I treat transgender children – banning puberty blockers is not a decision for politicians to make | Aidan Kelly

2 months ago 9

When Victoria Atkins, then the health secretary, introduced the temporary ban on puberty-blocking medication for transgender youth a day before parliament was dissolved, I saw it as a last-ditch attempt by the Conservative party to win votes before the general election.

Many of us had been hopeful to see how Labour would approach the ban, which is due to lapse in September. In a recent statement on X, however, Wes Streeting, the new health secretary, revealed his intention to make the ban permanent, subject to consultation.

As a professional with expertise in this field – I am a clinical psychologist and I worked at NHS gender services from 2016 to 2023 – I can see that Streeting is clearly misinformed about the treatment, and his rationale for making the puberty-blocker ban permanent is unsound.

For example, he focuses on the use of the medication in a particular developmental stage (adolescence) as the reason for taking an exceptional approach in banning the medication for transgender teens and not in children with precocious puberty or adults with pancreatic cancer.

However, he overlooks the fact that this ban does not include teenage patients with a difference of sex development (DSD), more commonly known as intersex. These individuals are prescribed puberty-blocking medication when they unexpectedly commence a puberty that is at odds with their gender identity. DSD patients are taking the medication for much the same reason as transgender patients – ie the puberty they are undergoing is causing distress, and pressing pause will probably manage that distress and minimise harm while a continuing care plan is developed. If we follow Streeting’s logic, the medication would also be banned for this patient cohort.

My colleagues and I know that puberty blockers can be helpful for a carefully selected minority of transgender youth who have a clear and consistent understanding of their gender identity, demonstrated distress in relation to the initial stages of puberty, and are mature enough to consider – with the support of their parents or carers – the likely implications of this treatment pathway, balancing any potential side-effects with the potential benefits. This position is supported by the Endocrine Society’s 2017 guidelines, which it has reviewed and reaffirmed this year after the final Cass report.

Sadly, it appears that Streeting has not learned from the lessons of the Bell v Tavistock judicial review, which was overturned in 2021 on appeal. The court of appeal found that it was “for clinicians to exercise their judgment” in relation to the use of this medication and that “a court was not entitled to take on the task of a clinician” when establishing whether a patient could consent to puberty-blocking treatment.

For five of the years I spent in NHS gender services, I worked at the child and adolescent gender identity development services (Gids). While there, I witnessed first-hand what Dr Hilary Cass stated in her final report; that only the minority (about 30%) of those who completed an assessment were ever referred for puberty-blocking treatment – a much lower number when compared with our international colleagues.

I also saw something else at Gids that was reported by Cass: that, for many, puberty-blocking treatment was prescribed too late to be effective (at an average age of 15 years). As a result, it was mostly viewed by patients as a stepping-stone to their desired treatment of gender-affirming (masculinising or feminising) hormones (GAH).

For this reason I welcomed the NHSE GAH policy document, published in March, that removed the requirement of puberty-blocker treatment as a prerequisite for gender-affirming hormones from 16 years of age. If this had been brought in earlier, as some Gids clinicians had been requesting of NHSE more than six years earlier, significantly fewer than the already small number of approximately 100 Gids young people a year would have ever accessed puberty blockers.

In this area of healthcare, like no other I know of, the professionals with the requisite expertise are positioned by their critics as having been “captured by ideology” and therefore lacking in credibility. Meanwhile, those without the expertise are positioned as “independent”, which critics argue makes them better able to evaluate the evidence – despite having never worked in the field and having no understanding of its complexities.

The Cass review pointed to the forthcoming NHS England puberty-blocker trial as the start of a “programme of research” to establish a firmer evidence base. But the NHSE research oversight board for the trial contains a distinct lack of notable clinical experience in the field. Cass, who does sit on the board, acquired her own knowledge by virtue of carrying out the NHSE review into gender services, which she was commissioned to conduct despite, at that time, having no direct experience of working in these services herself. The Cass review was concluded two years later than planned (in 2024 instead of 2022) and I fear the NIHR research trial will face similar delays owing to the lack of familiarity with the field.

Making the ban permanent is misguided, cruel and likely to make hundreds of young people less safe. It will mean that those young people who have started treatment will be forced to recommence a puberty that they previously found distressing and which was, in many cases, detrimental to their mental health.

Gender Plus, the private clinic where I am the director, does not prescribe puberty blockers, however, we do work with transgender young people and their families and so we hear first-hand how much distress and uncertainty this ban is causing. If Streeting is serious about his intention to carry out a consultation prior to making a final decision on this, then we would happily meet him and introduce him to the families and young people that this ban is directly affecting.

In such a meeting we can explain how this ban is making young people less safe, that the ban is not supported by the Cass review or the wider evidence, and how the exceptional approach to transgender youth is discriminatory and unfair.