Blog

by Michael Biggs

The Health Research Authority (HRA) has just published its investigation into the 2010 experiment with puberty blockers, or more precisely its role in giving ethical approval and oversight. The investigation was prompted by research published on Transgender Trend in March 2019, with an update in July (the full paper is here). The HRA report’s conclusions are predictably bland. Firstly, ‘the research team involved in the design and delivery of the study … worked in accordance with recognised practice for health research, and in some areas such as patient involvement and transparency were ahead of normal practice at the time’ (p. 11). Secondly, ‘The HRA has acted within its Standard Operating Procedures and its normal practice in relation to this study’ (p. 10).

On close reading, however, the report contains an astonishing admission. The paragraph deserves to be quoted in full:

It would have reduced confusion if the purpose of the treatment had been described as being offered specifically to children demonstrating a strong and persistent gender identity dysphoria at an early stage in puberty, such that the suppression of puberty would allow subsequent cross-sex hormone treatment without the need to surgically reverse or otherwise mask the unwanted physical effects of puberty in the birth gender. The present study was not designed to investigate the implications on persistence or desistence of offering puberty suppression to a wider range of patients, it was limited to a group that had already demonstrated persistence and were actively requesting puberty blockers. (p. 5, my own emphasis added in bold)

In fact the 2010 research protocol declared that one of its three aims was ‘[t]o evaluate persistence and desistence of the gender identity disorder and the continued wish for gender reassignment’ (Early pubertal suppression in a carefully selected group of adolescents with gender identity disorder, proposal submitted to Central London REC 2, November 2010, obtained under Freedom of Information from the HRA; italics added). History is being rewritten to alter the rationale for the experiment. It is not clear whether this revisionist history originates with the HRA, or whether the HRA is conveying the current views of the experiment’s chief investigator, Professor Russell Viner (Professor in Adolescent Health at University College London) or his co-investigator, Dr Polly Carmichael (Director of the Gender Identity Development Service, GIDS).

Whatever the source, this is a clear admission that puberty blockers were the first stage on the predestined path to cross-sex hormones. After four assessment interviews, a child of 12 would be consenting in effect to a lifetime of drug dependence and the loss of fertility and the probable loss of sexual functioning. Because the “treatment” was intended to enhance the child’s desire to change sex, it naturally exacerbated her or his gender dysphoria. ‘Worsening behavioural and emotional symptoms of dysphoria’, the HRA notes cheerily, ‘would therefore not in itself be unexpected’ (p. 6).

While the HRA is quite clear that puberty blockers were supposed to set the child on a course for full medical transition, it ignores one gruesome irony. For a boy who wishes to resemble a woman, puberty blockers will indeed prevent ‘the unwanted physical effects of puberty’ such as voice deepening. But they also leave the adolescent with the genitalia of a prepubescent boy. If he subsequently chooses (after the age of 18) to undergo genital surgery, there is insufficient for a vaginoplasty and so a piece of his bowel will have to be used. This point was underlined at a conference organized by the Gender Identity Research and Education Society in 2005:

‘Although there are surgical means to deal [with] this difficulty, the patient and her parents or guardians should be fully informed about its implications.’

The conference was attended by Viner and Carmichael. Unaccountably they forgot to mention these implications on the Patient Information Sheet they gave to children and carers in their experiment.

Following from the HRA’s admission that puberty blockers are really the start of irreversible physical transition, it makes one valuable recommendation. ‘Researchers and clinical staff should consider carefully the terms that they use in describing treatments e.g. avoid referring to puberty suppression as providing a “breathing space”, to avoid risk of misunderstanding.’

That phrase is common. According to Dr Gordon Wilkinson at the Young People’s Gender Clinic in Glasgow—the Scottish equivalent of GIDS—GnRHa drugs ‘provide breathing space to explore options’. Gendered Intelligence, a charity which trains staff in many universities, describes puberty blockers as giving ‘young trans people appropriate time and breathing space to ensure that they are sure about the permanent effects of cross-sex hormones, without the adverse effects of an incorrect [sic] puberty’. (The phrase is also widely used in the USA and New Zealand.)

It is not the only misleading phrase. Carmichael went on BBC children’s television in 2014 to tell one of the children in the experiment and the audience (aged 6 to 12) that puberty blockers merely pressed a pause button. We can only hope that the HRA’s report will stop clinicians and charities from misleading the public—and more importantly the children and carers who are making life-changing decisions.

The HRA’s investigation repeats a familiar misconception: because Gonadotropin-Releasing Hormone Agonist (GnRHa) drugs are licensed for the postponement of central precocious puberty, therefore ‘the treatment was licensed for the purpose of blocking progression of puberty’ (p. 4). In the case of precocious puberty, a child starts to go through puberty at an abnormally young age—a girl starts menstruating at five, for example. This condition has an objective physical diagnosis. GnRHa drugs are then prescribed in order to postpone puberty until the normal age of puberty is reached, when the drugs are stopped and puberty resumes normally. There is no similarity at all for the case of a child with gender dysphoria. This condition has no objective physical diagnosis. GnRHa drugs are prescribed in order to prevent the child from ever experiencing puberty. The adolescent never develops the ability to conceive a baby and might never develop the capacity to orgasm.

When it comes to the HRA’s own ethical procedures, its investigation throws some intriguing findings. The experiment was first rejected by one Research Ethics Committee (REC 1), and was then submitted to another Committee (REC 2). ‘A number of members’ on the latter ‘had connections with University College London’, which by coincidence was Viner’s own institution. The committee also co-opted a member who had co-authored with Viner. ‘It is not clear whether the potential conflict of interest was declared, whether this committee discussed this potential conflict of interests and agreed that it was not a concern, or whether the other members agreed that the individual concerned could contribute but that they would ensure that it did not influence their decision-making’ (p. 9). It is unfortunate that the minutes provide no information.

The Research Ethics Committee made the submission of annual progress reports ‘a condition of the favourable ethical opinion’, as it stressed in its letters (e.g. letter of 29 April 2013, obtained under Freedom of Information from the HRA). Viner failed to submit such reports in 2013, 2014, and 2015. The HRA reassures us that ‘it is common for researchers not to supply annual progress reports’ (p. 10). Rules, after all, are made to be broken.

After 2015, the Research Ethics Committee forgot about the experiment, as apparently did Viner and Carmichael. It had served its purpose, for what had been ‘research’ now became policy at GIDS: puberty blockers are routinely given to children from the age of 12, and in some cases as to children as young as 10.

Let us leave the last word to Viner, who spoke with remarkable candour in 2012:

If you suppress puberty for three years the bones do not get any stronger at a time when they should be, and we really don’t know what suppressing puberty does to your brain development. We are dealing with unknowns. (Daily Mail, 25 February 2012)

We know no more now than we did then.