The clinical management of children experiencing Gender Dysphoria is a hot topic with often very polarised views on how they should be treated. There is huge concern about the mental health of our children and young people in general and how society and the medical profession should be best supporting and treating them.
Children are vulnerable and still developing both physically and mentally. They deserve the best, evidence-based treatments to ensure good outcomes for their futures. In most areas of medicine, especially paediatrics, treatment pathways are only initiated once they have been trialled and found to be effective. The ethics surrounding clinical trials in children will always be difficult in that informed consent from the child is often not possible and it is the parent that gives consent on their behalf.
A recent edition of the BMJ drew attention to the study being undertaken at the Tavistock Gender Identity Development Service (GIDS) regarding treatment with puberty-blocking drugs (Gonadotropin-releasing hormone agonists or GnRHa)
GnRHa are typically prescribed by doctors seeking to give children a ‘breathing space’ to allow them to grow in maturity before making long-term decisions about their gendered future.
In a Panorama programme in February 2019, Trans Kids: why medicine matters, and a blog post in the BMJ by Karl Heneghan, significant concerns were raised about the evidence base for the use of GnRHa in children and the lack of knowledge around long-term outcomes for children. GIDS were undertaking a trial of these treatments but concerns about the way this trial was carried out, and some of the evidence that had not been formally published, were raised by Dr Michael Biggs in March 2019 when he used freedom of information requests to obtain the study’s protocol and information sheets. The study finished in February 2019, but the full results have not yet been published.
A report from the investigation into the study by the HRA (Health Research Authority) has just been published and notes several concerns raised by various parties including:
- Lack of a control arm
- Recruitment to study before ethical approval had been granted
- Parents and children were not adequately informed of the risks of taking part
- No annual progress reports submitted
- No interim or final report has been formally published
- Evidence that the study’s interim results were unfavourable but had been downplayed
- The study had been cited by the Gender Identity Development Service (GIDS) to justify extending the use of puberty blockers prior to the completion of the study
- All participants at interim analysis had progressed to cross-sex hormones and therefore puberty suppression was not acting as the intended ‘breathing space’ before making long-term decisions.
In the report, these concerns are discussed at length together with justifications given for approval and continuation of the study. The investigation concluded that the research team had ‘worked in accordance with recognised practice for medical research…no cause for the study to be reviewed or considered for suspension or termination‘.
Significant concerns remain over the use of puberty blockers for three main reasons:
- The unknown long-term effects, both physical and emotional, of blocking puberty
- The fact that almost 100% of children who take puberty blockers go on to take cross-sex hormones.
- Is it possible for a child or adolescent to give truly informed consent for a treatment that has lifelong implications?
Several ex-GIDS clinicians have gone public with their concerns about the use of puberty blockers, in particular about the increasing lack of comprehensive psychosocial assessment and consideration of other psychological therapies. Most recently, Sue Evans (a psychotherapist) is involved in a legal case being brought against the Tavistock seeking a judicial review of treatment with puberty blockers due to concerns about them being given to children who cannot properly consent.
In addition, there are increasing numbers of young adults coming forward (some who have had medical and surgical gender reassignment treatment) wishing to return to their biological sex (known as detransitioners). This further brings into question the ability of children and adolescents to give informed consent to treatment and the adequacy of assessment before treatment.
It has recently been reported that the world-renowned child and adolescent psychiatrist Christopher Gillberg says he thinks the unproven treatment of trans-identifying children is ‘possibly one of the greatest scandals in medical history’.
Jesus treated with absolute respect and kindness those marginalised by society and urged us to ‘Do to others as you would have them do to you‘; all health professionals regardless of faith would embrace the principle ‘Do no harm‘. A Christian medical response must therefore always seek to be both inclusively unconditional in the care we give and to ensure that the treatments we administer are going to be genuinely in the best interests of our patients.
Children with gender dysphoria deserve detailed psychosocial assessment, treatment for other co-morbid conditions and the best evidence-based treatments. Sadly, this is currently not happening. We can only hope that as more people are willing to speak out, a real debate can take place and these vulnerable children can get the help and support that they need.