Conversion therapy is harmful and shouldn’t inform NHS practice. This shouldn’t be controversial, but sadly in the UK conversive approaches are now mainstream.

A new article just published today shines an important lived-experience perspective on some old clinical literature.

An autoethnographic critique of a past report of inpatient psychiatric treatment for gender diverse children

by Jayne McFadyen, Timothy W Jones, Rowena Koek, Fintan Harte, Brendan Jansen, Megan Galbally, Warren Kealy‐Bateman, Catherine Wall, Quinnehtukqut McLamore and Anja Ravine

In this short blog I will briefly discuss this new article, and its place in modern healthcare policy in the UK. First a bit of background.

Kosky (1987)

The new article published today presents a lived experience critique of an old 1987 article:

Kosky (1987) Gender disordered children: Does inpatient treatment help?

The abstract to that 1987 article states:

“Treatment guide-lines for gender-disturbed children currently are unclear. This clinical report describes eight children with cross-gender behaviour who were treated in an inpatient unit for children. The short-term outcome and long-term clinical observations are provided, which indicate a generally good outcome. The findings may have both practical and theoretical significance because they suggest that some gender disorders may be determined by intrafamilial interactions which are correctable“.

You might not be familiar with that article. But if you have been paying attention to discourse on trans youth healthcare you will be familiar with a 2016 literature review that included the Kosky article.

Ristori and Steensma (2016) Gender dysphoria in childhood

This literature review is an absolute favourite of transphobes, and has been the key citation to justify terrible healthcare policy that has harmed trans children for the past decade. It is the key citation used to legitimse the idea of ‘desistance’ or the concept that trans children will grow out of being trans, as long as they are rejected rather than affirmed or allowed to socially transition, as long as they are forced through an unwanted puberty rather than receiving affirmative healthcare. It is a key citation supporting policy recommendations against social transition. It is a key citation supporting the rejection of trans children’s identities at school. It is a key citation given to parents of trans children to encourage them to reject their children. It is a key citation underpinning the claim that puberty blockers are dangerous and should be banned due to their impact on changing the trajectory of sexual and gender identity development. It is a mainstay of anti-trans policy making, and a key citation of the Cass Review.

The Cass Review utilises a 2016 literature review as a key citation, to avoid citing the underpinning literature, the titles of which would raise concerns. The Commission on Human Medicine adopts the same tactic, citing an even more modern literature review by Michael Biggs, that does the exact same thing, using a modern ‘literature review’ to rebrand and present as modern a literature review of some really old and problematic studies. 

If we look at the studies upon which the 2016 Ristori and Steensma literature review is based, we see just how old those studies actually are:

Bakwin (1968) Lebovitz (1972) Money & Russo (1979) Zuger (1984) Davenport (1986) Green (1987) and Kosky (1987)

These studies are HUGELY unethical trash, that should have been in the bin decades ago, as I’ve written about before here, here and here. Even looking at their titles shows a pathologising view of difference.

The new study that has been published today focuses on the last of these, Kosky (1987) “Gender-disordered children: Does inpatient treatment help”.

Kosky (1987)

The study Kosky 1987 provides a clinical perspective on the treatment of gender non-conforming children in and around the year 1975.

In 1975, Jayne McFadyen (a key author of the new article published today) was ten years old. She had known she was a girl since the age of 8, but lived in a time and a place where affirmation or being supported to be a trans girl was not considered an option by the professionals around her. Clinicians blamed her parents for causing her gender non-conformity, and took her away from them, putting her into an institution where she would be treated to convert her into a gender confirming boy.

Within the 1987 article, the clinicians in charge of ‘conversion therapy’ outline the success of their approach.   

Many decades later, Jayne recognised her experience, the location and dates of her own experience as lining up with the 1987 article. But she did not recognise the article’s central claim that the therapy had been beneficial and successful. She felt very strongly the opposite.

Now in her 60s, Jayne shared with a team of researchers her own perspective on her conversion therapy treatment at the age of 10, as well as sharing her own clinical file and notes that she was able to access. She recalls being shamed, abused and traumatised in attempts to wipe out her gender non-conformity.

According to the Kosky study, the institutionalisation, separation from parents, and abusive treatment was a success, removing gender non-conformity. The Kosky study has been used for decades, and continues to be cited today, to justify several claims:

• It is used to evidence a claim that a majority of gender non-conforming children, if unsupported/rejected, will not be gender non-conforming or trans as adults.
• It is used to evidence a claim that parental influence can cause a child to be gender non-conforming, and that separation from parental influence can remove gender non-conformity or transness.
• It is used to evidence a claim that that therapy can remove a child’s transness, gender non-conformity or gender confusion. 

The new article examines this woman’s memories and her clinical records, comparing these with the claims within the published study. Important differences are noted. Substantial ethical failings are noted, both in terms of clinical practice and in terms of research. The woman shares her life experience – the impact of the ‘treatment’ in creating and reinforcing shame and self-hate. The ‘treatment’ forced her, through fear, into repression and hiding. She reflects on how it took her decades to process the impact of the childhood abuse that she received at the age of ten – abuse that is claimed as a success in the Kosky study. She shares how in mid adulthood she finally transitioned. Now in her 60s, half a century on from her institutionalisation at the age of 10 in 1975, she reflects on the harms done to her as a child. She shares her perspective, how her identity as a girl and woman has not wavered since she recalled feeling that way at the age of 8. 

The new article argues that this 1987 publication “should not be considered reputable evidence in any debate over transgender policies — either by direct or indirect citation”.

It notes, however, that this article is indeed being used as evidence upon which healthcare policy is based in 2025. It notes it being used indirectly, via the 2016 literature review, by the Cass Review. It notes it being used by anti-trans parent organisations like Bayswater, by those advocating for conversion practices, and by those who accuse parents of ‘transing’ their children.

This article continues to be used, directly or indirectly, by actors including the NHS to justify plainly bad policy positions including:

• To justify restrictions on, or criminalisation of puberty blockers, on the basis that gender non-conforming kids naturally grew out of their gender non-conformity, before puberty blockers changed the outcome, unnaturally keeping kids on a trans pathway.
• To justify restrictions on social transition, including in schools, on the basis that unsupported children grew out of gender non-conformity
• To justify advising parents against supporting a trans child, on the basis that unsupported children grew out of gender non-conformity
• To justify safeguarding investigations into supportive parents of trans kids, on the assumption that parental action can cause a child to be mistakenly trans
• To justify in-depth questioning of trans kids without their parent present, on the assumption that parental action can cause a child to be mistakenly trans
• To justify denying the existence of trans children, replacing that group as a whole with the term ‘gender questioning children’, on the assumption that childhood gender variance is temporary, unstable and will be grown out of as long as it is not affirmed.
• To justify prolonged non-affirmation or rejection of a trans child’s identity, on the assumption that affirmation puts children on a lifelong medicalised pathway who would otherwise grow out of it.

The seven bullet points listed above are having a huge impact on trans children across the UK in 2025. Each one of them is so absurd to almost be laughable. Each one of them is having a cruel and abusive negative impact on trans children’s lives.

This abusive 1987 study was considered a terrible study on which to base modern healthcare policy even before this new lived-experience critique. This lived-experience critique adds further weight to a long-stated argument that these old abusive studies should have no influence over healthcare policy in 2025. Studies like the 2024 Cass Review, like the 2024 Commission on Human Medicine report that enabled the continued criminalisation of puberty blockers, continue to rely on literature reviews of very old and abusive research to justify harmful trans-hostile policy positions, while ignoring modern research that overwhelmingly supports affirmative care. This decision to ignore modern literature and rely on trans hostile literature summaries of old and abusive literature is entirely political and ideological.

The new article summarises its key finding thus:

“Contrary to ongoing representations of efficacy, “therapy” that aimed to change or suppress a gender diverse child served to delay self-acceptance for two decades and caused long term harm”.

The NHS already know this.

Those opposed to or ideologically in denial of trans children’s existence will continue to apply conversive approaches to trans children regardless.

The Cass Review, and UK NHS policy remains rigidly committed to doing everything it can to harm trans children. For more on this, I strongly recommend reading another article, also out today.

“Cass Review does not guide care for trans young people“

Last night we learnt that the failing-fast UK government, in one of its very last actions, did something unprecedented, just to make life more un-liveable for transgender children and adolescents in the UK.

They enacted a very rare government power to block access to the only two remaining routes to doctor-prescribed UK-pharmacy-dispensed puberty blockers.

They used an emergency legal power that as far as I can see has only been used once before. That was in 1999 for a barely-known drug that had caused a number of deaths. Even then they went through several steps to gain medical authority scrutiny and approval of government use of emergency powers to enforce a ban, also considering the likely impacts on existing users of the substance (there was no significant use of the 1999 substance that was considered highly toxic).

Yesterday afternoon the UK government used this same rare power to place an immediate (starts 3^rd June) emergency ban on puberty blockers a) from overseas prescribers and b) from NHS GPs in primary care.

