Young trans people face numerous challenges in life. These can include social discrimination, bullying, harassment and family rejection. It’s maybe not surprising then that trans youth are also at much higher risk of self-harm and suicide attempts than their peers.
Research shows that for some young trans people, puberty blocking drugs can help while they explore their gender identity. Puberty blockers are medications that temporarily cause the body to stop producing sex hormones and so delay puberty.
A recent study of more than 20,000 trans adults found those who received puberty blockers during adolescence had lower odds of lifetime suicidal thoughts than those who could not access treatment. Another recent review found that puberty blockers for trans youth were associated with marked improvements in depression, overall behavioural and emotional problems.
But in England, children under 16 will no longer be able to take puberty blockers without court authorisation. This is despite the fact that the World Health Organization recommends gender affirming healthcare – this is where medical interventions are designed to affirm a person’s gender identity.
This change comes following a recent ruling by the UK High Court that children under 16 are unlikely to be able to give informed consent to undergo such treatment. The case was against the Tavistock and Portman NHS trust – the UK’s only gender identity development service (GIDS) for children and adolescents.
One of the claimants, Kiera Bell now 23, was assessed by GIDS at 14 for gender dysphoria and prescribed puberty blockers at 16. Bell transferred to the adult Gender Identity Clinic (GIC) at 18, where she began medical transition, and at 22 underwent a double mastectomy. A year later she regretted her treatment and took the decision to detransition to female.
Bell said she was not provided with sufficient information to enable her to consent to treatment. And that this led her to follow the adult path to transition – which she later regretted.
The judgement resulted in the NHS making immediate changes to service specifications cancelling all new referrals and reviewing all patients under the age of 16. For a child under 16 to now be prescribed puberty blockers in England, they must be able to foresee that they will go on to full medical transition as an adult.
No one way to transition
There are numerous ways to transition medically and not all adults will undergo the numerous surgeries available or take hormone replacement therapy. Indeed, trans identity is more complex and less binary than simply becoming one type of cis man or woman. Gender identity is multifaceted and on a spectrum. But medically transitioning can be lifesaving for adults who are able to go through this process.
While there are some adults who, like Bell, do go on to destransition, research has found that the choice to detransition is also highly complex and that societal discrimination continues to impact people’s ability to live safely and comfortably in their affirmed gender. Urology and gynaecological complications, rejection and alienation from society and family along with changes in gender identity are common reasons as to why people might choose to detransition.
Recent research from the Netherlands also found the number of people who go on to regret their gender reassignment surgery is actually very low. The study assessed more than 6,500 people who attended the Netherlands’ largest gender identity clinic between 1972-2015, to find out about any regrets they had about their surgery. The study found that only 0.6% of trans women and 0.3% of trans men there said they experienced regret.
Barriers to trans healthcare
The recent UK judgment raises important questions about how the law (and the society that creates it) understands being transgender as a distinctly adult concern. In this way, medical transition is seen to be an “adult thing” children should be protected from.
The process of trying to get help for gender dysphoria is already rigorous and stressful for young people and their families. Children and adolescents have to fight to prove they are trans and many have delayed referrals to GIDS because (despite NHS guidelines to the contrary) GPs often refer to local mental health teams before GIDS because of self-harming or behaviour issues. This is even when the child is expressing gender dysphoria or incongruence.
One parent of a trans youth I interviewed for my current ongoing research into COVID-19 and barriers to trans healthcare, described how her son first came out as trans at 13, was referred by his GP to local mental health services and then referred to the Tavistock at 16.
She told me her son saw four different consultants in 18 months. None of the consultants at the Tavistock gave a diagnosis of gender dysphoria during this time or were willing to prescribe puberty blockers.
At 17 her son delayed his plans to go to university so he could work and pay for private healthcare. He received an official diagnosis of gender dysphoria via the private route and was transferred to adult GIC by the Tavistock.
While puberty blockers may not have been deemed appropriate by the Tavistock in this particular case, a later diagnosis means that certain treatment options (such as puberty blockers) are likely now closed off to this teenager, who is currently awaiting an appointment at the adult clinic – which has been delayed due to COVID-19.
Indeed, the high level of suicide attempts in the adult trans community shows the enduring impact of societal discrimination against trans people – along with the possible consequences of being unable to access gender-affirming treatment in a timely manner.
This is why listening to the trans community – including patients, families and trans scholars – is crucial. And while there’s much to be learnt from existing studies on puberty blockers – including the 30-year clinical history of their use to treat cis children with early onset puberty – what’s needed now is a balanced clinical evidence base alongside a gender-affirming model of healthcare.