Giving puberty blocker to ‘trans’ children is a leap into the unknown by Janice Turner in The Times 21.02.20

The original article is here.

An 11-year-old child is probably years from his or her first kiss. Yet the drug they are about to take will almost certainly lead to a medical pathway which will leave them sterile. Since their gametes will never be allowed to mature, doctors will not even be able to harvest their sperm or eggs. Can any 11-year-old understand the gravity of ruling out ever having children?

Moreover, can this child, for whom sex is an unimaginable, probably rather revolting adult business, consent to a treatment which will depress their future libido to the extent they may never have an orgasm? (Imagine trying to explain the concept, let alone the desirability, of an orgasm to an 11-year-old.)

These are the ethical issues which make puberty blockers the most controversial of medications. On one side are “affirmative” clinicians and trans activists who believe that halting the onset of natal puberty is the only way to alleviate the distress of gender dysphoria, a sense of being “born in the wrong body”. On the other is a growing number of psychotherapists, doctors and endocrinologists concerned that blockers are administered too readily and, since they are prescribed “off-label” with no research into the long-term outcome for patients, amount to conducting a medical experiment on children.

In recent months these brewing worries have crossed into the public sphere. A landmark judicial review is being brought by Susan Evans, a former psychiatric nurse at the Tavistock Gender Identity Development Services (GIDS), a woman known as Mrs A who is the mother of an autistic 16-year-old girl referred to the clinic, and Keira Bell, a 23-year-old woman who as a child was enabled by GIDS to transition into a male and now regrets it. The plaintiffs argue that prescribing hormone blockers to under-18s is illegal because, unable to understand their far-reaching consequences, children cannot consent to take them. They say the Tavistock is “materially misleading” child patients and their parents, omitting to say that “nearly 100 per cent of children who commence hormone blockers go on to take the irreversible cross-sex hormones”.

Meanwhile, in the light of a 3,000 per cent increase in referrals to GIDS in the past decade, the government has announced a long-awaited independent review, chaired by Dr Hilary Cass, a former president of the Royal College of Paediatrics and Child Health, to assess children’s gender services and make “evidence-based recommendations about the future use of these drugs”.

So what are puberty blockers and how did they come to be used on children worldwide? The group of drugs, GnRH agonists, release a form of the human hormone gonadotropin to stop the testicles and ovaries from producing sex hormones. Triptorelin, the most widely used, is licensed to treat advanced prostate cancer in men and endometriosis in women, to “chemically castrate” male sex offenders and in children to halt rare cases of early puberty, but not to treat child gender dysphoria.

Yet in 1994 a 16-year-old girl told the Amsterdam Gender Clinic she wanted to be a boy. Uniquely, three years earlier she had persuaded an endocrinologist to halt her puberty. Inspired, clinicians began administering hormonal blockers before secondary sex characteristics had occurred, then moving on to cross-sex hormones. The “Dutch protocol” was seen as a remarkable breakthrough for trans people whose most heartfelt desire is to “pass” as the opposite sex. Puberty blockers could end the agony of repeated cosmetic surgeries. If you never developed a beard you would never need painful electrolysis to remove it. If you never grew breasts you wouldn’t need a double mastectomy. Besides, for gender dysphoric children puberty is a dread moment when your hated body emerges categorically as the “wrong” sex.

Triptorelin is presented by gender clinics as a “pause button” which need not stop puberty forever but can give a “breathing space” while a young person decides whether they wished to proceed to transition. If not, you just stop taking them and your natal puberty will kick in. What parent, faced with a deeply distressed child, would not press that button?

The problem is that almost everyone who takes puberty blockers goes on to transition. Frozen Peter Pan-like, they see classmates develop into adults. Many have already “socially transitioned”, assuming opposite sex names and clothing. Going back is scary, so inevitably they press forward into cross-sex hormones.

