I was an academic expert invited to submit expert opinion & evidence to the Autumn 2024 closed consultation on the legal and criminal ban on puberty blockers. I’m one of the experts that Wes has claimed to have listened to in agreeing to make this ban permanent.

Here is my submission:

Proposed changes to the availability of puberty blockers

Question 1: Do you agree with making it permanent?

Strongly disagree.

The current policy has had very significant negative impacts and consequences for trans children, adolescents and their families. It is not evidence based and does not centre the rights, health or well-being of the children and adolescents who are directly impacted.

Question 2: Positive impacts

Absolutely zero. It has had devastating consequences for many trans children, adolescents and families.

Question 3: Negative impacts

As an academic and researcher specialising in transgender children’s health and well-being, I need to highlight my grave concerns with the unevidenced and risky decision to criminalise access to puberty blockers. The law has already led to significant severe harms/negative consequences, with significant risks to the young people directly impacted. Three items are important to note 1) Consequences of denial of blockers 2) Higher risk of alternative medical pathways 3) Wider healthcare differentials.

1. Consequences of denial of blockers

The current criminalisation of puberty blockers has not considered the serious consequences of denial of blockers to trans adolescents who feel endogenous puberty would be intolerable. Recent research has been conducted with UK trans adolescents using and seeking access to puberty blockers, and their families. These articles were not considered by the Cass Review as they were published in 2022 (the Cass Review only looked at literature published pre-2021). At this point the government needs to take stock of all modern evidence, including that published post 2021. This more recent research highlights the reasons for trans adolescents and supportive families seeking access to puberty blockers. This research substantiates the importance of puberty blockers in safeguarding and protecting trans youth happiness, self-esteem, mental health, and in enabling trans youth to stay in school, socialise with their friends, enjoy their adolescence. It also touches on the known harms where trans youth are forced through a puberty they find intolerable, including drop out from school, not wanting to leave their room, disconnecting from friends, not wanting to leave the house, stopping wanting to speak in public, anxiety, depression, self-harm, losing hope, suppressing food intake to prevent pubertal development, no longer wanting to be alive.

There are highly significant risks to the well-being and happiness of trans youth denied access to healthcare interventions such as puberty blockers. Being forced through a puberty that is deeply traumatic, when there is an effective and safe medication to prevent that, is a deeply significant interventions in a young person’s bodily autonomy, necessitating a very high barrier of justification, a justification that is simply not present in the case of puberty blockers. The known harms of forcing trans adolescents through endogenous puberty against their will have not been considered in making the decision to criminalise puberty blockers. Any policy in this area needs to draw upon effective risk assessments of the known dangers of not having access to puberty blockers.

• Higher risk of alternative medical pathways

When it comes to abortion, it is recognised that criminalisation does not prevent abortion, it merely prevents safe abortion, pushing individuals towards less safe routes to healthcare. There are clear parallels with criminalisation of puberty blockers, with clear evidence already apparent of adolescents and supportive families being pushed to less safe routes to healthcare. The risks of forcing individuals into less safe options have not been considered in making this law.

Many adolescents and families impacted by the current ban feel that being forced through unwanted endogenous puberty is entirely intolerable and inconceivable, and will navigate any other option to ensure that does not happen. Some are looking to flee the country, literally being driven out of their home by a criminal ban on essential healthcare that is more draconian than anywhere else in the democratic world. Some are applying for asylum, due to being persecuted by their government just for being trans. Some are needing to travel abroad every three months in order to access healthcare outside of the UK. This is a significant financial burned on supportive families, and a significant burden and stress on those adolescents who should be able to access healthcare locally, who should be able to spend their weekends having fun with their friends rather than travelling outside of the UK to maintain their right to bodily autonomy and a happy adolescence. Others are likely accessing the Black market, with risks especially related to a lack of blood hormone monitoring and medical oversight. Many are switching from puberty blockers to non-criminalised alternative medication that has a similar impact on preventing puberty, medication that is known to have greater side effects than puberty blockers. In the decision to criminalise puberty blockers, a medication known to be safe, there has been zero consideration of the risks of the alternative medication that youth are now switching to. Other adolescents are going directly to oestrogen or testosterone, at an earlier age than they would have chosen to do if puberty blockers were available. The current criminalisation is having very significant impacts on the healthcare options and pathways that trans youth are accessing. It is not stopping trans youth from accessing affirmative healthcare, merely pushing youth towards options that are less safe.

