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Withholding treatment with puberty blockers doesn’t save young trans people from making irreversible decisions, writes Sage Brice – It just denies them the chance to explore their natural doubts and uncertainties in a safe and supportive environment.

Amendment: This article has been amended to add more context on the ruling on the Tavistock Trust’s Gender Identity Clinic and more information about puberty blockers to better reflect the debate around this clinic and puberty blockers. The headline has also been amended to more closely fit the focus of the article. 

The Cable’s Spring print edition will include a clarification that this article should have been categorised as an opinion piece in the previous addition.

Illustration: Sage Brice

I recently interviewed Jacob, a young transmasculine dad, about his experience of pausing his testosterone treatment to conceive a child with his husband.

Reproductive futures can be a painful topic for trans people. It’s also a popular focus for anti-trans campaigners, who argue that gender-affirming medical treatment ‘denies’ trans young people the right to have genetically-related children later in life.

In a recent case brought against the Tavistock Trust – the only NHS service providing gender-related care to young people in England – High Court judges ruled that children under 16 were unlikely to be able to give informed consent for medical treatments relating to their gender.

A proud dad: Jacob and his son Micah in their Withywood home. (Photo: Florian Bouyer)

The centre’s gender identity development service, has just been rated inadequate by the Care Quality Commission (CQC), highlighting overwhelming caseloads, deficient record-keeping and poor leadership*. The service has long been struggling under an unmanageable caseload with insufficient funding and resources. Now it is caught between critics from both sides – trans advocates claim it is not doing enough to help trans young people, while so-called ‘gender critical’ campaigners are doing everything they can to stop it in its tracks.

The fear that young people might make hasty, irreversible medical decisions which could harm their future ability to have children makes for a compelling and relatable story. It’s easy for an uninformed reader to pick up this ‘concern’ without thinking to question the reality behind it.

But treatment with puberty-blockers (see box-out) is reversible, and lawyers for Tavistock maintain that they are widely deemed safe and medically necessary”, although NHS guidance was changed last year to state that any long term side effects of puberty blockers are little known*. And far from being a ‘conveyor belt’, the assessment process is already not only rigorous, but hampered by severe delays.

Adding additional legal obstacles to this process will make timely treatment even less accessible. Children and families have been plunged into despair since this unexpected ruling on the Tavistock Trust took away their hope of access to medical care.

Withholding treatment forces young people to make difficult decisions alone

I spoke to Jo Maugham of the Good Law Project who is supporting a teenage boy’s legal challenge to the NHS over unethical delays, which can range from 18 months to four years for a service, which should legally be provided within 18 weeks.

“Withholding puberty blockers, or imposing a long waiting time, is like having a five-month waiting list for abortion,” Jo told me. “It’s not delaying treatment, it’s effectively denying it.”

Linking this case to wider questions of reproductive justice is not mere speculation. The lawyer acting against Tavistock has a substantial portfolio of anti-abortion cases, including a failed legal challenge to prevent pregnant under-16s accessing abortion without parental knowledge. 

The key thrust of the Tavistock case, however, is the argument that gender-questioning young people who go on from puberty-blockers to cross-sex hormones or surgery might hypothetically, later in life, regret their transition and their inability to conceive.

“Underlying this approach is an unspoken belief that being trans is not a real thing, but a fad which society collectively should not indulge,” Jo stresses. “And that assumption is fundamentally transphobic.”

Jo’s fear is that by not providing a supportive and well thought-through pathway, the NHS risks driving young people to self-administer medication procured from poorly-regulated suppliers, and without access to therapy, monitoring for safety and potential side effects, or the opportunity to make informed choices about their reproductive futures.

In this scenario, young people end up making difficult decisions alone, unsupported, and more quickly than they might have done with appropriate guidance.

Creating a hostile environment for trans healthcare destroys the parenting dreams of many trans people – of all ages

If we are concerned for reproductive futures, then obstructing access to gender-affirmative healthcare is counterproductive. In practice, creating a hostile environment for trans healthcare destroys the parenting dreams of many trans people and their partners, of all ages.

For one thing, trans people frequently lack access to timely and accurate health information when starting out on our various journeys. As Ailbhe emphasised in a previous interview, “medical information and support should be available to us so that we can live our lives and not continue to feel alienated, pathologised, and dysphoric”.

