The fight to stop puberty blockers is far from over

Imagine for a moment that you are a doctor who specialises in treating eczema. There is no one size fits all ‘cure’ for eczema, and it’s a nasty condition that can cause sufferers a great deal of pain and discomfort. Fortunately, it is also very treatable. You have at your disposal a range of safe, evidence-based treatments that enable patients to manage their symptoms and get on with their lives. Sometimes the condition resolves by itself even without treatment.

One day, you become aware that a new treatment for eczema is being developed. It’s radical and highly invasive, with multiple unpleasant side effects and no data on long-term outcomes. Around a quarter of patients treated say their symptoms get better in the short term, but the remaining three-quarters either get worse or experience no change at all. There is emerging evidence that some people have been permanently harmed by undergoing treatment and deeply regret doing so.

Yet suddenly, your practice is full of patients demanding access to this radical new treatment. Powerful lobby groups insist that doctors who won’t prescribe it are deliberately harming their patients. Politicians frame it as a human-rights issue and propose legislation criminalising doctors who refuse to provide it.

Change ‘eczema’ to ‘gender-related distress’ and this is exactly what has happened with regards to puberty-blocking drugs. Despite little evidence of any benefits, and extensive evidence of harm, doctors have found themselves under unbearable pressure to prescribe puberty blockers to young people distressed about their sexed bodies. No matter that most young people’s symptoms will resolve themselves naturally after puberty. Or that many of them will grow up to be happily gay adults if they’re not given this irreversible medical treatment. The popular misconception, driven by lobby groups like Stonewall and enthusiastically perpetuated by activists like Jolyon Maugham, is that puberty blockers are the only acceptable treatment for gender-related distress.

Many of us believed that this misconception had finally been consigned to the dustbin by the landmark Cass Review, published in April this year. The review’s author, Dr Hilary Cass, found that a fixation on experimental puberty-blocking treatment had led doctors and researchers to ignore promising psychotherapeutic approaches, which reliably reduce young people’s distress without irreversibly changing their bodies. At the time, NHS England seemed to have taken this on board, halting the routine prescription of puberty blockers, before their sale and supply were then banned by the UK government – a ban which was made indefinite this week. Meanwhile, the NHS pledged to bring forward a ‘prioritised portfolio of research’ including an ‘evaluation of psychosocial interventions’.

Yet eight months on, the NHS has instead brought forward plans for yet another study into the effects of blocking puberty. Although there is minimal information about how the study will proceed, sources suggest that ‘several thousand’ young people will be eligible to participate, with recruitment due to start in early 2025. If the figure of ‘several thousand’ is accurate, then it seems that virtually all of the 5,700 young people currently on the NHS waiting list for gender-identity services will be invited to take part in the study. This would effectively nullify the government ban, which does not apply to clinical trials.

It is hard to see how the NHS can justify this continuing emphasis on risky medical pathways. The Cass Review did recommend a clinical trial of puberty blockers, but only ‘as part of a programme of research’ that would also examine the effectiveness of different psychotherapeutic treatments. Yet there are currently no plans to do this other research.

More importantly, the review found that puberty blockers were associated with multiple adverse side effects impacting fertility, psychological functioning, cognitive development and bone density, but psychotherapeutic treatment approaches showed no adverse consequences at all.

As for efficacy, Cass 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’. Psychotherapeutic interventions, on the other hand, showed improvements in a comfortable majority of the studies reviewed, including three out of four studies on suicidality that reported ‘significant improvements in suicidality scores’. Despite this, there is still no sign of a non-medicalised NHS clinical pathway for gender-distressed young people.

What explains this single-minded determination to medicalise thousands more young people, when the evidence suggests that many if not most of them would fare better under less invasive treatment? Cowardice appears to be the main explanation. Lobby groups like WPATH and Mermaids have been very successful in propagating the false belief that puberty blockers are ‘life-saving’. Dubious online influencers have taught gender-distressed young people that they will become suicidal if forced to go through ‘the wrong puberty’. Terrified parents have been menaced into medicalising their children with the despicable claim that they can have either ‘a dead daughter or a living son’, or vice versa – a line that Maugham continued to push aggressively, even after the Cass Review proved it isn’t true. It takes courage for a clinician to face down this wall of emotive misinformation and recommend evidence-based treatments instead. With a few notable exceptions, that courage has been sorely lacking. The NHS appears to have settled on another puberty-blocker study as a way to avoid openly confronting public misconceptions and aggressive activist lobbying with the evidence.

At Genspect UK, where I am director, we think it’s misguided to believe that the findings of this puberty-blocker study will finally settle the question of how to help kids who struggle with their gender. After all, the drive to prescribe puberty blockers is motivated by ideology, not evidence, and activists will continue to push for the medicalisation of gender-distressed youth regardless of what the proposed study finds. In any event, we don’t believe that the health of several thousand young people is a price worth paying to break the deadlock in the debate over the future of gender medicine. Only a return to the principles of evidence-based medicine can lead us towards better treatments for gender-related distress.

This week, Genspect UK wrote to UK health secretary Wes Streeting to raise our concerns about the puberty-blocker study. Together with our colleagues at Transgender Trend, LGB Alliance, Thoughtful Therapists, Save Mental Health, Just Therapy and Critical Therapy Antidote, we have outlined the ethical and practical challenges we think the study faces. We believe those challenges are fundamentally insurmountable and that, taken together, they show that there is no safe or ethical way to conduct a further study into puberty blockers.

The NHS must learn from its historic failings in this field. And it must be brave in correcting the misconception that puberty blockers are a safe and effective treatment.

Carrie Clark is director of Genspect UK. Follow her on X: @cwestonclark