You would hope that debates about medical treatment – and what children and young people can and cannot consent to – would be grounded in proper scientific evidence. But the incredibly fraught discussion about whether children with gender dysphoria can meaningfully consent to taking puberty-blocking drugs in order to stop the physical development associated with puberty has, instead, been dominated by campaigners with ideological skin in the game.
Puberty blockers have been licensed for use since the 1980s in order to delay the onset of precocious puberty in children, defined as girls showing signs of puberty before the age of eight, and boys before nine. But in the 1990s a group of Dutch clinicians started to use them to halt the onset of puberty in children experiencing gender dysphoria, who felt their actual sex did not match their feelings about which sex they belonged to. Puberty blockers are today used around the world for this purpose.
The controversy has arisen from the lack of evidence about the benefits of these drugs, concerns about potential long-term harms, and whether it’s possible to tell which children will experience persistent gender dysphoria throughout adolescence into adulthood, and which will find that such feelings resolve themselves naturally during puberty.
There are two schools of thought on how to support children with gender dysphoria. The first is advocated by campaigners who believe everyone has a gender identity – an inner feeling about whether they are a man or a woman that might not match the reality of that individual’s sex – and that someone’s self-declared gender identity should take precedence over their sex in law and society. They understand gender dysphoria in children as indicating a fixed trans identity that will last into adulthood and for the rest of their lives. This leads them to argue that when a child expresses a feeling of gender dysphoria, they must be affirmed as trans, and that any attempt to explore why they may be feeling distress or discomfort about their sex is harmful.
This “affirmative” model of healthcare has become dominant in recent years, including in the NHS. This thinking dictates that children with gender dysphoria should be treated as though they are the opposite sex (often referred to as social transition) and for some it may be appropriate to prescribe puberty blocking drugs to halt the signs of puberty and pave the way for cross-sex hormones after they turn sixteen.
The second “watchful waiting” approach is grounded in evidence that gender distress in young people is not a fixed trait but can be in flux until a person’s early 20s – and in many young people will naturally resolve itself through puberty without any intervention. An independent review for NHS England by the paediatrician Hilary Cass noted this, as well as the fact that an increasing incidence of gender dysphoria in children is associated with other things, such as: autism, children struggling to accept their own developing same-sex attraction, childhood trauma including sex abuse, and, particularly in girls, feeling uncomfortable about puberty.
This area of children’s healthcare has been shaped by a polarised, adult debate about identity
In her interim report, Cass was clear that social transition is not a neutral intervention: it is likely to have a long-term impact on psychological functioning, but we lack evidence on potential benefits and harms. There is no strong evidence that puberty blockers have positive impacts for mental health – in fact, there are concerns that by halting natural pubertal development, they bake in gender distress that could have otherwise been transient. And there are potential long-term impacts for children’s brain and bone development. In short, we simply do not know because there have not been clinical trials. Moreover, puberty blockers can make adult sex-change surgery (a procedure that already has serious complications and poor outcomes), even more difficult.
Taking all this into account, “watchful waiting” advocates for allowing children to experiment with their identity, with neither celebration nor negative reaction from adults. This is the approach the NHS has shifted to in the wake of the Cass review; NHS guidance now says social transition should only be done to alleviate clinically significant distress or impairment in social functioning.
And – critically – the NHS now recognises that children cannot consent to taking drugs that are the entry point of a medical pathway that can result in loss of fertility and sexual function and that has unknown and significant consequences for long-term health. In the wake of Cass’s interim report, children and young people in England will only be able to be prescribed puberty blockers as part of a clinical trial that will seek to measure their long-term impacts, positive and negative. Other countries have also shifted away from the use of puberty blockers in children with gender dysphoria, given the lack of evidence and potential for harm.
It is astonishing the extent to which this area of children’s healthcare has been shaped not by the highest standards of science, but by a polarised and adult debate about identity. While the NHS’s recent shift is welcome, it comes after many children have been put on a treatment pathway which may have caused some of them significant harm. There are many clinicians and teachers who still cling to the belief that the “affirmative model” is the correct one, despite the fact there is no clear evidence, as yet, that it is in participants’ best interests. It’s a sobering reminder of how quickly faddish but potentially damaging ideas can come to be embraced without any grounding in evidence or science.
Sonia Sodha is chief leader writer at the Observer and a Guardian/Observer columnist