Full stop for blockers

England changes course to protect vulnerable young people from experimental gender drugs

Photo by Melissa Askew on Unsplash

The gist

Puberty blocker drugs with unknown long-term effects will no longer be given as routine treatment to gender-distressed minors, England’s National Health Service (NHS) has announced.

The NHS cited “a lack of sufficient evidence relating to the safety and clinical effectiveness of [puberty blockers] for children and young people with gender incongruence/dysphoria, including about the benefits, risks and long-term outcomes.”

Psychosocial interventions will become the front-line response to gender distress from April 1, as the NHS-commissioned Tavistock gender clinic finally closes on March 31 and the first two successor clinics at hospitals in London and Liverpool take over.

Puberty blocker drugs, which are approved for other uses including treatment of hormone-driven cancers and precocious (premature) puberty, are given off-label to gender-distressed children as young as age 9-10, many with other complex issues such as autism spectrum disorder, depression, eating disorders and awkward same-sex attraction.

Puberty blockers were promoted as a safe, no-regrets option merely “pausing” puberty. The marketing of blockers internationally since 2010-15 has been followed by an unprecedented surge in young patients, mostly teenage females, rejecting their birth sex and seeking hormonal interventions and surgery.

Detransitioner Keira Bell, whose litigation against the Tavistock clinic galvanised the campaign for closer scrutiny of gender medicine, told The Times that the NHS decision was “a step in the right direction.”

“Puberty isn’t caused by a mechanical switch you can just turn on or off,” she said. Ms Bell was given blockers at age 16; over the years, about 2,000 young people¹ were reportedly referred for these drugs by the Tavistock.

“You’re blocking all hormones that would otherwise cause a natural process critical to not only your physical development but your cognitive development too. You can’t just start the process again,” Ms Bell said.

“These are chemical castration drugs used on sex offenders and those with prostate cancer.”

Video: GBNews interviews Conservative MP Miriam Cates on the NHS decision

The detail

The UK-wide effect of the English policy change is unclear. Scotland’s NHS Sandyford gender clinic refers minors for puberty blockers. And the drugs may still be available in England from some private practices, assuming they can maintain insurance coverage.

There are also online dispensers such as GenderGP, which claims “puberty blockers save lives” and says it uses the gender-affirming treatment guideline issued by the Royal Children’s Hospital Melbourne and judged to be “untrustworthy” by a pioneer of evidence-based medicine Professor Gordon Guyatt.

UK ministers are being urged to close loopholes by making it illegal for private clinics to prescribe blockers to gender dysphoric minors, The Times has reported.

“Private clinics have previously been found to prescribe puberty blockers to young children after online meetings. This includes GenderGP, a website run by the GP Dr Helen Webberley that is registered in Singapore,” The Times said.

Bev Jackson, co-founder of LGB Alliance, said allowing online dispensing of puberty blockers would “make a mockery” of the new cautious NHS policy.

“If these drugs cannot be provided on the NHS they should not be obtainable anywhere, particularly not by rogue private clinics operating largely online,” Ms Jackson told The Times.

General practitioners (primary care physicians) were warned by the NHS earlier this year not to work with GenderGP, The Telegraph has reported.

“The company is not registered within the UK nor is it an NHS- commissioned and regulated service. GenderGP do not provide physiological or psychological support or follow-up of patients,” the NHS body responsible for commissioning in south-east London reportedly said in an “urgent safety alert.”

On Tuesday, NHS England said it “strongly discourages the sourcing of any medication from unregulated providers and unregulated sources such as the Internet.”

“But the risk that some individuals may seek [puberty blockers] from unregulated sources regardless, cannot be used to compel the NHS to continue to prescribe [blockers], for which there is very limited evidence of safety.”

Loophole

Former UK prime minister Liz Truss has put up a private member’s bill that would prohibit any health professionals from giving medicine to a gender-distressed minor “for the purposes of stopping or delaying the normal onset of puberty, or affirming the child’s perception of their sex where that perception is inconsistent with the child’s sex.”

On Twitter, Ms Truss urged the UK Government to back her bill, which she said “will reinforce this [NHS England decision] in law and also prevent these drugs being supplied privately.”

Ms Jackson also called on Prime Minister Rishi Sunak to support the bill, expected to be debated in the House of Commons on Friday.