But would they have transitioned anyway? Most likely not. A statistic, undisputed by GIDS and North American gender clinics, is that without medical intervention around 85 per cent of gender dysphoric children come to terms with their biological sex after puberty. As GIDS notes: “‘Persistence [in identifying as trans] was strongly correlated with the commencement of physical interventions such as the hypothalamic blocker.” Moreover the vast majority of these non-conforming kids seen by clinics — girls who prefer short hair and skateboarding, boys who love Barbies — will grow up into lesbians or gay men. In the maelstrom of adolescence, are they confusing same-sex attraction with being trans?

Clinicians believe the natural cascade of sex hormones at puberty can resolve bodily self-hatred. Yet if puberty is thwarted this cannot happen. Moreover, the claim that blockers are fully reversible, that natal puberty will just spark up even years later if you stop taking them, is largely untested — because almost no one does that.

The Dutch protocol was quickly taken up by gender clinics worldwide but British clinicians, who upheld a “watchful waiting” approach, initially remained cautious, refusing to prescribe blockers to under-15s. But quickly these drugs became a political as much as a medical demand: campaigners argued that to deny them to children was transphobic.

Some British parents started taking their children to America where easy access to drugs and even paediatric surgeries — including mastectomies for 14-year old girls — are commonplace. Notably in 2007 Susie Green, an IT manager from Leeds, took her 12-year-old son Jack to a Boston clinic to be prescribed hormones, then at 16 to Thailand for genital surgery, illegal in Britain and now in Thailand. Later Green became chief executive of Mermaids, a charity for trans children, which under her leadership has fiercely advocated for blockers, hormones and early surgical interventions. The Mermaids website recommended Dr Helen Webberley, a private GP suspended by the GMC for running an unlicensed gender clinic, who prescribed triptorelin online.

Bowing to activist pressure, in 2010 GIDS reduced its lower age prescription limit from 15 to ten. Even though the known side-effects of the drugs include lowered bone density and height, plus depression. GIDS admits it has no idea how freezing puberty affects the fast-developing teenage brain. The question of adult sexual function is swerved as too tasteless, but real-life examples are emerging. Jazz Jennings, 19, a trans reality TV star in the US, who never experienced natal puberty and looks indistinguishable from a natal girl, has admitted having almost no libido and asked her parents if an orgasm was like a sneeze. Susie Green revealed that her trans daughter Jackie was left with a child’s penis, so the Thai surgeons inverting it into a vagina had little to work with.

Remembering that triptorelin is used off-label, shouldn’t every gender clinic conduct exhaustive long-term research, monitoring every patient to ensure that their radical drug regime works? In 2011 GIDS embarked on a study of 44 young people and Dr Michael Biggs, associate professor at Oxford’s Department of Sociology, has analysed the results that GIDS has only published in dribs and drabs. This includes findings that children — although happier and more confident after six months — noted “internalised problems and body dissatisfaction, especially in natal girls” after a year. Most alarming was a significant increase in patients agreeing with the statement: “I deliberately try to hurt or kill myself.” Given that parents are repeatedly told (wholly erroneously) their children will kill themselves if they don’t take blockers, this surely requires more scrutiny.

Dr Biggs is concerned by GIDS’s methodology, the clinic losing touch with patients in the trial and, above all, its failure to publish a conclusive report. Why is this? Would clinicians have to concede that they had sterilised children, consigned them to life-long patienthood, including needless surgeries to remove healthy body parts for no good reason?

Meanwhile the problem has increased exponentially: in 2009, only 77 children were referred to GIDS but a decade later it was 2,590. Whereas male referrals were once the majority, three quarters are now natal girls. In any other health sector researchers would leap to investigate such a trend. Yet GIDS remains incurious. Last year its senior consultant psychiatrist Dr Elizabeth van Horn said on Newsnight: “We do not know why the numbers have gone up so dramatically recently. Or why more of them are girls.”

