Letter to NHS England and Wes Streeting about puberty blockers trial

On your first point, while it’s possible that there will be people who might want to transition regardless of whether they pass as the opposite sex, the letter is making the point that this is the current premise on which paediatric medical transition is based. The established idea is that trans people will pass better as the opposite sex if they haven’t gone through puberty.

There’s an interesting point on this made in the new US paediatric gender dysphoria report (p12) (linked upthread) where it acknowledges this aim of medical transition in children:

In many areas of medicine, treatments are first established as safe and effective in adults before being extended to pediatric populations. In this case, however, the opposite occurred: clinician-researchers developed the pediatric medical transition protocol in response to disappointing psychosocial outcomes in adults who underwent medical transition.

I agree with you that other reasons to transition might become the dominant ones now that passing as the opposite sex is off the table. But the currently proposed PB trial would only have been based on current protocols and objectives, which is why this is the only relevant treatment objective here.

Re your second point about it being unethical anyway even before the SC ruling, I think the point the letter is making is that Sex Matters et al had already been arguing all those other points around ethics (as they say in the letter), but that this ‘you shall not pass’ argument is supplementary to all those other objections already put forward, in light of the SC ruling.

Feeling more like the gender they think they are" is quite a fluffy benefit compared to "yes, everyone will always treat you as the other sex if you pass well enough and here's the blockers you need to achieve that level of passing".
Oh I know, I don't disagree! Fluffy or not, though, I'm sure there are lots of kids/parents who find that a good enough reason to take them.

I think it's OK in the specific context of the Supreme Court decision. No matter how well they "pass" the decision confirms that these children will never be able to avoid bumping up against situations where they can't deny their sex, and there will always be situations where their sex will make a difference to how the outside world treats them. "Feeling more like the gender they think they are" is quite a fluffy benefit compared to "yes, everyone will always treat you as the other sex if you pass well enough and here's the blockers you need to achieve that level of passing".

I think the letter is unclear/not that useful in a couple of ways.
'no promise can be made that medical treatment will enable a person to use opposite-sex facilities.' some people might argue that the children don't want medical treatment in order to be able to do this, but just to feel more like the gender they think they are.
'The use of these drugs on children too young to understand this is ethically untenable.' Surely the use of these drugs on children too young to understand all of the side-effects and the irreversibility et cetera is untenable?

I hope so @Stepfordian ! That's reassuring and would be a shift away from some of the earlier practice.

Hopefully it will be a bit like the organ donation thing where if you don’t want to be a donor you go along to be ‘tested’ and say you don’t really want to donate and they wrote you a letter saying you’re not a match. They could ask the parents privately then if they say no tell them the clinician has said no for x reason.

The business of insurance companies is to observe reality not to pretend it doesn't exist.

They'd lose money if they didn't.

It seems insurance companies are doing a lot of work in favour of reality 😀

The protocol - what we know of it! - sounds horribly unfair on parents. You've got a teen who desperately wants puberty blockers. You've got a clinician who says "yes fine". But now there are parents with doubts who have heard about the downsides in the press and don't believe the suicide narrative and no longer swallow whatever they're told by the gender "experts". So they refuse consent. What will that do to their relationship with their child? Or they unwillingly consent for a relationship with their child, knowing the possible effects on their child's health and that 10 years down the line their child might utterly regret it and blame them.

The insurance question is probably the one which will have the biggest impact on whether a study goes ahead or not...

Another question is about clinical trial insurance:

What is clinical trial insurance?
Clinical trial insurance is an essential component of any medical research programme. It offers financial protection to both the researchers conducting the trial and the volunteers who are taking part, should unforeseen problems arise as a result. Usually, clinical trial insurance is a regulatory requirement so it’s important your policy provides a suitable level of cover for your needs.

I wonder who's paying the insurance for a NHS-sponsored trial , and if insurers have a say on the details of the protocol.

Does anyone know?

UK politicians from both main parties accepted Cass because we mostly see this kind of research study as independent and objective even if Labour would have preferred different results.

I do wish Cass had insisted that we get the data linkage results before giving any more kids puberty blockers for gender dysphoria, inside or outside of a study.

Is the US Gender Dysphoria Review likely to be undermined or rejected because Trump? Or is the OASH generally viewed as non-partisan?

(edited to clarify)

There are many problems with the proposed UK trial. A key argument against a trial and indeed against the entire affirmative model is the documented high rate of natural resolution of gender dysphoria with normal puberty. There is no justification to use high risk treatments for a condition with a spontaneous remission rate of between 66-90%.

