The NHS Ban on Puberty Blockers

NHS England announced on Tuesday 12th March that it would be banning the prescription of puberty blockers to minors.

The decision comes after years of controversy over the use of the drugs and care administered to children who experience a condition that is known as ‘gender dysphoria’, formerly known as ‘gender identity disorder’: a mental health condition whereby the sufferer experiences deep distress from an incongruence between their ‘gender identity’ and their birth sex. Gender dysphoria in children rarely occurs in isolation – it is often accompanied by a number of other co-morbidities, including anxiety, depression, eating disorders and substance abuse. In addition to this, children with gender dysphoria often suffer from co-morbities such as autism and/or deep trauma, usually sexual, which occurred earlier in their lives.

The NHS opened the Gender Identity Development Clinic in 1989 in St George’s Hospital in Tooting, South London and it was led by Dr Domenico Di Ceglie, an Italian psychiatrist who specialised in working with children and adolescents. He was driven to founding the clinic by a case that he dealt with in the early 1980s and became deeply interested in the phenomenon of children whose gender identity did not match their birth sex. He would only deal with three or four cases per year at that time, but found that the cases were so rare and so complex that he became convinced that a specialist clinic needed to be established to assist them.

At that time, the approach of clinicians when dealing with patients exhibiting these rare and very complex issues would be a therapeutic one: Patients would be encouraged to talk about the problems that they faced, often remaining patients of Dr Di Ceglie or one of his colleagues for years. Di Ceglie said that, of the patients that he looked after at that time, only around 5% would commit themselves to changing their gender, while somewhere in the region of 60-70% of patients would become homosexual. What seemed to be fairly consistent in the patients whose issues resolved through them becoming homosexual was that they had passed through puberty, which helped these confused young people to find some sort of clarity in terms of their own sexuality and their perceived gender incongruence. Indeed, many homosexual people have said anecdotally that they too experienced some gender incongruence in the period prior to puberty.

The phrase which psychologists coined when managing young patients displaying some form of gender incongruence was ‘watchful waiting’ – allowing children to talk through their anxieties and concerns and allow nature to take its course, which in most cases meant that the onset of puberty would offer some sort of resolution. However, where patients reached the age of around 16 and were still experiencing gender dysphoria, doctors would, in certain circumstances, administer medication to halt the pubertal process. They would be administered ‘gonadatropin-releasing hormone agonists’, or puberty blockers, the most well-known being a now discontinued puberty blocker known as Lupron, the brand name of a drug called leuprolide.

Originally developed as a drug for treating men with prostate cancer, the drug was found to have other ‘off label’ uses, including the ‘chemical castration’ of male sex offenders and the blocking of a rare condition known as ‘precocious puberty’, whereby a child enters puberty at far too early an age. However, in the context of administering puberty blockers to children experience gender dysphoria, the idea is to ‘pause’ the child’s puberty, for a short time, to allow the patient time to think about their dysphoria and what, if any steps they would like to take. They are also deployed because, in the view of the clinicians administering them, for a person suffering from gender dysphoria may find the physical manifestation of sex characteristics far too stressful to bear. This approach is known as the ‘Dutch Protocol’, the technique having been developed in the Netherlands and the most recent iteration of this protocol being published in 2018.

Clinicians have informed their patients that the administration of puberty blockers is completely safe and totally reversible. However, the evidence suggests that this is not the case. The administration of puberty blockers to children can curtail brain development and bone density growth, and can even cause osteoporosis and fertility problems In addition, despite being sold to gender-confused children as a ‘pause’ on their puberty, and therefore allowing them vital thinking time, almost every patient who begins taking puberty blockers does not desist from taking them and in fact goes through some form of transition – be it cross-sex hormones, surgery or both – in almost every case. In short, the administering of puberty blockers sets children on an inexorable path to transition.