Let’s start with the second one. The UK government has enacted draconian emergency powers to ban the medical prescribing of NHS GPs in primary care. GPs in primary care already only have ever prescribed puberty blockers as a harm minimisation strategy – where they know a trans adolescent is accessing from a source (eg grey market without any monitoring) and they recognise their duty of care to minimise harms and where the threat to that adolescent’s life is considered severe (adolescents who cannot conceive of living through the wrong puberty). The UK government has made this harm reduction care from NHS GPs illegal. This has now closed literally the last route to UK-prescribed puberty blockers.

The UK establishment has systematically closed every single UK route to puberty blockers. The GMC (the UK regulator of medical doctors) has used its powers against a series of trans positive doctors since the early 2000s (thereby deterring any other doctors from stepping forwards). The CQC has denied approval to any UK private practices seeking to support trans adolescents under the age of 16, meaning the UK registered private providers do not offer support to trans adolescents at the point of puberty. The NHS gender clinics maintained a tight monopoly, with one English and one Scottish clinic for under 18s. The former was closed in March 2024, and the latter has currently blocked routes to puberty blockers. The new English service (also covering Wales) has no route to access to puberty blockers. Every door has shut.

The primary target of the draconian emergency ruling is those who currently receive a prescription for puberty blockers from an overseas doctor. Currently, the vast majority (I would guess 98%) of UK trans adolescents on puberty blockers receive them from an overseas doctor’s prescription, that is dispensed in a UK high-street pharmacy. There must be high hundreds or low thousands of trans adolescents currently receiving puberty blockers via this route. This route will now stop working on the 3^rd of June. High hundreds or low thousands of trans adolescents will be without any route to receiving their prescription in a UK pharmacy.

What are those adolescents meant to do? Now they cannot even go to their GP as an emergency and harm-reduction route. Those who cannot or will not consider grey market routes will literally be medically detransitioned, something known to be an actual medical and well-being risk, by the edict of a transphobic government. This will not be safe. This was never about safety.

The power to take this step is based on emergency measures that can only be enacted where there is a critical threat to immediate safety. The government waved this through with the claim “the Cass Review…”.

The Cass Review was a shambles of transphobic medical policy. The Cass review approach to puberty blockers was based on one clever trick.

If the Cass review had asked these two questions, the answers would have been very clear. 1. Are puberty blockers effective at blocking puberty (Yes, very clearly). 2. Are they safe at blocking puberty (Yes, very clearly, used since the 1960s for precocious puberty in children who are 6 or 7, used since the 1980s for trans adolescents, NO EVIDENCE OF HARM).

The trick played by the Cass Review is that they didn’t ask these questions. They instead asked, 1. Are puberty blockers effective at treating gender dysphoria? Shifting to this question allowed them to ignore the very clear evidence that they are extremely effective at blocking puberty. They claimed that effective puberty blockers should improve well-being which has never been the case. Puberty blockers are intended to maintain well-being, in stark comparison to trans adolescents without puberty blockers whose mental health, well-being, wish to live, and ability to succeed at school and socially tends to nose-dive at puberty). Unless you have an unethical study watching the kids who fall off a cliff in mental health without blockers then how do you prove they help prevent a decline in mental health? Shifting the question to whether they ‘treat gender dysphoria’ allowed the Cass Review to state the evidence of effectiveness was ‘inconclusive’.

Secondly, instead of asking whether the medicine is ‘safe’, they asked a narrower question, is it ‘safe in treating gender dysphoria’? This allowed them to disregard decades of studies that puberty blockers are safe when used in cis children. The drug is very clearly safe. It is still today (and next week) prescribed by the NHS for younger children who are not trans. There are no safety concerns. The medication is clearly safe.

The only way that the Cass Review was able to raise any safety concerns at all, was through transphobic speculation. They speculate, with zero evidence, that perhaps puberty blockers may ‘change the outcome’, keeping a trans child as a trans adolescent, when all they need is a good dose of their endogenous hormone and then they would turn out normal (cis). (See my recent podcast transcript that dives into this). The severe safety risk that the Cass Review speculates about, is the risk of still being trans. There are some other speculations, that are only proposed for trans adolescents (not for cis youth receiving the same medication for any other purpose, including endometriosis or early puberty). None of the speculations are evidenced. The Cass Review also references things like bone density, which is a minor risk that endocrinologists are well aware of and can be easily managed by a) monitoring bone density b) taking vitamin supplements c) not being on blockers without hormones for more than a couple of years. There is no evidence of actual risk or actual harm at all of trans adolescents using puberty blockers.

The actual risk is, of course, the opposite. There is a very real risk to trans adolescents who need puberty blockers and are denied them. In the last week I’ve spoken to two parents whose children no longer wanted to be alive because of starting to be pushed through a puberty that is distressing and humiliating for them. For adolescents who are deeply distressed by puberty, instead of being offered a safe and effective medication that can stop those changes, they are being offered a big pile of nothing. They are being offered the suggestion that perhaps they are not really trans, and perhaps the changes that they find traumatic are just want they really need to grow up cis. That is where we are with trans healthcare in the UK today. Trans children and young teens are being told, ideally you should convert yourself into a cis person, or we literally do not care for you, your life, your safety, your well-being.

High hundreds or low thousands of trans adolescents who are on puberty blockers, happy and healthy, will be forceably detransitioned by government edict, without medical supervision or support, starting on the 3^rd of June. Some of these will turn in desperation to grey market sources, finding every route to UK pharmacy dispensing closed. There are risks to youth who are forced onto grey market sources, both in terms of ensuring the quality of medication that does not come from UK pharmacy, and perhaps even more so in terms of the risks associated with healthcare avoidance. Trans adolescents who are accessing grey market medication, having had every other route banned, will be reluctant to go to their GP for other health issues. There is a real risk of a whole generation of trans adolescents losing out of mainstream healthcare, and becoming at higher risk of the health impacts that occur when a portion of society is afraid of talking to their GP or health service. Communities who are afraid of talking to their healthcare providers (see undocumented immigrants) are likely to go to healthcare providers late when they have a routine health concern, are likely to wait until minor healthcare concerns become major, are likely to have significantly worse general healthcare outcomes. This is where we are heading today for trans adolescents in the UK. It is an absolute oppression. It is not about safety. It was never about safety.

The emergency legislation lasts for only 3 months, as the UK government is enacting an emergency power intended for a new and unexpected threat to life, not a power intended for a medication safely used since the 1960s. This temporality does not reassure me. Let’s look at the Labour Government’s reaction – are they going to condemn this transphobic intervention as dangerous and abusive government overreach into healthcare? I bet they will not. And if they do not, then I have no confidence that they will not extend this if they are in power come September.

In the name of ‘safety’ the UK government is making the UK more unsafe for trans adolescents. Transphobia is the biggest safety threat to trans adolescents, as to trans people of all ages. Trans children and adolescents can have a happy and safe and secure childhood and adolescence. But the UK government and the NHS is trying its utmost to take that happiness and safety and security away. We need to do better for trans young people. #TransRights #TransKidsShouldThrive #TransHappinessMatters

The Cass Review final report has now been published. It has been received with jubilation by transphobic hate groups, by conversion therapy proponents, by those advocating against trans rights, by those who do not believe in the existence of trans children. The report has been praised and endorsed by all major UK media outlets, by MPs from the Conservatives and Labour, with both main parties committing to the fulfilment of all Cass recommendations.

The report has been met with horror and fear by trans communities, by trans healthcare professionals around the world, by families supporting trans children. Trans healthcare scholar Ruth Pearce has collated such responses here.

The Cass Review is biased and prejudice-driven in its design, delivery, analysis and approach to evidence, as documented in my peer reviewed analysis, published in the leading journal for trans healthcare.

In this short blog I will not revisit the very many methodological, conceptual, interpretive, evidencial and policy failings of the Cass Review. Instead I will here summarise and very briefly comment on ten significant recommendations of the Cass Review, each of which will cause significant harms to trans children. Here I am summarising ten of the recommendations that have me concerned, drawing from across the full 400 page report. These are not the recommendations that Cass has chosen to draw attention to in the 5 page summary document (these are analysed by Gemma Stone here) but are recommendations embedded across the longer Cass Review document. Each of the recommendations summarised below is built on a foundation of prejudice, ignorance, cisnormativity and pathologisation of trans lives, running in direct opposition to the evidence base, and running in direct contravention of an NHS duty of care to children’s rights, children’s welfare, healthcare equality and healthcare ethics.

These Cass Review recommendations have already been endorsed by powerful politicians from both the Tories and Labour. They have been endorsed by powerful healthcare stakeholders from BPS to BMJ, and there is significant high level commitment and motivation to quickly rolling these recommendations out into practice in the NHS. This roll out is a very significant safeguarding risk for trans children in England and Wales (where I refer to the NHS from here onward, it refers to the NHS in England and Wales).

1. A current complete ban on NHS access to puberty blockers.

The Cass Review recommends a complete ban on access to puberty blockers outside of a research trial, with the research trial not yet developed. There is no current route to trans children accessing puberty blockers through the NHS. All previous access routes have been closed and no new children are accessing blockers. This is not labelled as a complete ban (although it is a complete ban currently in practice) as there is reference to a potential future research trial. NHS documents have been very clear that the current ban will continue even if the proposed research trial never commences. The trial has not yet been developed, and it is unlikely that such a trial would ever receive ethical approval to commence. Even if a trial does at some future point go ahead, it is likely to be highly restrictive and unethical.