It's like treating a sunburnt arm with amputation.

Worth a listen - Recent podcast (March 2025) "Beyond Gender" Stella O'Malley, Mia Hughes and Carrie Clark on the proposed UK trial:

"The only incluson criteria that have been made public so far are that the child must want puberty blockers, the child's parent must agree with them having puberty blockers, and that the gender dysphoria clinic say that the child should have puberty blockers."

"We know that roughly 9000 children went through the GIDS system, we know that maybe roughly 2000 children or so were on puberty bloockers, we have a control group. All we need to do is follow up how did those 9000 children get on."

"We heard from politicians that it [the new trial] is uncapped - most gender distressed teenagers would be part of this trial, several thousand people might be going to participate, and of course that's just GIDS. People arrive, they're set on a medical pathway, the assessment's not all that great, and they're in. I started looking for inclusion criteria and exlcusion criteria [for the new trial], the kind of things we would expect to see based on the evidence base that we already have, things like people with autism, and mental health difficulties who we know are at a higher risk of regret and detransition, whether they were going to be excluded; how they were going to control for things like having therapy at the same time so we weren't going to confound endocrine interventions with psychological ones, and it just didn't look as though any of these things were really being considered."

TL:DL "It looked like GIDS Mark II - we were just going to do this all over again"

(edited for typos and context)

I saw, it's awesome.

The US gender dysphoria report is out.

Agree. You'd have to be very naive and wholly inexperienced in safeguarding not to ask the obvious question of who will the dating pool be of legal adults who still look physically like children - and there is a strong suspicion and emerging evidence that they may be neurologically and psychologically immature too, not having been through a typical developmental puberty. And who will not reach sexual maturity or have the capacity for arousal.

What's the dating pool of adults who would be interested in such a relationship and for what reasons? And what would you likely anticipate as the risks within that dating pool, because very sadly they won't all be white knights pure of heart.

Why would we believe it would be different a second time around given all the push back currently?

There is simply a loss of trust now.

Given that no proper effort has been made by gender clinics to actually follow up their patients and look at outcomes I really can't see how you can justify exposing a new group of children to high risk, low benefit therapy for a condition strongly linked to childhood abuse, same sex attraction and/or autism/ADHD

Good to see the lack of definitions mentioned.

Even the concept of “gender identity” lacks a clear definition that is not circular, the report says, describing this as “a serious problem, because the term figures centrally in the justification for medical interventions”.

Making the point that this "treatment" is being used for a condition which can't even be defined. Does "gender identity" even exist in any sort of objective sense? Mutilating and sterilising children because of an indefinable feeling that they claim to have is insane.

The trial needs to be stopped by holding its designers' feet to the fire of scientific rigour. What is the null hypothesis? What is the condition being treated? Add to this the ethical concerns, for example the IQ drop found in girls who had been treated with PBs for precocious puberty in Mul et al's study. I'm not sure accessibility of opposite sex amenities needs to feature among the many reasons further PB studies shouldn't go ahead. So I'm ambivalent about this letter.

I have tried several times, as a thought experiment, to design an ethical trial that would give good quality information.

Prior to the trial:
get retrospective data from people who have received puberty blockers followed by cross sex hormones about fertility, sexual function and bone density; about mental health; about body satisfaction
conduct animal studies to assess the risks
build an accurate estimate about suicide risk
Although retrospective/animal studies do not give good quality information, they would provide the parents/cares and children with some information for the informed consensus

Eligibility:
Pre-pubertal children without additional mental health problems and without a neurodivergent diagnosis (which could be confounding factors - same criteria as the Dutch protocol?), that do not show a pre-homosexual orientation? (very different from the Dutch protocol), that show a persistence of XX years of severe (how to measure it?) gender distress (as you can see, already trying to write the inclusion criteria is so difficult). Do we include or exclude girls?

Readouts:
mental health, persistence/desistance, during the study and for the subsequent 10? 15? 20? years (when would we see regrets about loss of fertility? age 30, 35?)
bone density, IQ, fertility, sexual function, and any other issues that we know can be impacted by PB (taking in account side effects for all other licenced GnRH uses)

Aim of the study:
improve mental health during the study? mental health overall for the duration of follow up? increase feeling of body satisfaction for the duration of follow up? increase social functioning?

As concerns mental health, social functioning, etc.. compared to which control group??

Virtually impossible.

How do we know that "the most severe cases" won't be better off with mental health support and waiting till puberty is over?
We already have a natural experiment where children referred before X date were given them and after that weren't.
We can just compare those groups.