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On Wednesday the Women and Equalities Select Committee (WESC) held what they described as an ‘evidence session’ on the use of puberty blockers. We will give the first word to Keira Bell who attended the hearing to be a witness to what was said about the medical ‘treatment’ that harmed her:

It is now clearer than before that these ‘experts’ – one of whom was in charge of my treatment – do not have children’s wellbeing as their priority. I found it deeply troubling and hurtful to hear their lack of emotion in this matter, the denial of the lack of evidence and their ideologically driven spiel. I am sickened by the continuous lies and evasion of facts and accountability – Keira Bell

Keira’s full statement can be read at the end of this post.

Medical evidence is a subject outside the remit of a select committee on Equalities to assess in any meaningful way. We would not expect members of this committee to be qualified to do this. A select committee can discuss any issue it chooses, but as this hearing will have no impact on government policy it seemed like a colossal waste of everyone’s time for no definable purpose.

The medical evidence for puberty blockers to treat gender dysphoria has been thoroughly examined, research reviews have been done, the experts consulted, and the report published, after four years of work. Rather like the BMA’s arrogance in supposing they can complete an ‘evaluation’ of the Cass Review in a matter of months and as a trade union add anything useful, we have to ask the question: what was WESC trying to achieve with this meeting?

Rather than invite Hilary Cass or any of the researchers from the University of York who conducted the systematic reviews of evidence that informed the Cass Review, the committee chose three witnesses who could not, or would not, answer their questions.

Most inexplicably, one of these was Gary Butler, the former Clinical Director of the disgraced Tavistock Gender Identity Development Service (GIDS), the service that was shut down on the basis of being rated ‘Inadequate’ by the Care Quality Commission (CQC) and the Cass Review’s findings. Some might say that Butler should be held accountable for some of the failings of the GIDS rather than being given an expert witness platform by a government committee.

Butler is known for his continuing defence of the approach taken at the GIDS that failed so many children, and for questioning the personal integrity of Dr Cass.

Professor Simona Giordano, who sits on the ethics board of the discredited World Professional Association of Transgender Health (WPATH), is best known for publishing papers wholly in favour of medicalising children experiencing gender-related distress. Her review (2008) cited by the GIDS as an influence in the decision to establish the Early Intervention Study, argued that ‘the UK position of not offering early pubertal suppression was unethical.’

This is hardly surprising when Giordano also considers that it may be ethical, even moral, to offer surgery to minors. In 2016 Giordano was one of the authors of a published paper entitled Sex Change Surgery for Transgender Minors: Should Doctors Speak Out? which argued that “there are important moral and clinical reasons to think that it may be ethical to offer such surgery, or even that moral reasons require that it should be offered, to minors as well as adults in some circumstances.”

The third witness, Professor Ashley Grossman, is an endocrinologist who does not work in paediatrics or in gender services for children. Although potentially the only unbiased member of the panel, his medical expertise is therefore likely to be limited in this specific area.

For example, while correctly stating that the vast majority of children on blockers go on to cross-sex hormones, Professor Grossman mistakenly thought this was in adulthood. When he asked Professor Butler “Is that not right?” Butler did not correct him.

Nevertheless he was the only member of the panel who expressed concerns, which appeared to be genuinely heartfelt, at the exponential rise in numbers of children referred to gender clinics, particularly the predominance of teenage girls who commonly struggle with insecurities during adolescence. It was the only real feeling that was expressed by the panel, who otherwise seemed to be disconnected from compassion for their subjects, or curiosity about their experienced distress at puberty.

“Concerns are not evidence” pronounced Professor Giordano with authority, as if complacency is.

Holding this discussion by a government committee with an Equalities brief was revealing in itself. Equalities is an inadequate and dangerously misleading framework within which to view medical procedures on children.

It was striking how many questions by committee members were focused on other conditions where blockers are used in medical treatment of both adults and children. ‘Equalities’ doesn’t distinguish between adult and child, or between different clinical indications, it distinguishes between ‘transgender’ and ‘cisgender.’

These are politically useful terms for activists only. Although they are essentially undefinable words relating to subjective self-described feelings, they are used to separate children into two concrete, distinct categories. Thus they serve to obstruct understanding and distract attention away from the real issue: are puberty blockers safe and effective treatment for this one particular presentation in children?

‘Equalities’ frames the issue as one of ‘rights,’ the rights of the ‘transgender child’ v the ‘cisgender child’ and this was a hearing that clearly attempted to distort the issue through that lens.

