Upon stepping into Parliament’s committee room six yesterday afternoon (22 January), I felt like I had travelled back in time. Otherwise, there is little to explain the anachronistic, ignorant questions put forward by members of the Women and Equalities Select Committee (WESC) and their bizarre choice of witnesses, who were ill-equipped to answer them. All it went to show is how so many politicians have failed to engage in the detail of the debate on how best to care for gender-distressed young people and how far we are, still, from settling it.
The committee had chosen to hold a one-off session on the “Evidence base on the safety and effectiveness of puberty blockers”. This seemed strange given the recent four-year review into youth gender services that looked at that very question. Surely, therefore, you’d call the person who led that process, Dr Hilary Cass, as a witness? Apparently not. Or a member of the team from the University of York who carried out the independent, peer-reviewed study of the evidence base for the use of puberty blockers to treat gender-related distress? This group had concluded: “There is a lack of high-quality research assessing puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development. Bone health and height may be compromised during treatment.” None of them were invited either.
Instead, Sarah Owen, the committee’s Labour chair, chose to hear from the former clinical director of the Gender Identity Development Service (Gids, the Tavistock children’s service roundly criticised and closed down as a consequence of the Cass Review); a professor in bioethics who has argued for close to two decades that it is unethical to deny children treatment with puberty blockers; and an emeritus professor of endocrinology who, while no doubt an excellent endocrinologist, has never worked with gender-distressed children, nor contributed to the research in this area.
Throughout the session, consultant paediatric endocrinologist Professor Gary Butler, who ran the endocrine clinic at University College London Hospitals (UCLH) which prescribed puberty blockers, seemed to be talking about a completely different Tavistock clinic to the one that was closed by NHS England. We know from Gids’ own data, CQC inspections and clinicians who carried out the assessments of young people, that these could be completed – at times – over just two or three appointments. Yet Butler talked of each child receiving an “extensive review”.
When the diagnosis of gender dysphoria had been made, Butler explained, he and an endocrine colleague would assess again for a child’s suitability for puberty blockers, including assessment of competence or capacity.” Yet we know, from Butler’s own published data in 2022, that just one young person – out of 1,089 referred by Gids and seen by endocrinologists – was judged to lack capacity to consent to treatment. Butler apparently didn’t see the hundreds of teenage girls who filled Gids’ waiting room either, the ones whose distress had only begun after the onset of puberty, and who were often contending with other difficulties. They didn’t ever “get in the way of endocrinology”, he said. “We were not seeing them. And furthermore, because they had already gone through their biological puberty, there really wasn’t a place for puberty blockers.” Butler did not offer an opinion on whether he shared the concerns of some Gids staff that many of the young people prescribed puberty blockers on his watch, would most probably have grown up to be gay or lesbian, had they not transitioned.
[See also: Hilary Cass interview: “Do I regret doing it? Absolutely not”]
Not one of those asking the early questions pushed back against this. Thankfully, after 45 minutes, a dissenting voice emerged in the form of Rosie Duffield, who not only knew what went wrong at Gids, but has also read the Cass Review. (It’s unclear where the others have been for the last five years.) How did Butler know all those children who had gone through Gids and his care were OK? Earlier comments, Butler clarified, had been about children with precocious puberty. “I know there are some situations where we don’t know the full outcome in terms of every person who’s received puberty blockers from the trans field. We don’t know all the details yet.” This is putting it mildly. We don’t know any of the details. And we don’t know them because neither Butler and his team at UCLH, nor the professionals at the Tavistock followed any of their patients up. It was unbelievable to hear Butler say later – when questioning the viability of a new research trial – that in his view, “The only way… to really get an idea of whether an intervention is successful or not is the long-term outcomes.”
Duffield probed further: “Why did you continue to prescribe puberty blockers when the preliminary results from the early intervention study in 2015-16 – which of course you were heavily involved with – didn’t demonstrate clear benefit?” Butler appeared to put the blame for this on NHS England, simply stating that it had produced the service specification which guided the conduct of the gender services. The Cass Review noted, by contrast, that “clinical practice subsequently appears to have deviated from the parameters set out in the service specification”. Why were the results of that study not published until 2020 (almost a decade after the study began), Duffield asked? “I wasn’t directly involved in that study,” Butler replied. Again, this is demonstrably false. Butler is the second author listed on the paper revealing the study’s results. His roles are recorded as “Conceptualization, Investigation, Writing – original draft, Writing – review & editing”.
Duffield’s time was limited, so her questioning did not extend to Professor Simona Giordano, who Gids once cited as being instrumental in its decision to block puberty in younger children. Giordano had, the gender service said, “argued strongly that it was in the best interests of the child to offer earlier pubertal suppression, that arguments about irreversibility were spurious and that if it were impossible to consent to interventions whose outcome is uncertain, much medical research involving human beings would be unethical”. Judging from what she said at the hearing, Giordano’s views remain the same. But, in Duffield’s absence, no one could scrutinise them properly.
According to Giordano, scientists who had looked into the impact of puberty blockers on the adolescent brain – on executive functioning, cognitive functioning or IQ – “found no difference in the scores of trans young people treated with puberty blockers compared to their cisgender cohorts”. The truth is that scientists just haven’t looked at the cognitive impacts properly at all. Animal studies and controlled case studies suggest that neurodevelopment will be impacted by pubertal suppression. But we don’t know by how much, or how long it may take people to catch up, if ever. Absence of evidence is not evidence of absence. Giordano, who sits on the World Professional Association of Transgender Health Ethics Committee, seemed to dismiss concerns about the impact of puberty blockers on adolescent bones, too, claiming that there were “no cases” in the literature or reports of complaints from patients. Journalists have spoken to them though – both in Sweden, and here in the UK. I have spoken with – and documented – the story of one young trans man who broke four bones while on puberty blockers and under Butler’s care. Butler told the committee that the breaking of bones was “not something we would see in puberty… Even if there is a change in bone density, it rarely gets into the range you would expect fractures to occur.”
That the committee would try to better in two hours what the Cass Review spent four years carefully investigating is incomprehensible. That Sarah Owen believed the WESC could genuinely learn about the safety and efficacy of puberty blockers or gain any meaningful suggestions on how to run a robust research trial from these two witnesses is highly questionable. Butler was the clinical lead of a service that has been closed down in part because of the poor care it provided. He presided over what the Cass Review called, “a departure from normal clinical practice”. It is also publicised that he has been highly critical of Cass in the past, and has questioned the need for any change to the help given to gender-questioning young people.
For her part, Giordano seems to be of the view that it is too much to expect studies to show anything other than that puberty blockers block puberty. They are not intended to improve mental health, nor ease gender dysphoria. She said she does not think that a clinical trial is the way to conduct research, and that in this area of medicine, “it’s perhaps necessary to change the goalposts” and not require the highest grade of evidence because this area of medicine has “such vast repercussions on people’s lives”. Except, there’s the rub. The evidence we have does not show this.
With this pointless, error-strewn hearing (there were many more mistakes I have not mentioned), the only thing the WESC has succeeded in is creating the impression that it seeks to undermine the Cass Review. It was as tone deaf as Giordano’s remark that it was “ethically problematic to withhold medical treatment that is experienced as beneficial, that nobody has complained about, on the grounds that there is not enough evidence yet”, while Keira Bell sat a few feet away. Bell took her “complaints” about treatment, and the regret she felt at having made irreversible changes to her body, all the way to the Supreme Court. The public deserves better than this committee. And young people deserve better than witnesses who don’t think they deserve a higher standard of evidence underpinning their care.
[See also: Why courts could stop a teenager changing her gender]
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