Ethical and Practical Challenges for the NHS Puberty Blocker Study

What do we know about the NHS puberty blocker study?

There is very limited publicly available information about how the puberty blocker study will be conducted. The following can be established from published NHS sources:

• Study aims: The puberty blocker study aims to evaluate: “the potential benefits and harms of puberty suppressing hormones as a treatment option for children and young people with gender incongruence”.
• Outcome measures: “The study will measure a range of potential treatment benefits and harms (for example whether puberty suppressing hormones impact in a meaningful way on levels of anxiety or depression, on body image, or brain development)”.
• Methodology: The puberty blocker study will use: “a range of validated tools, questionnaires and user feedback.”
• Inclusion and exclusion criteria: “It is envisaged that children and young people in both England and Wales will be able to participate in the study with access through NHS children and young people’s gender services. A multi-disciplinary team approach will be taken to identify those children who, with the consent of their parents, may be deemed clinically suitable for consideration of puberty suppressing hormones through the study. Children participating in the study will also continue to receive comprehensive psychosocial support.”
• Consultation with interested parties: “Key measures included in the study…will also be shaped by engagement with a range of stakeholders, including children and young people referred into NHS gender services and their families or carers.”¹
• Timeline: “The study protocol should be complete by December 2024 and, subject to academic approval, recruitment to the trial would commence in early 2025.”²

Rationale for prioritising research into medical pathways

The Cass Review (2024, p.157) recommended the development of: “An explicit clinical pathway…for non-medical interventions, as well as a research strategy for evaluating their effectiveness”, in addition to a living systematic review and a data linkage study.

The NHS accepted these recommendations, pledging to create a “prioritised portfolio of research” and stating that:

NHS England agrees with the Cass Review’s conclusions that the evidence base underpinning medical and non-medical interventions in this clinical area must be improved. Future research studies will include academic evaluation of psychosocial interventions.³

But in terms of priority setting, the speed with which the puberty blocker study has been brought forward suggests that it is medical, as opposed to non-medical, pathways that the NHS intends to focus on. There is no evidence that similar efforts are underway to develop a study into psychological or psychosocial interventions and this is a puzzling choice, given the established evidence and broader message of the Cass Review.

With reference to the prioritisation of medical approaches, Cass (2024, p.180) emphasised that the focus on experimental medical pathways had led to a failure to develop less invasive treatment modalities:

The focus on puberty blockers and beliefs about their efficacy has arguably meant that other treatments…have not been studied/developed to support this group, doing the children and young people a further disservice.

The systematic reviews undertaken by the University of York to inform the Cass Review (2024, p.179) found:

no evidence that puberty blockers improve body image or dysphoria, and very limited evidence for positive mental health outcomes, which without a control group could be due to placebo effect or concomitant psychological support.

Further:

There was insufficient/inconsistent evidence about the effects of puberty suppression on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk or fertility (Cass. 2024, p.32).

The limited evidence we have therefore suggests puberty blockade is associated with considerable risk of harm and very little evidence of benefit. Conversely, while the evidence on psychological and psychosocial interventions to treat gender related distress is also limited, Cass (2024, p.153) reported that: “There was no indication across the studies of adverse or negative effects.” A comfortable majority of the studies reviewed by the University of York found ‘significant improvements’ from psychological and psychosocial treatments, including three out of four studies on suicidality that reported “significant improvements in suicidality scores” (Cass. 2024, p.153). This suggests that non-medicalised interventions represent the safest and most promising area of research for treatment of gender related distress.

It’s also not clear why the puberty blocker study has been brought forward at pace before the other research projects recommended by the Cass Review have been completed. In particular, the data linkage study, which aims to track long term outcomes of patients who have transitioned from child to adult services, may yield results that mitigate against a further study into puberty blockers. We do not yet know whether this study will show positive or negative outcomes in adulthood for children treated with puberty blockers by the young people’s service, and it is surely desirable to be in possession of this information before deciding whether it is ethical to conduct a further puberty blocker study.

