In the more hyperbolic echo chambers of social media, the decision was cast as a lifeline withdrawn for no other reason than state-sanctioned bigotry and transphobia, possibly as part of a covert programme of eugenics. The hysterical pitch of this suicide narrative eventually prompted Professor Louis Appleby, head of the national Suicide Prevention Strategy, to stage an intervention on X. He stated that invoking suicide in this debate was both “mistaken and potentially harmful” and called time on “that line about choosing a living daughter or a dead son” — a line that has terrified so many parents into submission when presented with a medical pathway as the only option for their distressed children. So what does the NHS withdrawal of puberty blockers as a treatment for gender distress actually mean?

Every drug prescribed by a doctor requires a licence issued by a relevant regulatory authority. These bodies carefully review the data from clinical trials to ensure that the drug is effective, safe and meets manufacturing quality standards. However, once licensed for one purpose, these drugs can then be used off-label for another. Off-label means the drug can be prescribed for a condition (or at a dose) other than that for which it has been approved. Off-label prescribing is common, particularly in paediatric medicine, as children are rarely participants in clinical trials for ethical reasons. Up to 20% of drugs may be prescribed off-label. Puberty blockers are licensed in children to treat precocious puberty, a condition where children hit puberty years before their peers, sometimes before the age of five. Although the impacts on bone density are recognised, the drugs are effective at preventing the short stature and ameliorate the significant emotional and behavioural difficulties associated with such an early onset.

Once a drug has a licence for one condition, doctors are free to prescribe the medication for an off-label use, if they have a reason to believe it might help. This is how puberty blockers came to be prescribed to children with gender related distress. The announcement last week effectively put an end to this practice in the NHS.

For as long as puberty blockers were being offered as an off-label treatment by the NHS, clinicians were both ethically and duty bound to monitor their effectiveness. This fundamental duty was largely ignored by the clinicians at Gids who failed to collect adequate data, and rolled out the experimental treatment regardless. In a sign of just how far outside the bounds of normal clinical practice Gids was operating, one senior clinician appeared to be under the impression that auditing the outcomes of the experimental treatments they offered would actually be illegal.

As a result of their failings, we are left with a vacuum of data on the safety and effectiveness of puberty blockers and are back to square one when it comes to evaluating the medication as a prospective treatment for children with gender distress. It’s one thing to attempt to persuade an ethics committee to allow you to monitor the impact of a treatment already in use, albeit in an off-label capacity, quite another to convince them to give the go-ahead to experiment in children with a powerful treatment that will interfere with a critical stage of maturation. Following the withdrawal of off-label prescribing, anyone attempting to design an NHS trial to explore the efficacy of these drugs will need to convince an ethics committee of a sound rationale for reintroducing the drugs in the first place.

In most clinical trials, identifying the target or primary outcome of the treatment is the easy part: antibiotics reduce infection, epilepsy medications stop seizures, cancer treatments eliminate malignancy. No one needs a trial to prove that puberty blockers block puberty — the drugs are unequivocally effective in this regard. But puberty is neither a disease nor an illness. It is a vital stage in the transition from childhood to adulthood, marked by changes that extend far beyond the development of secondary sex characteristics. The brain undergoes extensive rewiring during puberty, creating the adult capacity for nuanced thought and complex decision-making, a process that isn’t complete until well into the third decade of life. Changes in the brain also allow sexual identity to develop. And elsewhere in the body, respiratory and circulatory systems undergo rapid growth and development. The skeletal system changes, increasing in bone density and musculature. Puberty blockers interfere with all of these processes in ways that may or may not be completely reversible — we can’t be sure, as many have not been studied.

But the importance of puberty as a critical developmental stage is such that any case to block it would need to be exceptionally strong to convince an ethics committee to green light a clinical trial. The bar will be set even higher, given the vulnerability of the target population: children who often present with multiple other psychiatric difficulties.

