England Removes Access to Puberty Blockers for Trans Youth
Cisgender children will still be able to receive the drugs, which have been portrayed as too risky for trans youth.
by Mira Lazine
Last week, England’s NHS - the country’s public healthcare system - announced it will no longer be prescribing puberty blockers for children with gender dysphoria. Puberty blockers will, however, still be prescribed to cisgender children with early puberty. This decision also does not affect Scotland, Wales, or Northern Ireland.
However, contrary to some reports, this is not a total ban on puberty blockers in the country. As a spokesperson for the transgender charity Mermaids said to Sky News, the children currently on puberty blockers are allowed to continue their care. This is only a restriction on additional prescriptions. It also should be noted that any changes to this prohibition are pending a study by the NHS that’ll start sometime in December of 2024. Any characteristics of this study, such as who will be conducting it or its proposed methods, is currently unknown, but young people enrolled will presumably still receive puberty blocking drugs.
Fewer than 100 children are currently on puberty blockers for gender dysphoria across all of England. While this may be partly due to the notoriously long wait times for accessing care, it’s also reflective of a reality critics of transgender care often overlook – there is no crisis in youth being overprescribed puberty blockers.
This restriction was reported on by many mainstream news outlets - The Guardian, Time, and Huffington Post among many others. Particularly noteworthy is the coverage seen from right-wing media - outlets like the Daily Mail, Focus on the Family, National Review and Daily Wire all try to paint a picture that puberty blockers are unsafe and experimental. The left-leaning New Statesman, which has a lengthy history of endorsing anti-trans bias, paints a similar picture. These outlets all justify the decision by the NHS as a net good, citing many anti-trans talking points seen throughout the past few years on UK trans politics.
screenshot from Fox News
These articles cite the infamous 2022 interim report by Dr. Hilary Cass, which recommended closing of the Tavistock clinic in favor of regional facilities. This is cited in spite of a detailed critique of it published by World Professional Association for Transgender Health (WPATH). Instead of recognizing WPATH’s authority in the world of transgender medicine, some of these outlets reference the non-story of the WPATH Files to try and discredit the medical organization
This approach to the reporting ties into what motivates the end to prescriptions in the first place - the politicization of transgender medicine, especially that for children. NHS England states explicitly references a 2020 review of puberty blockers, spearheaded by Cass and the National Institute for Health and Care Excellence, as a motivator for the prohibition on puberty blockers. This review, however, has been criticized in detail by Dr. AJ Eckert for leaving out many studies on the topic, as well as misunderstanding the role that puberty blockers are supposed to play in preventing further gender dysphoria as opposed to alleviating what is there. It has additionally been criticized by WPATH.
Cass had no prior experience in the field of transgender medicine.
Nevertheless, this review, among others, is used to reference the alleged danger puberty blockers pose to youth. This is aligned with how right wing media aims to paint a picture about the alleged dangers that puberty blockers pose to youth.
Puberty blocking works through medications known as gonadotropin-releasing hormone agonists (GnRHas). These severely limit the production of sex hormones - estrogen, testosterone, and progesterone - thus preventing any pubertal changes. It was initially developed for use in children who experience early puberty, also known as precocious puberty.
Typically administered through semiregular shots, puberty blockers are almost always taken after puberty has already started. According to Vin Tangpricha, an endocrinologist who spoke to Scientific American, youth are typically only on GNRHas for a short period of time, often about a year. This is because the goal of puberty blockers is not to keep youth on them for lengthy periods, but rather to give them more time to figure out what direction they want to go.
If a young person decides to go through with their initial puberty, they easily can by just stopping GnRHas. Far from experimental,the effects of these medications are well regarded as reversible. If a patient decides to continue to transition, which happens in a large majority of cases due to the stringent requirements for starting blockers, then hormone replacement therapy begins.
screenshot from HRC & AAP collaboration doc
Concern over puberty blockers comes from the claim that this medicine is under-researched in transgender youth. This isn’t completely true, however - as while more research is definitely needed, we nonetheless have decades of research in those with precocious puberty to support that it is safe in both the short term and the long term.
The main concerns cited are whether people are still able to reproduce after puberty is resumed, whether bone density is preserved, and the cognitive effects of it. For the first point, it’s established that puberty blockers are entirely reversible and so this extends to any reproductive or sexual functions. However, for transgender girls who start blockers in the earliest stages of puberty and go directly to estrogen therapy, the absence of any testosterone-fueled puberty may permanently impact fertility. The extent of that risk is currently unknown. The same risk does not seem to pertain to transgender boys. WPATH guidelines recommend all youth and their families be counseled about risks to fertility before beginning treatment.
As for bone density, the main concern associated with it is whether bone fractures are going to increase as a result. While there is some evidence that it is reduced in those on puberty blockers, it typically recovers after people are back on hormones, with medical advice focusing on bone strengthening regimens like raising vitamin D or calcium levels.
It should be noted that transgender women often have a lower bone density than cisgender people as a baseline, and that this typically improves after starting hormone replacement therapy. It is currently unknown why this is the case.
As for the cognitive effects, there is no evidence that puberty blockers negatively affect the brain. The only claim to evidence comes from a literature review, published by someone who has been a speaker for the anti-trans pressure group the Society for Evidence-Based Gender Medicine, that was published earlier this year. I and others have criticized this review and the interpretation of the cited studies in detail. The primary claim of this review was based on a tiny study of less than 30 kids which suggested a 7-point, “not clinically relevant” drop in IQ. This drop, due to being in such a small sample, was likely due to a single outlier restricting the range. This is evidenced by the standard deviation decreasing in addition to the overall lowest score actually increasing after puberty blockers.
screenshot from Mul et al, 2001
Puberty blockers are supported by leading medical organizations, including the American Medical Association, the Endocrine Society, WPATH, and the American Psychological Association.
In short, there is a wide array of evidence to support that puberty blockers are safe for youth both in the short and long term. There is little evidence of harm from them, with the primary ones cited being easily solved.
Thus, the discourse around puberty blockers, and the NHS’s decision, is tied less into the evidence of how puberty blockers work and instead is based on fear as a result of the politicization of transgender medicine. The solution to any gaps in the research is not to take away medically necessary care from transgender youth, but rather to expand it to all the kids that need it. Academics and doctors recognize this, it’s time that the rest of us do too.
Mira Lazine is a freelance journalist covering transgender issues, politics, and science. She can be found on Twitter, Mastodon, and BlueSky, @MiraLazine