BBC Woman’s Hour reported today on an important change to the NHS website section on gender dysphoria: the NHS no longer says that puberty blockers are ‘reversible.’

The new updated section on the NHS website is an improvement on older versions, the information is more accurate and fact-based, there is less ideology and more care is taken with language. It represents a step in the right direction and we welcome the positive changes.

There are some particularly significant amendments in the updated version, the most important of which is the issue of reversibility of puberty blockers. Here are the main changes:

Puberty Blockers

GONE is the claim that puberty blockers are considered to be fully reversible:

“The effects of treatment with GnRH analogues are considered to be fully reversible, so treatment can usually be stopped at any time after a discussion between you, your child and your MDT”.

NEW is the admission that long-term effects are unknown:

“Little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria.

Although the Gender Identity Development Service (GIDS) advises this is a physically reversible treatment if stopped, it is not known what the psychological effects may be.

It’s also not known whether hormone blockers affect the development of the teenage brain or children’s bones. Side effects may also include hot flushes, fatigue and mood alterations.”

This paints a very different picture. The Tavistock GIDS is saying that the effects of blockers are physically reversible yet the NHS is now saying that this is not known.

Unknown effects on the developing adolescent brain should be reason enough to question the use of puberty blockers for this age-group; the fact that this has not been flagged before is testament to the existence of the seemingly different rules that govern transgender healthcare.  Would parents say yes to puberty blockers if they knew that trials on sheep suggest that blockers impair brain development in significant areas, which is not reversed if blockers are discontinued? We know there is a window of development in puberty which, if missed, cannot be regained at a later stage.

We also know that nearly 100% of children on blockers progress to cross-sex hormones and we know nothing about the long-term neurological effects if a person never experiences the surge of sex hormones their body needs and expects in adolescence according to whether they are male or female.

Suicide

GONE are these references to self-harm and suicide:

“Having or supressing these feelings is often very difficult to deal with and, as a result, many transsexuals and people with gender dysphoria experience depression, self-harm or suicidal thoughts.”

“See your GP as soon as possible if you’ve been feeling depressed or suicidal”.

The new version references depression, anxiety and distress, but there is no association made between gender dysphoria and suicide, which should never have been made in the first place on the NHS website.

Young children

GONE is this statement that creates an association between gender dysphoria and having the ‘wrong’ interests as a very young child:

“The first signs of gender dysphoria can appear at a very young age. For example, a child may refuse to wear typical boys’ or girls’ clothes, or dislike taking part in typical boys’ or girls’ games and activities.”

GONE is the list of common behaviours which were previously linked to gender dysphoria.  Although the older version does emphasise that most children will grow out of these feelings, it begins by describing normal behaviours as ‘gender dysphoria behaviours’:

“Gender dysphoria behaviours in children can include:

insisting they’re of the opposite sex

disliking or refusing to wear clothes that are typically worn by their sex and wanting to wear clothes typically worn by the opposite sex

disliking or refusing to take part in activities and games that are typically associated with their sex, and wanting to take part in activities and games typically associated with the opposite sex

preferring to play with children of the opposite biological sex”

NEW are more careful statements that don’t associate a child’s interests with gender dysphoria and instead emphasise the rarity of the condition and the societal influences:

“A diagnosis of gender dysphoria in childhood is rare. Most children who seem confused about their gender identity when young will not continue to feel the same way beyond puberty. Role playing is not unusual in young children.”

“Children may show an interest in clothes or toys that society tells us are more often associated with the opposite gender. They may be unhappy with their physical sex characteristics. However, this type of behaviour is reasonably common in childhood and is part of growing up.”

Teenagers

NEW is the acknowledgment of desistance and the suggestion that your feelings may be an indication of your sexual orientation:

“However, you may also find out that the feelings you had at a younger age disappear over time and you feel at ease with your biological sex.”

“Or you may find you identify as gay, lesbian or bisexual.”

Cross-sex hormones

GONE are the lists of cosmetic changes to your body that hormones will produce and gone is this strange statement about the benefits of hormones:

“Hormone therapy may be all the treatment you need to enable you to live with your gender dysphoria. The hormones may improve how you feel and mean that you don’t need to start living in your preferred gender or have surgery.”

NEW is this information:

“The NHS in England is currently reviewing the evidence on the use of cross-sex hormones by the Gender Identity Development Service.”

Three new conditions have been added to the list of risks of cross-sex hormones:

Dyslipidaemia (abnormal levels of fat in the blood)

Elevated liver enzymes

Polycythaemia (high concentration of red blood cells)

Surgery

GONE are the claims that surgery has a high rate of satisfaction:

“After surgery, most trans women and men are happy with their new sex and feel comfortable with their gender identity. One review of a number of studies that were carried out over a 20-year period found that 96% of people who had genital reconstructive surgery were satisfied.”

“Despite high levels of personal satisfaction, people who have had genital reconstructive surgery may face prejudice or discrimination because of their condition.”

GONE also are the suggestions that hormones and surgery actually change your sex:

“For some people, support and advice from a clinic are all they need to feel comfortable in their gender identity. Others will need more extensive treatment, such as a full transition to the opposite sex.”

“Once you’ve completed your social gender role transition and you and your care team feels you’re ready, you may decide to have surgery to permanently alter your sex.”