2. Legitimisation of conversion therapy

The Cass Review recommends therapeutic practices that run counter to an affirmative approach that welcomes trans lives as equal to cis lives. The Cass Review endorses ‘exploratory therapy’, a re-branded title for conversive practices. The Cass Review is careful to avoid actively calling for conversion therapy, but Cass has appeared in the media since the report’s launch speaking against a ban on conversion therapy, highlighting that such a ban could impede the type of ‘therapeutic practice’ that Cass recommends.

3. Intrusive and abusive ‘assessments’

The old GIDS service was criticised for assessments (as part of gaining approval for transfer to endocrinology) that were abusive and intrusive. Cass recommends the new service takes this intrusive approach to questioning a step further. Here this is not even a discrete step in eligibility for endocrinology (as under 16s will never be eligible for medical intervention) but an ‘assessment’ for its own sake, enforcing a prolonged intrusion into trans children’s lives. Cass recommends that trans children are questioned on a bewildering range of intrusive topics, on sexuality, on masturbation, on porn viewing, on experiences of abuse, on family violence, on mental health, on anything and everything that could have influenced them to be trans. This type of expanded questioning deeply problematises transness, and is a deeply pathologizing and abusive approach for children who just happen to be trans. It is particularly harmful for the trans children who are without support, who are left feeling there is something deeply wrong or shameful about who they are to justify such ongoing intrusions. In the old GIDS intrusive ‘assessment’ was tied to referral to endocrine services, with at least a theoretical end in sight. In the new system I see no safeguards to protect trans children from intrusive assessments that never end.

4. An immediate removal of 17 year old access to adult healthcare clinics

The Cass Review recommended an immediate cessation of 17 year olds being able to access adult gender clinics (an approach that had been adopted following the huge delays in children’s services). NHS England immediately adopted and actioned this recommendation, pulling away hope from trans adolescents. Trans youth who have already been waiting for 5+ years for access to healthcare, who some of whom were counting the weeks to the 17^th birthdays, have had this hope immediately pulled. Some 16 year olds are taking this news very hard. The NHS does not have any idea or concern for the well-being of trans adolescents who are left without healthcare.

5. Clinical control over social transition

The report recommends caution on social transition, proposing that showing respect and support for a trans child be considered an active intervention that necessitates engagement with clinical services, and by inference, clinical oversight. The process and timelines for gaining clinical permission to socially transition are unclear, but I can foresee children waiting years without clinical permission to socially transition, especially for younger trans children. Delays to social transition are harmful, shaming, and abusive, with a direct impact on trans children’s happiness and mental health. Delays to social transition are a form of conversion therapy. This approach will have particularly damaging implications for trans children in care, where care providers or foster carers may not feel able to support a child without clinical permission. It is also likely to increase delays and barriers to social transition in families who are lacking in trans-positivity, or where parents are divided in their supportiveness. My recent peer reviewed article on social transition synthesised all existing evidence on social transition, with a wide range of evidence of the benefits of social transition, and zero evidence on harm.

6. Potential restrictions for young adults

The Cass Review has already expanded into having a view on adult trans healthcare, proposing a Cass-style review of the evidence base supporting trans adult services. Given the major flaws and prejudices of the children’s Cass Review, any parallel endeavour in adult services is a very significant concern. The Cass Review talks in vague terms about changing the service for 18-25 year olds. This raises concern that this will lead to barriers to healthcare for young adults. It does not seem a coincidence that this vague recommendation aligns with the policy priorities of anti-trans actors who have long sought to restrict healthcare access for 18-25 year olds – indeed the Cass Review relies upon exactly the same flawed and misinterpreted studies on brain maturation that are used by anti-trans campaigners to advocate that trans adults are too young for mature decision making.

7. A ban on peer concordant puberty (with severe HRT restrictions even for 16 and 17 year olds)

Best practices worldwide for trans healthcare includes the option of trans adolescents taking HRT at the same time as their peers. There is growing evidence that peer concordant puberty is important for emotional well-being, physical health and educational attainment. For many trans youth, waiting until 16 to access HRT is too late, with implications for their mental and physical health.

The Cass Review recommends that even HRT at 16 and 17 be seen as an exception, with a majority denied any access to medical intervention until adulthood. The Cass recommendations to restrict HRT to 16 year olds also appear to make it harder for those who have accessed puberty blockers and HRT privately to transfer back into NHS services at 16, completely isolating trans under 18s who have gone private from returning to NHS healthcare. These approaches lead to significant inequalities between those who can access private healthcare and those who cannot, between those with or without the financial means to afford private healthcare until age 18.

8. Recommends CQC restrictions on private healthcare

The Cass Review recommends the Care Quality Commission intervene in private healthcare provision to ensure Cass recommendations are equally enforced in private healthcare. This ensures the Cass approaches, with their ban on puberty blocker access, their intrusive questioning, their ‘exploratory’ therapy, is the monopoly approach in the UK, preventing the development of any affirmative provision in private or non-GIC healthcare services. This is immediately a threat to any existing services who want to provide affirmative healthcare for trans 16 and 17 year olds outside of the Cass model. It also provides a more significant barrier to any future CQC registered private providers supporting trans under 16s. This guidance reinforces the monopoly of the Cass position.

9. Recommends Pharmaceutical Council intervention in overseas prescriptions

The Cass Review recommends the General Pharmaceutical Council takes action to prevent pharmacies from fulfilling gender affirmative prescriptions from overseas clinics. In a country where there are zero NHS or CQC registered healthcare providers prescribing for trans under 16s, action to prevent or deter pharmacies from fulfilling private prescriptions would close down the only current route to healthcare for trans under 16s. This would force desperate families into emigration or black market provision. Cass has no consideration of the NHS’s duty to adopt a harm reduction approach.

10. Problematisation of trans identities

The Cass Review has worsened pathologisation and problematisation of trans identities, legitimising those who seek discrimination under the banner of it being justified to ‘protect children’. The Cass endorsed problematisation of transness has implications for how trans children and trans communities are treated across our society.

The Cass Review reinforces a number of myths about likely parental, social, peer, abuse or porn related influences on a trans child’s identity. There is no acknowledgement that some children are trans and this is fine (or even to be celebrated). There is no recognition that being trans is a healthy part of human diversity. This message and the concerns around negative factors that can cause a trans identity in childhood can be devastating in sphere like family courts, social services, schools. It is likely to discourage parental support and provide legitimacy to abusive anti-trans families. These messages of a trans child being created through outside influence can be particularly harmful in custody battles between affirming and rejecting parents. There is no consideration of the need to protect and safeguard the well-being of trans children.

Last night I couldn’t sleep.

Today I can hardly breathe.

The weight on my chest and heart and spirit feels too much to bear.

In the UK right now, as a trans person, as a parent of a trans little person:

• I do not feel safe
• I do not feel hope
• We do not feel safe
• We do not feel hope

How do we protect those we care about from a society where there is so much hate. So much prejudice. So much injustice. So much indifference.

How do we endure such overwhelming oppression?

I’m trying to help my child stay afloat in the face of injustice and persecution. I’m trying to keep us afloat. But it is rough. It has been rough for years and keeps getting rougher. I am tired of the struggle. We are all so tired.

• I can’t withstand this on my own.
• My child can’t withstand this on her own
• We can’t withstand this on our own.

We need community. We need solidarity. We need resistance.

I feel particularly isolated and alienated (and gaslit) when I see supposed allies participating in our oppression. Seeing a prominent LGBT org ‘welcome’ the Cass Review felt like a stab in the heart. Over the past few years I continue to feel let down by UK civil society. The child rights or LGBT or trans rights organisations who look the other way, who do not stand with trans kids, who minimise current harms

As we face and endure state violence, it hurts to see parts of civil society complicit in such violence.

We need ‘allies’ to call out state violence and systemic oppression. Instead too many are afraid to challenge the Cass Review – too afraid to challenge the opinion of a medical doctor, even when the approach and findings are so clearly wrapped in prejudice. Instead staying quiet or siding with our oppressors.

It is not good enough.

We are all sinking.

So many trans folks I know are struggling right now. I’m struggling. So many trans kids I know are struggling.

We need to acknowledge state violence. That is a very low expectation of our supposed allies.

We need to acknowledge systemic oppression and persecution.

We need to be talking about strategies of resistance.

Trans communities, and especially trans children, need to resist state violence in the UK right now. Trans kids need to resist and endure the violence endorsed and recommended in the Cass Review, the violence in government policy, in media discourse, in school policy, in hostile and abusive homes.

Now is not the time for complicity in such oppression.

Now is the time for reaching out to trans people who are scared and without hope. I have a lot of relative privilege, and I am scared and low on hope today.

Now is the time for those of us with any privilege or power to stand up and be counted. Now is the time to pull together, acknowledging state violence and oppression, and focusing on strategies of resistance.

It is not easy to resist state violence. Especially for a child.

