Puberty Blockers: A Ban in Name Only?
By Carrie Clark
The jubilation that accompanied the UK’s announcement of an indefinite ban on puberty blockers at the end of last year was entirely understandable. The ban is a tremendous victory for young people’s safety and it took many years of difficult campaigning to achieve. Nonetheless, while we were celebrating, the British government made a very bleak admission: in post-Cass Review Britain, nothing has really changed in the way the NHS treats gender distressed young people. Despite the ban, puberty blockers are still very much on the table and non-medical alternatives simply aren’t available through the NHS.
This admission slipped out last month, in a statement about the puberty blocker ban by Baroness Gillian Merron of the Department of Health and Social Care. Asked what non-medical treatments the NHS was making available to young people with gender related distress, she admitted that “no exact alternatives” to medicalisation are on offer. It seems that young people referred to the new NHS regional gender identity clinics (GIC) are not receiving carefully tailored psychological therapies, as many of us hoped they would be following the publication of the Cass Review last year. Instead, the NHS appears to be keeping them in a holding pattern, providing nebulous ‘psychosocial support’ and eagerly waiting for the start of the NHS puberty blocker study.
Sources suggest that several thousand young people will be eligible to participate in that study, but government figures have been keen to emphasise that it will be uncapped, meaning there is no limit to the number of young people who will be able to take part. Baroness Claire Fox has described this commitment to providing young people with limitless access to experimental hormone treatment as ‘scary’. I am inclined to agree with her. It means that most of the 6,000 or so patients currently waiting to be seen by a GIC may ultimately be prescribed blockers in spite of the ban. This sounds like business as usual, the same toxic pattern of indiscriminate medicalisation that held sway at the disgraced Tavistock GIC.
Still Medicalising Gender Distressed Kids
As Director of Gensepct UK, my main criticism of the puberty blocker study is that it ensures that all the emphasis remains on the medicalisation of gender distressed young people. Dr Hilary Cass and various politicians are occasionally heard stating that blockers are not the ‘gold standard’ of treatment anymore, but the priority given to the study (and the absence of alternatives) sends a message that medicalisation is still the only game in town. Why would the new GICs attempt to grow the promising evidence base for psychological therapies when virtually all gender distressed young people are now destined to take puberty blockers for research purposes? The new GICs face massive waiting lists and have struggled to recruit staff. Why waste time exploring less invasive treatments when the study will shortly make it possible to fast-track patients off the waiting list with an endocrinology referral, just as the Tavistock used to? GICs continue to be dominated by advocates of so called ‘gender affirming’ care and, thanks to the puberty blocker study, the ban seems to represent only a temporary pause on the GIC to medical transition conveyor belt.
I fear our celebration of the puberty blocker ban was premature. And I fear we risk falling prey to ‘post-Cass complacency’ if we don’t mobilise now to stop the puberty blocker study going ahead. With a few exceptions, opposition to the study has so far been muted, cautious or ambivalent, even among critics of so called ‘gender affirming’ care. People that we are accustomed to regarding as allies, including Dr Cass herself, have come out in support of the study and I think we have been reluctant to criticise something that appears to have her not insignificant seal of approval. Much has been said lately about courage, the courage it took for Dr Cass to recommend the puberty blocker ban in the first place and the courage Health Secretary Wes Streeting showed in upholding it, despite opposition from colleagues in his own party. No doubt these were courageous acts, but when it comes to saying no to the puberty blocker study that courage seems to have failed both Cass and Streeting. There is an uncomfortable sense that the ban and the study represent an awkward political compromise that has been agreed behind closed doors: the ban placates critics of so called ‘gender affirming’ care while the study placates activists and the desperate families they have so unforgivably lied to about the supposedly miraculous benefits of puberty blockers.
Stop the Study
We can celebrate the ban, and recognise the courage of Cass and Streeting in making it happen, while still asserting firmly that the puberty blocker study is a mistake that it is not too late to stop. Over the coming months, Genspect UK will be campaigning to raise awareness of the problems with the study, starting with an online webinar on January 31st.
Join us for a lively panel debate about puberty blockers with guest speakers Professor Michael Biggs, Dr Louise Irvine and psychotherapist and Tavistock whistleblower Sue Evans.
But before we move ahead, I think it’s important to address some of the criticisms we’ve so far heard about our campaign to stop the study.
Five Misconceptions
“You shouldn’t campaign against the study at all. We need it to go ahead and fail because it will settle the debate about puberty blockers once and for all.”
Genspect is aware that some people think the study should go ahead, even though they don’t believe that puberty blockers are a safe or effective treatment. They believe the study will produce negative results, thereby definitively resolving the question of whether blockers should be prescribed to gender distressed young people.
The first thing to say about this is that it treats the wellbeing of an entire cohort of young people with gender related distress as a price worth paying to end the exhausting deadlock over the use of puberty blockers. We know they will be harmed by taking part in the study, with almost 100% proceeding to sterilising cross sex hormones, but their sacrifice will prevent future generations from undergoing similar harm. If we knew with certainty that the study was guaranteed to end the dispute over puberty blockers then we might engage in an abstract philosophical debate about whether it should go ahead “for the greater good”.