• Wider healthcare differentials

A significant impact of criminalisation is a very significant rise in trans children, trans adolescent and supportive family distrust of healthcare providers including GPs. Adolescents and supportive families forced into less ideal paths to healthcare to avoid criminalisation also now have significant reasons to avoid engagement with their local GP. I am deeply concerned about the wider health impacts, both short and long-term, of having a population who are avoiding routine healthcare interactions with their GP and other healthcare providers, related to current criminalisation. This is and will continue to feed into wider healthcare differentials and poorer healthcare outcomes far beyond trans health.

References on puberty blockers (peer reviewed journal articles)

Horton, C. (2022). Experiences of puberty and ‘puberty blockers’ – Insights from trans children, trans adolescents and their parents. Journal of Adolescent Research.

Horton, C. (2022). “I didn’t want him to disappear” Parental decision-making on access to puberty blockers for trans early adolescents. Journal of Early Adolescence.

Question 4: Benefits

It is extremely dangerous and damaging – making it permanent would magnify and entrench the current harms.

Question 5: Risks and risk mitigation

There is no way of mitigating the current risks. It is deeply dangerous and damaging.

Question 6: Impact on protected groups

It is evidently directly discriminatory against those with the protected characteristics of gender reassignment. The same medication, with the exact same purpose (preventing puberty), is considered safe and not criminalised when used by other groups. The argument that it is not discrimination because use for preventing puberty in trans youth has a separate (outdated) psychiatric diagnosis label is not a credible argument. The same medication, the same purpose (preventing puberty), fine for an individual who is not trans, a criminal offense if they are trans. Absolutely direct discrimination.

Looked after children/children in care are being disproportionately negatively impacted by the current criminalisation. The impact of the current criminalisation is being unevenly carried. There are systemic inequalities in which adolescents are being forced to medically de-transition and forced through a endogenous puberty they find intolerable. I am particularly worried about those least able to circumnavigate current criminalisation, especially looked after children. Whilst many other youth with supportive families find some alternative route to avoid being forced through an intolerable puberty, looked after children, even those with supportive carers, are least able to find a route through. The burden of this criminalisation, and its heavy expected negative impacts on trans youth, is falling most heavily on those who are already disadvantaged through being in the care system. Criminalisation is a very blunt instrument for healthcare, and it is particularly blunt in its impact on trans youth in care who desperately need to avoid being forced through an endogenous puberty. There need to be pathways for individualised healthcare, without the law providing a blanket barrier to providing individualised healthcare to each child and adolescent.

Question 7: Additional evidence

As an academic and researcher specialising in transgender children’s health and well-being, I need to highlight my grave concerns with the unevidenced and risky decision to criminalise access to puberty blockers. In addition to the severe harms/negative consequences, and significant risks of criminalising access to puberty blockers outlined above, I will here highlight five serious flaws and miscalculations that have influenced this poor policy, relating to 1) puberty blocker effectiveness 2) safety 3) erosion of child rights and healthcare ethics 4) Pathologisation & mental health led approaches to trans healthcare 5) Government interference in healthcare.

