The New Puberty Blocker Experiment on the UK’s Children

In March 2022, the interim findings of the Cass Review into the United Kingdom’s childhood gender services proposed the closure of the Gender Identity Development Service (GIDS) based at the Tavistock Centre, in London. It seems many people assumed that GIDS had been shut down, with some reporting that ‘the Tavistock’ itself had closed.

Two years later, GIDS is still operating, declaring it is not accepting new referrals. NHS England has recently published “Clinical Policy: Puberty suppressing hormones” which includes the statement: “Puberty suppressing hormones (PSH) are not available as a routine commissioning treatment option for treatment of children and young people who have gender incongruence/gender dysphoria.”

As with the reported closure of the Tavistock, getting to the truth requires reading beyond the headlines. This medical pathway was available to children via GIDS only relatively recently and was far from routine treatment across the UK. Moreover, the new National Health Service policy has not banned the use of puberty blockers. The BBC has reported that “clinicians can still apply to have the drugs funded for patients on a case-by-case basis”.

In theory, new gender services will be available for children in the UK from April 2024. In practice, the ‘National Referral Support Service’ is building a waiting list while those new services are worked out.

In January 2024, The Guardian newspaper reported that the preparation of new training materials for these gender services had stalled due to multiple resignations from the team at Great Ormond Street, the UK’s preeminent children’s hospital.

Those who know the background of the GIDS service should not be surprised that replacing it has not proved straightforward. While the name of ‘the Tavistock’, the original Freudian clinic in the UK, is used as a shorthand to refer to the Tavistock Centre building or the Tavistock and Portman NHS Trust which runs the centre, GIDS joined this psychoanalytic enterprise in 1994 as part of the Portman Clinic.

The Portman Clinic was once known as the ‘Psychopathic Clinic’ by the National Health Service when the UK government nationalised healthcare in the late 1940s. Presumably, the name change was considered less stigmatising for patients. The founder of the clinic, psychoanalytic criminologist Edward Glover, was a Freudian who had specialised in juvenile delinquency during the inter-war period of the 1920s, opening this clinic in 1933. Glover’s collected papers published in 1960 as ‘The Roots of Crime’ include the text of a 1922 talk to magistrates, mentioning the case of a girl caught stealing pencils who had attempted to kill her baby brother. For a Freudian criminologist, the obvious answer was penis envy (pencils=penises).

The roots of GIDS as a ‘gender affirming’ service are therefore intertwined with the concepts of psychopathy and psychosexual development. The Psychopathic Clinic was not so much a healthcare provider as it was the psychoanalytic branch of the courts and prison system, attempting to deal with those disturbed individuals who fell outside of the standard of the ‘reasonable person’, capable of understanding or responding to social norms. The ‘transgender child’ was considered a subset of those juvenile deviants who needed specialist attention, lest they become dangerous adults, and so gender identity development was part of that early intervention.

This history helps explain why transgender people are conflated with psychopaths in the popular imagination. The cross-dressing character of Norman Bates was the most famous representation of transgender people for decades, based as it was on a real-life serial killer. Alfred Hitchcock used Freudian themes in several of his movies, reflecting public interest in psychoanalysis during the mid-20th century. In reality, transgender people are not psychopaths if they are merely breaking society’s rules about gender. The psychopath is willing to break all of society’s rules, including gender norms, which is why prisons have become a flash point in the contemporary gender debate.

Moving childhood gender services to a respected specialist hospital like Great Ormond Street would be a logical recommendation for an experienced paediatrician like Dr Cass. However, GIDS is not primarily a medical service, as its history and setting demonstrate. The Tavistock and Portman Trust, a mental health service with psychoanalytic foundations, has recently sent children to hospitals for puberty blocker prescriptions because ‘gender affirming’ therapists are not usually doctors, and therefore cannot prescribe the treatments they advocate for.

The Trust had apparently become influenced by the eugenic concept that transgender people have a congenital ‘inversion’ from one sex to the other, based on 19th-century pseudo-scientific speculations intended to counter the criminalisation of male homosexuality at the time. Society is not supposed to punish people for matters beyond their control.

