Background
Following the closure of the Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust, an independent review of gender identity services for children and young people was undertaken, led by Dr Hilary Cass (2022). Subsequently, NHS England published its Interim Service Specification for the Specialist Service for Children and Young People with Gender Dysphoria (2022; 2023). This proposed various changes to the management of trans adolescents, many of which are very restrictive.
As of June 2023, NHS England has stated that puberty blockers will no longer be available for trans adolescents and will only be prescribed as part of clinical research.
This article examines the rationale underlying NHS England’s decision and explains why it is deeply inadequate. As will become clear, the decision to ban puberty blockers for trans adolescents is both empirically unjustified and ethically unacceptable.
Rationale
NHS England suggests that there is “a lack of evidence to support families in making informed decisions about interventions that may have life-long consequences”. This judgement was partly based on two systematic reviews by the National Institute for Health and Care Excellence (NICE, 2022a; 2022b), which examined the evidence for the benefits of puberty blockers and hormone replacement therapy for trans adolescents. In these reviews, NICE deemed the evidence to be of “low certainty”.
NHS England also claims that “while young people who are gender querying or who express gender incongruence may have started their journey as younger children, in most pre-pubertal children, gender incongruence does not persist into adolescence”. Hence, the decision was also partly based on the assumption that children who exhibit gender incongruence may later revert to their assigned genders at birth without needing gender affirming medical treatment.
Criticism
The Evidence Base
As noted above NHS England’s decision to ban puberty blockers for trans adolescents was partly informed by two systematic reviews by NICE (2022a; 2022b). These systematic reviews have been criticised for failing to properly acknowledge the evidence base for the benefits of puberty blockers for trans adolescents (Ashley, 2022; Ashley et al., 2023; Maung, 2024).
First, the systematic reviews by NICE fail to include several important studies which demonstrate clear benefits of puberty blockers for the psychological health and social wellbeing of trans youth (Chen et al., 2023; Grannis et al., 2021; Green et al., 2022; Tordoff et al., 2022; van der Miesen et al., 2020). These are methodologically robust studies that use large samples sizes (Green et al., 2022), use appropriate comparison groups (Tordoff et al., 2022; van der Miesen et al., 2020), and yield insight into the mechanisms through which gender affirming medical treatment produces benefits (Chen et al., 2023; Grannis et al., 2021). Therefore, the systematic reviews by NICE are seriously incomplete and fail to consider the all the relevant evidence on the benefits of puberty blockers for trans adolescents.
Second, the systematic reviews by NICE use an inappropriate framework for assessing the quality of evidence for the benefits of puberty blockers for trans adolescents, namely the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework (Guyatt et al., 2008). Under this framework, evidence from randomised controlled trials is considered to be of higher certainty than evidence from observational studies. Given that the evidence of the benefits of puberty blockers does not come from randomised controlled trials, NICE has deemed this evidence to be of “low certainty”.
There are serious problems with the way that NICE uses the GRADE framework in the context of gender affirming medical treatment. For many medical interventions, including puberty blockers for trans adolescents, randomised controlled trials are unfeasible and unethical, because the consequences of not intervening would be very apparent to the participants and also would be unacceptably harmful (Ashley et al., 2023). Accordingly, evidence from randomised controlled trials is often not required of many medical interventions. These include abortion, appendicectomy for acute appendicitis, aortic aneurysm repair, and so on (Worrall, 2008). Indeed, the assumption that randomised controlled trials represent the “gold standard” in evidence-based medicine has been extensively criticised for neglecting other important sources of evidence (Anjum and Mumford 2017; Deaton and Cartwright 2018; Grossman and Mackenzie 2005).
When randomised controlled trials are unfeasible or unethical, other forms of evidence are used to inform clinical decisions. The assessment of causation in healthcare generally requires: (1) evidence of a statistically significant association between an intervention and an outcome; and (2) evidence of a mechanism linking the intervention and the outcome (Russo and Williamson, 2007). These are precisely what the studies on puberty blockers in trans adolescents demonstrate. Some of the studies used comparison groups and large sample sizes, which enabled the demonstration of a statistically significant association between gender affirming medical treatment and improved health in trans adolescents (Green et al., 2022; Tordoff et al., 2022). Other studies found evidence of social, psychological, and biological mechanisms through which gender affirming hormone treatment decreases depression and anxiety in trans adolescents (Chen et al., 2023; Grannis et al., 2021).
Therefore, while they are not randomised controlled trials, the numerous studies mentioned above provide sufficient evidence of the benefits of puberty blockers for the health and wellbeing of trans adolescents. The systematic reviews by NICE not only fail to include all of the relevant studies, but fail to evaluate the evidence appropriately.
The Stability of Gender Identity
The decision by NHS England was also partly based on the assumption that many children who exhibit gender incongruence may later revert to their assigned genders at birth. This has been criticised for being inaccurate and for ignoring the scientific evidence for the stability of gender identity in adolescence (Kennedy, 2022).
Early research seemed to suggest that the large majority of children who present with gender dysphoria later revert to their genders assigned at birth when they reach adolescence (Zucker and Bradley, 1995). However, significant methodological problems with these study have been raised, which suggest that it cannot reliably support claims about regret rates for gender affirming medical treatment. First, the studies examined the persistence of gender noncomformity in prepubertal children, which is a different thing from the stability of gender identity in peripubertal adolescents, and so it cannot be used to draw conclusions about the outcomes of medical transition in peripubertal adolescents (Ashley, 2021). Second, the diagnostic criteria used by the study did not distinguish transgender identity from other kinds of gender nonconformity (Temple Newhook et al., 2018). Hence, the study would have included children who do not consider themselves to be transgender, which would have resulted in a significant overestimate of the regret rate.
More recent research has shown gender identity in adolescence to be much more stable. Notably, a recent prospective study of 317 transgender adolescents, found that five years after socially transitioning, 94% had maintained their male or female transgender identities, 3.5% had proceeded to identify as nonbinary, and only 2.5% had reverted to their previous cisgender identities (Olson et al., 2022). This indicates that gender identities are generally stable in peripubertal adolescents.
Clinical research also indicates that the regret rate for gender affirming medical treatment in transgender youth is very low. In an early study of 22 transgender people who received gender affirming medical treatment in adolescence, none of the participants in adulthood regretted the decisions to transition medically (Cohen-Kettenis and van Goozen, 1997). More recently, two studies found that 96.5% and 100% of transgender adolescents who had initiated puberty blockers were subsequently happy to proceed with hormone replacement therapy at a later stage (Brik et al., 2020; de Vries et al., 2011). A recent study of 720 transgender people who commenced hormone replacement therapy in adolescence also found that 98% of participants chose to continue gender affirming hormone treatment into adulthood (van der Loos et al., 2022).
The above evidence indicates that gender identity in adolescence is reasonably stable and that the risk of regret for gender affirming medical treatment in transgender youth is very low, with studies consistently yielding regret rates lower than 5%. Indeed, the risk of regret for gender affirming medical treatment appears to be substantially lower than for many other healthcare interventions, such as knee replacement surgery (Kahlenberg et al., 2018) and radical prostatectomy (Ratcliff et al., 2013), which are often in excess of 20%. Therefore, NHS England’s claim about the instability of gender identity is inaccurate and empirically unjustified.
Ethical Considerations
NHS England’s decision to ban puberty blockers for transgender adolescents has been widely criticised as being unethical (Kennedy, 2022; Pearce, 2022). From a philosophical perspective, it has been argued that NHS England’s decision fails to acknowledge the evidence for the benefits of puberty blockers for trans adolescents, causes serious harms to trans adolescents, violates people’s rights to determine their own identities, and perpetuates injustices against the gtrans community (Maung, 2024).
Lack of access to gender affirming medical treatment has been shown to cause very serious harms to trans people, including increased risks of depression, anxiety, and suicide (Tan et al., 2023; Tordoff et al., 2022). Hence, by banning puberty blockers for trans adolescents, NHS England are potentially exacerbating these harms.
Accordingly, the World Professional Association for Transgender Health and other professional organisations around the world have strongly condemned NHS England’s decision to ban puberty blockers for trans adolescents (WPATH et al., 2022).
Conclusion
The decision by NHS England to ban puberty blockers for trans adolescents is empirically unjustified, ethically unacceptable, and is based on assumptions that are inaccurate and unsupported. The systematic reviews by NICE which informed NHS England’s decision not only fail to acknowledge several relevant studies, but also use an inappropriate evaluative framework that unduly minimises several important sources of evidence. Furthermore, NHS England makes assumptions about gender identity that have been discredited by several studies which indicate that gender identity in adolescence is reasonably stable.
Learn more about healthcare for Trans Youth on our Knowledgebase website.
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