1. Puberty Blocker Effectiveness.

Puberty blockers are extremely effective at their primary purpose – stopping puberty. Their effectiveness is well studied and not in doubt. Supposed concerns about a lack of evidence of the ‘benefit’ of puberty blockers fail to engage with a critical question. Are they effective at stopping puberty (answer – yes – this is beyond doubt). Trans healthcare scholars and gender service users are very clear that the key purpose of puberty blockers is to prevent endogenous puberty, preventing the progression of unwanted secondary sexual characteristics. Puberty blockers are not expected to resolve ‘gender dysphoria’, where gender dysphoria is a psychiatric diagnosis under the DSM-V that proxies being trans. Puberty blockers are not expected to lead to an improvement in mental health and well-being, they are intended to prevent the catastrophic decline in mental health and well-being that is known to occur when trans youth are forced through a puberty they find intolerable. Discussions on a lack of evidence of puberty blockers resolving gender dysphoria or improving mental health are, at best, a severe misunderstanding of trans youth healthcare. Their purpose is to prevent puberty, and at this they are undoubtably highly effective.

• Safety

Puberty blockers have been used and studied in different populations for many decades, including use in trans adolescents since 1988. There is no evidence of significant safety concerns when used in trans or non-trans patients. The medication does not work any differently in trans compared to non-trans patients, having the exact same purpose in preventing puberty. There can be different reasons for wanting to prevent puberty (for precocious puberty it is to delay puberty to align with ones peers, for trans adolescents it is for bodily autonomy and preventing progression of a puberty they find intolerable and incompatible with their bodily aspirations, for some cancer treatment it is to remove sex hormones that impact on their cancer). The reasons for stopping puberty are different, but the medication is equally safe. Here the medication is permitted for all uses to prevent puberty in cis (non-trans) people, and is only deemed unsafe for trans people. There is zero evidence that puberty blockers work in a different manner in trans versus cis bodies. There is zero evidence that the same medication, for the same purpose (preventing release of endogenous sex hormones), is somehow safe in cis people an unsafe in trans people. There has been no documented evidence of serious risk in use of this medication, certainly nothing to justify criminalisation.

The known risks of puberty blockers can be monitored and minimised as part of standard endocrine care. Bone health can be monitored, with exogenous sex hormones provided before bone health is compromised, alongside recommendations for exercise and vitamin supplements. There is simply no evidence of any serious safety concern.

The only current suggested harms of puberty blockers for trans youth fall into a category of ‘speculation and pseudoscience’. The Cass Review includes an unevidenced statement speculating that puberty blockers may change the outcome, preventing trans children from shifting into cis identities in adolescence. Trans scholars and healthcare professionals have raised very significant concerns about the Cass, as written in peer reviewed academic publications and scientific commentaries. The Cass Review’s unevidenced speculation on blockers potentially keeping trans children as trans is a gross misunderstanding of existing scholarship on this topic. There is no such evidence that trans children denied puberty blockers become cis youth, or that puberty blockers have any impact on identity. This speculation of a psychological impact of puberty blockers on identity is entirely unsubstantiated, and is in fact directly contradicted by modern evidence that shows trans children frequently grow into trans adults, regardless of healthcare provision or denial. There is zero credible evidence that puberty blockers, a medication used on cis children without any anticipated impact on their gender identity, will have any impact on identity in trans people.

The second speculated ‘risk’ of puberty blockers, is the suggestion that there are ‘unknown’ impacts on brain development. Again, this is entirely unevidenced and speculative. Puberty blockers have been used for many decades, including for trans youth since 1988, with no recorded negative impacts on brain development. Speculation should not be substantiating a highly unusual decision to criminalise a medication. Especially when that speculation is only used to criminalise use of a medication in a highly persecuted minority, while leaving the same medication available to all other populations.

• Erosion of child rights and healthcare ethics

The current criminalisation of puberty blockers runs in the face of core concepts of child rights, bodily autonomy and healthcare ethics. Decisions on this topic need to bring ethics and healthcare rights into much greater focus. This also needs to consider the reality that puberty blockers are supposedly criminalised apart from for youth under a proposed NHS trial. This trial is not yet designed nevermind launched, with youth being forced to navigate alternative routes to healthcare while waiting for said trial. There are also very significant ethical concerns about the proposed trial, in a UK gender service that has long been critiqued for severe ethical failings. Many many families will not force their child through a service and trial that has significant ethical failings, and currently criminalisation is one tool being used to coerce children into such an unethical trial.