The UK’s criminal justice system adopted endocrine disruption in the mid-20th century, using compulsory cross-sex hormones as an alternative to custodial sentences. Most notoriously, British computing pioneer Alan Turing was sentenced to ‘chemical castration’ in 1952 for being gay and committed suicide two years later. Prolonged endocrine disruption rendered these gay men infertile, supposedly completing the eugenic solution by preventing ‘inversion’ from being inherited.

‘Inversion’, essentially the idea of being ‘born in the wrong body’, was promoted in the 1920s by progressives like the eugenic ‘sexologist’ and psychedelic cactus enthusiast Havelock Ellis, not by psychoanalysis. To use a sporting analogy, the difference in approach to gender between psychoanalysis and sexology is like an American football team and an English football team. Both teams are sure that they are playing football correctly, according to their own rules. If one team played against the other, chaos would ensue. Making all of these footballers play on the same team and hoping for a good result would be wishful thinking indeed.

The transfer of gender services to a hospital setting reinforces the medical model of gender identity, which derives from sexology. The UK’s Children and Young People’s Gender Dysphoria Research Oversight Board has approved a new trial of endocrine disruptors to block puberty in children, despite the controversy at GIDS.

This oversight board is dominated by psychiatrists (doctors), paediatricians (doctors), and more doctors, with a nod to individuals and parents with ‘lived experience’. The doctors who might anticipate new NHS funding for childhood gender transition services, including the prescription of puberty blockers, could now be in charge of the evaluation of those services. It seems like the NHS’s problem with GIDS was not having enough doctors in it, rather than the treatment model itself being open to question.

Yet the evidence base for medical intervention in the case of gender incongruence is compromised by questionable theories falling far outside of mainstream medicine. If you believe in ‘sexual inversion’ you will not countenance the idea of watchful waiting in a therapeutic setting, because you already ‘know’ why some children wish to become the opposite sex and will seek transition for the child as soon as possible.

If NHS gender services were fully disaggregated between medical and psychotherapeutic models, the Tavistock and Portman Trust would have the chance to redeem its previous reputation as the UK’s flagship psychoanalytic institute. Healthy competition from evidence-based gender therapists could broaden provision around the UK, helping to tackle the waiting list. Genspect’s ‘Gender Framework‘ document could inform the development of a variety of talking therapy services within NHS mental health provision.

The public trust and goodwill that children’s hospitals like Great Ormond Street enjoy could be maintained if they are steadfast in using evidence-based medicine in the treatment of children with transgender presentation. They could also avoid medical malpractice lawsuits by simply not being involved in new gender transitions. Hospitals which were founded to treat the body are not known to have a background in psychotherapy, gender, sexology or criminology, and so the failed GIDS cannot simply be transplanted for a successful transition. A good transplant needs a healthy organ.

NHS hospitals should be monitoring children and adults who have already undergone a medical or surgical form of gender transition in order to provide appropriate healthcare to them. The Cass Review is not complete, and yet the prescription of puberty blockers to children is set to resume in the UK. Enabling new gender transitions in a clinical trial, without firm evidence that gender transition is medically necessary for children, would simply repeat the mistakes of GIDS. How many test subjects will be recruited for this new puberty blocker experiment on the UK’s children? The general research principle is that the greater the number of experimental subjects, the more valid the results. If these children are physically healthy to begin with, what is the acceptable level of risk for this clinical trial?

The UK’s National Institute for Health and Care Excellence (NICE) which evaluates the efficacy of NHS-funded procedures has recently taken an interest in metoidioplasty, the surgical modification of the clitoris in transmasculine patients. It previously investigated the use of puberty blockers and cross-sex hormones for children as part of the Cass Review, publishing in March 2021 its finding that the quality of evidence for these procedures was poor. NICE has the authority to evaluate all of the gender services that the NHS provides or pays for in private clinics, and yet NICE does not appear to be officially represented on the Children and Young People’s Gender Dysphoria Research Oversight Board.

Medical and surgical interventions on children for existential problems need to stop. The UK government has a short window of opportunity to address this ongoing scandal before new gender-affirming services become established.