How England Became an ‘Alarming’ Outlier in Its Treatment of Trans Children

England has become an exception in the West in how it provides medical care for trans children.

All young people who experience gender dysphoria in England and Wales face a battle to be prescribed reversible medicine and treatments that are commonplace in most Western countries.

Late last year, the High Court of England and Wales ruled against the use of puberty blockers for young people with gender dysphoria, following a case brought by Keira Bell – a woman who detransitioned – and the mother of a trans child.

The judges controversially decided that as puberty blockers – a reversible treatment to delay puberty – often led to the use of cross-sex hormones, a non-reversible treatment, young people under 16 could not provide consent, and therefore shouldn’t be prescribed them. In order to receive such treatment, individuals must apply to the High Court for approval, essentially banning the use of puberty blockers.

Meanwhile, lobbying by anti-trans groups, such as the LGB Alliance, has strengthened the call for restrictions on medical procedures.

Outside of the UK, young trans people do not face such a battle, or opposition, to getting the treatment they need. Most EU most member states allow the use of puberty blockers, with different rules on the minimum age that cross-sex hormones can be prescribed. In the US, puberty blockers are commonplace in most states. Recent attempts in some states, such as South Dakota, to restrict puberty blockers have failed. However, like in the UK, there are still threats to services in certain Republican-controlled state legislatures.

“You will find a lot of clinicians and researchers in this area of medicine are very supportive of puberty blockers, as all the major organisations are,” Amy Tishelman, director of clinical research at Boston Children's Hospital’s Gender Multispecialty Service (GeMS) and assistant professor of psychiatry at Harvard Medical School tells VICE World News. “It's certainly in the United States pretty accepted as a standard of care.”

Through her years of work and research, Tishelman has seen the benefits puberty blockers provide to young trans kids. “They really do give a chance for other kids who are not so certain about their gender, or who may be still evolving in their understanding of their identity and gender to develop some maturity, before making a more long term decision about what kinds of gender-affirming interventions they may want. And although I think people have the idea that everybody on puberty blockers goes on cross-sex hormones, I don't think that that's true.”

Tishelman says there are risks associated with preventing access to puberty blockers: “I do worry about rates of significant depression and anxiety without access to medication.”

For many clinicians, the life-saving features of puberty blockers can not be underestimated. “Puberty blocking medication for gender diverse and transgender youth who have been properly assessed can decrease psychological distress and gender dysphoria, and can sometimes be life-saving,” says Dr Laura Edwards-Leeper, an associate professor in the School of Graduate Psychology at Pacific University in Oregon and a clinician. “For those individuals who do ultimately transition physically, the blockers offer the benefit of allowing them to more easily be perceived by society as their affirmed gender because they do not develop the sex characteristics of their birth-assigned gender.”

“Restricting access to puberty-blocking medication would be tragic, as this intervention is essential for the psychological health of many gender dysphoric young people,” she continues. “Not offering this medication and forcing gender dysphoric youth to go through a puberty that is completely at odds with their gender identity will cause significant mental health problems for the youth, such as depression, anxiety, self-harming behaviours, and suicidal thoughts and attempts.”

Edwards-Leeper was shocked when the High Court ruling was made in London. “It is incredibly alarming that the UK has chosen to turn to the courts as a way of controlling the use of puberty blocking medication for trans youth,” she says. “To my knowledge, the Tavistock Clinic [the NHS clinic involved in the ruling] has historically provided one of the most comprehensive assessment processes for gender dysphoric youth seeking medical intervention in the world. The diagnostic and treatment planning process should be left to the mental health and medical providers who are trained in this field, not the legal system.”

Although the UK has regressed in its treatment, there’s still hope for its position to change. Until 2018, Italian doctors were only able to prescribe puberty blockers in cases where it was considered a “life-saving procedure.”

“We would have to assess that their psychological functioning was really bad – depression, high risk of suicide, and then we were saying, ‘if we don't prescribe the blockers, it's going to get worse,” Jiska Ristori, a psychologist and psychotherapist in andrology, endocrinology and gender incongruence at Careggi University Hospital in Florence explains over the phone. “But what happened is, things changed really drastically in 2018, because the medicinal pharmacies made it possible to prescribe blockers also for transgender adolescents. So we have an official way now to prescribe it.”

Three years ago, the changes to prescriptions in the country meant young people could be treated without having to become clinically very vulnerable. 

“We know that if they didn't get blockers,” she continued, “then their psychological functioning would be compromised, and then the problems would arise. And this is what we know from the literature as well. I mean, we know that puberty can be really challenging for a transgender person. So puberty blockers also have a way of preventing psychological difficulties that can also end up in psychopathology. We know that, for example, depression and suicide risk may arise during puberty for some transgender”

For Ristori, the UK’s decision – even temporarily – could cause serious damage. Until a court rules on an appeal scheduled for next year, trans adolescents in England and Wales will face a stripping back of their medical rights – that is if extreme waiting times don’t delay their treatment already. 

“I find it dangerous that one case may have bad consequences on the way of guaranteeing help for other adolescents,” Ristori says. “I find that dangerous in the interest of those adolescents that do need puberty blockers, and that really may benefit from it.”

The NHS Tavistock Clinic has appealed the decision which will be heard before March 2022. Before then, however, trans supporting charities Stonewall, Endocrine Society, Gendered Intelligence, and sexual health charity Brook have launched an intervention with the Good Law Project to provide evidence in the appeal, and have been told they could be expected to present evidence as early as May.