Should we give puberty blockers to children with gender dysphoria?

Too little is known about the way gender identity forms and evolves in adolescence. To give truly informed consent, young people must be made aware of the absence of data.

By Phil Whitaker

When counselling men requesting vasectomy, I ask them to contemplate difficult scenarios: starting a new relationship having lost their partner, or what they would do were one of their children to die. No one has changed their mind as a result but for every 100 such men, six or seven will ultimately regret the decision.

The data on adults who have undergone medical procedures to assist gender transition suggest the incidence of “transition regret” is lower – around 1 per cent. Nevertheless, there is a small minority who ultimately wish they hadn’t used hormones or undergone surgery to effect permanent bodily change. Keira Bell is one – a woman in her mid-twenties who had previously been transitioning to become a man. Her story made national news because when she was 16 years old she was given puberty blockers (drugs that “pause” pubertal development) while under the care of the NHS’s only gender identity development service (Gids) for children, run by the Tavistock and Portman Trust. She went on to be prescribed testosterone to promote male characteristics including voice change and facial hair, and, aged 20, to have surgery to remove her breasts. Bell believes she was insufficiently challenged by her doctors at Gids and in early 2020 joined a legal action that sought judicial review of the Tavistock’s use of puberty blockers.

[see also: How to talk about trans rights]

The High Court judgment last December found that it was “highly unlikely” that a child under the age of 13 would be able to consent to such treatment, and “doubtful” that a 14- or 15-year-old could fully understand its implications, and further commented that doctors would probably want to seek authorisation from a court before prescribing to 16- and 17-year-olds. Tavistock suspended new referrals for such drugs in minors. On 17 September 2021 the Court of Appeal quashed the High Court judgment and confirmed that the Tavistock had acted lawfully. At issue is the 1985 legal precedent known as Gillick competence, which states that a child under 16 can consent to medical treatment if they are sufficiently mature to understand the issues and reach a decision. That capacity is assessed by doctors, not courts.

Gender dysphoria commonly has its onset in childhood; during adolescence it is associated with high levels of psychiatric morbidity – anxiety, depression, self-harm and suicide. The desire to help these distressed young people is entirely appropriate.

Puberty blockers are described by critics as “experimental drugs”. They aren’t; their use in other medical conditions is well-established. But it is right to describe their application to gender dysphoria in adolescence in such terms. Too little is known at present about the way gender identity forms and evolves during this critical developmental stage. Puberty blockers aren’t prescribed until pubertal changes have become firmly established; around 80 per cent of childhood gender dysphoria resolves once puberty begins. For the 20 per cent whose dysphoria intensifies in adolescence, there is too little research evidence to inform the risks and benefits of intervention. Hormonal manipulation in adolescence may have long-term health impacts in terms of stature, brain development and susceptibility to future disease.

To give truly informed consent, adolescents must be made aware of the absence of data surrounding long-term mental and physical health outcomes. If given this information, though, and if capable of weighing it, there is no reason why young people cannot consent to treatments with uncertain outcomes. The professionals involved in their care must provide balanced information and carefully evaluate each individual’s capacity to consent.

Keira Bell has vowed to continue her campaign. The Court of Appeal has put responsibility for oversight back into the hands of healthcare professionals. The NHS needs to show it is equal to the task of serving young people with gender dysphoria both ethically and well.