The rationale for using these drugs in gender clinics has undergone a highly unusual evolution over the past two decades. Initially prescribed to a very small number of boys to help them “pass” more easily as adult women, the drugs later began to be prescribed to the increasing number of adolescent girls presenting to these services. With the change in clinical caseload, the rationale for prescribing puberty blockers morphed into the notion that pausing puberty would give these distressed young people “time to think”. However, it is very clear from the data in the UK and Holland that the drugs did anything but, since more than 97% of children who took the puberty blockers went on to take cross-sex hormones. As Dr Anna Hutchinson, one of the original Gids whistleblowers, pointed out: “What are the chances that everyone given time to think, ends up thinking the same thing?”

More from this author

Doctors have failed detransitioners

By Sallie Baxendale

As a neuropsychologist, the irony of stopping puberty in an effort to give young people time to think is not lost on me. Puberty is the neurodevelopmental process that literally constructs the neural architecture that allows people to think about complex and nuanced issues. Blocking puberty prevents the critical rewiring in the brain that underpins the ability make complex decisions. Puberty blockers may give children time to think but they simultaneously rob them of their developing capacity to do so.

In a pivot away from the “time to think” narrative, proponents currently argue that puberty blockers are vital to relieve the intense, even life-threatening psychological distress that trans and gender diverse people experience when puberty begins. This positions the treatment as a mental health intervention for acute psychological distress. Yet this distress may be anticipated rather than acute in those started on the medications as young as eight.

This is a world away from the original rationale. Chemically preventing a vital stage of maturation as a pre-emptive treatment for acute psychological distress also represents a major paradigm shift away from every other approach to treating psychological distress. This rationale is even more extraordinary given the evidence that puberty itself may be the best “cure” for gender related distress in many young people. The proportion of children diagnosed with gender identity disorder in childhood who persist into adulthood is contested, but most studies report that the majority (70% or more) no longer meet the diagnostic criteria once they have gone through natural puberty.

For a clinical trial to go ahead, an ethics committee must first be convinced of a solid rationale to override the safety concerns that were significant enough for the NHS to call a halt to off-label prescribing in this a highly vulnerable group. Researchers will also need to present a strong argument for trialling such an unprecedented treatment paradigm for psychological distress in young people.

If the researchers get this far, there is one final ethical barrier to overcome — and it is huge. The presence of detransitioners demonstrates that this medical pathway has the potential to cause significant, irreversible and lifelong harm. This is often minimised by gender clinicians as “treatment regret”, something which is common in many areas of medicine: many patients regret undergoing treatment when something has gone wrong with a procedure, or the results are not as they hoped. This is an inevitable part of all medical practice; results can never be guaranteed. However, detransitioners were given the wrong diagnosis and the wrong treatment for their distress. They represent the failure of the doctors treating them, not the failure of the treatment.

Even the fiercest advocates for puberty blockers acknowledge that there is no way of knowing who will or won’t be helped by medical transition. There is no middle ground; those who aren’t helped are harmed. Without a reliable clinical test to identify those who will benefit in the long run, an ethics committee that gives the go-ahead for a clinical trial does so in the knowledge that at least some of the children who take part will be unnecessarily put on a pathway of lifelong medicalisation with all its attendant risks and harms. Will any ethics committee in the land be persuaded that this is a price worth paying?

In the meantime, the new NHS gender services have a chance to right some of catastrophic wrongs of the original Gids service. Starting afresh, clinicians can ensure the careful record keeping and clinical audit that should be hard baked into every NHS service. Rigorous, standardised assessments and continuous monitoring of outcomes will provide much-needed information on the holistic treatments, including exploratory therapy that will be offered in the new services for young people with gender distress, since these, too, need to be evaluated.

If a puberty blocker trial ever gets past an ethics committee, we will face a further wait for the results. In the meantime, it is likely that vulnerable children will continue to seek these medications in the private sector, a place where puberty blockers have been  marketed anew as “necessary, safe, effective and life-saving” since the NHS announcement. At least parents now have a choice. When it comes to their children, they can believe the experts in the NHS who, having examined all of the evidence for both the safety and clinical effectiveness of puberty blockers, found it sufficiently lacking to withdraw the treatment. Or they can believe those who frame access to these drugs as a fundamental human right, while profiting financially from every prescription they issue. Rights do have a place in the treatment of children with gender distress: these children deserve the same evidence-based treatments as everyone else.