It is not easy to support a child to resist state violence, especially when isolated and threatened.

We all need hope. We all need community. We need genuine solidarity.

None of that can come from denial or minimisation of current harms.

We need to acknowledge that the UK is a seriously hostile location for trans people and especially trans children. We need to talk about resistance and survival.

We need to support each other. We especially need to support the trans children we know and love, to withstand the many current injustices, and those we see on the horizon looming down on us.

Solidarity. Justice. Resistance.

Sending love to all who are struggling. Sending love to all who will help. We need each other.

The Cass Review final report is released tomorrow. I’ve seen the summary and it is as expected.

After a 4 year process the Cass Review final report is a deeply depressing outcome. I have repeatedly, over many years, called for paediatricians to take a role in trans children’s healthcare. In other countries paediatrician-led care has helped shift trans children’s healthcare from harmful and pathologising conversive practices endorsed by those who treat transness as a mental health disorder, into modern, child-centred, trans-positive healthcare. In this, Dr Cass has failed.

The Cass final report fails to take any meaningful steps to improve the lives of trans children. It fails to depathologise trans lives. It fails to centre trans children’s rights. It provides a veneer of credibility to policies, practices and systems that are backwards, pathologising, abusive, and deeply damaging to trans children and young people.

The Cass final report repeats the failings of earlier Cass publications. I have published a peer reviewed analysis and critique of all earlier Cass related reports in the leading journal on trans health (the International Journal of Transgender Health). This analysis highlighted four major concerns with the Cass approach and outputs.

The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children

These concerns relate to (1) prejudice; (2) cisnormative bias; (3) pathologisation; and (4) inconsistent standards of evidence.

Each of these concerns impacts the Cass Review’s approach to trans children’s healthcare, with negative repercussions for trans children’s healthcare rights and well-being.

Trans children face unbearable challenges at present in the UK. The scale of hurt, pain and trauma is hard to describe.

There is currently no accessible NHS healthcare for trans adolescents, in part due to the Cass Review. Newly proposed centres will not offer timely affirmative medical intervention, care that is recognised as essential and life-enhancing for many trans adolescents.

There is a real risk that professionals in new NHS centres will be emboldened to adopt pathologising conversion practices that cause immense harm. The Cass Review’s ‘caution’ on social transition will lead to more trans children enduring the harm, shame and trauma of delayed or denied transition, with significant consequences for trans children’s self-esteem and mental health. There is a growing body of global evidence on the benefits of social transition and no evidence of harm. Current guidance will deny many trans children the chance for a shame-free and joy-filled childhood.

Trans children face severe barriers to equality in education, with many experiencing trauma in UK schools.

Too many trans children face rejection and abuse at home, including from families who are mis-led into anti-trans practices by lobbying organisations who fundamentally reject the very existence of trans children.

Trans children face harm and injustice at every turn. The Cass Review’s final report does nothing to help trans children live happy, healthy, safe and confident childhoods.

I hope that those who actually care for trans children will take action today – calling out the dire situation for trans children in the UK and highlighting the failures of the Cass Review. I hope more people will stand up alongside trans children, resisting the most outrageous harms, and defending trans children’s rights.

Trans children have a right to safe, supported and happy childhoods.

The UK media is full of scaremongering about puberty blockers (GnRHa) and the evidence or supposed lack thereof in support of their use for trans adolescents. Opinions abound, but few, however, have the opportunity or access to read the academic literature. In this article, a comprehensive overview of the studies and academic literature on puberty blockers are presented, providing improved access to this evidence. Links to the papers are provided throughout, supported by a full bibliography.

Puberty blockers are a recommended intervention for trans youth at the start of puberty (when such interventions are requested), endorsed by the global Endocrine Society and WPATH (the World Professional Association for Transgender Health). Within medical and clinical service provider communities, strong consensus in support of puberty blockers has grown, with endorsement from the world’s largest paediatric health body the American Academy of Pediatrics, providing access to blockers throughout the USA, and national health services around the world including centres in Spain, Australia & New Zealand. Authors from the conservative UK NHS children’s gender service (GIDS), wrote a position paper in 2016 (Costa) stating that “Despite a limited number of studies, the existing literature supports puberty suppression as an early, sufficiently safe, and preventive treatment for gender dysphoria in childhood and adolescence”, with a more recent 2019 UK paediatric endocrinologist authored piece (Joseph) affirming that puberty suppression “is now a recommended treatment option”.

Puberty blockers have been used since the 1970s for children with precocious puberty, with extensive studies for this cohort (Eun Young Kim provides an overview of the literature), on their long-term use “considering evidence of impact on height, reproductive function, obesity and metabolic syndrome, bone mineral density and bone markers, polycystic ovary syndrome, psychosocial problems”. “Long–term studies on the recovery of reproductive function in precocious puberty patients of more than 6–20 years are being reported”. “Puberty was recovered within 1 year after GnRHa treatment discontinuation, and there were no abnormalities in reproductive function”. “Bone mineral density decreases during GnRHa treatment but recovers to normal afterwards, and peak bone mass formation through bone mineral accretion during puberty is not affected”. “Some studies have reported decreases in psychosocial problems after GnRHa treatment. Overall, GnRHa seems effective and safe for CPP patients, based on long-term follow-up studies.”

In trans youth, blockers have been studied since the late 1980s. An early paper published in 1998 (Cohen Kettenis) reported on the protocols followed for a 13 year old trans boy who was treated with puberty blockers, with HRT (Hormone Replacement Therapy) and surgery after turning 18. This was the first longitudinal case study, which documented a successful outcome from using early puberty blockers. As an adult, the subject was happy and satisfied with the outcomes, (though noted the delays between blockers and HRT were overly long).

The longest follow-up study is of a Dutch trans man who started on puberty blockers at age 13 in 1988. His health and well being was monitored\ regularly for over 22 years, when he was last followed up, aged 35 (in 2010) he was well-functioning with no clinical signs of a negative impact of earlier puberty suppression on brain development, metabolic and endocrine parameters, or bone mineral density (Cohen Kettenis, 2011).

Their use in trans adolescents has been well studied in the Netherlands. In 2011 (Kreukels) the then world leaders in what became known as “the Dutch Approach” wrote that they “believe that offering this medical intervention minimizes the harm to the youth while maximizing the opportunity for a good quality of life including social and sexual relationships, and that it respects the wishes of the person involved”. “Because the effects are reversible, this treatment phase could be considered an extended diagnostic phase. Knowing that the treatment will put a halt to the physical puberty development often results in a vast reduction of the distress that the physical feminization or masculinization was producing.”

Another 2011 study (De Vries) collected data from 2000-2008 of 70 trans youth (33 trans feminine, 37 trans masculine) capturing the time period when they were only receiving puberty blockers. Puberty blockers were started at an average age of 14.75 (youngest was 11.3). Youth received puberty blockers alone before starting HRT alongside for an average of 1.88 years (the shortest period on just puberty blockers was 0.42 years, the longest was 5.06 years). Whilst on puberty blockers there were improvements in behavioural and emotional problems, and reduced symptoms of depression, enabling healthy psychological development. There were not improvements in body image and gender dysphoria. “As expected, puberty suppression did not result in an amelioration of gender dysphoria. Previous studies have shown that only gender reassignment consisting of CSH (cross sex hormone) treatment and surgery may end the actual gender dysphoria”. All youths later went onto HRT (which did lead to improvements in body image and gender dysphoria as well as wider improvements to wellbeing (see 2014 study for follow up). In a clinic with a clear route to HRT (all youth in the study were later prescribed HRT) the authors speculate that improvements in wellbeing whilst on puberty blockers may be due to the youths on puberty blockers having confidence that a route to HRT is available.

A summary position statement from Amsterdam in 2011 (Kreukals) outlined their view: “In our opinion, to deny these youngsters GnRHa treatment is unreasonable. Although the physical effects of puberty suppression are reversible, it has been argued that the effects on psychosexual develop ment are not reversible: the adolescents will miss puberty that is a result of their own natal sex hormones. However, in this sense, denying GnRHa treatment is equally irreversible: the adolescents will never know how puberty in accordance with their gender identity will be, because that is made impossible by the effects of their own sex hormones. Transsexual adolescents often consider not experiencing the puberty of their desired sex more harmful than missing their natal puberty. As puberty suppression therapy generally results in a physical appearance that makes it possible to live unobtrusively in the desired gender role, withholding GnRHa treatment is also harmful because of the potential life-long social consequence s (such as stigmatization).”

Hembree (2011) reviewed other studies noting increased suicidal ideation where blockers were not given.