I am also deeply concerned that the proposed criminalisation on puberty blockers is being pushed through without effective and meaningful listening to the adolescents most directly impacted, and their caregivers and Doctors. I am concerned that the latest policy proposal document dismisses the need for further stakeholder consultation, claiming that the Cass Review itself “include(ed) extensive stakeholder engagement with those with ‘lived experience’”. Any engagement with trans communities in the UK will quickly reveal a very widespread belief that Cass Review stakeholder engagement did not meaningfully inform the final report, with community, academic and professional critiques of the Cass process and outcomes extensive, well-documented and growing. Trans communities and trans adolescents have a right to a seat at the table in influencing trans healthcare policy, and this current criminalisation is yet another in a long series of processes where lived experience voices are not being heard or listened to. If the government has any care for trans children and young people, there needs to be a process of committed rebuilding of faith with trans communities, including a commitment to ensuring lived experience specialists are given a seat at the table in informing trans healthcare policy and legislation. 

Current policy documents fail to even recognise the scale of the impact on trans youth. Several documents convey the impression that youth currently accessing puberty blockers are unlikely to be forced to medically de-transition. In reality, the vast majority (over a thousand) trans adolescents currently in receipt of puberty blockers at the point of the introduction of the ban found themselves immediately without any legal route to continue their prescription, and facing an immediate risk of medical de-transition, a forced medical de-transition known to have significant psychological and well-being risks. There has been no estimation of the scale of impacts on trans children who have entered into puberty in the months since the criminal ban, and no estimation on the psychological toll, fear and distress of trans children approaching puberty. The government has taken no effort to understand the experiences and impacts on trans children and adolescents.  

• Pathologisation & mental health led approaches to trans healthcare

I am also deeply concerned that the proposed policy document references the “importance of ensuring that children and young people impacted by the order can access appropriate support”. Noticeably this does not specify what ‘support’ is effective and appropriate for a child or adolescent who is being forcibly medically detransitioned or who is being coerced through a puberty they find intolerable. This oversight, and the failure to consider what is “appropriate support” in lieu of affirmative healthcare is a fundamental and deep rooted flaw in this whole approach. There is no approach to support for trans adolescents with more evidence of effectiveness than affirmative healthcare, including access to puberty blockers and HRT. The government is criminalising the best currently available healthcare. There is no evidence that alternative medication to treat the symptoms of denial of trans healthcare (including anti anxiety and anti depression medication, or psychotherapy) is effective for trans youth wanting to avoid distressing pubertal changes. I am deeply concerned that the government policy is paying lip service to “support” to those children and adolescents affected by criminalisation, whilst having no evidence-based support to offer.

In managing the ‘risks’ to trans children and adolescents denied affirmative healthcare, the current consultation places significant emphasis on ‘access to mental health services’. There is significant evidence of pathologisation of trans identities in this approach. Trans children and adolescents, when supported and provided access to affirmative healthcare, may not ever need access to mental health services. The assumption that mental health services are needed by trans children and adolescents is worrying, especially when the mental health need to be managed, is the need directly caused by a UK government ban on essential healthcare. The NHS is supposed to have switched from the view of transness as a mental health disorder as categorised in older healthcare standards, through to acknowledgement that trans-ness is not a mental health condition but a natural part of human diversity, as categoried in the World Health Organisation’s ICD-11. The NHS is yet again failing in its supposed commitments to depathologisation of trans identities, proposing mental health led care for trans young people. This is an extremely dangerous and harmful approach.