That is why the medical condition of central precocious puberty featured heavily in the debate, and why a physical, medical condition was conflated so often with the completely different psychological presentation of gender dysphoria. When asked, for example, about the reversibility of blockers Professor Butler was able to profess ‘In the main, yes, it is recognised as a reversible treatment – I cannot recall a case where puberty did not restart.’ He was also able to say that there ‘aren’t any side-effects as such, just normal resumption of puberty.’

How many people following this debate would realise that he was talking about children who experience precocious puberty and not children who are gender distressed, for whom we do not have this evidence?

Later on in the discussion Professor Grossman said ‘I don’t think we have that evidence do we?’ in response to another question about physiological reversibility, using the example of a 14 year-old girl on blockers who stops them at age 17. Even then, Professor Butler replied yes, there were ‘some cases’ where puberty had resumed. As only one child stopped blockers without progressing to cross-sex hormones in the Tavistock’s own Early Intervention Study, where are all these girls who resumed normal puberty with no physiological effects and why haven’t we heard about them?

“It is regarded, certainly in children and adolescents, as just a standard treatment” said Professor Butler in response to the next question about different uses for children, including for those with physical growth abnormalities and cancers. When asked whether there was any difference between these treatments and the approach for children with gender dysphoria, Professor Butler stated that the latter receive a full psychosocial assessment beforehand and that the only difference is that it is not the endocrinologist who makes the decision to treat.

This was a masterclass in obfuscating the facts.

It was down to Professor Grossman to point out the real difference: that in precocious puberty you are changing an abnormal puberty into a normal puberty, whereas for gender dysphoria you are changing a normal puberty into an abnormal puberty.

In contrast to Professor Butler and Professor Giordano, who seemed to be more interested in demonstrating their own professional authority, Professor Grossman’s contributions were relevant and to the point. He described blockers as ‘highly potent drugs with rather uncertain consequences’ and pointed out the fact that there is no way of determining whether a child will benefit or not.

Professor Giordano spent some time insisting that clinicians were very careful and would never prescribe blockers unless they were very certain that the benefits would outweigh the risks for a particular child. This is impossible to predict; doctors do not possess the ability to see into the future.

Professor Grossman explained that in different indications, such as prostate cancer or endometriosis there are clear biological measures of a physical abnormality to treat, whereas in the case of gender dysphoria you are ‘interfering on subjective grounds’ with a natural process.

To this statement of fact Professor Butler responded defensively that at the GIDS they also looked at similar physical measures such as height and weight before treating. Did he really not understand the point Dr Grossman was making, or did he want to mislead his non-medical audience to think that the two cases are comparable? He then claimed that lifestyle factors such as diet, vitamin D and exercise successfully mitigate loss of bone density. Professor Giordano supported him in this assertion by adding that a research study showed that there had been ’no complaints.’

In response to questions about off-label drugs Professor Giordano claimed that the gender dysphoria cohort was ‘remarkably similar’ to the precocious puberty cohort as in both cases the aim was to delay pubertal development. It sometimes felt as if she wasn’t aware that there is a living, breathing human child attached to that puberty. In fact this was Giordano’s whole stance: blockers work to block puberty, therefore it is an effective treatment.

Professor Giordano’s comment that the rules for clinical trials are especially stringent for children and you cannot conduct a trial if you don’t know the benefit/risk ratio is likely to be positive, seemed like a good argument for not going ahead with the proposed trial, as that criteria cannot be met. But Giordano was actually using that fact to advocate for puberty blockers to be given routinely, outside a trial setting.   

It was left to Independent MP Rosie Duffield to properly challenge Professor Butler, pointing out that Keira Bell was sitting behind him, and that she, along with other detransitioners, would probably take issue with his previous comments that puberty would resume if treatment was stopped. This finally  forced Butler to concede that actually he’d previously been talking about children with precocious puberty. Why didn’t he clarify this earlier and why did no other member of the committee take him up on it?

Duffield also asked the million dollar question: what outcome are blockers used to achieve? Other than in the case of precocious puberty?

It was a very good question as it forced Butler to move from his previous display of authoritative medical knowledge into the ideology that underpins the ‘gender affirmative’ model he believes in. He answered that blockers are used ‘as part of the management of dysphoria and to support the young people through their transgender journey, and this is one way of helping them in that regard.’

Children are on a transgender journey. That, in a nutshell, is the belief that drives the medicalisation of troubled adolescents. It is the message of activists.

Duffield then asked another good question given the false claims made against the methods of the Cass Review: ‘Do you know of any good evidence that Hilary Cass didn’t look at, that shows that puberty blockers achieve that purpose?’

Butler responded that according to the hierarchy of evidence it doesn’t meet that standard as most studies are observational. He might have added that the wealth of existing studies are confounded, biased, and use poor methodology, written by researchers ideologically invested in the ‘gender affirmative’ approach.