Recommendation: The NHS should prioritise research into non-medical interventions to treat gender related distress. The puberty blocker study should be paused until results of the data linkage study are available and a complementary study protocol has been developed to examine non-medical interventions. If the results of the data linkage study show long term harms arising from use of puberty blockers, then the puberty blocker study should not go ahead.

Intended benefits and rationale for conducting experimental treatment on minors

There are conflicting views about the intended benefits of puberty blocking treatment. The Cass Review (2024, p.174) found that:

The synthesis of international guidelines by the University of York (Hewitt et al: Guidelines 2: Synthesis) found that there is no clarity about the treatment aims of puberty suppression, with options including reducing gender dysphoria, improving quality of life, allowing time to make decisions, supporting gender exploration, extending the diagnostic phase and ‘passing’ better in adult life.

In fact, many of these indications are either contradicted by evidence cited elsewhere in Cass or remain unproven:

• Reducing gender dysphoria: “The University of York systematic review found no evidence that puberty blockers improve body image or dysphoria” (Cass. 2024, p.179).
• Improving quality of life: The University of York (Cass. 2024, p.32) found “insufficient and/or inconsistent evidence about the effects of puberty suppression on psychological or psychosocial health.” In fact, Cass (2024, p.179) noted that “a known side effect of puberty blockers on mood is that it may reduce psychological functioning” and reanalysis of the GIDS Early Intervention Study has shown that 34% of child participants experienced deteriorating mental health. A further 37% experienced no change from baseline, meaning that fully 71% of participants were exposed to all the documented risks and unknowns of puberty blockade but experienced either no benefit or a worsening of their wellbeing (McPherson & Freedman. 2023. Cited in Cass. 2024, p.179).
• Allowing time to make decisions/Supporting gender exploration/Extending the diagnostic phase: Evidence repeatedly shows that almost 100% of children treated with puberty blockers proceed to take cross sex hormones. As the Cass Review (2024, p.176) states: “puberty blockers are not buying time to think, given that the vast majority of those who start puberty suppression continue to masculinising/feminising hormones”. A treatment that leads to a pre-determined outcome in nearly 100% of cases cannot be said to be ‘allowing time’, ‘supporting…exploration’ or ‘extending’ diagnosis. The view that puberty blockers buy “time to think” has been comprehensively debunked, most prominently in Hannah Barnes’ book of the same name.
• ‘Passing’ better in adult life: We would dispute that this is a valid indication for carrying out experimental medical interventions on children. This rationale is derived from the original Dutch study, which proposed the medicalisation of gender distressed children on the basis that adult transsexuals were unhappy with their cosmetic appearance. We would argue that gender distressed children have the right to an open future and that the adults in their lives have a responsibility to safeguard that future by protecting them from irreversible decisions. Altering the superficial appearance of a child’s body through radical hormonal and surgical intervention in service of what that child’s ’embodiment goals’ might be as an adult, before they have even developed into the healthy body that they have, is a radical proposition that would require extensive ethical justification. In any event, in relation to this rationale the Cass Review (2024, p.180) recognises only an extremely limited indication for the use of puberty blockers, exclusively in birth registered boys at Tanner Stage 3 or below. While we disagree that this is a valid indication, its implications for the puberty blocker study are further discussed below.

Recommendation: The NHS must articulate a clear rationale for conducting a programme of experimental medical treatment on minor children, in the face of established evidence demonstrating adverse outcomes. Where the treatment aims identified by the University of York systematic review do not pose insurmountable ethical challenges, they are directly contradicted by the existing evidence. The NHS must address this explicitly.

Inclusion and exclusion criteria

There is very little information in the public domain about the eligibility criteria for the puberty blocker study. It is not even clear whether the study will be conducted using the DSM-5 diagnosis of gender dysphoria, or the WHO ICD definition of gender incongruence. Both these diagnostic frameworks have considerable conceptual problems, but the DSM-5 diagnosis does require that the symptoms be accompanied by significant distress. The ICD diagnosis does not and therefore risks pathologizing naturally occurring gender non-conformity. Concerningly, much of the publicly available material on the puberty blocker trial appears to refer to ‘gender incongruence’ rather than ‘gender dysphoria’, suggesting that the NHS are using the less stringent ICD diagnosis.