The sheep studies were particularly interesting as they used twin lambs, administering the puberty blockers to only one in the pair. More than one year after stopping the medication, the sheep who had taken the puberty blockers had still not “caught up” with their untreated siblings in their ability to complete a test of spatial memory. It can, however, be fairly argued that we can only extrapolate so much from the abilities of sheep to remember the way through a maze of hay bales. It is really the studies in humans that are of most interest to those considering prescribing or taking these drugs.

Yet such studies are hard to come by. There are only five that have looked at the impact of puberty blockers on cognitive function in children, and only three of these have looked at these effects in adolescents given the medication for gender dysphoria. In one of these studies, the researchers didn’t measure how well the children were doing before they administered the drugs, so it is difficult to know whether the subsequent difficulties they had on a strategy task could be attributed to the medication. A second study established an excellent baseline, and the researchers employed a gold-standard measure to test the cognitive abilities of the children in the programme before they started the puberty blockers.

Unfortunately, they didn’t re-administer these tests to assess the impact of the medication, but chose instead to report how many of a subset of these children completed a vocational education and how many completed a higher vocational education years later. No outcomes at all were reported on 40% of the children who started out in the study. The final study, however, was beautifully designed: the researchers assessed IQ prior to the administration of puberty blockers and regularly monitored the impact of the treatment over 28 months on a comprehensive battery of cognitive tasks. The results were concerning and suggested an overall drop in IQ of 10 points which extended to 15 points in verbal comprehension. But regrettably, this was a single case study, and while alarming, the conclusions we can draw from one person’s experience are limited.

Last year, I wrote a paper to summarise the results of these studies. The paper explained in relatively simple terms why we might think that blocking puberty in young people could impact their cognitive development. In a nutshell: puberty doesn’t just trigger the development of secondary sex characteristics; it is a really important time in the development of brain function and structure. My review of the medical literature highlighted that while there is a fairly solid scientific basis to suspect that any process that interrupts puberty will have an impact on brain development, nobody has really bothered to look at this properly in children with gender dysphoria.

I didn’t call for puberty blockers to be banned. Most medical treatments have some side effects and the choice of whether to take them depends on a careful analysis of the risk/benefit ratio for each patient. My paper didn’t conduct this kind of analysis, although others have and have judged the evidence to be so weak that these treatments can only be viewed as experimental. My summary merely provided one piece of the jigsaw. I concluded my manuscript with a list of outstanding questions and called for further research to answer these questions, as every review of the medical literature in any field always does.

As a scientific paper, it was not ground-breaking — reviews rarely are. But by summarising the research so far, I thought it would serve as a convenient resource for the numerous authorities currently examining the efficacy of these treatments. It also provided key information for parents and children currently considering medical options. Every patient needs to be aware of what doctors do and do not know about any elective treatment if they are going to make an informed decision about going ahead. Doctors have a duty of candour to provide this.

I was surprised at just how little, and how low quality, the evidence was in this field. I was also concerned that clinicians working in gender medicine continue to describe the impacts of puberty blockers as “completely physically reversible”, when it is clear that we just don’t know whether this is the case, at least with respect to the cognitive impact. But these were not the only troubling aspects of this project. The progress of this paper towards publication has been extraordinary, and unique in my three-decades-long experience of academic publishing.

The paper has now been accepted for publication in a well-respected, peer-reviewed journal. However, prior to this, the manuscript was submitted to three academic journals, all of whom rejected it. “Academic has paper rejected from journal” is not headline news. I have published many academic papers and have also served on the editorial boards of a number of high impact scientific journals. I have both delivered and received rejections. In high-quality journals, many more papers are rejected than accepted. The reasons for rejection are usually a variation on the themes that the paper isn’t telling us anything new or that the data is weak and doesn’t support the conclusions that the authors are trying to draw. In a paper that is reviewing other studies, reasons for rejection typically include criticisms of the ways the authors have looked for or selected the studies they have included in their review, with the implication that they may have missed a big chunk of evidence. Sometimes the subject of the review is too wide, too narrow or too niche to be of value to the wider readership.

