In a stunning decision with international implications, the United Kingdom’s High Court ruled December 12 in Bell vs. Tavistock that puberty blockers (PB) and cross-sex hormone (CSH) use in gender dysphoric minors was experimental and should not, in most cases, be given to children under 16 without court order, adding that such petitioning was also advisable for 16 to 17 year olds.[1] They clarified that the consent issue was not about the breadth and depth of information the minors were given, but that “There is no age appropriate way to explain to many of these children what losing their fertility or full sexual function may mean to them in later years.”

The full conclusion section of the High Court decision, paragraphs 133 to 153, is well worth reading, but I will focus on a few points therein. The High Court conclusion repeatedly emphasized (paragraphs 134, 143, 148, 151 and 152) the experimental nature of PB and CSH use due to the limited evidence for efficacy and safety. Though stipulating that a court order should usually be sought for PB use in gender dysphoric children under age 16, they advised that even for minors under age 16 to 17, “clinicians may well regard these as cases where the authorisation of the court should be sought prior to commencing the clinical treatment.”

The decision acknowledges that children have developing brains and simply cannot grasp the long-term results of transition (paragraph 141): “That adolescents find it difficult to contemplate or comprehend what their life will be like as adults and that they do not always consider the longer-term consequences of their actions is perhaps a statement of the obvious.” In the current ideological climate, stating the obvious is increasingly a necessity.

Striking a blow against the popular slogan that puberty blocking provides a “pause” or “wait and see” button “buying time” to allow gender dysphoric minors to reflect, the High Court found (paragraph 136), “The evidence shows that the vast majority of children who take PBs move on to take cross-sex hormones, that Stages 1 and 2 are two stages of one clinical pathway and once on that pathway it is extremely rare for a child to get off it.” They asserted (paragraph 137), “Indeed, the statistical correlation between the use of puberty blockers and cross-sex hormones supports the case that it is appropriate to view PBs as a stepping stone to cross-sex hormones.” Quite right. The discontinuation rate for transition after initiating PBs is low: 1.4 percent per Wiepjes, et al.,[2] 1.9 percent per Brik, et al.,[3] 3.5 percent per Kuper, et al.[4] and 2 percent per Carmichael, et al.[5]

The legal challenge against the National Health Service’s Tavistock and Portman NHS Trust, the only Gender Identity Development Service (GIDS) for minors in the UK, was filed jointly by Sue Evans, a former GIDS nurse, along with the anonymous mother of a Tavistock patient[6]. Ms. Evans resigned from Tavistock over a decade prior due to her concerns that gender dysphoric youth were not receiving adequate psychological assessment and intervention. Keira Bell, a former GIDS patient and one of two case claimants (along with “MRS A,” mother of a 15-year-old autistic girl awaiting GIDS treatment), had stated to the BBC, “I should have been challenged on the proposals or the claims that I was making for myself.”[7] The BBC article states she received a year of PBs, then testosterone, and three years ago underwent mastectomy, much to her current regret.

There is ample background to the British Tavistock GIDS center controversy. In 2018, UK Equalities Minister Penny Mordaunt ordered an inquiry regarding why the number of girls seeking gender reassignment skyrocketed 4,000 percent in under a decade, citing figures of 40 such girls in 2009-2010 that ballooned to 1,806 in 2017-18.[8] Over a three-year period, 35 psychologists had resigned from Tavistock and Portman claiming excessive diagnosing of gender dysphoria in minors along with a rush to medicalize them.[9] Psychologists reported being prohibited from properly assessing patients for fear they would be labelled “transphobic.” Psychoanalyst Marcus Evans penned his account in “Why I Resigned from Tavistock: Trans-Identified Children Need Therapy, Not Just ‘Affirmation’ and Drugs.”[10]

The Royal College of General Practitioners issued a 2019 position statement, “The role of the GP in caring for gender-questioning and transgender patients,”[11] in which they noted, “There is a significant lack of robust, comprehensive evidence around the outcomes, side effects and unintended consequences of such treatments for people with gender dysphoria, particularly children and young people, which prevents GPs from helping patients and their families in making an informed decision.”

Editor in Chief of the BMJ Carl Heneghan wrote,[12] “There are significant problems with how the evidence for Gender-affirming cross sex hormone has been collected and analyzed that prevents definitive conclusions to be drawn.” He concluded, “The current evidence does not support informed decision making and safe practice in children.” Heneghan also cited a letter to Archives of Disease in Childhood insightfully titled “Use of puberty blockers for gender dysphoria: a momentous step in the dark.”[13]

Oxford Professor Michael Biggs reviewed the findings, including unpublished data, from what was at the time the only paper to have come out of the Tavistock and Portman GIDS’ puberty blocker trial for gender dysphoric teenagers.

[14] Professor Biggs found that, “after a year on GnRHa [puberty blockers] children reported greater self-harm, and that girls experienced more behavioral and emotional problems and expressed greater dissatisfaction with their body—so puberty blockers exacerbated gender dysphoria.”

