Puberty Blockers for Minors: The Ethics of Healthcare in a Politicised Landscape
Written By Riddhi Shivkar
Contextualising the Issue
Gender services in the UK have been thrust into thorny territory, leaving no one exempt from the pressure to adopt a polarising standpoint on either end of the debate. Operating in this highly politicised context poses many challenges to healthcare workers, particularly with the sharp increase in under-18s referred to gender services in the last five years.
The Cass Review, published this April, was a direct reaction to this surge in referrals: an independent review of NHS England’s gender identity services for minors. One of its aims was to guide clinicians on usage of puberty blockers, i.e. gonadotropin-releasing hormone agonists (GnRHa), in children struggling with gender dysphoria. The review underscored the undetermined biological consequences and ethical challenges of using these drugs, whose effects in this clinical context are still under-researched.
Reflecting this uncertainty, the Labour government recently announced an indefinite ban on the prescription of puberty blockers for under-18s, outside tightly controlled NHS clinical trials: a controversial decision that has been met with divided opinion. Supporters emphasise the importance of well-founded evidence, whereas critics warn of the dangers of restricting care to an at-risk demographic. Both sides raise integral concerns that complicate clinical decision-making, without even attempting to wade into the hostile socio-political commentary surrounding the trans experience in general.
Untangling these intersecting issues in a double-page spread to a degree that does them justice is an impossible task. Nevertheless, in writing this article, I hope to shed some light on the conversations at the crux of this debate and underscore the uncertain basis on which trans healthcare policy rests in the NHS.
The Question of Competency
The Bell v Tavistock case, running from 2020 to 2021, was a pivotal ruling in the realm of trans healthcare for minors. Keira Bell, a former patient of The Tavistock Centre, challenged their practices on the usage of puberty blockers, she herself feeling misinformed and regretful about being prescribed them at age 16. This case raised significant concerns about the application of Gillick Competency in decisions regarding medical treatments for minors, with a unique spotlight placed on the lack of clear, evidence-based research surrounding the long-term effects of these drugs on adolescent bodies.
Gillick Competency, established in the 1985 Gillick v West Norfolk case, allows under-16s to consent to medical treatment if they demonstrate sufficient understanding of the nature and consequences of it. Casting doubt on this framework, the backbone of the NHS's guidelines on children’s decision-making, risks a slippery slope. What implications does it impress upon similar areas of debate, such as abortion or contraception? Are we leaving vulnerable young people increasingly subject to stricter judicial or parental oversight, limiting their access to essential healthcare?
In the Bell v Tavistock case, the High Court ruling in 2020 suggested those under 16 may not possess the maturity required to fully grasp the irreversible effects of such treatments - though, less than a year later, the Court of Appeal overturned this. Emphasis was placed on the fact that it should be the clinician’s role, not the court’s, to decide on a child’s competency on an individual basis - an apparent, neatly resolved conclusion to this debate.
The Question of Consent
Of course - it is not that simple. For clinicians to adequately inform patients, they themselves need adequate amounts of information and an unbiased perspective. The uncertainty surrounding GnRHa used as puberty blockers raises an essential question: how can anyone, let alone children, be expected to give truly informed consent when the necessary information isn’t available, or obscured by socio-politically biased beliefs?
The issue of the unknown seems to be key here; after all, evidence-based research is the cornerstone of modern medicine. However, off-label prescribing, the official term for the use of a licensed medication in unapproved patient groups or dosages - is not unheard of, and is not unique to GnRHas. Another example of this practice is the use of Avastin (primarily approved as a cancer drug) for age-related macular degeneration, despite not having been clinically trialed in that specific disease context. So, rather than the lack of clinical-trial based research into GnRHas’ repurposed use as puberty blockers, is the central issue really that these patients are adolescents? GnRHas are approved for use in precocious puberty, for children as young as eight, so this also seems unlikely.
We circle back now, to a child’s capacity to consent and, more poignantly, the unspecified long-term effects. An unanswered question remains: why do we still not have this information? Is transphobic rhetoric so deeply entrenched into our society that the patient demographic being trans youth, in itself, is a barrier to further research? To conduct this specific research is a difficult task, yet pharmaceutical companies seem all the more reluctant to engage for fear of the socio-political backlash and minimal economic gain. Here, a Catch-22 is created and, inevitably, children are left to suffer - either from the consequences of under-researched treatments or the consequences of delayed or denied care - while the debate remains stuck in a cycle of ideological conflict rather than scientific clarity.
The Question of Care
At the heart of this issue is the fundamental question: how do we alleviate these children’s suffering? Gender dysphoria is not a trivial matter of "bad feelings" or fleeting confusion—it is an intensely distressing and debilitating condition that can have serious psychosocial impacts on a child’s day-to-day life. Effective care must begin with acknowledging this and providing a compassionate, evidence-based approach.
One method already used is the psychological screening of children with gender dysphoria for underlying conditions or comorbidities, which is critical in understanding the full scope of a young person’s needs. Nonetheless, to many of these patients, puberty blockers are seen as a more concrete medical intervention, providing a level of tangibility to the treatment being received through gender services. The physical and biochemical changes promised by these drugs are the epitome of why they have sought out medical help in the first place – their own self-perception being given a chance to align with the way their bodies act and interact with others. For some children, puberty blockers may seem like the only way to feel truly at ease with themselves and to navigate a world where fitting into societal norms can be a matter of survival. The political eclipsing of these children’s right to social and emotional stability is detrimental, and a poor snapshot of the standard of care the NHS should be delivering to an already marginalised demographic.
What do we do?
Growing up is inherently a challenging phase of life, and to add to that a disjointed sense of self and fears of social exclusion, stemming from this intrinsic part of one’s identity, is a burden we should not let these children face alone. Re-education and re-aligning societal views on the rigid, binary construct of gender would be an idealistic, ultimate goal – an understanding of this would promote a much more nuanced lens in which gender services and trans healthcare policy could be examined and put across.
However, this could take generations: on the issue of puberty blocker usage, the government’s promise of rigorous clinical trialling is a small victory in light of the recent ban; more engagement and research to secure robust foundations for this science to rest on is imperative. This would ensure that children fully understand what they are consenting to and allow them the space to look into other treatments—medical or otherwise—that could aid them through this exciting, exhausting, explorative, and critically formative period of their lives, with as little turbulence as possible.
Read the rest of the edition here