While imperfect, anonymous peer review remains the foundation of scientific publishing. Theoretically, the anonymity releases reviewers from any inhibitions they may have in telling their esteemed colleagues that, on this occasion, they appear to have produced a pile of pants. When it works well, authors and editors receive a coherent critique of the submitted manuscript, with reviewers independently highlighting — and ideally converging — on the strengths and weaknesses of the paper. If done sloppily, or if the reviewers have been poorly selected, the author may be presented with a commentary on their work that is riddled with misunderstandings and inaccuracies. Requests for information already provided are common, as are suggestions that the author include reference to the anonymous reviewer’s own body of work, however tangential to the matter in hand. I have been on the receiving end of both the best and worst of these practices over the course of my career. However, I have never encountered the kinds of concerns that some of the reviewers expressed in response to my review of puberty blockers. In this case, it wasn’t the methods they objected to, it was the actual findings.

None of the reviewers identified any studies that I had missed that demonstrated safe and reversible impacts of puberty blockers on cognitive development, or presented any evidence contrary to my conclusions that the work just hasn’t been done. However, one suggested the evidence may be out there, it just hadn’t been published. They suggested that I trawl through non-peer reviewed conference presentations to look for unpublished studies that might tell a more positive story. The reviewer appeared to be under the naïve apprehension that studies proving that puberty blockers were safe and effective would have difficulty being published. The very low quality of studies in this field, and the positive spin on any results reported by gender clinicians suggest that this is unlikely to be the case.

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Why I stopped being a good girl

By Hadley Freeman

Another reviewer expressed concerns that publishing the conclusions from these studies risked stigmatising an already stigmatised group. A third suggested that I should focus on the positive things that puberty blockers could do, while a fourth suggested there was no point in publishing a review when there wasn’t enough literature to review. Another sought to diminish an entire field of neuroscience that has established puberty as a critical period of brain development as “my view”.

In a rather telling response, one of the reviewers used religious language to criticise the paper. They argued that the sex-based terms I had employed to describe the children in the studies — natal sex, male-to-female, female-to-male — indicated a pre-existing scepticism about the use of blockers. They suggested that the very presence of these terms would cause people who prescribe these medications to “outright dismiss the article”, and went on to say that by using these terms the paper was “preaching to the choir” and would do a “poor job of attracting new members to the fold”. However, the most astonishing response I received was from a reviewer who was concerned that I appeared to be approaching the topic from a “bias” of heavy caution. This reviewer argued that lots of things needed to be sorted out before a clear case for the “riskiness” of puberty blockers could be made, even circumstantially. Indeed, they appeared to be advocating for a default position of assuming medical treatments are safe, until proven otherwise.

Yet “safe and fully reversible” can never be the default position for any medical intervention, never mind a treatment that is now deemed experimental by authorities in Europe and the UK. Extraordinary claims demand extraordinary evidence, and the only extraordinary evidence here is the gaping chasm of knowledge, or even apparent curiosity, of the clinicians who continue to chant “safe and completely reversible” as they prescribe these medications to the children in their care. It is not the job of a scientific paper to “bring people into the fold”; it is the job of clinicians to understand the evidence base of the treatments they offer and communicate this to the patients they are treating.

I sincerely hope that any arrest in brain development associated with puberty blockers is recoverable for young trans and gender diverse people, who are already facing significant challenges in their lives. I would welcome any research that indicates that this is the case, not least for the significant insights that would present to our current understanding of puberty as a critical window of neurodevelopment in adolescence. Puberty blockers almost invariably set young people on a course of lifetime medicalisation with high personal, physical and social costs. At present we cannot guarantee that cognitive costs are not added to this burden. Any clinician claiming their treatments are “safe and reversible” without evidence to back it up is failing in their fundamental duty of candour to their patients. Such an approach is unacceptable in any branch of medicine, not least that dealing with highly complex and vulnerable young people.

From her early interviews in 2012, when her trans daughter, Jackie, then 19, became a Miss England finalist, Green, then an IT-manager, was utterly open about how she first knew her child was trans: “As a toddler, Jackie always headed for the dolls in toy shops.” And if a four-year-old looking at dolls weren’t evidence enough that this child should be committed to a lifetime of medicalisation, Green added, “[Jackie] loathed having her hair cut.” Green put Jack — as he was then known — on puberty-blockers and flew him to Thailand for a sex change operation when he was 16, making him the youngest person in the world to undergo that surgery.