A 2012 paper (Edwards Leeper) from a major paediatric treatment centre in the USA, emphasised a key reason for puberty blockers – “44% of transgender youth presenting for medical intervention had been previously diagnosed with a psychiatric disorder, the most common being depression, anxiety, and bipolar disorder. Thirty-six percent of these patients had been prescribed psychotropic medications and 9% had been hospitalized psychiatrically in the past. These psychological problems often intensify when transgender children reach puberty”. They also note that “it is not uncommon for these symptoms to decrease and even disappear once the adolescent begins a social and physical transition. The previous diagnoses of major psychiatric disorders, especially mood disorders (e.g., major depressive disorder, bipolar disorder) in these patients are often secondary to their gender identity issue and many patients are “cured” of these disorders through medical intervention for the gender issue.” The authors emphasise multiple psychological benefits of pubertal suppression, especially through avoiding needless emotional and psychological suffering, which can be severe for some adolescents (e.g., self-harming behaviors and suicidality). Delamarre , in an earlier 2006 paper, highlights that once trans adolescents are on puberty blockers, their anxiety at physical changes is taken away, enabling them to concentrate on other issues, enabling them to better develop and socially connect with peers.

A 2014 study (De Vries) of 55 trans youth (22 trans feminine and 33 trans masculine) followed them over an 8 year period from before starting blockers (mean aged 13.6 years), through to start of blockers (average age 14.8, youngest 11.5) through to HRT (mean age 16.7, youngest 13.9) and at least one year after gender reassignment surgery for those who wanted surgery (mean age 20.7). This monitored not only psychological functioning (gender dysphoria, body image, global functioning, depression, anxiety, emotional and behavioural problems) but also tracked wellbeing (social and educational/professional functioning; quality of life, satisfaction with life and happiness). Psychological functioning steadily improved. Well-being improved to similar or better than same age young adults from the general population. “GD (gender dysphoria) and body image difficulties persisted through puberty suppression and remitted after the administration of CSH and GRS (at T2) (significant linear effects in 3 of 4 indicators, and significant quadratic effects in all indicators)“ “None of the participants reported regret during puberty suppression, CSH, treatment, or after GRS. Satisfaction with appearance in the new gender was high, and at T2 no one reported being treated by others as someone of their assigned gender”. “All young adults in this study were generally satisfied with their physical appearance and none regretted treatment. Puberty suppression had caused their bodies to not (further) develop contrary to their experienced gender”. “Psychological functioning improved steadily over time, resulting in rates of clinical problems that are indistinguishable from general population samples (eg, percent in the clinical range dropped from 30% to 7% on the YSR/ASR30) and quality of life, satisfaction with life, and subjective happiness comparable to same-age peers. They note that this support gave “these formerly gender dysphoric youth the opportunity to develop into well-functioning young adults. These individuals, of whom an even higher percentage than the general population were pursuing higher education, seem different from the transgender youth in community samples with high rates of mental health disorders, suicidality and self-harming behaviour”.

Paediatric endocrinologist Rosenthal outlined key endocrine considerations in 2014, highlighting the potential negative impact on bone health of extended pubertal suppression and arguing for earlier introduction of HRT, stating that delaying HRT until age 16 can be “detrimental to bone health”. In addition he stated the negative impacts on emotional well-being of denying trans youth the opportunity to progress through puberty at the same time as their peers, and thereby isolating them. For this reason, gender centres are “studying the impact of cross-sex hormone treatment initiation at 14 years of age (which approximates the upper end of the age range for normal pubertal onset in natal males and 1 year beyond the upper end of the age range in natal females”).

A 2014 paper (Khatchadourian) summarising treatment in a Canadian clinic emphasises the high rates of suicidal ideation before treatment, in a cohort not treated until an average age 16. “Importantly, 10 of the 84 patients (12%) had attempted suicide with a resultant visit to an emergency department before being seen in our clinic”. “The older age of our cohort of patients compared with the Dutch cohort (mean age 16.6 vs 14.6 years, respectively) may also explain differences in frequency of psychiatric comorbidity, as our patients had more time to develop these comorbidities.” They note a decrease in suicide attempts or visits to emergency departments for suicidal ideation once engaged with the clinic (from 10 incidents before treatments, to 4 after). “Although our numbers are quite small, this finding suggests a lessening of emotional problems and suicidality when puberty blockers or cross-sex hormones are started. This is further corroborated by findings in the Dutch cohort, where an improvement in psychological functioning in areas such as depressive symptoms was demonstrated in adolescents with gender dysphoria treated with GnRHa for nearly 2 years.” This study also emphasises youth who do not need to undergo interventions like painful electrolysis or chest surgery, as early treatment prevented unwanted pubertal development. The authors conclude that “most experts in transgender care would agree that initiation of GnRHa therapy at an earlier stage ofpuberty is preferred, because preventing the development of unwanted secondary sexual characteristics can alleviate distress.”.

A 2014 paper (Fisher) outlines the negative consequences in Italy where puberty blockers were not offered – 23 youth, (14 trans feminine, 9 trans masculine, average age 16.3 years old), who had been diagnosed with gender dysphoria but who had not been granted any medical intervention, had low levels of wellbeing, and high levels of emotional and behavioural problems. They also noted that a high proportion, 42%, had dropped out of school early. The authors from Italian clinical services consider ethical implications of prescribing or denying blockers. They discuss fertility, referring to wider studies and concluding “several studies report that fertility potential is not impaired by long-term treatment with GnRHa even when used in younger subjects, before age 7, to treat precocious puberty. In addition, GnRHa treatment seems to have a protective effect on the reproductive outcomes, as fertility problems were more prevalent in subjects with precocious puberty that were not treated when compared with those treated. Professionals should inform patients that sperm production can be satisfactory after cessation of GnRHa or with gonadotropin treatment (both associated with body virilisation. FtM individuals have to be informed that no adverse effects are expected in relation to their fertility when treated with GnRHa” They argue that the current (2014) clinical evidence as well as international clinical guidelines suggests that prompt prescription of puberty blockers provides the best outcome for trans adolescents. They note experience from Italy that later pubertal changes can be unbearable, changes that “are usually profoundly humiliating for transgender youth”. They add that unwanted pubertal changes “often perceived as devastating, may seriously interfere with healthy psychological functioning and well-being”, being associated with worsening gender dysphoria, distress, depression, self-harming behaviour, anxiety, low self-esteem, social isolation and suicidal ideation. They emphasise that “although there are cases of comorbid psychiatric disorders, these psychological symptoms are often a result of the discomfort that Gender dysphoric individuals feel in their own bodies and of the social rejection they experience”. They go on to outline eight reasons to endorse blockers including 1) immediately reducing suffering 2) enable better decision making on further medical intervention 3) the physical effects are fully reversible 4) outcomes for physical transition are enhanced if unwanted secondary sex characteristics are not developed 5) Future surgeries are less likely to be needed 6) Can prevent emotional and psychological suffering that can have short term and longer term risks for well-being 7) provide better psychosocial functioning 8) avoids unsupported youth turning to illicit un-prescribed medication. They conclude that the “current inadequacy of Italian services offering specialized support for GD youth may lead to negative consequences. Omitting or delaying treatment is not a neutral option. In fact, some GD adolescents may develop psychiatric problems, suicidality, and social marginalization. With access to specialized GD services, emotional problems, as well as self-harming behaviour, may decrease and general functioning may significantly improve. In particular, puberty suppression seems to be beneficial for GD adolescents by relieving their acute suffering and distress and thus improving their quality of life.”

A 2015 UK study (Costa) compared adolescents supported with puberty blockers to those denied access to blockers. 201 Adolescents with gender dysphoria aged 12-17 (average age 15) were assessed for psychosocial functioning, using an assessment called CGAS. All the youth in the study registered low levels of psychosocial functioning at baseline (CGAS = 57). One group of 61 youth were not granted puberty blockers, instead having 18 months of just psychological support. Their psychosocial functioning improved after 6 months of psychological support (to CGAS = 60) but then plateaued and stayed significantly below the levels of children without psychological symptoms (staying at CGAS = 62). Another group of 60 youth were allocated blockers after 6 months of just psychological support. Like the untreated group, their psychosocial functioning improved when just receiving psychological support (to CGAS = 60). Their psychosocial functioning then improved more significantly at each six monthly check up whilst on puberty blockers. The psychosocial functioning of youth after 12 months of puberty blockers had improved to match that of children without psychological symptoms (CGAS = 67). Trans youth with puberty blockers were able to reach levels of psychosocial functioning the same as their peers.

Another 2015 study (Staphorsius) looked at the impact of puberty suppression on executive functioning in trans adolescents, using a well-established task called ‘Tower of London’ and comparing trans adolescents on blockers to trans adolescents not on blockers. They found no significant effect of blockers on performance scores (reaction times and accuracy) when comparing trans girls on blockers (8) to those not on blockers (10), or when comparing trans boys on blockers (12) with those not on blockers (10). “In conclusion, our results suggest that there are no detrimental effects of GnRHa on Executive Function.

A 2015 study (Klink) followed 34 trans youth through adolescence and into adulthood. 15 trans girls/women and 19 trans boys/men were followed from starting blockers at an average age of 15.0, through to starting HRT at an average age of 16.5, through to final follow up at an average age of 22.0. The paper analyses data on bone mineral density.
A 2017 study (Vlot) looked at the impact of puberty blockers and HRT on bone health. 34 trans boys and 22 trans girls were studied, providing data on impacts on different bone health related measures. These studies are followed up by a 2019 study (Joseph) below.