Now the results of another Tavistock/GIDS study were reportedly accepted by a peer-reviewed journal on the same day as the High Court judgment. Titled “Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK,”[15] it took nine years to produce, yet it had only 44 participants, no control group and 43 of the 44 (98 percent) went on to cross-sex hormones. This is more evidence that puberty blockers are gateway drugs, a “stepping stone” to CSH, and that PB and CSH are “two stages of one clinical pathway,” as the High Court had written. The authors stated, “All had normal karyotype and endocrinology consistent with birth-registered sex,” supplying a reminder that disorders of sex development, aka intersex, and gender dysphoria are separate entities.

The study looked at intervals of 12, 24 and 36 months at bone mineral density (BMD), bone mineral content (BMC) and the total t-scores and self-harm indices of Child Behavioral Checklists (CBCL) and Youth Self-Reports (YSR). Results showed “As anticipated, pubertal suppression reduced growth that was dependent on puberty hormones, i.e. height and BMD.” Also, “There was no change from baseline in spine BMD at 12 months nor in hip BMD at 24 and 36 months, but at 24 months lumbar spine BMC and BMD were higher than at baseline.” This means “suppression of growth” and density precisely when the surge of a lifetime should have occurred. It is not an encouraging finding.

As for mental health assessment, “We found no evidence of change in psychological function with GnRHa treatment as indicated by parent report (CBCL) or self-report (YSR) of overall problems, internalising or externalising problems or self-harm.” Translation, puberty blockers did not help psychological distress or self-harm based on survey instruments from parents and patients both.

The British High Court has done a great service to gender dysphoric youth worldwide with the decision that puberty blockers and cross-sex hormones are indeed experimental, their long-term safety and efficacy are not established, PBs are a “stepping stone” to CSH, PBs and CSH hinder bone density and growth, they do not improve mental health and self-harm, and minors really don’t have the ability to provide truly informed consent to them.

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[1] https://www.judiciary.uk/wp-content/uploads/2020/12/Bell-v-Tavistock-Judgment.pdf

[2] Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam cohort of gender dysphoria study (1972-2015): trends in prevalence, treatment, and regrets. J Sex Med. 2018;15(4):582–590

[3] Brik T, Vrouenraets LJJJ, de Vries MC, Hannema SE. Trajectories of

adolescents treated with gonadotropinreleasing hormone analogues for gender dysphoria [published online ahead of print March 9, 2020]. Arch Sex Behav. doi:10.1007/s10508-020-01660-8

[4] Kuper LE, Stewart S, Preston S, Lau M, Lopez X. Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy. Pediatrics. 2020;145(4):e20193006

[5] Polly Carmichael, Gary Butler, et al.. Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. medRxiv 2020.12.01.20241653; doi:https://doi.org/10.1101/2020.12.01.20241653

[6] Alison Holt. NHS use of puberty blockers legal challenge begins. bbc.com, 08 January 2020. https://www.bbc.com/news/health-51033911

[7] Alison Holt. NHS gender clinic ‘should have challenged me more’ over transition. bbc.com, 01 March 2020. https://www.bbc.com/news/health-51676020

[8] https://www.thetimes.co.uk/article/inquiry-into-surge-in-gender-treatment-ordered-by-penny-mordaunt-b2ftz9hfn?wgu=270525_54264_15983781843502_fa5c729d13&wgexpiry=1606154184

[9] “NHS ‘over-diagnosing’ children having transgender treatment, former staff warn,” news.sky.com, 12 Dec. 2019. https://news.sky.com/story/nhs-over-diagnosing-children-having-transgender-treatment-former-staff-warn-11875624

[10] “Why I Resigned from Tavistock: Trans-Identified Children Need Therapy, Not Just ‘Affirmation’ and Drugs” by psychoanalyst Marcus Evans, Quillette.com, Jan. 17, 2020. https://quillette.com/2020/01/17/why-i-resigned-from-tavistock-trans-identified-children-need-therapy-not-just-affirmation-and-drugs/

[11] https://www.rcgp.org.uk/-/media/Files/Policy/A-Z-policy/2019/RCGP-transgender-care-position-statement-june-2019.ashx?la=en , p.5

[12] Heneghan, Carl. “Gender-Affirming Hormone in Children and Adolescents.” BMJ EBM Spotlight, February 25, 2019,

blogs.bmj.com/bmjebmspotlight/2019/02/25/gender-affirming-hormone-inchildren-and-adolescents-evidence-review/.

[13] Richards C, Maxwell J, McCune N. Use of puberty blockers for gender dysphoria: a momentous step in the dark. Archives of Disease in Childhood 2019;104:611-612.

[14] Michael Biggs, “Tavistock’s Experimentation with Puberty Blockers: Scrutinizing the Evidence,” TransgenderTrend.com, March 5, 2019. https://www.transgendertrend.com/tavistock-experiment-puberty-blockers/

[15] Polly Carmichael, Gary Butler, Una Masic, Tim J Cole, Bianca L De Stavola, SarahDavidson, Elin M. Skageberg, Sophie Khadr, Russell Viner. Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. medRxiv 2020.12.01.20241653; doi:https://doi.org/10.1101/2020.12.01.20241653