NEW is this more accurate statement:

“Some people may decide to have surgery to permanently alter body parts associated with their biological sex.”

NEW also is an acknowledgment of the reality, the risks and the limitations of surgery:

“You’ll need lifelong monitoring of your hormone levels by your GP.”

“As with all surgical procedures there can be complications. Your surgeon should discuss the risks and limitations of surgery with you before you consent to the procedure.”

Biological accuracy

GONE is the claim that biological sex is “assigned at birth”. The previous version stated confidently:

“Biological sex is assigned at birth, depending on the appearance of the genitals. Gender identity is the gender that a person “identifies” with or feels themselves to be.”

“Gender dysphoria – discomfort or distress caused by a mismatch between a person’s gender identity and their biological sex assigned at birth.”

NEW is this definition:

“Gender dysphoria is a term that describes a sense of unease that a person may have because of a mismatch between their biological sex and their gender identity.”

GONE is the section “What causes gender dysphoria?” that confused gender dysphoria with various differences of sexual development (DSDs) or intersex conditions such as androgen insensitivity syndrome (AIS) and congenital adrenal hyperplasia (CAH).

GONE is the link to the WPATH guidelines, previously listed under the heading Clinical Guidelines.

Overall, then, the updated NHS gender dysphoria pages are an improvement on what went before; less ideological, more careful with language and more factually informative.

However, there are two sections in the ‘healthy body’ section of the NHS website that repeat the old information and are not up for review until June 2021. The ideological tone of these two pages contrasts sharply with the new more accurate explanatory tone of the updated pages. The page Think your child might be trans or non-binary? tells us that:

“We now believe that gender identity is on a spectrum, with male at one end, female at the other and a “diversity” of of gender identities in between. These can include male and female, non-binary or even agender (no gender).”

And that:

“A small number of children who have continuing, strong feelings of a different gender identity will go to live full-time in a gender different from the one assigned at birth.”

The page also contains information which reinforces the idea that puberty blockers are simply a ‘pause button’ that buys time:

“Possible treatment options will be discussed, such as talking therapy and treatment with hormone blockers, which will pause puberty while your child thinks through their gender identity.”

Worried about your gender identity? Advice for teenagers tells adolescents that:

“You may question your gender if your interests and social life don’t fit with society’s expectations of the gender you were assigned at birth. You may be uncertain about your gender identity and feel that you can’t identify with being either male or female.”

“You may feel that you are both male and female or that you have no gender, which can be referred to as non-binary or agender.”

“You may have a strong sense of being the opposite gender to the one you were assigned at birth and may feel that you have been in the “wrong body” since early childhood.”

“For young people who feel distressed about their gender, puberty can be a very difficult and stressful time. This is the stage where your assigned gender at birth is physically marked by body changes, such as the growth of breasts or facial hair.”

“If you experience discomfort with your gender identity, you may feel unhappy, lonely or isolated from other teenagers.”

Imagine being a socially awkward, non-conforming teenager reading this. Same-sex attracted teens, those with autism or those who are bullied or simply feel that they don’t ‘fit in’, together with a large percentage of teenage girls who experience distress at the changes of puberty, could so easily identify with the information on this page and the explanation it gives. 

The danger of understanding your feelings and personality in this prescribed gender-focused way becomes apparent in the following information which normalises medical intervention and minimises the effects. Although the unknowns are acknowledged in the updated section, teenagers are told that blockers are ‘reversible’:

“If you have strong and continuing feelings of identifying as a gender that is not the one you were assigned at birth, and are distressed about this, there are various options available.”

“The hormone blockers will pause the physical changes of puberty, such as breast development or facial hair, and can also provide the time and opportunity you may need to decide how you feel about your gender identity.”

“Older teenagers who are already going through puberty can also find hormone blockers helpful in alleviating distress around the way their body is developing.”

“Although the effects of hormone blockers are reversible once the medication is stopped, it’s important that you understand the physical implications of hormone treatment before you go ahead with the treatment.”

To the unhappy teen struggling with body changes they can’t control, blockers must seem like a solution to all their problems; a gift that, crucially, puts them back in control. How easy it seems: a drug that stops all the changes you’re struggling with, and free on the NHS so it must be okay.

Compare the confident and certain language above with the position statement issued by the Royal College of General Practitioners last year:

RCGP Position statement:

“There is a significant lack of robust, comprehensive evidence around the outcomes, side effects and unintended consequences of such treatments for people with gender dysphoria, particularly children and young people, which prevents GPs from helping patients and their families in making an informed decision.”

“The promotion and funding of independent research into the effects of various forms of interventions (including ‘wait and see’ policies) for gender dysphoria is urgently needed, to ensure there is a robust evidence base which GPs and other healthcare professionals can rely upon when advising patients and their families. There are currently significant gaps in evidence for nearly all aspects of clinical management of gender dysphoria in youth. Urgent investment in research on the impacts of treatments for children and young people is needed.”

The updates the NHS has made to the gender dysphoria pages are significant and the changes are welcome. However, out-of-date information is still available on the page parents of young children will look to for information, and on the page that teenagers may read. Information has been updated because the old information was misleading in critical areas, so these two pages need an urgent review to reflect current thinking and to be consistent with the new section.

The new section can be found here: