A Guide to the NHS England Decision on Puberty Blockers

What the Media in North America Is not Telling You

Photo by A Perry on Unsplash

The recent decision by the National Health Service England to halt the routine use of puberty blockers for gender dysphoria has been reported by news outlets in Canada and the United States that have, up to now, not reported anything about the growing international movement against medical transition of children and young people. There have been stories by Global News, CBC News,  Time Magazine, ABC News, CNN, USA Today,  CTV News and many others. Although the controversy over pediatric gender medicine is now too big to ignore it is still not being adequately reported on this side of the Atlantic. Many articles display obvious bias and even the better ones do not provide essential background to the story. This is an attempt to fill in some of the gaps for the benefit of readers who are learning about this issue for the first time.

What just happened in England?

The National Health Care Service (NHS) England is the public health care provider for England in the United Kingdom. There are separate services for Scotland, Wales and Northern Ireland which have their own policies. Most people in England obtain health services through the NHS. The clinical policy says that puberty blockers will not be available “as a routine commissioning treatment option for treatment of children and young people 17 years or younger who have gender incongruence / gender dysphoria.”  This means that, unless they fall into one of the exceptions, children and young people will not be able to obtain puberty blockers through the NHS but, if their parents can afford it, the still have the option of obtaining them through a private clinic. The Society for Evidence Based Gender Medicine has prepared a more detailed discussion of the changes.

Is this a total ban?

It’s not quite a total ban but it is close. There will be three exceptions. Anyone who is already receiving puberty blockers or has been referred for puberty blockers but not yet assessed when the policy comes into effect on April 1, 2024 may continue to receive them. Puberty blockers are often used in combination with cross sex hormones to suppress testosterone in natal males and this use may continue in patients 16 and older. This exception may be affected if there is a change of policy regarding cross sex hormones. The final exception is for children and young people enrolled in a research program.

The research exception is likely to be very limited.  There are currently no research trials for puberty blockers in England and it is not a foregone conclusion that any will be set up.  There are strict requirements for clinical trials and these are especially strict where children are involved. Any new research studies will have to be approved by a research ethics board which will need to take into account what is now known about the risks of puberty suppression.

The informed consent process is much more restrictive and, where minors are involved, the consent of both the child and the parents is required even if the child might be competent to consent to treatment in normal situations. Researchers will have to inform parents of unstudied risks like the effects on cognitive development and may have to explain, for example, why they want to do baseline and follow up IQ tests. The new policy is clear that if no clinical trials are set up puberty blockers will not be available through NHS England.

What brought about this change?

Although this is the first time many news outlets in Canada and the United States have reported on developments in gender medicine in England, the new policy was the result of many years of work.  The group Transgender Trend was founded in 2015 to raise concerns about the medical transition of children at the NHS Gender Identity Development Service (GIDS), which was then based at the Tavistock Clinic, a world-renowned mental health centre. In 2019 it was reported that over the previous three years 35 psychologists had  resigned from their positions with the GIDS because they were concerned about the rush to start gender questioning youth on medical transition.

Some of these clinicians shared their concerns with Dr. David Bell, a psychiatrist who was also a member of the Tavistock board of governors. Dr. Bell wrote a critical report on the GIDS which the governors ignored. Psychoanalyst Marcus Evans, another member of the Tavistock governors, resigned and went public with his concerns. Michael Biggs, a sociologist at Oxford, investigated the use of puberty blockers at Tavistock and published a series of reports on questionable research practices.

The government responded by appointing a commission headed by retired pediatrician Hilary Cass to conduct an independent review into NHS programs for gender questioning young people. In  February, 2022 the Cass Review issued an interim report which found significant problems with the Tavistock service and recommended a “fundamentally different service model.”

 In July, 2022,  the government announced that the gender clinic at the Tavistock would be closed and replaced by a series of regional centres. The spin that transgender activists put on the announcement at the time was that the major problem was the long waiting list at the Tavistock and that the new regional clinic model would provide faster access to puberty blockers and cross sex hormones. However, it should have been clear to anyone who read the interim report, that the concern was the entire model of gender affirming care. In October, 2022, NHS England issued an interim service specification which stated that puberty blockers would only be available as part of a research protocol.  

