Introduction
TransLucent has carefully considered the factors contributing to the withdrawal of puberty blocker treatment, sometimes referred to as Gonadotropin-releasing hormone (GnRH) analogues for young trans people.
Puberty blockers (GnRH analogues) work by mimicking a natural hormone, binding to receptors on the pituitary gland, which eventually pauses the production of sex hormones that lead to the physical changes of puberty. GnRH analogues have been used in various medical conditions since the 1980s – it is imperative to stress this medication is not new, and adverse reports by users are rare.
We have concluded that there is insufficient evidence on which to endorse the ban, and we call on the government to return to the normative clinical practice wherein professional practitioners assess the suitability of the treatment for their patients in consultation with them and their parents.
The ban on puberty blockers has relied substantially on The Cass Review for validation, although neither the Review itself nor Dame Hillary Cass takes responsibility for this outcome or its consequences. The interpretations presented within the Review were accepted at face value by the previous government, the Department of Health and Social Care, NHS England and the Labour government. There has been considerable international criticism of the Cass Review and the withdrawal of puberty blockers by the Endocrine Society, the Integrity Project at Yale University, the Amsterdam University Medical Centre, the Australian Professional Association for Transgender Health, the American Academy of Paediatrics and many others.
Dame Cass overstates the lack of consensus regarding puberty suppression across the international clinical community. She cites a 2015 study by Vrouenraets et al but fails to note that “the treatment teams were purposefully selected on the basis of their stance in favour or against puberty suppression in the past”, according to the authors. The participants were, therefore, known to have outspoken and divergent views as criteria for their inclusion, suggesting that they may not represent the views of most who work in transgender healthcare.
Potential Bias of the Cass Review
The Cass Review commissioned a systematic research review into puberty blockers undertaken by the University of York. This team included a Visiting Research Fellow who is noted to have met with Kemi Badenoch to advocate for psychotherapy practices that are believed to be akin to conversion therapy. She has also advocated for Transgender Trend who state that “Medical intervention can only ever effect cosmetic change; the child’s sex remains the same”. These associations must be investigated to assure that the research protocol used in the review was not biased.
Before undertaking the Review, Dame Cass announced that she would not include trans people on her Advisory Board due to perceived bias. One of the Review’s most influential Advisors was the Head of a Gender Identity Service in Finland, where reduced access to puberty blockers is seen as a successful outcome. This is problematic because it suggests that the criteria for inclusion on the Advisory Board was a bias against the use of puberty blockers. If these partisan perspectives are proven, then the Review’s findings on them are ascientific and must be set aside.
Puberty Blocker (GnRH Analogues) – Clinical Trials
It has been argued that young trans people wishing to take puberty blockers should only be able to do so if they participate in a clinical trial. Along with the British Medical Association (BMA), The Council of Europe, the oldest intergovernmental human rights organisation in Europe, suggests that restricting access to puberty blockers to a clinical trial would contravene the human rights of those taking part if all other avenues to receiving this medication have been made unlawful. Therefore, participation in the trial could not be construed as voluntary.
The Cass Review predicates its requirement for a trial on the rhetoric that clinicians cannot satisfactorily identify those who would benefit from blockers. This view is contradicted by the Review’s own data, which shows that only 22% of patients were referred to endocrinologyendocrinology https://en.wikipedia.org/wiki/Endocrinology Endocrinology (from endocrine + -ology) is a branch of biology and medicine dealing with the endocrine system, its diseases, and its specific secretions known as hormones. It is also concerned with the integration of developmental events proliferation, growth, and differentiation, and the psychological or behavioral activities of metabolism, growth and development, tissue function, sleep, digestion, respiration, excretion, mood, stress, lactation, movement, reproduction, and sensory perception caused by hormones. Specializations include behavioral endocrinology[1][2][3] and comparative endocrinology. services for the prescription of puberty blockers.
The Review also shows that at least 77% of referrals into endocrinology for blockers reached assurance levels and were therefore appropriately made. This undermines the argument that clinicians over-referred into endocrinology or that they were unable to identify who would most benefit from this intervention. The Cass Review suggests that normative clinical practice, in which referrals are identified by expert practitioners, should be discontinued and replaced with research protocol.
What is most concerning about this is the potential for those who would not have been referred for puberty blockers, taking part in a trial that might see them inappropriately receiving medication they never intended to take.
Details of the research project have not yet been made public, so it is impossible to state with certainty what research models are being considered or will be implemented. What is certain is that trans people have not been part of any discussion or decision-making process related to the trial.
Potential Bias of the Research Advisory Panel
Despite statements by NHS England that progress is being made on implementing the puberty blocker trial, there are still two vacancies on the Advisory Board – they are stated as “a person with lived experience” and “a parent of a person with lived experience”.