“We have to close this loophole. If not, then everybody who is convinced they need these drugs will try to get them somewhere else,” Ms Jackson said.

Video: Psychiatrist Dr Andrew Amos on the implications for Australia of the Tavistock’s closure

Transatlantic

Genspect USA director Dr Carrie Mendoza has launched a petition requesting President Biden to prohibit the use of poorly evidenced puberty blockers with gender-distressed minors.

In Australia, Senator Claire Chandler tweeted: “Gender clinics in the UK banned from prescribing puberty blockers to children following a thorough independent review. How much longer will Australian authorities keep their heads in the sand?”

England’s decision is relevant anywhere the puberty blocker-driven “Dutch protocol” is used.

Psychiatrist Dr David Bell, a former staff governor at the Tavistock and Portman NHS Foundation Trust whose pleas for caution were ignored, told The Times: “It’s not the first time in medicine that treatments have been celebrated without any real evidence.”

“[But] it’s extraordinary how a completely un-evidence-based so-called treatment very quickly became the dominant paradigm to treat children who presented with gender distress,” Dr Bell said.

“Yet those who had their eyes open, who were worried about the psychological and physical consequences for these children, had their concerns shut down.”

UK Health Minister Maria Caulfield said: “We have always been clear that children’s safety and wellbeing is paramount, so we welcome this landmark decision by the NHS. Ending the routine prescription of puberty blockers will help ensure that care is based on evidence, expert clinical opinion and is in the best interests of the child.”

The shift to caution follows a 2020 systematic review of the (very uncertain) evidence base for blockers undertaken by the UK National Institute for Health and Care Excellence (NICE).

That systematic review fed into a 2022 interim report from the independent reviewer Dr Hilary Cass, whose concerns included the unknown cognitive effects of puberty blockers on the brain and the risk that suppressing puberty only locks-in gender distress otherwise eased with time and natural development. English and Dutch data suggests the vast majority of those begun on blockers proceed to cross-sex hormones, meant to be taken lifelong.

“Although not a factor in NHS England’s decision-making process, many international health systems and medical bodies are now moving to restrict the use of [puberty blockers] as a response to gender incongruence-dysphoria because of the limited evidence base, including [the province of Alberta in] Canada, Sweden, Finland and France,” the NHS said.

The NHS cited three drivers of inquiry and reform—a sharp rise in referrals at the Tavistock clinic (more than 5,000 in 2021-22, as opposed to 250 in 2011-12); a change in patient profile (now mostly girls with adolescent-onset dysphoria); and “scarce and inconclusive international evidence” to guide clinical choices and informed decisions by families about potentially life-altering treatment.

Oxford University sociologist Dr Michael Biggs, who pursued the long unpublished results of the Tavistock’s 2011-14 failed attempt to replicate pioneering research for the Dutch protocol for medical transition, said the NHS decision was “good news, though painfully delayed.”

“It’s five years to the month since I broke the news [in The Telegraph] that the Tavistock clinic was covering up the results of its experiment on puberty blockers,” Dr Biggs told GCN.

“It’s telling that it took a sociologist with no vested interests in gender medicine to analyse the data—I published the first article in a medical journal on the Tavistock experiment, in 2020—seven months before the clinicians at the Tavistock published their own results.”

Some exceptions

Under the NHS reforms, the remaining Tavistock patients on blockers—reportedly less than 100—are to be allowed to continue, although the slew of documents released on Tuesday includes mention of a new “framework for obtaining informed consent”, raising the question of how consent can be informed by an evidence base of such uncertainty.

Males aged 16 or older seeking to transition with oestrogen will still be allowed puberty blockers to help suppress their natural testosterone.

Draft advice from the NHS had stipulated that puberty blockers would be limited to clinical trials, apart from “exceptional” circumstances. But the finalised process for exceptions appears to be stricter than expected, with a heavy onus on the clinician to show unusual benefits for a treatment judged unsafe for routine use.

And the NHS has said that while plans are “well underway” for a clinical trial—the ethics of which are disputed—there is no guarantee it will get the necessary approvals. The ban on routine use of puberty blockers would not be postponed in the event there is no clinical trial.

