the procedure and are certain that this is the right thing for him to do. Emery is intelligent and mature for his age. He has discussed the treatment at length with his doctors and the parents have no doubt that Emery understands all aspects of the treatment, “the pros and cons”, and that he is capable of making an informed decision. The parents have noted that since the beginning of his transition from female to male, Emery has not wavered in his belief that he is male.
The parents have also discussed the matter with Emery’s doctors and believe that continuing with the transition process will improve Emery’s psychological well-being and development.
Evidence of Associate Professor P
Associate Professor P is a consultant child and adolescent psychiatrist with 35 years of practice at the hospital where Emery is to be treated. He deposes to working with over 150 young people with gender developmental needs. He has seen Emery since mid-2014 and prepared a report dated 11 March 2016 in support of the application. I accept the expertise of Associate Professor P and I accept his unchallenged expert evidence in the terms that follow.
Associate Professor P deposes that Emery meets the diagnostic criteria of Gender Dysphoria in Adolescents and Adults pursuant to the DSM V 302.85, previously known as Gender Identity Disorder under the DSM-IV. It is also his opinion that Emery meets the criteria for a diagnosis of Gender Identity Disorder of Adolescence under the World Health Organisation ICD 10 health classifications. Associate Professor P considers that Emery has the capacity to make an informed decision about testosterone therapy.
Associate Professor P deposes to meeting Emery in mid-2014 when he sought assistance with his experience of distress with his gendered body. He has seen Emery with his parents at the hospital and notes that Emery strongly identifies as a boy. He undertook a mental health evaluation and an assessment with Emery in respect of his experience of gender over several sessions and continued to provide supportive psychotherapy with Emery and his family since meeting them. He noted that Emery’s parents are very supportive of the process of his transitioning to live as a boy and in particular of him commencing treatment with testosterone therapy.
Associate Professor P is of the opinion that commencing testosterone treatment is necessary for Emery’s overall welfare. He records that Emery has been seeking treatment since at least the middle of 2014 and has been consistent and insistent in his request to receive testosterone treatment. He states that he has spoken with Emery on many occasions about his understanding of the consequences of the treatment and that Emery has a comprehensive understanding of the impact of testosterone upon his body. He is of the opinion that Emery has a mature and thoughtful understanding of the impact of hormone treatments and that he has a thoroughly researched understanding of the nature of the treatment. He records that Emery has demonstrated a clear and thorough understanding of the role of testosterone therapy in changing his body and its potential adverse effects over time. He is of the opinion that Emery has the capacity to decide what is in his best interests.
Associate Professor P deposes to seeking a second medical opinion from Dr S, consultant child and adolescent psychiatrist, in March 2014. He confirmed the diagnosis of gender dysphoria and otherwise reported that Emery had no symptoms of major mental disorder.
Associate Professor P adopts the treatment proposed by Dr F. He agrees with the effects and risks of testosterone administration to which Dr F deposes. He observes that without testosterone administration, there is a severe and real risk to Emery’s psychological, educational, social and emotional well-being.
Evidence of Dr F
Dr F works as a subspecialist Adolescent Medicine Physician at the Gender Dysphoria Service of the X Hospital. She has worked in paediatrics since 2006, including in the Paediatric Emergency Department at Y Hospital. Dr F prepared a report dated 25 February 2016 in support of the parties’ application.
I accept the expertise of Dr F and her unchallenged expert evidence in the terms that follow.
Dr F’s opinion is that Emery is competent to make an informed decision about testosterone administration. She proposes to treat him according to the following schedule:
·Testosterone Undecanoate oral capsules, taken by mouth once or twice daily;
·Testosterone Enanthate, given as an intramuscular injection every 2-4 weeks;
·Testosterone Undecanoate, a long acting intramuscular injection given every 2-3 months;
·Testosterone 200 mg pellets, inserted beneath the skin every 4-6 months;
·Testosterone patches and testosterone gels that are applied to the skin.
Dr F deposes to the following effects of testosterone:
·Development of hair in the pubic area, armpits and on the beard area of the face;
·Changes in facial shape and appearance;
·Irreversible changing of the voice, due to growth of the larynx and lengthening of the vocal chords;
·Muscle development;
·Increased oil production by the skin, which may result in acne;
·Growth of the clitoris and an increased number of erections;
·Stopping of the development of ova (eggs) in the ovaries, with loss of fertility. This effect is reversible if the testosterone treatment is stopped;
·Stimulation of bone mineral density;
·More assertiveness (sometimes aggression) and sexual desire.
Dr F set out the risks of testosterone therapy upon Emery in the following ways:
·Emery could become aggressive if testosterone dosages are increased too rapidly;
·there is a currently unknown risk of ovarian cancer if Emery’s ovaries are not removed; and
·there is a risk of regret if Emery later changes his mind about testosterone and some physiological changes are found to be irreversible.
As to the risk of ovarian cancer, Dr F specified that there were no conclusive studies establishing or negating the risk, and that Emery can elect to consult with a specialist for check-ups should Emery retain his ovaries.
Dr F deposes that there is no way to masculinise the body other than by administering testosterone.
Dr F reports that Emery has read the pamphlet information available at the X Hospital and has asked appropriate questions about the proposed treatment. She deposes that she believes that Emery is competent to make decisions regarding this treatment and that he is an intelligent young person who presents as a mature and thoughtful young person able to understand the treatment and the risks and benefits that are known. This includes the risk of regret and the potential impact on fertility. She noted that Emery has asked appropriate questions and had discussions with her about fertility. It is on the basis of this understanding that she considers Emery to have the capacity to consent to his own treatment.
Dr F also confirms the support of Emery’s parents in seeking treatment.
Findings and Conclusion
I accept the unchallenged evidence of the expert witnesses and Emery’s parents and note that the treating professionals are supportive of the application. Emery has demonstrated the intellectual capacity and sophistication to understand the information relevant to making the decision and to appreciate the potential consequences, some of which may be irreversible. His views are clear and have not changed. I am satisfied that the risks have been explained in detail, researched by Emery and understood by Emery.
On the basis of all of the evidence, I am satisfied on the balance of probabilities that Emery is competent to fully understand the nature and consequences of the treatment described in the application and to make his own decision in relation to that treatment. Emery is in the transition phase from childhood to adulthood referred to in the Gillick case and is competent to consent to treatment.
I am satisfied that it is appropriate to make a finding that Emery is competent to consent to the medical treatment described in the Initiating Application being Stage Two treatment for Gender Dysphoria as described in Order 3 of the Initiating Application.
I certify that the preceding sixty-one (61) paragraphs are a true copy of the reasons for judgment of the Honourable Justice Thornton delivered on 15 April 2016.
Associate:
Date: 15 April 2016
Annexure A
Documents Relied Upon by the Applicant Parents:
Initiating Application filed 4 April 2016;
Affidavit of the Mother (mother) filed 4 April 2016;
Affidavit of the Father (father) filed 4 April 2016;
Affidavit of Dr F (paediatrician) filed 4 April 2016;
Affidavit of Associate Professor P (Consultant Child and Adolescent Psychiatrist) filed 4 April 2016;
Affidavit of service in respect of the first Government Authority filed 8 April 2016 and acknowledgment of service filed 13 April 2016;
Affidavit of service in respect of the second Government Authority filed 8 April 2016 and acknowledgment of service filed 15 April 2016;
Letter dated 13 April 2016 from the first Government Authority;
Email correspondence dated 15 April 2016 from the second Government Authority.
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