Some of those on the Research Advisory Committee have been publicly named. They include senior NHS employees who attended and delivered speeches promoting psychotherapeutic approaches to the treatment of young trans people at a conference held in Greece and delivered by the American-based Society for Evidence-Based Medicine (SEGM), who have supported Donald Trump’s 2025 agenda and anti-trans campaign across that country.
SEGM has been designated an anti-trans hate group by the Southern Poverty Law Centre, a prominent human rights organisation. It is not known what, if any, payment or expenses were paid by SEGM or the NHS for attendance at this conference.
Puberty blockers (GnRH analogues) – Evaluating the Evidence
The current ban on puberty blockers is restricted to gender-diverse young people. No evidence is provided by NHS England that puberty blockers are more harmful to trans young people than they are to cisgender young people experiencing precocious puberty.
There is no literature or research citation in the Cass Review that substantiates the view that the same physiological mechanisms are not triggered in both groups or that the consequences are not comparable for both subsequent to the onset of puberty. It is incorrect to say that children with precocious puberty have too much hormone in comparison to trans children. Both groups have enough hormones to trigger puberty, which, in both cases, is problematic.
Puberty blockers (GnRH analogues) – Bone Density
Additionally, the Cass Review states that, “Evidence to date suggests that puberty blockers neither lead to substantially reduced adult height in transgender females (Boogers et al., 2022), nor increased eventual height in transgender males (Loi-Koe et al., 2018)”. It is confusing, then, that in section 14.43 of the review, without citation of specific research evidence, the Cass report states that the systematic review was inconclusive on bone density.
It is essential to recognise that the evaluation of medical interventions is a dynamic process with a growing body of research outcomes. There is salient new evidence in the area of bone density. In a narrative review, Giacomelli and Meriggiola (2022) state that “Data reported thus far are quite reassuring suggesting that, with adequate compliance, bone health is preserved in adult trans people undergoing GAHT” (Gender-Affirming Hormone Therapy).
Research studies show that transgender people of all ages tend to have lower bone density before any treatment is initiated. Van der Loos et al, Boogers, Willemsen et al and Ciancia et al have all published research in 2023 concluding that use of gender-affirming hormones is safe in terms of bone density, though trans women should have regard to lifestyle in order to optimise bone health.
Concerns about bone density have centred on the potential for increased fracture rates in trans people. However, Stevenson et al (2019) found, “No differences in fracture rates have been seen in trans women or men in short, prospective trials”.
Puberty blockers (GnRH analogues) – Executive Brain Function
In undertaking its research, the Cass Review did not study brain development in children and young people. Yet, this was the basis on which it was decided that cis children do not suffer demonstrable loss of executive brain function, whereas trans children might.
Cass cites a paper by Baxendale (2024) which aims to review the literature on puberty blockers. Baxendale’s previous work does not feature original research on gender-diverse individuals or hormonal replacement therapy.
Surprisingly, having shown potential harm to cis children in the paper, Baxendale’s conclusions appear to be aimed solely at transgender young people. Part of the evidence in Baxendale’s (2024) paper is taken from a single case study that showed a reduction in IQ subsequent to taking puberty blockers.
This concern is problematic in several ways. Baxendale did not report that the child had Conversion Therapy from the age of three to seven years or that, during this time, she met the criteria for a major depressive disorder. Another significant omission of the paper is that subsequent to taking puberty blockers, the child showed improvements in their affective and social life “due to the prevention of sexual secondary characteristics” (Schneider et al, 2017). Raising the alarm on potential cognitive harm to young trans people on the basis of this research paper is to overstate the significance of the evidence, which the authors themselves discounted.
Arnoldussen et al (2022) have shown that the correlation between pretreatment IQ at a young age and post-treatment educational achievement in young adulthood appears to be comparable to the general population. Additionally, Staphorsius (2015) found that puberty suppression does not have an effect on brain executive function when compared with gender dysphoric adolescents not on puberty blockers.
Puberty blockers (GnRH analogues) – Mental Health
In a further anomaly within the Cass Review, it suggests that van der Miesen et al’s (2020), research produced “an intermediate result with improvements in some mental health measures but not others”. This was a noted high-quality study that showed that trans adolescents receiving puberty suppression had fewer emotional and behavioural problems than a referral group that had not been treated. Improvements were found across depression, anxiety and suicidality. That no improvement was shown in externalising issues (which includes autism) is unremarkable.