• Government interference in healthcare

I am very concerned about political interference in healthcare, especially when targeting a persecuted minority. There needs to be an exceptionally high bar of justification for political interference in healthcare, especially for use of a blunt instrument like a criminal ban on a medication only when used by a minority population. Trans scholars and communities have long flagged the serious injustices, misunderstandings, and structural violence in navigating healthcare services that fail to provide equitable healthcare to trans people. Here, the government has taken a step to criminalise an aspect of healthcare that is strongly supported by many healthcare professional bodies worldwide. Doctors are being prevented from making individualised decisions with their patients. The law is a very crude tool and politicians stepping between Dr and patient need to be very confident that the risk clearly merits this intervention, bearing in mind also the expected risks of criminalisation. In this case the risk of puberty blockers is entirely unsubstantiated, indeed they are deemed safe for every other population group, and are deemed safe enough for an NHS trial. The statement in the equality and impact assessment that this criminalisation does not directly discriminate against people with the protected characteristic of gender reassignment is entirely uncredible. The policy very clearly directly discriminates against use of puberty blockers only when used by trans adolescents. Children using them for the exact same purpose (preventing puberty), are not criminalised, if they are not trans. The risks of criminalisation are already very clear and growing by the day, pushing trans adolescents towards routes that are known to be less safe than puberty blockers. The policy does not stand up to scrutiny as necessary or evidence based. It is not driven by any understanding of trans adolescents nor care for their rights and well-being. It is not informed by engagement with trans healthcare experts. It will certainly go down in history as an example of government persecution of trans communities. Healthcare should be individualised and evidence based, with no room for prejudice. Criminalisation of a medication only when used by trans adolescents is a very clear example of prejudice informed healthcare.  

References

On failings in the Cass Review (peer reviewed journal article)

Horton, C. (2024) The Cass Review:  Cis-supremacy in the UK’s approach to healthcare for trans children. International Journal of Transgender Health

On failings in the Cass Review (commentary)

Horton, C. and Pearce, R. (2024) The U.K.’s Cass Review Badly Fails Trans Children, Scientific American

Pearce, Ruth (2024) What’s wrong with the Cass Review: A round up of commentary and evidence. Blog post.

Horton, Cal (2024). “Social transition, puberty blockers and the Cass Review”, What the Trans Podcast: https://whatthetrans.com/social-transition-puberty-blockers-and-the-cass-review-podcast-transcript/

On ethical failings in trans healthcare services in the UK (peer reviewed journal articles)

Horton, C. (2021) “It felt like they were trying to destabilise us”:  Parent assessment in UK Children’s Gender Services, International Journal of Transgender Health

Horton, C. (2022). “Of Course, I’m Intimidated by Them. They Could Take My Human Rights Away”: Trans Children’s Experiences with UK Gender Clinics. Bulletin of Applied Transgender Studies.

Horton, C. (2022). De-pathologising diversity: Trans children and families’ experiences of pathologisation in the UK. Children and Society.

On the need for child voice and child rights in healthcare research and policy (peer reviewed journal articles)

Horton, C. (2024) The importance of child voice in trans health research: a critical review of research on social transition & well-being in trans children. International Journal of Transgender Health

Horton, C., Pearce, R., Veale, J., Oakes-Monger, T. C., Pang, K. C., Pullen Sansfaçon, A., & Quinney, S. (2024). Child rights in trans healthcare – a call to action. International Journal of Transgender Health, 25(3), 313–320.

On the need for depathologisation of healthcare (peer reviewed journal article)

Horton, C. (2022). De-pathologising diversity: Trans children and families’ experiences of pathologisation in the UK. Children and Society.

Question 8: Data gathering

There is no way to gather meaningful data on those trans children, adolescents and supportive families directly harmed by this law without trust. Currently the UK government hold no such trust amongst impacted communities, who view this current criminalisation as a direct attack on trans children’s rights, lives and well-being. Without trust building, people will continue to be afraid to engage with government or NHS related data collection on this topic. Trust needs to be earned through removal of this harmful attach on trans children and adolescents, through ensuring lived experience experts are given an influential and respected seat at the table in government and NHS policy spheres, and through enacting policy that is actually guided by listening to and ensuring the best interests of trans children and young people.

Question 9: Satisfaction with consultation

Very little faith that this consultation will be listened to, or that the harms to trans children will carry weight in the eyes of those making decisions.