In most cases, we end up educating our healthcare providers, rather than the other way round. For example, many GPs don’t know that in certain circumstances they can prescribe temporary hormone treatment to trans people waiting for their GIC diagnosis.

This is a problem when what we don’t know can hurt us – as is sometimes the case with reproductive side effects of transition. Trans people are often required to live openly in their ‘preferred’ gender for a year or more before doctors will consider medical treatment such as hormone management. To fulfil this requirement, many trans women and transfeminine people, for example, ‘tuck’ our genitals so as to prevent a visible front bulge.

This can be necessary in order to feel safe, comfortable and dignified under public scrutiny, or to alleviate feelings of dysphoria. What many women don’t know until too late, however, is that the process can significantly impact fertility.

NHS guidelines acknowledge that hormone management can compromise fertility, and recommend that trans women should be able to access cryopreservation of gametes (sperm or eggs) prior to treatment. In practice, this service is rarely authorised by local funding bodies.

Madeleine, a freelance stage manager in Bristol, was refused cryopreservation when she was 17. Although she eventually accessed an alternative service, this meant a ten-month delay to starting hormones, at a critical time in her life. Sian, a student, ended up going private for cryopreservation, which was not only expensive but involved coming off hormones, with a long delay while she searched for a (relatively) affordable clinic.

Even where this policy is respected, however, a formal diagnosis is required to access the treatment on the NHS. Even in the best case scenario (that is, disregarding the years-long delays currently affecting GIC services), this effectively ensures that a trans woman will likely have incurred damage at least a year prior to becoming formally eligible for treatment.

For trans men and transmasculine people, the prevailing medical approach has long assumed that medical transition automatically involves a hysterectomy (removing the womb). While for some this surgery is a desired outcome, for others it is an unnecessary invasive operation that makes pregnancy impossible.

“Underlying this approach is an unspoken belief that being trans is not a real thing, but a fad which society collectively should not indulge”

Jo Maugham, the Good Law Project

There is no medical imperative to remove the dormant uterus unless a complication develops – a relatively rare occurrence. Instead, this unofficial policy seems to arise from outdated binary ideas about sex and gender.

The growing number of trans fathers who – like Jacob – choose to carry and birth their own children shows that this is nonsense. It is important for trans and non-binary people to be supported in reviewing all options and making informed choices when considering medical transition. This applies, regardless what age a person begins their transition journey.

In fact, if young people’s reproductive futures are the priority, then making life difficult for those who want to access gender-affirming medical care may have the opposite of the desired effect. Creating a hostile, suspicious environment for trans young people puts excessive pressure on them to take up and defend a definite, fixed and binary position about their identities and desires for the future.

Knowing it’s going to take all you’ve got to fight for access to healthcare may be a deterrent for the fainthearted, but for most of us all it does is deny us the chance to explore our natural doubts and uncertainties in a safe and supportive environment.

*Added or amended

This is part of the Struggle for trans healthcare equality mini-series, looking at issues affecting local transgender, nonbinary and gender-diverse (trans) communities, driven by people’s lived experiences.

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  • kevin heath says:

    So much myth and trans-activism ‘truth’ in this piece.
    Puberty blockers are not safe and neither are they reversible. That’s the science, not trans-activism myth and fake truth.
    The NHS conceded this when they were forced to remove that ‘safe and reversible’ statement from the web site after NICE took action.
    There is no scientific evidence that puberty blockers are safe and quite a lot of studies proving they are unsafe.
    Research is ongoing – when it’s not shut down by threats from trans-activist – and the evidence is mounting that puberty blockers are anything but safe. From weak bones and increased risk of thrombosis through to cognitive health and lower IQ’s.
    Puberty blockers are used to treat women with severe endometriosis as a last resort treatment. NICE recommends that no women has more than 2 courses of 3 months treatment in a lifetime because of the risks.
    Children with early puberty are put on puberty blockers for a short time (no more than 2 years) and the evidence is that girls in particular suffer from weak bones with some having new hips in their late 20’s and early 30’s. They also grow less than their counter parts, have lower IQ’s suffer from mental health issues and a number of other issues.
    The manufacturers of Lupron one of the puberty blockers used by GIDs is facing a class action lawsuit by people who was prescribed Lupron for early puberty.
    It’s still early days in research on the impact of puberty blockers on children but so far all the evidence is that they are not safe and certainly not reversible.
    Trans activists should wake up and accept the truth instead of continually putting their head in the sand.