Whichever diagnostic framework is used, we must presume that the study will aim to be compliant with the findings of the Cass Review and if this is the case a strict set of inclusion and exclusion criteria will need to be applied. Cass (2024, p.180) found that: “puberty blockers only have clearly defined benefits in quite narrow circumstances” and the wider evidence justifies strict exclusion of young people with particular presentations.

Sex of participants

The Cass Review (2024, p.180) noted that “Transgender males [birth-registered females] masculinise well on testosterone, so there is no obvious benefit of puberty blockers in helping them to ‘pass’ in later life”. The Review ultimately concluded that:

there seems to be a very narrow indication for the use of puberty blockers in birth-registered males as the start of a medical transition pathway in order to stop irreversible pubertal changes. Other indications remain unproven at this time.

On face value, this suggests that only male children should be eligible to participate in the puberty blocker study. But this depends on prior acceptance of the rationale that experimental medical intervention on children is warranted in order to help them ‘pass’ cosmetically in adulthood. As outlined above, we believe that rationale faces insurmountable ethical challenges.

However, even if this rationale is accepted, it is further complicated by the known impact of puberty blockade on penile growth and the resulting complications arising from future vaginoplasty. As Cass (2024, P.180) states, the potential for halting male pubertal development in the service of ‘passing’ in later life “has to be balanced against adequacy of penile growth for vaginoplasty”. We struggle to see how a minor child could calculate this balance as part of the informed consent process.

Age of onset

Cass (2024, p.197) states unambiguously that: “Long-standing gender incongruence should be an essential pre-requisite for medical treatment”. Therefore, only children and young people with early-childhood-onset gender dysphoria should be considered eligible for a puberty blocker study. It is important that age of onset is established in consultation with the patient’s wider family and not just on the basis of self-report.

Age of participants

The Cass Review (2024, p.179) highlighted that: “Puberty suppression was never intended to continue for extended periods”, so it is vitally important for any proposed study to consider the age at which treatment is commenced and terminated. This is doubly so due to the “small window of time” in which puberty blocking treatment stands to achieve the aims of suppressing male pubertal changes while still allowing adequate penile growth for later vaginoplasty.

As discussed above, the only indication for the use of puberty blockers identified by the Cass Review is in the limited case of males. Boys begin puberty, on average, at age 12. The most recent research suggests that puberty should not be blocked until Tanner Stage 4 (average age 14) in order to ensure adequate penile growth for later vaginoplasty (Lee et al., 2023. Cited in Cass. 2024, p.178). However, by Tanner Stage 4 most boys have already begun to experience the pubertal changes that puberty blocking treatment is intended to prevent, and which represent the only legitimate indication for treatment identified by Cass. In fact, changes like rapid increase in height, deepened voice and growth of facial hair may begin even earlier, in Tanner Stage 3 (average age 13).

The University of York found that the average age at which young people commenced puberty blocking treatment was 15 and, between April 2018 and December 2022, the mean and median age at which patients were referred to GIDS was 14 (Cass. 2024, p.86). This would appear to be an insoluble problem in determining eligibility criteria for the puberty blocker study. Due to the length of the waiting list, most young people will have aged out of Tanner Stage 3 before they are seen by clinicians. If the rationale for the puberty blocker study is to examine the impact of preventing pubertal changes in gender distressed boys, then treatment would have to commence at Tanner Stage 3 or earlier to have the desired effect. If the intention is to preserve sufficient penile growth for later vaginoplasty then there can be no rationale for treatment at all.

Comorbidities

The Cass Review (2024, p.176) found that the presence of mental health or autistic spectrum conditions was associated with higher rates of discontinuation among young people prescribed puberty blockers. Feelings of gender distress are sometimes symptomatic of a mental health or neurodevelopmental condition, rather than evidence of a discrete diagnosis of gender dysphoria. For example, autism spectrum disorders are associated with both natural gender non-conformity and sensory sensitivities that may lead people to prefer the clothing of the opposite sex.