But we have no such guarantee and, in fact, we are less than twelve months away from the publication of another piece of research that was meant to bring a definitive end to the debate over gender medicine: the Cass Review itself. In our jubilation at the publication of the Review, I think we have lost sight of the fact that trans ideology, and the accompanying practice of denouncing anyone who questions childhood transition as a transphobic bigot, are likely to have had a lasting impact on public perceptions. The evidence is already on our side. Now we need to persuade people to listen to it.
Announcing the puberty blocker ban, Health Secretary Wes Streeting spoke movingly about the heartbreaking stories he has heard from gender distressed young people and how heavily their experiences weighed on his conscience. The Trans Kids Deserve Better campaign have left cardboard coffins outside his office and accused him of being “responsible for the deaths of Trans youth”. Streeting is clearly a good man. It’s hard to overstate how difficult it must have been to fully implement the ban in the face of such desperate emotion. Walled in by years of misinformation, many parents still genuinely believe that their children are at risk of suicide if they do not receive puberty blockers. It doesn’t matter that Professor Louis Appleby, the government’s expert advisor on suicide prevention, has debunked this myth and begged the public not to further circulate it. Intense demand for blockers isn’t driven by a careful assessment of the medical evidence. It is a product of the emotive misinformation whipped up by trans activists and perpetuated by the medical profession, and the resulting desperation felt by gender distressed young people and their families.
We need to think seriously about what it will really take to reach these people because it’s unlikely to be the empirical results of another puberty blocker study or a list of statistics proving that their fears are factually wrong. One of the young people participating in the Trans Kids Deserve Better campaign believes that the government has “put laws in place that make kids commit suicide”. Another says that politicians are “full of unadulterated hatred towards us, watching as our friends die”. These young people are profoundly detached from reality and extremely vulnerable. It will take skilful and compassionate support to gain their trust and help them understand that the world is not as bleak as they have been told. A good first step would be for authorities to stop incentivising their desperate rhetoric by answering all concerns about their wellbeing with a promise that the NHS study is being brought forward at speed so that they can access puberty blockers as soon as possible.
If the response to the Cass Review has shown anything it is that medical evidence can only get us so far in bringing an end to this scandal. Rather than medicalising more young people in the misguided belief that their sacrifice will settle matters we need to draw a line in the sand and begin the difficult work of helping them to move on. A public awareness campaign that seeks to make young people aware of the many non-medical ways to manage feelings of gender distress would surely be a strong start. Likewise, a programme of research that seeks to grow the promising evidence base for psychotherapeutic treatments. But now is the time to defend the evidence we already have and use it to stop the perpetuation of myths and misconceptions about puberty blockers.
“Surely more research is a good thing. Why would you oppose efforts to get more research?”
Genspect is an evidence-led organisation, and we support ethical research that seeks to build on what we already know in pursuit of safer and more effective treatments for gender related distress.
But the Cass Review established that puberty blockers are neither safe nor effective, finding: “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.” The proposed study is therefore ignoring what is already known and, inexplicably, prioritising research into an ineffective, high risk intervention when the evidence that less invasive treatments are safe and effective has never been stronger. By contrast with puberty blockers, the Cass Review found that psychological treatments had “no adverse or negative effects” and were associated with significant improvements in anxiety, depression and suicidality.
It is also completely unnecessary to medicalise a new cohort of gender distressed young people in order to generate more data on the impact of puberty blockers. Advocates of blockers have been running a largely unregulated experiment on their off-label use in vulnerable young people since the Dutch Protocol was popularised in the 1990s. Over the past 30 years, British GICs have prescribed blockers to thousands of children who they have failed to collect long term data about. We wouldn’t even be having this debate if they had conducted proper follow up. Before setting thousands more on an irreversible medical pathway, the NHS could easily complete the Cass recommended Data Linkage Study, which would connect records from youth GICs with those from adult services to find out what has actually happened to people who have already been prescribed puberty blockers.
In the Lords last December, Baroness Merron boasted that the puberty blocker study “will be a world first”. But she’s dead wrong. The NHS study is just another unnecessary experiment on children who might otherwise have benefited from non-medical treatments. A real ‘world first’ would be to prioritise research into those treatments and start fixing some of the mess created over the last 30 years by completing the Data Linkage Study.
“You should wait for the study protocol to be published. It might be fine.”
Some of Genspect’s supporters have asked if we’re jumping the gun by making our criticisms before the study protocol is published. People have asked how we can be sure that the study will be unethical and impractical without having sight of the protocol.
This might be a valid criticism if we knew nothing at all about the relative costs and benefits of different treatments for gender related distress. But thanks to the Cass Review, we know that puberty blockers are associated with multiple adverse effects and little evidence of benefit, while psychological treatments reliably improve patient wellbeing and have no negative side effects.
No study protocol can justify the decision to prioritise research on the least promising, most dangerous form of treatment, particularly given that the patient cohort is made up of uniquely vulnerable young people. We don’t need to see a study protocol to know that this is the wrong decision and that it further entrenches the misapprehension that medicalisation is the only option for young people with gender related distress.