Very few studies focus on asking what trans youth themselves think about puberty blockers. One exception is a 2016 study (Vrouenraets) of 13 adolescents (5 trans girls and 8 trans boys), 12 of whom received puberty blockers, at an age range between 13 and 18, with median age 17. Asked about a lack of data on the long-term effects of puberty suppression the majority said that being happy in life was more important for them than any possible negative long-term consequence of puberty suppression “The possible long-term consequences are incomparable with the unhappy feeling that you have and will keep having if you don’t receive treatment with puberty suppression” (trans youth age 18)”. “It isn’t a choice, even though a lot of people think that. Well, actually it is a choice: living a happy life or living an unhappy life. (trans girl, age 14). Interviewed youth also understood that treatment has to be given in order to obtain long-term data, and were more than willing to be the person to test it.

A 2016 study (Schagen) aimed to evaluate the efficacy and safety of GnRHa treatment in trans adolescents, evaluating the extent to which (early) pubertal physical changes can be reversed, the need for monitoring of gonadotropins and sex steroid levels, and the need for screening of liver and renal function. Forty-nine trans feminine adolescents (average age 13.6, range 11.6-17.9) and 67 trans masculine adolescents (average age 14.2, range 11.1 – 18.6, 77% had started menarche) treated between 1998 and 2009 were included in the analysis. “None of the adolescents discontinued GnRHa treatment because of side effects. This is in agreement with the finding that GnRHa treatment is well tolerated by children and adolescents”. “Gonadotropins and sex steroid levels were suppressed within 3 months. Treatment did not have to be adjusted because of insufficient suppression in any subject”. “We did not identify any renal or hepatic complications of the treatment, and previous studies on GnRHa treatment in children with precocious puberty did not find such adverse effects. Therefore, it does not seem necessary to routinely monitor these parameters”.

A 2017 paper (Schneider) provided a case study of the brain of a single trans youth during pubertal suppression. “Brain white matter fractional anisotropy remained unchanged in a GD girl during pubertal suppression with GnRHa treatment for 28 months, which may be related to reduced serum testosterone levels. The global performance in the Weschler scale was slightly lower during pubertal suppression compared with baseline, predominantly due to the reduction in operational memory. Either a baseline of a low average cognition or the hormonal status could play a role in cognitive performance during pubertal suppression”. A major limitation is a sample size of one, and comparing white matter in a trans girl to post pubertal cis boys. Also, the adolescent in the case study suffered conversion therapy and associated depression at a young age, and studies show the link between memory and childhood trauma. A 2020 paper (Chen) conducted a brain study on a larger sample of 18 girls with precocious puberty – the study did not provide any clear recommendations, but simple concluded that this is adding to the body of research on the effects of GnRHa on brain function.

A 2018 paper (Wiepjes) summarised overall data on all people treated in Amsterdam up to 2015. Out of those referred to the clinic in before the age of 18 and treated with puberty blockers, they found that 4 out of 207 trans girls (2%) stopped puberty suppression without proceeding to HRT and 2 out of 370 trans boys (less than 1%) stopped puberty suppression without proceeding to HRT. Reasons for discontinuation of GnRHa were not reported. In addition to these youth, a further 112 trans girls and 148 trans boys referred in adolescence went straight to CSH without taking blockers.

A 2019 study (Joseph) of the impact of puberty suppression on bone mass  followed 70 adolescents, referred to the UK GIDS between 2011-2016. The sample included 31 trans girls and 39 trans boys aged 12-14 years, and all but two of the trans boys (95%) were postmenarchal. Two analyses were performed, a complete longitudinal analysis (n = 31) where patients had scans over a 2-year treatment period, and a larger cohort over the first treatment year (n = 70). All youth were required to stay without addition of HRT until age 16. At baseline trans boys had lower bone mineral density (BMD) measures than trans girls. There was no significant change in the absolute values of hip or spine BMD or lumbar spine BMAD after 1 year on GnRHa. BMD-Z scores were low, but the authors highlight the debatable utility of measuring and contrasting Z scores (which compares BMD to same age youth who are not on puberty blockers). Bone mineral density rises due to sex hormones at puberty, so those with delayed puberty will automatically not gain this rise at the same age as un-suppressed cis adolescents of the gender they were assigned at birth, and will automatically score low when compared to such Z scores. The authors highlight that their observations mirror the observations in studies by Klink 2015 and Vlot 2016 which also demonstrate no significant change in absolute BMD under pubertal suppression. They “propose that it may be clinically inappropriate to compare these subjects’ BMD with that of contemporaries who have not had pubertal blockade as the bone development in the GD subjects has been halted in comparison to those of their age group”. They suggest developing expected-BMD charts for pubertally suppressed adolescents, as a more useful way of tracking BMD. The authors note that there are no international guidelines for the surveillance of bone health in young people with gender dysphoria, that reference ranges may need to be redefined for this patient cohort, and that there needs to be clarity on treatment options where an adolescent is found to have low bone mineral density (BMD). More important than tracking bone health whilst on blockers, is understanding the long term impact on BMD once sex hormones are added. They conclude that absolute BMD and BMAD scores do not change substantially over a 3 year period in trans adolescents on GnRHa treatment and recommend that yearly bone scans while on puberty blockers may be unnecessary.

In a 2019 letter to the BMJ (Ferguson) Australian clinicians reviewed existing datasets of impact of puberty suppression on bone health. They outlined heterogeneity in the outcomes, and recommended identifying and tracking individuals who are more significantly affected in terms of bone mineral density, rather than reporting on the average. They note that regardless of the positive impacts of puberty blockers, clinicians have a duty to maximise bone health of trans youth on puberty blockers.

A 2020 study (Achille) tracked 50 youth (mean age 16.2) over one year of endocrine intervention (data captured between 2013 and 2018). 4 trans masculine youth were just on blockers, 8 trans feminine youth were just on blockers, 24 trans masculine youth were just on testosterone, 7 trans feminine youth were on oestrogen and blockers, and 4 trans masculine youth were on testosterone and blockers. Four different measures of wellbeing (depression, quality of life, suicidal ideation) were tracked, controlling for engagement in counselling, and all measures of wellbeing showed improvements with treatment. A key measure of depression showed a reduction from levels indicating clinical depression to below the threshold for clinical depression. (Mean baseline CESD-R score was 21.4 and decreased to 13.9 – A score less than 16 implies no clinical depression)”. The study concludes that endocrine intervention may improve mental health in transgender youth.

A 2020 cross-sectional survey (Turban) of 20,619 trans adults (aged 18-36) used multivariable logistic regression to examine associations between access to pubertal suppression and adult mental health outcomes, including multiple measures of suicidality. 3,494 adults (16.9%) reported that they had wanted pubertal suppression, but only 89 (2.5%) had received it. After controlling for other variables, pubertal suppression was associated with decreased odds of lifetime suicidal ideation – 90% of those who had not received blockers had experienced suicidal ideation, compared to 75% in those who had had blockers at an average age of 15. The study adds to evidence on the relationship between pubertal suppression and positive mental health outcomes. It avoids the physical changes known to cause significant distress, and when provided in affirmative care may also protect against minority stress.

A 2020 study (Miesen) compared three groups for emotional and behavioural problems (internalizing, externalizing, peer relations, and suicidality), assessed by youth self-report. They compared 272 adolescents (mean age 14.5 years) who had been referred to a specialised gender identity clinic and were undergoing assessment but had not yet received puberty blockers, with 178 transgender adolescents (mean age 16.8 years) who were on puberty blockers and about to receive HRT – the two trans groups did not differ in scores at baseline (when first assessed in the gender clinic). These two groups were compared with a comparison sample of 651 Dutch high school cisgender adolescents from the general population (mean age 15.4 years). Results: Before medical treatment, clinic-referred adolescents showed more internalising problems and reported increased self-harm/suicidality and poorer peer relations compared with their age-equivalent peers. Transgender adolescents receiving puberty suppression had fewer emotional and behavioural problems than the group that had just been referred to transgender care and had similar or fewer problems than their same-age cisgender peers. Before treatment 31.3% of trans youth had clinical levels of internalising problems, whereas amongst trans youth receiving puberty blocker treatment and about to start HRT only 16.3 % had clinical levels of internalising problems, lower than in the cisgender sample (22.9%). Before treatment 17.3% of trans youth had clinical levels of externalising problems, whereas amongst trans youth receiving puberty blockers and about to start HRT 14% had clinical levels of externalising problems, similar to the cisgender sample (13.8%). In suicidality, this was reported by 27.2% of trans youth before treatment, whereas in the sample of trans youth receiving puberty blockers and about to start HRT it was 12.4% – similar to the cisgender sample (11.9%). Conclusions: Transgender adolescents show poorer psychological well-being before treatment but show similar or better psychological functioning compared with cisgender peers from the general population after the start of specialized transgender care involving puberty suppression. The study provides further evidence that trans youth could benefit from gender affirmative care. “A clinical implication of these findings is the need for worldwide availability of gender-affirmative care, including puberty suppression for transgender adolescents to alleviate mental health problems of transgender adolescents”. “This first study comparing a group of transgender adolescents just referred for gender-affirmative care, a group of transgender adolescents receiving treatment with puberty suppression, and a group of cisgender adolescents, from the general population showed that when affirmative care involving puberty suppression is provided, transgender adolescents may have comparable mental health levels to their cisgender peers. This type of gender-affirmative care seems thus extremely important for this group”.