It has been well established that gender based medical interventions do not resolve the co-occurring mental health and neurodevelopmental challenges that are common among young people referred to gender identity services and that hormonal intervention is a risk factor for an increase in psychiatric problems in some 25% of young people. For this reason, national guidelines in Finland require comorbidities to have been addressed before a referral to specialist gender services is accepted (Kaltiala. 2024).

These findings suggest young people with mental health and neurodevelopmental challenges should be excluded from the puberty blocker study.

Family relationships, adverse childhood experiences and psychosocial functioning

Stable family relationships, in addition to good psychosocial functioning at school and with peers, are associated with better outcomes following the commencement of hormonal intervention (Kaltiala. 2024). It follows that young people experiencing instability in these domains should be excluded from the puberty blocker study.

Similarly, trauma and adverse childhood experiences seem to be connected to a higher risk of detransition and regret. One study (Littman. 2021) indicated that nearly 40% of detransitioned participants reported that their gender dysphoria was a response to trauma. Young people with a history of family instability, abuse, neglect or sexual trauma are therefore at greater risk of being harmed by irreversible medical intervention and should be disqualified from participating in the puberty blocker study.

Recommendation: Only male patients at Tanner Stage 3 or below, with a documented history of early-childhood-onset gender dysphoria, and who are capable of giving informed consent to the possibility of future surgical complications, should be eligible to participate in the puberty blocker study. Young people from this cohort who have comorbid mental health or neurodevelopmental conditions, unstable family relationships, poor psychosocial functioning or a history of trauma should be excluded from the puberty blocker study. We anticipate that this will be a very small number of people.

Sample size

The Cass Review (2024, p.51) states that:

There must also be enough patients in a trial (the term ‘sufficiently powered’ is often used where there are) to be sure the results reflect the range of possible outcomes and do not give a ‘positive´ result by chance… This is why substantial numbers of participants are required and a key requirement of any trial is a pre-recruitment estimate of how many will be needed for the study to produce meaningful results.

There is currently no pre-recruitment estimate of how many participants the puberty blocker study will need to recruit in order to be sufficiently powered. The Guardian’s Health Policy Editor, Denis Campbell, has speculated that “Up to several thousand children and young people in England who are questioning their gender identity may opt to participate in the trial”⁴. Campbell attributes this estimate to unnamed ‘sources’ but it appeared to be reiterated by Dr Hilary Cass in a recent Woman’s Hour Interview⁵. The Guardian itself reported that the waiting list for young people’s gender identity services stood at 5,700 people in August of this year⁶. If Campbell’s estimate is correct, then it appears that all those children will be eligible to participate in the trial.

This would not be in alignment with the evidence-based inclusion and exclusion criteria outlined above. Male patients with early-childhood-onset gender dysphoria, who are at Tanner Stage 3 or below and who are presenting without comorbid mental health or neurodevelopmental conditions, family instability, trauma or poor psychosocial functioning can be expected to make up only a tiny number of the patients on the current waiting list. It is well established that young people presenting to gender identity services are predominantly birth-registered females with adolescent-onset symptoms (Cass. 2024, p.85) and multiple comorbid conditions (Cass. 2024, p.90). Looked after children, children in care and young people experiencing family instability and poor psychosocial functioning (as determined by measures like school attendance), are overrepresented among patients at the gender identity service (Cass. 2024, p.94).

If the study requires several thousand participants to be sufficiently powered, and aims to abide by evidence-based inclusion and exclusion criteria to minimise the risk of unnecessary harm, then it may struggle to recruit an adequate sample of patients from the present cohort.

Recommendation: The NHS must produce a pre-recruitment estimate of the number of participants required to make the puberty blocker study sufficiently powered. It must explain how it will recruit an adequate number of participants, given that puberty blocker treatment would be contraindicated for the majority of patients on the current waiting list.

Accounting for persistence to cross sex hormones and same sex attraction

The Cass Review found that: “the vast majority of those who start puberty suppression continue to masculinising/feminising hormones, particularly if they start earlier in puberty.” Studies show that almost 98% (Cass. 2024, p.176) of young people treated with puberty blockers continue to cross sex hormones. By contrast, the majority of children treated with psychological and psychosocial support experience resolution of gender dysphoria after natural puberty (Ristori, Steensma, 2016; Kaltiala-Heino, 2018a; Temple Newhook, et al., 2018; Singh et al., 2021), often growing up to be happily same sex attracted adults (Wallien & Cohen-Kettenis, 2008).