We are also in a position to compare what information we do have about the terms of the study with the Cass Review’s findings about puberty blockers. So, for example, it has been confirmed that the study will be uncapped and aims to recruit as many young people as possible, even though the Cass Review found only a very limited potential indication for use of puberty blockers in birth registered males with childhood-onset of symptoms. If the study protocol abides by this finding, and limits participation to birth registered males, it will struggle to recruit a sufficient number of participants from the mainly female patient cohort. If it doesn’t, it will expose female children to all the documented risks of blockers, even though Cass could identify no benefits of treatment for girls.
Similarly, gender distressed young people with co-occurring mental health problems will not be excluded from the study, even though re-analysis of the Tavistock Early Intervention Study showed that nearly 35% of children who took puberty blockers experienced worsening mental health. Despite the Cass Review’s finding that the confounding of endocrine and psychological interventions is a key weakness of the existing evidence base, the NHS has confirmed that all participants in the study will receive psychological therapy in addition to puberty blocking drugs. This will compromise its findings right from the start, making it almost impossible to disentangle the impacts of therapy from those of blockers.
We feel confident making these criticisms now because we already know that the relative safety of puberty blockers and psychological treatments points to a cost benefit ratio that no study protocol can address. If even a fraction of the details in the public domain are true, then the proposed study is at odds with key findings of the Cass Review and threatens to unnecessarily medicalises an entire cohort of young people at a time when the evidence for safer, less invasive treatments has never been more promising.
Genspect UK will issue a comprehensive response to the study protocol when it is published but, in the meantime, we think it’s important that we start marshalling our arguments and making sure that policy makers can hear them.
“What are you worrying about? The study will never get ethical approval anyway.”
Other people have argued that the puberty blocker study will never get the ethics approval it needs to proceed and that Genspect therefore needn’t worry about campaigning to stop it. We really hope they’re right! If the study fails at the ethics stage this will signal a momentous and welcome change of direction for medical research. But it would also represent a radical break with historical trends.
In the 1990s, the Dutch Protocol introduced the idea that some children have an innate cross sex identity and that such children require invasive hormonal and cosmetic interventions in order to grow into happy adults. The theory arose from the observation that adult transsexuals usually suffered from complex mental health problems, even after undergoing medical transition, and were unhappy that they did not ‘pass’ as the opposite sex. Puzzlingly, this was seen as a reason to start transitioning children, rather than an indication that medical transition was not an effective treatment for mental health problems.
No ethics committee yet has seen fit to question this extraordinary premise and, as a result, legions of poor quality, unethical studies have been allowed to proceed in an increasingly irrational effort to prove it true. Even as the evidence of poor outcomes, regret and debilitating side effects has mounted, ethics committees have continued to approve such studies, passively nodding them through one after the other.
Just last year, in 2024, some of the clinicians involved in the Dutch Protocol reported that they were offering epiphysiodesis, or leg shortening surgeries, to young gender distressed males who wished to lower their height. This procedure entails drilling bolts into the growth plates of young boys in order to prevent the expansion of their leg bones. It is being performed on perfectly healthy adolescent boys, on the basis that their mental health will improve if they are able to meet their ‘embodiment goals’ through cosmetic surgery. An ethics committee somewhere has presumably given its blessing to this grisly experiment, even as more and more evidence shows that cosmetic surgery typically fails to resolve, or even deepens, a person’s distress. With very few exceptions, the deranged logic that the Dutch Protocol lodged at the heart of research into so called ‘gender affirming’ care has been accepted unconditionally by medical ethicists across the board, despite all the evidence that it is in error.
Will the ethics committee tasked with considering the NHS puberty blocker study be different? Will it really grapple with what it means to perform irreversible cosmetic interventions on children on the basis that it might improve their mental health, or help them better mimic the opposite sex in adulthood? If it does, it will be the first.
Historically, ethics committees have failed to prevent unethical gender research taking place and so far only a small number of UK politicians have stated unambiguous opposition to the NHS study going ahead. The price of delaying our criticisms while we wait to see if the study gets ethical approval could be the unnecessary medicalisation of thousands more young people. That being the case, we think now is the time to rally opposition to the study. If it fails at the ethics stage, we’ll be sincerely grateful that our efforts were unnecessary and that ethics committees are finally taking their work seriously.
“What’s wrong with you?! We don’t need to look at the evidence to know that blocking puberty is a moral outrage.”
I have been puzzled to see people who support Genspect UK’s goal of ending the puberty blocker study nonetheless criticising our campaign for being evidence based. As I have written elsewhere, moral outrage alone is a lousy basis for political action. The force of moral arguments doesn’t weaken just because they’re informed by evidence. Quite the contrary.
I would gently point out to people making this criticism that there is a great deal of moral outrage on the other side too. Just look at the dire quotes above from the young people at the Trans Kids Deserve Better campaign. Who decides whether their moral outrage or ours should win out? I’d argue that the evidence is on our side and that this is one of the things that gives force to our moral arguments.
We’re outraged about the puberty blocker study too, but if we’re going to make our case to policy makers then it needs to be based on more than gut feeling.