Great reviews

The 2020 systematic review undertaken by NICE for the NHS was designed to focus on studies relevant to testing the clinical effectiveness, safety and cost effectiveness of puberty blockers as a treatment for gender dysphoria in minors. Of 525 references identified by literature searches, 25 studies made it to the next stage where they were checked for relevance and only nine were eligible for the review.

NICE said those nine were “all small, uncontrolled observational studies, which are subject to bias and confounding, and all the results are of very low certainty [the lowest possible quality rating under the system of modified GRADE].”

On Tuesday, the NHS also noted the “very limited research on the sexual, cognitive or broader developmental outcomes” of using drugs to suppress the natural sex hormones of an adolescent’s puberty.

Early puberty blocking followed by cross-sex hormones may interfere with sexual orientation by suppressing “homo-, bi- or heterosexual developments”, according to a recent German review of the evidence base.

Sweden’s systematic review, with full results published last year, had narrowed the search from 9,934 abstracts to 24 studies relevant to puberty blockers and cross-sex hormones for dysphoric minors.

“I am surprised by the shortage of studies in this field. We found no randomised trials, and only 24 relevant [lower-quality] observational studies,” said Professor Jonas F Ludvigsson of the Karolinska Institute; he was the lead author of the paper published in the journal Acta Paediatrica.

His co-author and Karolinska colleague Professor Mikael Landén said: “Against the background of almost non-existent long-term data, we conclude that [puberty blocker] treatment in children with gender dysphoria should be considered experimental treatment rather than standard procedure.”

“This is to say that treatment should only be administered in the context of a clinical trial under informed consent.”

The NHS had its review of the evidence updated in 2023. During public consultation, the NHS was alerted to much supposedly relevant new evidence, including the 2022 standards of care (SOC-8) from the World Professional Association for Transgender Health, as well as other treatment guidelines and position statements issued by medical societies.

In all this new or allegedly overlooked material, the NHS experts found nothing to change the 2020 verdict that the evidence for blockers is very weak.

Another objection during consultation on the 2023 draft plan to restrict puberty blockers was that the NHS had failed to take account of the “lived experience” of trans people.

On Tuesday, the NHS replied that its new cautious treatment approach had been adopted using its “established method for forming clinical commissioning policies.”

“This method takes account of relevant, peer-reviewed, quality academic and clinical research—it does not take account of lived experiences.” Stakeholders got a say elsewhere in the NHS processes.

Why so long?

Dr Biggs said it was not surprising that the NHS had taken years to end its uncontrolled experiment with puberty blockers.

“First, the Tavistock NHS Trust benefitted financially from its children’s gender clinic, which by 2020 had become a major revenue stream,” he said.

“Second, gender clinicians are ideologically invested in their practice—they are not willing or able to evaluate evidence scientifically.

“Third, there were many adolescents and parents who were desperate to access these drugs, in the mistaken belief that they would enable them to change sex.

“Fourth, ‘LGBT’ groups wield an outsize amount of power within the NHS and the political and media system, which makes almost everyone else frightened to challenge the orthodoxy.”

Some reaction to the news

Writer JK Rowling: “The evidence has been out there for years, for all who were prepared to open their eyes.”

Psychotherapist and Tavistock whistleblower Sue Evans: “Follow-up and research has not been enacted in any serious way [at the Tavistock gender clinic, and they] don’t even know what happened to their own patients in adulthood after being prescribed puberty blockers… What I’ve learned about medicine and the NHS was that, largely, it was cautious [but in] this one area [of gender dysphoria], it was as if the rule book got thrown out the window.”

Gender medicine critic Transgender Trend: “We welcome the news that NHS England has ended the use of puberty blockers. But unless the clinical commissioning policy for cross-sex hormones follows suit, children and young people are still at risk of experimental medical intervention they don’t need.”

UK Equalities Minister Kemi Badenoch: “This decision is a victory for safeguarding children in NHS care. Very pleased to see the changes on ‘exceptional circumstances’ to prescribing puberty blockers. Evidence, not ideology, must always inform our approach to children’s health and wellbeing.”

Keith Jordan of parents’ group Our Duty: “Even if no kid is given puberty blockers, plenty will be given wrong-sex hormones, plenty will end up in the adult clinics from age 17. Even the 25-year-olds caught up in the cult are vulnerable and should not be medicalised. We have a long way yet to go, folks.”