Psychotherapy, the proposed alternative treatment to puberty blockers, has not been shown to be efficacious in the treatment of gender dysphoria. There is vast evidence in the literature that gender-affirming care is the best option to support young people experiencing gender dysphoria, reducing depressive symptoms and suicidal ideations. In another high-quality study conducted by Olson et al. (2024) at Princeton University, high levels of satisfaction and low levels of regret amongst both young people and their parents were found.
American states that have implemented measures to restrict access to puberty blockers for trans people have experienced an increase in suicidality by as much as 72%, according to the Trevor Project. The message here is clear, placing legal prohibitions on gender-affirming care leads to more deaths and more misery of young people.
Puberty blockers (GnRH analogues) – Positive Outcomes
It is concerning that the Cass Review fails to mention the potentially significant benefits of puberty blockers.
One such benefit is that when taken with cross-sex hormones, they can reduce the dosage required for the latter, according to Jensen (2019). When arguing that puberty blockers may reduce tissue availability for vaginoplasty, the review omits the positive fact that mastectomy is less likely and, when performed, can be less invasive (Lee et al. 2023 and van der Meisen et al. 2020), resulting in lower overall risk and costs for future surgical interventions.
By making the puberty blocker ban permanent, trans young people may avoid presenting to services if they feel the model under offer will demean their identity and cause further distress. Similar to the adverse practices that are employed in banning abortion, banning puberty blockers may result in long-term harm due to the lack of safe alternatives offered by trained healthcare professionals.
Withdrawing Puberty Blockers (GnRH analogues) as a Treatment Option
TransLucent is increasingly hearing from trans people whose medication is being withdrawn or withheld in the wake of the Cass Review and its conclusions regarding puberty blockers. In one such case, we know of a trans woman whose puberty blockers and hormones were withdrawn by her GP after months of treatment, essentially enforcing detransition.
The GP practice believed it was sufficient to refer her to a Gender Identity Service, who would see her in approximately eight years’ time. After finding another GP who prescribed treatment for several years, she was told that this was again being withdrawn. Due to the anxiety of having to consider detransitioning again, she raised the funds for a vaginoplasty so that she would no longer need to take puberty blockers. She believed that the health risks of not taking hormones subsequent to the surgery would be such that an agreement could be reached on their prescription. This turned out not to be the case, and she has been left with the prospect of facing serious healthcare issues as a consequence.
Puberty Blockers GnRH analogues – Conclusion
We know of no body of evidence displaying any concerning pattern of ill health to trans young people over decades of use of puberty blockers, and the Cass Review was unable to point to any such issue convincingly.
Ideologically, throughout the Cass Review, remaining trans at the end of treatment is construed as an undesirable outcome. The enforcement of laws which ban the very treatment that would validate trans identities could be perceived as reifying this ideology.
By banning puberty blockers and enforcing a research protocol to access them, young trans people are set outside the normal parameters of healthcare practices, removing their bodily autonomy and discriminating against them.
It could, therefore, be argued that the puberty blocker ban for trans children, which excludes cis children, is discriminatory and contravenes the Equality Act 2010. The ban does not satisfy the criteria of being a proportionate means to achieve a legitimate aim. In consultation with their patients and their parents, clinicians should be able to decide on a case-by-case basis whether or not puberty blockers are indicated.
As puberty blockers are often the only healthcare treatment available to young people facing puberty, if permanently removed, it would effectively remove all hope of any treatment to halt the increased causes of distress that may be experienced.
When hope is removed, it comes with the risk of devastating consequences.
ENDS
ADDITIONAL NOTES FOR MEDIA: For over a decade, NHS healthcare for both trans adults and children has been disastrous, with suggestions it is the worst in Western Europe and well behind other countries globally.
It has been stated by an NHS surgeon that around one in five trans people take their own life if they are unable to access gender-affirming healthcare. Sadly, because of media campaigns propagated by bad-faith actors connected to named SPLC trans-hostile hate groups (particularly SEGM, Genspect and The Alliance Defending Freedom), children’s gender-identity services are now left decimated.
While the Cass Review was commissioned to improve the healthcare of gender questioning and trans children, the net result is that children, together with their parents, are waiting some six years for help via the NHS and have minimal chance of receiving gender-affirming healthcare.
In regards to puberty blockers, which provide time for children to think, the UK has the most draconian laws in the world, with private healthcare providers banned from prescribing them – the consequence of which parents need to take their children outside the UK to be prescribed them. Occasionally, private healthcare providers (again often based outside the UK) may be able to offer less effective medications than GnRH analogues to young adults living in the UK.
TransLucent will continue to campaign for the use of puberty blockers (GnRH Analogues) to be readily available for those children who need them, as is the case in most countries across the world.
TransLucent Puberty Blocker (GnRH Analogues) Position Statement – Copyright 4th December 2024
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