Puberty blockade therefore acts as a decisive psychosocial switch, virtually guaranteeing persistence and lifelong medical dependency in patients who would otherwise have experienced relief from their symptoms with less invasive treatment. For young people with nascent same sex attraction, puberty blocking treatment halts psychosexual development, foreclosing on the possibility of gender related distress resolving naturally as the young person comes to understand their innate sexual orientation.

Persistence to cross sex hormones is such a reliable outcome of puberty blockade that it is hard to see how a study could understand the impact of puberty blockers as a discrete treatment. This also has repercussions for informed consent. As the Cass Review (2024, p.176) states:

It was on the basis of this finding [persistence to cross sex hormones] that the High Court in Bell vs Tavistock suggested that children/ young people would need to understand the consequences of a full transition pathway in order to consent to treatment with puberty blockers

Further, the puberty blocker study should not go ahead until NHS England have conducted their promised review of the clinical commissioning policy for cross sex hormones⁷. No date has yet been announced for the conclusion of this review, but the puberty blocker study will be creating a cohort who are certain to persist to cross sex hormones. At minimum, the revised clinical commissioning policy must be in place before the study begins.

Ethically speaking, it is difficult to justify carrying out an intervention that leads to lifelong medical dependency and a high rate of complications in nearly 100% of cases, when the majority of patients can be expected to experience natural resolution of their symptoms with less invasive treatment. Likewise, it is ethically questionable to medicalise young people who would otherwise grow up to be same sex attracted adults.

Recommendation: For all practical purposes, the decision to start a gender distressed child on puberty blockers must be treated as a decision to start them on cross sex hormones. The NHS must account for this fact, both in study design and in its processes for obtaining informed consent. In practical terms, the study design must articulate how the effects of puberty blockade will be disentangled from virtually guaranteed persistence to cross sex hormones, in order to assess the outcome of puberty blockers as a discrete treatment. In ethical terms, the study design must provide justification for performing invasive medical interventions on young people who would otherwise experience resolution of their symptoms after puberty, including a large number of gender non-conforming youths who would otherwise develop into comfortably same sex attracted adults. We predict that the puberty blocker study will struggle to adequately address these practical and ethical challenges. At minimum, the study should be paused until the NHS’s clinical commissioning policy for cross sex hormones has been updated in light of the most up to date evidence.

Confounding variables

Failure to account for confounding variables is a key weakness of the existing literature on the use of puberty blockers. As the Cass Review (2024, p.179) states:

The University of York systematic review found no evidence that puberty blockers improve body image or dysphoria, and very limited evidence for positive mental health outcomes, which without a control group could be due to placebo effect or concomitant psychological support [emphasis added].

And (2024, p.70):

It is unfortunate that a controlled study was not conducted by the UK team, given that this was the only formal attempt to replicate the Dutch approach using directly comparable outcome measures. Using the same methods as the Dutch observational study meant that the same limitations apply; that is, confounding of endocrine and psychological interventions [emphasis added] and significant attrition at follow-up.

The limited information available in the public domain suggests that the NHS puberty blocker study will replicate this error. The Children and Young People’s Gender Dysphoria Research Oversight Board states that: “Children participating in the study will also continue to receive comprehensive psychosocial support.”⁸

It would be entirely unethical to administer puberty blockers, which are known to cause worsening mental health and poor psychological functioning in a proportion of patients, without simultaneously providing comprehensive psychosocial support. Equally, if the NHS proceeds with a puberty blocker study, then the results must not be another weak contribution to an already weak evidence base. Given the documented harms and unknowns of puberty blocking treatment, any further studies must aim to be decisive and end the demand for further risky experimental treatment on minor children.