A 2020 study from the Netherland (Brik) examined the trajectories of trans and gender questioning adolescents after initiation of blockers. Prior to 2016 the clinic protocol required adolescents to be 16, and on blockers for at least 6 months, before they could start HRT. From 2016 youth could progress to HRT at age 15 if they had been on blockers for 3 years, and from 2017 the protocol shifted again to allow progression to HRT at age 15 if they had been on blockers for 2 years. The study looked at 143 adolescents who were deemed eligible for puberty blockers, all of whom started blocker treatment between November 2010 and January 2018. This included 38 trans girls, median age for starting blockers was age 15 (range 11.1-18.6) and 105 trans boys, median age for starting blockers 16.1 years (range, 10.1–17.9). Treatment status as of July 2019 was reviewed.

From the sample of 143 adolescents, 11 were too young to be eligible for HRT at the point of the study (having been on blockers for a maximum of 2.8 years). One of these 11 had stopped blockers as his parents were unable to regularly take him to collect medication and get it injected and had instead switched to other medication to stop periods, being too young to be eligible for HRT).

132 adolescents were old enough to be eligible for HRT. 123/132 (93%) had gone from just blockers onto HRT. Median age at the start of gender-affirming hormones was 16.2 years (range, 14.5–18.6 years) in trans girls and 17.1 years (range, 14.9–18.8 years) in trans boys. The majority of these (103/132) had proceeded to HRT as soon as they were eligible. 19/132 had what the clinic called an extended amount of time on just blockers before going on to HRT. This extended time on blockers ranged from 0.8 years to a maximum of 2.4 years, with a median duration of 1 year. Reasons for spending an extended time on just blockers included i) lack of family support (n=6) ii) lack of safe home/school absenteeism n=5) iii) what the authors call a ‘comorbidity’ like autism or depression (n = 8) or iv) logistical issues (n=8). One adolescent was kept on blockers for an extended period for additional assessment due to being non-binary. Only one adolescent had additional time on blockers to allow the adolescent more time for decision-making about gender-affirming hormone treatment. Those delayed because of mental health or psycho-social issues had monthly mental health appointments during the extended period on just blockers. 1 youth had moved clinic and at age 17 had decided to stay on just blockers for a while longer, delaying initiation of testosterone until after exams, having been on blockers for 2.5 years.

From the 132 adolescents old enough to be eligible for HRT, 3 (2%) stopped taking blockers but later went on to HRT. 1 of these, a trans boy, experienced hot flushes, an increase in migraine and fear of injections in addition to problems and school and unrelated medical issues and wished to temporarily discontinue blockers. He restarted blockers after 5 months and later proceeded on to HRT.  One of these, a trans boy, interviewed at age 19, reported an increase in mood problems and suicidal thoughts and confusion attributed to GnRHa treatment and stated: “I was already fully matured when I started GnRHa, menstruations were already suppressed by contraceptives. For me, it had no added value”. The third case, a transboy, experienced mood swings starting 4 months after he had begun GnRHa treatment. A year later, he started to frequently feel unwell and miss school. After 2.2 years, he developed severe nausea and rapid weight loss for which no cause was identified. Because of this deterioration of his general condition, he wished to discontinue GnRHa treatment after 2.4 years. He gradually recovered over the next 2 years and subsequently started HRT.

From the 132 adolescents old enough to be eligible for HRT, 5 (4%) stopped blockers and reported no wish for gender affirming treatment at this time. Their identities and stories were individual. Two described non-binary identities. One had psycho-social problems. One found the period on blockers helpful in understanding a cisgender identity. One described falling in love and questioning his gender identity before identifying with his assigned gender.

In conclusion: Out of the 132 adolescents old enough for HRT, 126 (95%) were on HRT at the time of the study, 1 had chosen to extend their time on blockers before HRT, and 5 (4%) had decided not to have gender affirming treatment. The adolescents and parents were asked their views on GnRHa. All felt free to stop GnRHa.  Some stated it gave them time to think and feel who they were and what they wanted in the future and felt that without GnRHa treatment they would not have been able to make these decisions. Others stated that GnRHa should not be routinely offered before the start of gender-affirming hormones when adolescents are already fully matured, because of the lack of physical benefits. Instead, a consideration time of 6 months with psychological follow-up was suggested.

Continued questions

Despite the decades of studies, critics of blockers continue to claim they are new and experimental, a claim refuted by  Giordano and Holm in a 2020 paper. Critics also point to low quality evidence, especially lack of randomised control trials. However, a wide number of studies comment on the impossibility of conducting randomised control trials on this cohort. A 2011 paper (De Vries) by the leading practitioners at the time from the Netherlands states “Finally, this study was a longitudinal observational descriptive cohort study. Ideally, a blinded randomized controlled trial design should have been performed. However, it is highly unlikely that adolescents would be motivated to participate. Also, disallowing puberty suppression, resulting in irreversible development of secondary sex characteristics, may be considered unethical.” Giordano and Holm (2020) are stronger, being clear this “particular use cannot be investigated by a RCT ”. Rosenthal (2014) agrees “Furthermore, randomized controlled trials for hormonal interventions in gender-dysphoric youth have not been considered feasible or ethical ”.

The latest 2020 paper (Brik) similarly states: “A randomized controlled trial in adolescents presenting with gender dysphoria, comparing groups with and without GnRHa treatment, could theoretically shed light on the effect of GnRHa treatment on gender identity development. However, many would consider a trial where the control group is withheld treatment unethical, as the treatment has been used since the nineties and outcome studies although limited have been positive. In addition, it is likely that adolescents will not want to participate in such a trial if this means they will not receive treatment that is available at other centers. Mul et al. (2001) experienced this problem and were unable to include a control group in their study on GnRHa treatment in adopted girls with early puberty because all that were randomized to the control group refused further participation“.

Although global consensus for puberty blockers is strong, a variety of different views remain. A 2015 study (Vrouenraets) interviewed psychiatrists, psychologists and endocrinologists from 17 treatment teams worldwide, gaining insights into the views underpinning different attitudes towards treatment. Those opposed to treatment diverged from those who supported treatment in their view on whether gender dysphoria is natural variation or mental illness; the potential role of puberty in developing identity; the role of comorbidity; and the physical or psychological effects of enabling or denying intervention.

Ethics are discussed in a number of articles. Giordano reviewed the ethics for and against puberty blockers over a decade ago, in 2007 and 2008, noting the high risk outcomes in trans children who could not access medical intervention. They concluded that “suspension of puberty is not only not unethical: if it is likely to improve the child’s quality of life and even save his or her life, then it is indeed unethical to defer treatment”. Giordano and Holm followed up in 2020 with a review of the latest studies, highlighting the evidence of benefits and reinforcing the earlier conclusion on the ethical prerogative to provide treatment.

A 2017 article (Giovanardi) on ethics from a fly-by-night unrated journal is discredited for misrepresenting key literature (as discussed here, the researcher whose research is misrepresented made a complaint but the journal had folded before the paper could be retracted or corrected).

Lopez (2018) examines data on puberty blocker implants for precocious puberty as compared to trans adolescents. In a 2016 dataset blockers were used in 512 cases for precocious puberty at average age 8.9 years olds, whereas they were only used in 62 cases for trans adolescents at an average age of 14 years old. The age-based arguments against trans adolescents accessing blockers do not seem to apply for the much younger cohort in precocious puberty, suggesting it is not the medication or the age of use that people have a problem with, but rather its use for gender dysphoric adolescents.

A 2020 article (Pang) examines the ethics of extended puberty blocker treatment for an agender teen – a teen who started blockers at 12, is now 15 and wants to continue on just blockers till 18. One commentator contrasts the two main risks; impaired fertility in the future and low bone density, with the one key benefit: continued alleviation of gender dysphoria and anxiety. They quantify the bone density related risks: with a bone density in the lowest 2.5 percentile a person “has a 0.2% to 0.3% risk of sustaining a hip fracture and a 1% to 2% risk of other fractures in the next 5 to 10 years compared with a control with normal bone density (0% risk of hip fracture and 0.7%–1% risk of other fractures in the next 5–10 years).” They highlight that the adolescent and/or their parents may still decide that these risks are outweighed by the potential psychosocial benefits from relieved gender dysphoria. Another commentator, whilst recognising the clear benefits of puberty blocker usage, highlights that with shorter term use (2 years), bone density increases significantly once sex hormones are introduced, and recommends a shorter time on blockers to promote optimal bone density.

References

Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., et al. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. Int J Pediatr Endocrinol 2020, 8. doi:10.1186/s13633-020-00078-2.

Brik, T., Vrouenraets, L. J. J. J., de Vries, M. C., and Hannema, S. E. (2020). Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dysphoria. Arch Sex Behav. doi:10.1007/s10508-020-01660-8.