This is a very brief overview of an extended debate. More information can be found in Hannah Barnes’s book Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children and her recent article in The New Statesman.

All of these developments were very different from the highly partisan debate that is taking place in the United States and starting in Canada. The Conservatives were in office during the entire period when the GIDS started to the present but the debate was largely non-partisan. Many of the clinicians who first raised concerns about the Tavistock’s practices were gay or lesbian or strongly supportive of the LGB community. One of their main concerns was that many young people who would otherwise have grown up to be gay or lesbian were being harmed by the rush to medical transition.

Why trust NHS England?

A typical story on the NHS England policy change in the Canadian or American media usually ends by listing medical organizations which support the affirming care model and the use of puberty blockers. These include the Canadian Medical Association, the American Medical Association, the American Academy of Pediatrics, the Canadian Paediatric Association and many others. This raises the question of why NHS England should be trusted over all of these eminent organizations?

The answer is that the NHS England policy is the result of an evidence-based process while the position statements of various medical associations in North America and around the world are consensus-based statements. The consensus based process for medical guideline development is sometimes called GOBSAT for good old boys sitting around a table.

A consensus-based process for medical guidelines is unreliable because it is too prone to being swayed by bias and conflict of interest. A panel where the members rely on their own clinical experience will tend to favour research that supports their preferred treatments and down play unfavourable results.

An evidence-based guideline development process attempts to eliminate bias and conflict of interest by assessing evidence through a systematic review. This is a process in which the review team selects all relevant studies using predefined search criteria and then evaluates them using standard predefined tests. The result of the review is to rate the evidence supporting the benefits of a treatment as having very low, low, moderate or high certainty.

The Cass Review commissioned a systematic review of puberty blockers from the National Institute of Care Excellence (NICE)  which found that the evidence that they led to any improvement in mental health was very low certainty. The NICE review covered the period up to July 2020 but a systematic review by German researchers found that no new studies had been published up to August 2023 which would change the result. Health authorities in Finland and Sweden also conducted systematic reviews of puberty blockers and reached similar results.

NHS England used the NICE systematic review as its starting point and then conducted consultations with a clinical panel, stakeholder groups and the public. It also prepared a detailed equality and health inequality impact assessment.  This assessment found that:

The policy is a reasonable, rational and clinically necessary response to the findings of NICE and the Cass Review that there is a lack of sufficient evidence relating to the safety and clinical effectiveness of GnRHa for children and young people with gender incongruence / dysphoria, including about the benefits, risks and long-term outcomes. It is therefore proposed that adoption of the policy would in itself be a risk mitigation measure.

No professional organization or public health agency in Canada or the United States, which still supports the use of puberty blockers, has conducted this kind of comprehensive evidence review to support its position. For the most part, they rely on the World Professional Association for Transgender Health (WPATH) which the revelations in the WPATH files have shown not to be a reliable clinical or scientific organization.

 The position statement of the American Academy of Pediatrics has been criticized by James Cantor, PhD, for making recommendations that were not only without evidence but contrary to evidence. It announced last year that it would be ordering an evidence review but has not changed its position. The Endocrine Society is also working on updating its guidelines on gender affirming care but the guideline development group has serious conflicts of interest.

What About Cross Sex Hormones?

NHS England has also issued a clinical policy for cross sex hormones which allows them to be provided to minors from “around their 16^th birthday.” The contrast between this policy and the puberty blockers policy is striking. While the puberty blockers policy is supported by 10 working papers, the policy on cross sex hormones is a single 8-page document. It does not mention the NICE systematic review of cross sex hormones which found that the evidence of benefit is low or very low certainty and “must be weighed against the largely unknown long-term safety profile of these treatments.”

The Society for Evidence Based Gender Medicine Report speculates that this policy is simply a stop-gap measure. NHS England needed to have a clinical policy in place before the Tavistock GIDS closed on March 31, 2024 but did not want to make major changes until the Cass Review issues its final report, which is expected sometime in April. More change is coming to gender medicine in the United Kingdom and both professional organizations and the media in North America should be paying closer attention.