Perhaps this isn’t surprising when anyone who interrogates this phenomenon is hounded by an activist lobby. Dr Lisa Littman, of Brown University, explored what is termed “rapid-onset gender dysphoria”: clusters of teenage girls, often friends, often same-sex attracted, who after long exposure to online transition forums in early puberty abruptly declare themselves trans. Her paper was denounced as bigotry and removed from her university’s website.

Yet her views are echoed by GIDS clinicians, 35 of whom have resigned in the past three years, many alarmed by the rush to medicalisation and the way Mermaids, Instagram trans influencers and the CBBC programme I Am Leo present transition as uncomplicated. They say they are seeing girls with a panoply of other issues — anxiety, depression, self-harm, undiagnosed autism, victims of homophobic bullying and sexual abuse — for whom transition to a male body was presented online as the universal panacea. Often a normal, tom-boyish disgust at their new breasts, eliciting sudden and unwanted sexual attention from men, is interpreted as a certainty that they are in the “wrong body”. Yet instead of interrogating these underlying issues, clinicians are told to “affirm” a young person’s “trans identity” and prescribe the puberty blockers that trans campaigners fiercely insist are their right.

The former psychiatric nurse Susan Evans, in her statement to the judicial review, says she saw triptorelin prescribed after just three or four sessions. One ex-GIDS psychotherapist tells me that getting a blockers prescription is seen as an end in itself, a sign you are truly on your trans journey. Even if a young person has already gone through puberty — so the side-effects for girls are akin to sudden menopause — they must take triptorelin for around a year before being allowed cross-sex hormones. Although this period is supposed to be a pause for reflection, young people then receive less therapy not more: “They are told, ‘Go away we’ll see you in three months’.”

The trouble for clinicians is that there is no diagnostic tool which can predict who will “desist” and who will go on to transition. For adult trans people, who have felt from childhood that to live authentically and free from mental distress they must live in the opposite gender, whose painful lives are marked by bullying, discrimination and search for treatment, it is wholly understandable that they wish to save younger people their pain. “I would without doubt have accepted the opportunity of early female hormone therapy and early sex-change surgery,” a trans woman wrote to me. “I would be ecstatic and have grabbed the opportunity as a young teenager to become the woman that I am.” Many, however, regard the haste with which children are put on a medical pathway with grave unease.

That such controversial drugs will come under the scrutiny of a judicial review and a public inquiry should be welcomed. Dr Hilary Cass proved herself a fearless whistleblower in 2013 when working at Great Ormond Street Children’s Hospital, exposing how poor management was endangering patients. She will need to be robust to deal with the inevitable vicious accusations of transphobia which greet anyone probing gender ideology and medicine.

Above all, any examination needs to be cool, objective and above the frenzied politicisation of the culture wars. In the US, eight state legislatures have introduced bills to ban doctors prescribing puberty blockers or cross-sex hormones to minors, a move easily dismissed as more bigotry from anti-choice Republicans. But in the US few liberal voices or newspapers dare to interrogate the explosion of highly lucrative paediatric gender clinics willing to diagnose kindergarten kids as trans or how pharmaceutical companies will profit from having millions of life-long customers. Dr Cass might ponder why Ferring Pharmaceuticals, which produces triptorelin, not only financially supported a trial into the Dutch protocol but since 2013 has donated £1.4 million to the Lib Dems, the most vocal supporters of gender self-ID.

Doubts about puberty blockers have come from senior clinicians, from LGBT campaigners worried that gender clinics are performing “gay conversion therapy” on future homosexual kids, and from feminists appalled that girls who do not conform to sexist gender stereotypes feel they cannot be girls. Already a growing number of “de-transitioners”, mainly young women, are coming forward, angry that doctors rushed them into irreversible treatment.

How will this play out in the next decade, as the first cohort on puberty blockers come to terms with their probable infertility? Such experimental paediatric medicine has been politicised and shrouded in secrecy for too long. It is time to ask serious questions.