  • Laila says:

    Love this! Thank you for this really important information!

  • KK says:

    Well said Kevin Heath. You need only read the studies and reports regarding puberty blockers, they all state further long term research is needed. When taking puberty blockers do they also temporarily halt or slow down the essential development of a childs brain meaning by the time they reach the age and agree to cross sex hormones their brain perhaps is not yet matured enough to realise the reality of the long term effects their choices will have, after all the brain does not mature until around the age of 25yrs. You need only search Youtube, Reddit and other sites for the word “detransition” to read the increasing number of regret stories, and some are awful to hear.

  • SJ says:

    Kevin you are absolutely correct.
    Indeed, the NHS Clinical Commissioning Group for Bristol, North Somerset and South Gloucestershire agrees.
    They are removing all reference to hormone blockers for children and young people their transgender patients guidance after clinicians explained the risks and lack of evidence.

    https://bnssgccg.nhs.uk/library/governing-body-paper-1-december-2020-item-61/

    It’s important to understand that the majority of children and teenagers who were being given puberty blockers are girls.
    Without hormone blockers and blind affirmation that they are really boys, the vast majority of teenage girls experiencing gender dysphoria grow up to be happy lesbians.

  • SJ says:

    We must also do the heroic young woman who brought the case the honour this article does not and say her name:

    Keira Bell

  • Rose says:

    A Lancet review of the available empirical evidence on the cognitive, physical, and surgical implications of puberty suppression in gender-incongruent children and adolescents including over 96 studies found that puberty suppression is safe. The few studies that have examined the psychological effects of suppressing puberty have shown benefits. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(17)30099-2/fulltext#box4

  • Rose says:

    To follow up on that here are a whole host of statements and studies from the actual experts demonstrating puberty blockers are not experimental, not harmful, but are essential for the care of transgender and non-binary kids.

    The Endocrine Society: https://www.endocrine.org/news-and-advocacy/news-room/2020/discriminatory-policies-threaten-care-for-transgender-gender-diverse-individuals

    American Psychological Association: https://www.apa.org/practice/guidelines/transgender.pdf

    Endocrine Society again: https://academic.oup.com/jcem/article/102/11/3869/4157558#99603316

    In fact these drugs have been used for cisgender kids for decades, for example with precocious puberty https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342775/
    https://academic.oup.com/jcem/article/84/12/4583/2864749
    https://academic.oup.com/jcem/article-abstract/67/2/368/2651998

    To top it off: PBs have no effect on executive functioning: https://pubmed.ncbi.nlm.nih.gov/25837854/

  • Rose says:

    Finally I think it’s important to give the statement of the international associations for transgender health: https://www.gendergp.com/wp-content/uploads/2020/12/FINAL-Statement-Regarding-Informed-Consent-Court-Case_Dec-16-2020.docx.pdf

    “As professional medical organizations, the European Professional Association for Transgender Health (EPATH), and the World Professional Association for Transgender Health (WPATH), as well as the other signatories to this statement, all have serious concerns about this ruling and wish to express that although treatment for young transgender adolescents involves uncertainties, as is the case in many fields involving young people, several studies demonstrate the clear mental health benefit of gender-affirming medical treatment (including puberty blockers). Withholding such treatment is harmful and carries potential life-long social, psychological, and medical consequences.”

  • Alison McClean says:

    The Lancet review is more than 4 years old. Its conclusion also states that “Gender incongruence in children and adolescents is complex, and medical treatment raises several ethical considerations. Clinical decision making has been fostered by research efforts, but there are still substantial knowledge gaps that warrant examination to inform best clinical practice”.

    The “gaps” in this knowledge were further demonstrated in Bell v Tavistock by the failure of GIDS to provide any data relating to the long-term outcomes for its patients. Indeed, when GIDS finally got round to publishing the research it had undertaken (earlier this year), it demonstrated a significant retardation in bone development among those who had been prescribed Puberty Blockers. The CQC report also found serious weaknesses in clinical practice at GIDs, including the failure to take account of the existing co-morbidities of some patients (particularly those with ASD); failure to keep appropriate records of clinical decision making; and failure to obtain the necessary consents for treatment. As Professor Carl Heneghan, Director of the Centre for Evidence Based Medicine at the University of Oxford has stated the prescription of puberty blockers is “an unregulated live experiment on children”.
    This is a massive medical scandal that is harming some very vulnerable children and adolescents.

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