Chen, T., Yu, W., Xie, X., Ge, H., Fu, Y., Yang, D., et al. (2020). Influence of Gonadotropin Hormone Releasing Hormone Agonists on Interhemispheric Functional Connectivity in Girls With Idiopathic Central Precocious Puberty. Front Neurol 11, 17. doi:10.3389/fneur.2020.00017.

Cohen-Kettenis, P. T., Schagen, S. E. E., Steensma, T. D., de Vries, A. L. C., and Delemarre-van de Waal, H. A. (2011). Puberty Suppression in a Gender-Dysphoric Adolescent: A 22-Year Follow-Up. Arch Sex Behav 40, 843–847. doi:10.1007/s10508-011-9758-9.

Cohen-Kettenis, P. T., and van Goozen, S. H. M. (1998). Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent. European Child & Adolescent Psychiatry 7, 246–248. doi:10.1007/s007870050073.

Costa, R., Carmichael, P., and Colizzi, M. (2016). To treat or not to treat: puberty suppression in childhood-onset gender dysphoria. Nat Rev Urol 13, 456–462. doi:10.1038/nrurol.2016.128.

Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., and Colizzi, M. (2015). Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria. The Journal of Sexual Medicine 12, 2206–2214. doi:10.1111/jsm.13034.

de Vries, A. L. C., Steensma, T. D., Doreleijers, T. A. H., and Cohen-Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med 8, 2276–2283. doi:10.1111/j.1743-6109.2010.01943.x.

Delemarre-van de Waal, H. A., and Cohen-Kettenis, P. T. (2006). Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. European Journal of Endocrinology 155, S131–S137. doi:10.1530/eje.1.02231.

Edwards-Leeper, L., and Spack, N. P. (2012). Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “Gender Management Service” (GeMS) in a major pediatric center. J Homosex 59, 321–336. doi:10.1080/00918369.2012.653302.

Ferguson, G., Simm, P., O’Connell, M., and Pang, K. C. (2019). Gender dysphoria: puberty blockers and loss of bone mineral density. BMJ 367. doi:10.1136/bmj.l6471.

Fisher, A. D., Ristori, J., Bandini, E., Giordano, S., Mosconi, M., Jannini, E. A., et al. (2014). Medical treatment in gender dysphoric adolescents endorsed by SIAMS-SIE-SIEDP-ONIG. J. Endocrinol. Invest. 37, 675–687. doi:10.1007/s40618-014-0077-6.

Giordano, S. (2007). Gender Atypical Organisation in Children and Adolescents: Ethico-legal Issues and a Proposal for New Guidelines. Int J Child Rights 15, 365–390. doi:10.1163/092755607X262793.

Giordano, S. (2008). Lives in a chiaroscuro. Should we suspend the puberty of children with gender identity disorder? Journal of Medical Ethics 34, 580–584. doi:10.1136/jme.2007.021097.

Giordano, S., and Holm, S. (2020). Is puberty delaying treatment ‘experimental treatment’? International Journal of Transgender Health 21, 113–121. doi:10.1080/26895269.2020.1747768.

Hembree, W. C. (2011). Guidelines for pubertal suspension and gender reassignment for transgender adolescents. Child and Adolescent Psychiatric Clinics of North America 20, 725–732. doi:10.1016/j.chc.2011.08.004.

Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., et al. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J. Clin. Endocrinol. Metab. 102, 3869–3903. doi:10.1210/jc.2017-01658.

Joseph, T., Ting, J., and Butler, G. (2019). The effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria: findings from a large national cohort. J. Pediatr. Endocrinol. Metab. 32, 1077–1081. doi:10.1515/jpem-2019-0046.

Khatchadourian, K., Amed, S., and Metzger, D. L. (2014). Clinical management of youth with gender dysphoria in Vancouver. J. Pediatr. 164, 906–911. doi:10.1016/j.jpeds.2013.10.068.

Kim, E. Y. (2015). Long-term effects of gonadotropin-releasing hormone analogs in girls with central precocious puberty. Korean J Pediatr 58, 1–7. doi:10.3345/kjp.2015.58.1.1.

Klink, D., Caris, M., Heijboer, A., van Trotsenburg, M., and Rotteveel, J. (2015). Bone mass in young adulthood following gonadotropin-releasing hormone analog treatment and cross-sex hormone treatment in adolescents with gender dysphoria. J. Clin. Endocrinol. Metab. 100, E270-275. doi:10.1210/jc.2014-2439.

Kreukels, B. P. C., and Cohen-Kettenis, P. T. (2011). Puberty suppression in gender identity disorder: the Amsterdam experience. Nat Rev Endocrinol 7, 466–472. doi:10.1038/nrendo.2011.78.

Lopez, C. M., Solomon, D., Boulware, S. D., and Christison-Lagay, E. R. (2018). Trends in the use of puberty blockers among transgender children in the United States. J. Pediatr. Endocrinol. Metab. 31, 665–670. doi:10.1515/jpem-2018-0048.

Miesen, A. I. R. van der, Steensma, T. D., Vries, A. L. C. de, Bos, H., and Popma, A. (2020). Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared With Cisgender General Population Peers. Journal of Adolescent Health 66, 699–704. doi:10.1016/j.jadohealth.2019.12.018.

Murchison, G., Adkins, D., Conard, L. A., Ph, R., Ehrensaft, D., Elliott, T., et al. (2016). Supporting & Caring for Transgender Children’. Human Rights Campaign Available at: https://www.hrc.org/resources/supporting-caring-for-transgender-children/. [Accessed October 3, 2019].

Oliphant, J., Veale, J., Macdonald, J., Carroll, R., Johnson, R., Harte, M., et al. (2018). Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa New Zealand. Available at: https://researchcommons.waikato.ac.nz/handle/10289/12160 [Accessed October 3, 2019].

Pang, K. C., Notini, L., McDougall, R., Gillam, L., Savulescu, J., Wilkinson, D., et al. (2020). Long-term Puberty Suppression for a Nonbinary Teenager. Pediatrics 145. doi:10.1542/peds.2019-1606.

Rosenthal, S. M. (2014). Approach to the patient: transgender youth: endocrine considerations. J. Clin. Endocrinol. Metab. 99, 4379–4389. doi:10.1210/jc.2014-1919.

Schagen, S. E. E., Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., and Hannema, S. E. (2016). Efficacy and Safety of Gonadotropin-Releasing Hormone Agonist Treatment to Suppress Puberty in Gender Dysphoric Adolescents. J Sex Med 13, 1125–1132. doi:10.1016/j.jsxm.2016.05.004.

Schneider, M. A., Spritzer, P. M., Soll, B. M. B., Fontanari, A. M. V., Carneiro, M., Tovar-Moll, F., et al. (2017). Brain Maturation, Cognition and Voice Pattern in a Gender Dysphoria Case under Pubertal Suppression. Front Hum Neurosci 11, 528. doi:10.3389/fnhum.2017.00528.

Staphorsius, A. S., Kreukels, B. P. C., Cohen-Kettenis, P. T., Veltman, D. J., Burke, S. M., Schagen, S. E. E., et al. (2015). Puberty suppression and executive functioning: An fMRI-study in adolescents with gender dysphoria. Psychoneuroendocrinology 56, 190–199. doi:10.1016/j.psyneuen.2015.03.007.

Telfer, M.M., Tollit, M.A., Pace, C.C., & Pang, K.C. (2018). Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Chil-dren and Adolescents. Melbourne: The Royal Children’s Hospital Available at: https://www.rch.org.au/uploadedFiles/Main/Content/adolescent-medicine/australian-standards-of-care-and-treatment-guidelines-for-trans-and-gender-diverse-children-and-adolescents.pdf [Accessed October 4, 2019].

Turban, J. L., King, D., Carswell, J. M., and Keuroghlian, A. S. (2020). Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics 145. doi:10.1542/peds.2019-1725.

Vlot, M. C., Klink, D. T., den Heijer, M., Blankenstein, M. A., Rotteveel, J., and Heijboer, A. C. (2017). Effect of pubertal suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density (BMAD) in transgender adolescents. Bone 95, 11–19. doi:10.1016/j.bone.2016.11.008.

Vries, A. L. C. de, McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., and Cohen-Kettenis, P. T. (2014). Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment. Pediatrics 134, 696–704. doi:10.1542/peds.2013-2958.

Vrouenraets, L. J. J. J., Fredriks, A. M., Hannema, S. E., Cohen-Kettenis, P. T., and de Vries, M. C. (2015). Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study. J Adolesc Health 57, 367–373. doi:10.1016/j.jadohealth.2015.04.004.

Vrouenraets, L. J. J. J., Fredriks, A. M., Hannema, S. E., Cohen-Kettenis, P. T., and de Vries, M. C. (2016). Perceptions of Sex, Gender, and Puberty Suppression: A Qualitative Analysis of Transgender Youth. Arch Sex Behav 45, 1697–1703. doi:10.1007/s10508-016-0764-9.

Wiepjes, C. M., Nota, N. M., de Blok, C. J. M., Klaver, M., de Vries, A. L. C., Wensing-Kruger, S. A., et al. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med 15, 582–590. doi:10.1016/j.jsxm.2018.01.016.

World Professional Association for Transgender Health (WPATH). (2011). Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version.