Exploring issues behind the desire to transition is not transphobia, it’s common sense

Rushing children into treatment with puberty blockers could risk permanent damage. A more cautious approach is essential

We need to talk about girls. It is probably more challenging to be a teenager today than ever, and no one is suggesting that it is a picnic for boys. Girls, however, are manifesting distress in a new way in recent years.

The Cass Review, an independent review commissioned by the NHS of gender identity development services (GIDS) for children and young people, highlights the extraordinary surge in children and young people presenting with gender distress in England.

From approximately 50 referrals to GIDS per annum in 2009, there was a steep increase in 2014-2015. By 2020, there were 2,500 children and young people being referred per annum, and 4,600 children and young people on the waiting list.

Strikingly, In the early 2000s, those being referred were “predominantly birth-registered males presenting with gender incongruence from an early age”, but now the majority are “predominantly birth-registered females presenting with later onset of reported gender incongruence in early teen years”.


What is going on? Why is there such an increase in the number of teenage girls seeking to transition?

Approximately one-third of children and young people referred to GIDS have “autism or other types of neurodiversity”. There is also an over-representation of children in the care of the state.

What is going on? Why is there such an increase in the number of teenage girls seeking to transition?

It is vital that we discuss these issues. The Cass Review states that the existing but limited research on outcomes for transitioning individuals is based on birth-registered males presenting with gender dysphoria since early childhood, yet is being applied to a very different category.

Primary and secondary care staff told the review that they felt under pressure to adopt an “unquestioning affirmative approach”. The Review says that young people who have gender identity issues deserve the same standard of care they can expect elsewhere in the health services – a multi-disciplinary, evidence-based approach with appropriate protocols and record-keeping. The lack of these foundational practices has led to the planned closure next year of the Tavistock and Portman Trust, the sole provider of GIDS in NHS England. It will be replaced with a number of regional centres.

Child safeguarding

Child safeguarding is central to any service for children and young people. Sonia Appleby, a child safeguarding expert “at the end of a blameless professional career in a senior position”, received compensation for detriment due to whistleblowing last September from an employment tribunal.

She was sidelined by Tavistock after she raised serious red flags. Staff reported to her that they were discouraged from reporting safeguarding concerns and were labelled as transphobic if they did so, or if they suggested that children might be gay rather than transgender. She is but one of a number of whistleblowers.

Yet the HSE has said that it will continue to use the service until it is closed on the grounds that it has not been found to be “unsafe”.

Consultant paediatrician Dr Hilary Cass, the review chair, raises serious questions about the use of puberty blockers.

Dr Cass states that the drugs were originally designed to delay precocious puberty, that is, puberty starting before the age of eight in girls and nine in boys. Puberty blockers are technically reversible because puberty will re-commence once they are stopped, but no one has any idea what impact delaying puberty has on healthy bodies.

Dr Cass raises the question of the impact of puberty blockers on brain development and whether there is a “critical time window” for brain maturation that may be missed by using them

The short-term impacts are well-known: “headaches, hot flushes, weight gain, tiredness, low mood and anxiety, all of which may make day-to-day functioning more difficult for a child or young person who is already experiencing distress.”

Worryingly, Dr Cass raises the question of the impact of puberty blockers on brain development and whether there is a “critical time window” for brain maturation that may be missed by using them.

Virtually all who are given puberty blockers go on to have sex hormone treatment – 96.5 per cent of children and 98 per cent of young people. This can hardly be considered a pubertal pause to consider options.

Astonishingly sanguine

The review states that some young people learn through peers and social media how to successfully receive hormone treatment, for example, not to admit to previous abuse or trauma, or uncertainty about their sexual orientation.

It is astonishing that the HSE is so sanguine about continuing to use the Tavistock service.

In recent years, Finland and Sweden have put much more stringent GIDS safeguards in place. An Irish doctor working with adults in the National Gender Service, Dr Paul Moran, has predicted that significant numbers of Irish teens and children treated by the Tavistock will regret transitioning or have other adverse outcomes because they were “rushed” onto puberty blockers and hormones.

Girls are particularly vulnerable. They are living in the relentless, ruthless scrutiny of social media, presented constantly with unrealistically perfect bodies. Add to that the impact of earlier exposure to often violent and misogynistic pornography and it may be unsurprising that their bodies are sources of pain and confusion to them.

Adolescence is often a time of trauma and questioning. Girls (and boys) need adults who can help them to navigate the storms. The bare minimum standard of care is to investigate the complex issues that have an impact on gender dysphoria and the desire to transition. This is not transphobia. This is common sense.