This brings us back to the Gender Identity Development Clinic, which renamed itself as the Gender Identity Development Service (GIDS) and relocated to the Tavistock Centre in North London. It had also set up a base in Leeds in West Yorkshire and was seeing an increasing number of patients: In the financial year of 2011-12, a total of 210 people were referred to the service, by 2021-22, that number was 3585. The The reasons for this explosion in cases is complex and will be tackled in a later article, but the waiting list for therapy became so long that some patients would have to wait years for treatment, if they were given treatment at all. In short, GIDS was struggling to cope.

The medical approach to helping these gender-confused people also changed – from the ‘watchful waiting’ approach to a newer ‘gender affirming’ model, whereby clinicians would administer medical interventions based on the feelings of the patient. This new approach achieved primacy through a combination of activist clinicians working in the gender identity field, including at GIDS, and charities such as Mermaids, who built strong links with GIDS and developed a disproportionate and pernicious influence on the service and its senior officials. Indeed, the tried and tested method of ‘watchful waiting’ was criticised by this activist layer of clinicians as being ‘conversion therapy’ or simply ‘transphobic’.

This combination of factors meant that some young patients were being prescribed puberty blockers after as few as three consultations with their specialist at GIDS. One example of this was Keira Bell, a gender-confused young woman who was referred to GIDS in 2013, when she was 15 years old. Keira, who was convinced at the time that she wanted to become a boy, began a course of puberty blockers after three appointments when she was aged 16. A year after this, she began to take testosterone, which had the effect of lowering her voice and giving her male-like facial hair. At aged 20, she went through a double mastectomy in order to giver her body a more male appearance. Two years later, she came to deeply regret her decision.

In 2020, Keira took GIDS to court. She claimed that she could not have been able to give informed consent given her age and mental state at the time the decision was made to administer puberty blockers. The court found in her favour – three judges ruled that it was ‘highly unlikely’ that a child aged 13 could ever consent to take puberty blockers and that it was ‘very doubtful’ that children aged 14 or 15 could understand the life-changing effects that the administration of puberty blockers, and the drugs that inevitably follow, would have on them. The court also ruled that clinicians with patients aged 16 or 17 should refer their cases to court prior to the administration of puberty blockers and cross-sex hormones.

However, Keira’s landmark victory was overturned in the Court of Appeal, where three judges ruled that the court was ‘inappropriate’ in issuing guidance to refer cases of 16 or 17 year olds who wished to pursue treatment with puberty blockers to court. The self-proclaimed human rights organisation Liberty intervened in the case in support of GIDS, apparently not overly concerned with Keira Bell’s human rights. But for GIDS, the damage had already been done. The genie had been released from the bottle and the wider general public was now aware, at least to some degree, what was happening to gender-confused children in the name of affirmative care.

In 2020, an investigation of GIDS and its practices was commissioned, headed by Dr Hilary Cass, one of the leading paediatricians in the country. Her interim report, published in March 2022, was damning: Cass said that GIDS “single specialist provider model is not a safe or viable long-term option” for young people with gender dysphoria or gender incongruence. She also stated that there were “significant gaps in the research and evidence base” and recommended that the Tavistock Clinic in North London be closed down. For many people who worked at the Tavistock, Dr Cass’s report reflected their own personal experience, including that the service prioritised the treatment of gender-related distress over any and all other co-morbities. The clinic was due to close in March 2023, but this was delayed until March of this year, when the clinic finally closes its doors. Patients will in future be treated in the regions where they live.

What is striking is that the Cass Report highlighted the lack of hard medical evidence to support the strategies employed by clinicians at GIDS, yet it is feasible to assert that every single clinician working there was already aware of this lack of evidence, yet they pressed ahead regardless with treatments which come with life-altering consequences for young people into their adulthood. History has shown with past medical phenomena such as lobotomies and oophorectomies that clinicians need little to no evidence to adopt novel techniques to tackle deep-seated and complicated mental health conditions which require years of therapy and support.

Activism on the part of many clinicians in the field of gender care goes some way to explain why this happens, however in a disordered capitalist society like ours it is depressingly inevitable that pharmaceutical companies would be willing to use gender-confused children as profit centres by setting them on a life-long path of medicalisation which is far more profitable than years of psychological therapy and support.