Responses were predictably mixed to the announcement last week that the NHS would no longer prescribe puberty blockers to youngsters. While some celebrated the end of an era of grotesque medical experimentation on children, others took to social media to warn of the inevitable suicide of desperate young people.
In the more hyperbolic echo chambers of social media, the decision was cast as a lifeline withdrawn for no other reason than state-sanctioned bigotry and transphobia, possibly as part of a covert programme of eugenics. The hysterical pitch of this suicide narrative eventually prompted Professor Louis Appleby, head of the national Suicide Prevention Strategy, to stage an intervention on X. He stated that invoking suicide in this debate was both “mistaken and potentially harmful” and called time on “that line about choosing a living daughter or a dead son” — a line that has terrified so many parents into submission when presented with a medical pathway as the only option for their distressed children. So what does the NHS withdrawal of puberty blockers as a treatment for gender distress actually mean?
Every drug prescribed by a doctor requires a licence issued by a relevant regulatory authority. These bodies carefully review the data from clinical trials to ensure that the drug is effective, safe and meets manufacturing quality standards. However, once licensed for one purpose, these drugs can then be used off-label for another. Off-label means the drug can be prescribed for a condition (or at a dose) other than that for which it has been approved. Off-label prescribing is common, particularly in paediatric medicine, as children are rarely participants in clinical trials for ethical reasons. Up to 20% of drugs may be prescribed off-label. Puberty blockers are licensed in children to treat precocious puberty, a condition where children hit puberty years before their peers, sometimes before the age of five. Although the impacts on bone density are recognised, the drugs are effective at preventing the short stature and ameliorate the significant emotional and behavioural difficulties associated with such an early onset.
Once a drug has a licence for one condition, doctors are free to prescribe the medication for an off-label use, if they have a reason to believe it might help. This is how puberty blockers came to be prescribed to children with gender related distress. The announcement last week effectively put an end to this practice in the NHS.
For as long as puberty blockers were being offered as an off-label treatment by the NHS, clinicians were both ethically and duty bound to monitor their effectiveness. This fundamental duty was largely ignored by the clinicians at Gids who failed to collect adequate data, and rolled out the experimental treatment regardless. In a sign of just how far outside the bounds of normal clinical practice Gids was operating, one senior clinician appeared to be under the impression that auditing the outcomes of the experimental treatments they offered would actually be illegal.
As a result of their failings, we are left with a vacuum of data on the safety and effectiveness of puberty blockers and are back to square one when it comes to evaluating the medication as a prospective treatment for children with gender distress. It’s one thing to attempt to persuade an ethics committee to allow you to monitor the impact of a treatment already in use, albeit in an off-label capacity, quite another to convince them to give the go-ahead to experiment in children with a powerful treatment that will interfere with a critical stage of maturation. Following the withdrawal of off-label prescribing, anyone attempting to design an NHS trial to explore the efficacy of these drugs will need to convince an ethics committee of a sound rationale for reintroducing the drugs in the first place.
In most clinical trials, identifying the target or primary outcome of the treatment is the easy part: antibiotics reduce infection, epilepsy medications stop seizures, cancer treatments eliminate malignancy. No one needs a trial to prove that puberty blockers block puberty — the drugs are unequivocally effective in this regard. But puberty is neither a disease nor an illness. It is a vital stage in the transition from childhood to adulthood, marked by changes that extend far beyond the development of secondary sex characteristics. The brain undergoes extensive rewiring during puberty, creating the adult capacity for nuanced thought and complex decision-making, a process that isn’t complete until well into the third decade of life. Changes in the brain also allow sexual identity to develop. And elsewhere in the body, respiratory and circulatory systems undergo rapid growth and development. The skeletal system changes, increasing in bone density and musculature. Puberty blockers interfere with all of these processes in ways that may or may not be completely reversible — we can’t be sure, as many have not been studied.
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