She merrily recalls in a YouTube interview that because Jack’s penis hadn’t developed due to the blockers, “there wasn’t much for the surgeon to work with” when constructing their vagina. “Sorry, Jackie!” she laughs.

During her time at Mermaids, Green has been advising parents, schools, the police, the media and NHS trusts about how to deal with other children who dare to not be gender stereotypes. She was their first staff member — before Mermaids was run by volunteers — and under her leadership, she has transformed the organisation from a quiet, low-key charity to an energetically active lobbying group, and her theories about childhood and gender have been at least as influential as Judith Butler’s. Mermaids has been endorsed by the Be Kind brigade, including Alexandria Ocasio-Cortez, Jameela Jamil and Emma Watson, accrued a slew of corporate sponsors and been awarded £500,000 by the National Lottery. Progressive newspapers advise readers to contact the service should they have any concerns about their child.

Since 2017, I regularly asked editors at the newspaper where I worked if I could write about Mermaids in general and Green specifically, because it was so obvious that something was very wrong here. The answer, always, was no, but the reasons given were fuzzy: it wouldn’t be right in that section, they couldn’t see the news peg, it felt too niche. A more likely reason was one articulated to me with some passion on social media any time I tweeted anything sceptical about Green or Mermaids: to question either was to wish trans children would die. Doubt the charity, hate the cause, in other words. Weirdly, this attitude seems to hold true only for charities connected to trans issues: no one, as far as I know, screamed that The Times hates starving people when they investigated Oxfam in 2018 about allegations that some of its workers paid for sex.

I do have some sympathy with those who were too scared to question Mermaids. Under Green’s leadership, the organisation has done its utmost to evade scrutiny, trotting out — even in parliamentary committees, even in the 2018 ITV drama Butterfly, starring Anna Friel, and for which Green was the series lead consultant — the claim that 48% of young trans people attempt suicide. A terrifying statistic for any parent of a gender dysphoric child, and almost as scary for any organisation that cares more about being kind than being accurate. Happily, the statistic is bunkum, as the researcher behind the study it’s based on has said, because the study involved 27 self-selecting trans volunteers, and therefore its findings should not be widened out to all gender dysphoric young people, as Mermaids had done.

You would think that discovering attempted suicide is not as common among young gender dysphoric people as previously believed would be greeted with triumphant cheers and celebrations by a charity that claims to support them, and the celebrities who frequently tweet their love for the group routinely described as “the most oppressed people in the world”. And yet, strangely, not so much. As a result, that statistic is still routinely banded around by activists. (Is telling oppressed people that they are likely to try to kill themselves, despite the facts suggesting otherwise, really Being Kind?) It’s the same story with puberty blockers: for years, Green and Mermaids insisted they were fully reversable. Green had given them to her child, as she repeated so often, and she wouldn’t deliberately harm her own child, right? Online obsessives — such as one full-time tweeter, part-time lawyer and occasional fox murderer — parroted these claims, and people went along with the theory that a drug originally licensed to treat prostate cancer would be fine for children. In fact, it is now becoming widely accepted that blockers affect bone development, and may prevent the young person from ever being able to orgasm.

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Mermaids is endangering children

By Julie Bindel

Despite telling Jackie’s story over and over, and always including the detail about the girls’ toys, Green took pains to stress that being trans child went deeper than a desire for dolls. But how else would a four-year-old boy express a wish to be a girl other than through the medium of toys? What else would being a girl mean to them? In her Tedx talk, Green says that as soon as her baby boy “got mobile” — ie, learned to crawl — “he was gravitating to things that you would think are stereotypically female”. Like what, tampons? Was her one-year-old trying to book an appointment for a cervical smear test? Nope, “the Polly Pocket and My Little Pony”, she says, and then quickly adds “that was fine – but not for Dad”. Green’s then husband disapproved of his son playing with My Little Pony toys and therefore banned them from the house. (A macho father who abhors effeminacy in his son is a common feature in the life stories of trans women; Paris Lees’ semi-autobiographical novel, What It Feels Like for a Girl, is a recent example.)