We believe this is another insoluble problem: puberty blockers cannot ethically be administered without concomitant psychosocial support, but where such support is provided the effects of endocrine interventions are inevitably confounded by the provision of multiple treatments. The issue is further complicated when we consider that psychosocial and psychological support is associated with resolution of symptoms after puberty for most young people experiencing gender related distress. Again, this would seem to strongly mitigate against a further study into puberty blockers and support the prioritisation of research into psychological treatments for gender distress.

Recommendation: If the puberty blocker study proceeds, it must not replicate the errors of previous research by producing results confounded by the provision of both endocrine and psychosocial treatment. Given that puberty blocking treatment is associated with persistence and a high risk of harm, whereas psychological treatment is associated with natural resolution of gender related distress after puberty, the NHS should aim to minimise potential harm by prioritising research into psychological treatments.

Services to support detransitioners and those harmed by participation

Research is beginning to show that transition regret can take between 8-11 years to materialise (Dhejne et al., 2014; Wiepjes et al., 2018), but studies into all aspects of gender medicine have suffered from remarkably high rates of loss to follow up and a consequent lack of evidence on long term outcomes. The unique situation of detransitioners, who typically experience a radical loss of trust in the medical professionals who facilitated their transition, has so far made the needs of this population almost invisible. Seventy six percent of the participants in Lisa Littman’s detransition study (2021) did not inform the clinicians involved in their treatment that they had detransitioned and the Cass Review (2024, p.43) noted that, “people experiencing regret may be hesitant to engage with the gender services that supported them through their initial transition”.

While estimates vary, a percentage of the participants in the puberty blocker study can be expected to detransition, probably after progressing to taking cross sex hormones and undergoing irreversible physical changes that may now be a source of debilitating distress. Detransitioners have unique and little understood healthcare needs, both physically and psychologically.

While the Cass Review recommended that the NHS develop a detransition pathway, there is as yet little sign of comprehensive services to address the needs of those who detransition. We would argue that it is essential for these services to be in place before the puberty blocker study commences, to ensure that the NHS can meet the needs of patients who are harmed by their participation. The puberty blocker study must also be designed to gather data in the long term, accounting for persistence to cross sex hormones and the length of time it takes for regret to manifest. If it does not, adverse outcomes including detransition will be missed.

Recommendation: The NHS must ensure that services to support detransitioners and others harmed by their participation in the puberty blockers are in place before the study begins recruitment. It seems unlikely that such services will be in place by January 2025, the NHS’s provisional date for beginning recruitment. The puberty blocker study should be halted until services for detransitioners are in place.

Two personal accounts of taking puberty blockers

Finally, we would like to offer two personal accounts from Jett and Johnny, young people who were treated with puberty blockers and who later detransitioned. We fear that the puberty blocker study will result in more young people experiencing the avoidable harms described by Jett and Johnny. In light of the ethical and practical difficulties outlined in this report, we do not think a puberty blocker study, no matter how well designed, can avoid replicating these harms.

Jett – Adolescent Development and the Sexual Awakening

“I think it’s a human rights violation to take that from a child because, like I said, I had no sexual experience before I went on blockers at 16,” from Jett, a detransitioned lesbian woman.

Listen to Jett’s full story here.

Adolescence is a critical period of development, not just physically but socially, psychologically and sexually. As adolescents move towards adulthood, they come to understand themselves in relation to others, as the desire to be accepted by their peers and seek a romantic partner moves them away from the individualistic mindset of childhood towards the relational mindset of adulthood. Sexual and romantic awakening is a crucial part of this process and may eventually lead some young people distressed by pubertal changes to a renewed sense of self-acceptance. Early research showed that childhood feelings of gender distress resolved after adolescence for some 85% of patients who did not undergo medical intervention, suggesting that weathering the storms of puberty may be crucial to developing self-acceptance and becoming comfortable in our bodies. Blocking puberty may interfere with this process, unnecessarily altering the trajectory of a young person’s identity development towards further medicalisation and all the risks that entails.