Psychiatrist and Tavistock whistleblower Dr David Bell: “Gender dysphoria is a symptom, so to call it ‘trans’ is to close [any exploration] down. We know that the majority of children who present with gender distress, will desist, they will change their minds. We do not know what [the right] treatment will be without watching and waiting for at least a year or two to understand what’s behind it at all.”

Investigative journalist Hannah Barnes: “The thorny issue of private providers prescribing puberty blockers remains unaddressed by the announcement. NHS England says it fell outside the scope of its consultation. However, it said that it did not know of any regulated source of blockers outside the NHS and could not support anyone sourcing them privately because of a lack of sufficient evidence over the ‘safety and clinical effectiveness’ of the drugs.” 

Co-founder of Thoughtful Therapists James Esses: “For daring to say that children should not be prescribed irreversible and harmful puberty blockers, I was expelled from my Masters’ degree. As of today, it is official NHS England policy. Yet, I remain expelled. Cancel culture is real. It must be stopped.”

Co-founder of LGB Alliance Malcolm Clark: “Two years ago no news outlet or billboard company would take an advert from [LGB Alliance] pointing out concerns about puberty blockers. Labour, Lib Dems and SNP wouldn’t allow a stand at their conference on them. Now NHS England has withdrawn [blockers].”

GBNews host and writer Andrew Doyle: “We can only hope that the NHS ban on puberty blockers for kids will begin a global trend. Between 80-90 per cent of adolescents referred to the Tavistock were same-sex attracted. The NHS was practicing gay conversion therapy in plain sight.”

Canada-based journalist Mia Hughes: “The puberty blockers experiment will go down in history as one of the greatest medical catastrophes of all time. It’s very fitting that NHS England made this announcement on #DetransAwarenessDay. Now, when will Canada face up to the devastation occurring in our gender clinics?”

Detransitioner Sam: “Most young detransitioners undergo medical transition after the age of 18. The indoctrination starts during their teenage years at school or online, which is promptly followed by sex-change mutilation and hormones as soon as they reach adulthood. I think we have to be careful not to create a dichotomy between adolescent and adult transition, where the former is viewed as evil while the latter is acceptable. Neither are acceptable, but the overwhelming majority of the harm is inflicted on young adults, not adolescents.”

Watchdog blog 4thWaveNow: “Really hoping today’s NHS England decision to halt prescribing puberty blockers won’t open the door to approval of cross-sex hormones for tweens/young teens. The more radical US clinicians have been doing this for years. Famous ‘affirming’ clinicians state publicly that ‘trans kids know who they are’ from toddlerhood. The belief that blockers ‘buy time’ has largely been rejected; [but these clinicians] are perfectly happy to start kids on irreversible cross-sex hormones as soon as possible. Will the NHS prohibit that?”

Columnist Victoria Smith: “It is staggering to realise just how flimsy the evidence in favour of all this was. Experiments have been conducted on the bodies of children due to the political cowardice of adults. Humans cannot change sex. We cannot go through any other puberty than the one our body is destined to go through. This is what makes us adults. It is obscene that so many have lied to children, and by doing so put them at risk of so much long-term damage.”

US presidential candidate and entrepreneur Vivek Ramaswamy: “England just banned puberty blockers in minors—because gender dysphoria is a mental health disorder. Affirming a kid’s confusion isn’t compassion. It’s cruelty. Truth and compassion aren’t in tension, they actually go together.”

Psychiatrist and government adviser on suicide prevention Prof Louis Appleby: “Children with gender distress may face bullying, isolation and family conflict—reasons to be alert to suicide risk. Empathic support is vital, but evidence that puberty blockers reduce risk is weak and unreliable. Invoking suicide in this debate is mistaken and potentially harmful.”

Family law barrister Sarah Phillimore: “The Tavistock had nearly a decade to gather data and follow-up patients and to provide the actual evidence that this was ‘lifesaving’ treatment, rather than experiments on traumatised, gay or autistic teenagers. As Keira Bell’s [court case] showed, they kept no data. They did no follow-up… A public inquiry is needed, and preparation for what is coming in the next 10-20 years when these children realise what was done to them.”

1. I have updated this figure, using the best estimate given by the journalist Hannah Barnes of Time To Think fame.