Shortly after that, the child then known as Jack told his mother, “God made a mistake and I should have been a girl.” As Green recounts in her talk, “What I had come to the conclusion, up until she was about two, was that I had a very sensitive, quite effeminate little boy who was probably gay.” So when four-year-old Jack told her he should be a girl, Green felt “it explained so many things”. And to be fair, a trans four-year-old makes about as much sense as a gay two-year-old. No one has ever accused Green of failing to maintain fidelity to her extraordinary version of logic.

Suggested reading

Why did my daughter become trans?

By Jo Brown

Jackie Green has occasionally spoken up in defence of her mother. In 2018, a journalist tweeted that Green had “castrated” her teenage son when she arranged for the sex change operation in Thailand. Jackie tweeted back that this was untrue: “I was meant to be female and thus had surgery to correct my small defect,” was how she put it. As to how she knew she was meant to be a girl, Jackie said, “For a long time I was told I had to play with action men and other ‘boy toys’, another concept I find rather silly, but I still wanted the Barbies and little mermaids.” And so her mother arranged for the “small defect” to be “corrected” so she could.

No one has said why Green is suddenly no longer the CEO of Mermaids. But the fact that the charity has said they are appointing an interim one for now suggests the decision was quite sudden. The timing was certainly peculiar, coming 10 days after Green gave a rare interview, refuting all recent criticisms of her organisation.

Slowly, it seems, the tide is turning against Mermaids. When it was announced this year that the NHS was going shut down Gids, its gender identity clinic for children, in the spring, attention quickly turned to Mermaids. Former clinicians at Gids have accused the charity of having a “harmful” effect on the clinic by promoting transition as a cure. Mermaids has denied this, but it didn’t help matters by putting itself in the spotlight when it launched an appeal against the Charity Commission’s decision to award charitable status to the LGB Alliance, now the only specifically gay charity in this country which does not include trans people. Witnesses for Mermaids have had to defend gender theories under questioning this autumn, which has led to extraordinary moments such as Mermaids’ chair of trustees, claiming, “I’m not sure that people come out of the womb with a sex.”

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Why the Tavistock had to fall

By Kathleen Stock

A Daily Telegraph investigation in September found that the charity was offering to send breast binders to children against their parents’ wishes, which prompted the Charity Commission to open a regulatory compliance case. Green later defended Mermaids in The Guardian by saying a binder is better than “a young person using duct tape on themselves”. In October, the Times revealed that one of the Mermaids trustees, Jacob Breslow, gave a 2011 presentation for B4U-ACT, an organisation that aims to promote better understanding of paedophiles, in which he criticised the negative ideas about “paedophilic desire”. “We did some general top-level Google and internet searches. We did a social media search [and it] didn’t come up,” Green told The Guardian. Then, 10 days later, she was ousted.

Maybe the Mermaids board belatedly realised that if they want their organisation to endure, they needed to get rid of the wacky front woman. Ultimately, I don’t care why she went, because so much damage has already been done. But what I do want to know is this: how did so many people take Green so seriously for so long? Why did so many people turn off their intelligence when faced with this former IT consultant from Leeds? And how could so many LGBT activists champion and defend a woman who saw effeminacy — and therefore homosexuality — in her two-year-old and feel she had to “correct” this “defect”?

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JK Rowling sees through her enemies

By Kat Rosenfield

Green kept telling the story of Jackie because, for a long time, it gave her moral authority. No doubt, parents have long been great advocates for the rights of their marginalised children. But an alternative way of looking at Green is she was at least as good an advocate for her own rights: the right to put her child on untested hormone pills, the right to take her child to Thailand for a sex change. There is a fine line between using your parenting experience to help others, and validating your parenting choices by encouraging others to do the same.

I’m not waiting for celebrities such as Emma Watson to own up to their foolishness, mainly because I don’t care what Emma Watson thinks about anything. But all the journalists, teachers, editors and activists who endorsed Green’s obviously ludicrous ideas and shouted down anyone who didn’t, they really need to take a long look at their judgement, their motives and themselves. Because Green never once hid who she was.