When asked why did you continue to prescribe blockers when the results of the Early Intervention Study didn’t demonstrate clear benefit? the answer from Butler was revealing: it was because they had a contract with the NHS and that it was within the service specification. He might just as well have said ‘I was just following orders.’

He further absolved himself of any responsibility in reply to the next question.

On being asked why the results were not published until 2020, Butler claimed that he wasn’t directly involved with that study (in fact, he was the second author.) He also claimed that longitudinal studies take time, but this wasn’t a longitudinal study. The participants were not followed up once they transferred to adult services.

The question ‘is this transing away the gay?’ was put to Professor Grossman, perhaps as the panel member most likely to give an honest answer. What he said was in stark contrast to Professor Butler’s obfuscation, dishonesty and deflection.

Grossman’s concern is that the treatment puts children on a trajectory to an automatic transgender state (the transgender journey as Butler called it) and that at the Tavistock they were put on a conveyor belt with inadequate follow-up and ‘probably inadequate assessment in the first place.’

After Butler and Giordano it was a relief to hear someone talk honestly about both the failings that led to the closure of the GIDS and the reality of adolescence. At this stage of life, he said, ‘many other things are going on’ and that problems with neurodiversity and autism were not properly explored.

When the question was thrown open by the Chair, Butler claimed that despite GIDS being ‘overwhelmed’ with the ‘exponential rise’ in referrals, particularly of girls, that in Endocrinology ‘we were not seeing them.’ He did not answer the question about children who would likely grow up to be gay or lesbian.

Giordano fell back on the excuse that ‘international consensus and recognised practice is to consider puberty blockers’, a justification that is wearing a little thin now that it is no longer true.

Duffield managed to get one more question in, on whether the GIDS had been ‘overwhelmed’ with autistic children?

Butler said that the NHS were aware of expansion of numbers of autistic children but were not able to take action at the time because the service was overwhelmed.

Towards the end of the hearing the claims became ever more extraordinary. Professor Giordano said that in the case of gender dysphoria, we cannot expect improvement with blockers: stability can be a good clinical outcome because the expectation would be that the distress would get worse. Why? This is not reflected in the recent study of 2,772 adolescents, which found that gender non-contentedness ‘in general decreases with age.’ Growing up is a common cure for adolescent troubles.

We heard that although blockers have no benefit, that’s not what blockers are for, blockers are not a treatment for gender dysphoria. It was claimed with certainty that in the case of precocious puberty there are no long term harmful effects on brain development, bone density or fertility. Professor Butler said he doesn’t see why the use for gender dysphoria would be any different. That extraordinary comment cemented the conflation of two very different indications, neatly rolled up as one and the same.

And the solution for the lack of quality evidence? Professor Giordano summed up what she and Butler had been advocating throughout: move the goalposts. Accept low quality evidence for this one area of medicine. And this is not a matter for parliament or legislators, it’s between clinician, child and family.

If we were asked to guess at the brief for this hearing, it would be: ‘try to get them to say that precocious puberty and gender dysphoria are just the same, so we can claim it’s discrimination against trans kids to deny them the puberty blockers that cisgender children get.’ If not for Professor Grossman on the panel and committee member Rosie Duffield, this could well have been the conclusion of this hearing. We are grateful to both of them for their incisive questions and comments.

At the very least the hearing sought to undermine and discredit the Cass Review, the NHS and the current and previous governments. In fact the Women and Equalities Select Committee only managed to discredit themselves as a serious committee.

Together with Keira Bell we attended this WESC hearing to be witnesses. It felt like we were back in 2015. What we heard was shocking and inexcusable. Given what we know about the harms of the ‘gender affirmative’ medical pathway it was difficult to listen to the complacency of the so-called experts. How much more difficult – and courageous – for Keira, who is visible sitting behind Professor Butler every time he speaks. The last word goes to Keira Bell.

It is now clearer than before that these ‘experts’ – one of whom was in charge of my treatment – do not have children’s wellbeing as their priority. I found it deeply troubling and hurtful to hear their lack of emotion in this matter, the denial of the lack of evidence and their ideologically driven spiel. I am sickened by the continuous lies and evasion of facts and accountability.

A minor in distress signifies a deeper problem, rather than a need for experimental drugs to drastically alter their physical appearance – damaging them in the process. The system these so-called experts work with leans on this distress and twists it in a way that profits them, instead of genuinely helping these people via honest enquiry and therapy. This is something the Cass Report has recommended and it is something I wish was afforded to me as a teenager – Keira Bell