Jett, a detransitioned lesbian from the Netherlands who took puberty blockers from the age of 16, has described how her intimate and sexual development was derailed by puberty blocking treatment:

I had never really had a crush on anyone before I went on puberty blockers. I never met any gay person before I went on puberty blockers, never met a lesbian. And then…while I was on puberty blockers I met a lesbian girl and I knew I liked her but I just…I didn’t have any feelings for her, like I didn’t want to kiss her, I didn’t have any sexual feelings because I was on blockers. I knew I liked her, and it just wasn’t making any sense…I didn’t have my own sexuality and so I knew I was in love with this girl, but I wasn’t experiencing actual attraction to her. And like, you do need that sexual attraction when you’re crushing on someone. It’s important also in the context of love.

Jett experienced physical side effects from taking puberty blockers including pain in her genitals and at orgasm. These effects further alienated her from her body and made sexual intimacy appear painful and scary:

I had no experience with my body, none whatsoever. Only at the age of 22 have I experienced healthy genitals, and non-painful orgasms and that sexuality is actually nice. While for those six years between age 16 and 22 I thought sexuality was gross, I thought my body was gross. My genitals hurt; orgasms hurt. I didn’t want to be with anyone. I was ashamed of my body and like I said I wasn’t actually crushing on anyone in a normal way. Nothing made any sense.

Jett is quoted at the beginning of this section describing puberty blocker treatments as a human rights violation. We tend to agree. Adolescence is a crucial and turbulent period of development which is irreversibly disrupted by puberty blocking treatment, closing down a young person’s right to an open future.

Johnny (Previously known as Scarlett) – Puberty Anxiety

“Well, maybe it would be ok for me to try and like, give it up to mother nature for a while. Instead of constantly fighting like I’ve felt like I have to be doing. Maybe I just need to try surrendering for once…People think medicine improves everything but sometimes it’s best to just like, relax and let nature do its thing,” from Johnny, a detransitioned gay man.

Listen to Johnny’s full story here.

Many adolescents, including those who do not have gender dysphoria, experience distress around pubertal changes like periods, the growth of pubic hair and other physical changes. It’s also normal for young people to feel squeamish, ashamed, uncertain or overwhelmed by their developing sexuality. Blocking adolescent development may temporarily relieve these feelings of puberty anxiety but it also enables young people to engage in avoidance, running away from the source of their distress rather than building resilience by confronting developmental fears in a supportive environment.

Johnny, a male detransitioner who adopted a trans identity in adolescence, started taking puberty blockers when he was 13. Johnny was diagnosed with high functioning autism in childhood and realised early on that he was attracted to other boys. But same sex attraction was stigmatised in his fundamentalist Christian community and Johnny, already struggling with body image issues, was disgusted by the overtly sexual messages he received from older men online. He has described seeking puberty blockers not because he positively wanted to be a woman, but because he was disgusted by the thought of developing into a man, which he associated with aggression, shame and sexualisation.

Johnny initially felt relieved when he began taking puberty blockers. It felt like his fears about development had been put on pause. But then he began experiencing debilitating hot flashes and repeated urinary infections. Genital atrophy caused knife like stabbing pains and Johnny suffered with painful full body muscle spasms. After two years on the blockers Johnny had to stop, saying: “It literally felt like my body was breaking down.”

Johnny was prescribed estrogen which he continued to take after stopping the blocker. Since detransitioning, he has shared that his developmentally altered body can make his intimate relationships difficult, saying: “The public doesn’t know how to react to me.” He has spoken movingly about his youthful to desire to “meet Prince Charming” and his disappointment on discovering that his feminised male body limits his dating pool, drawing unwanted attention from fetishistic older males seeking sexual novelty rather than meaningful connection. When the blockers were first prescribed to him at the age of 13, he simply didn’t have the life experience to anticipate or understand these consequences of radically altering his natural development.

Johnny’s story shows how powerful and profound the urge to hide from developmental fears can be and the way in which puberty blockers offer only illusory relief from such fears. As he states in the quote at the beginning of this section, “People think medicine improves everything.” Medicalising developmental anxiety with puberty blockers fails to resolve underlying feelings of distress while causing irreversible changes to the body.

We believe it is time to move towards a more holistic understanding of human distress, one that sensitively supports young people to build self-understanding and acceptance through the turbulent years of adolescence.

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