In 2020 NHS England and Improvement commissioned the Cass Review into gender identity services for children and young people.

To help inform the review, The National Institute of Clinical Excellence (NICE) has published a document. This aims to assess the evidence for the clinical effectiveness, safety and cost-effectiveness of gonadotropin releasing hormone (GnRH) analogues (Puberty Blockers) for children and adolescents aged 18 years or under, with gender dysphoria.

NICE states that,GnRH analogues suppress puberty by delaying the development of secondary sexual characteristics. The intention is to alleviate the distress associated with the development of secondary sex characteristics, thereby providing a time for on-going discussion and exploration of gender identity before deciding whether to take less reversible steps.

NICE then goes on to review the existing research that explores the following:

  • Impact on gender dysphoria
  • Impact on mental health
  • Impact on quality of life
  • Impact on body image
  • Psychosocial impact
  • Engagement with health care services
  • Stopping treatment
  • Bone density
  • Cognitive development
  • Other safety outcomes
  • Cost-effectiveness

The conclusion drawn following this review is that, ‘The results of the studies ‘suggested little change with GnRH analogues from baseline to follow-up, and all the studies that reported safety outcomes provided very low certainty evidence.’

This, of course, then piques UK media attention and resulting sensationalist headlines run with: ‘Evidence for puberty blockers use very low, says NICE.’ Aimed at further perpetuating a narrative to prevent essential care to this patient population.


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What has not been considered is the fact that there are many reasons why a young transgender person will experience gender dysphoria. Reasons that cannot be eased by the use of puberty blockers alone, as that is only one part of the puzzle.

Will puberty blockers ease the gender dysphoria associated with any of the following:

  • Pubertal development – YES
  • Delayed puberty – NO
  • Social prejudice – NO
  • Family dissonance – NO
  • School bullying – NO
  • Barriers to medical care – NO

It’s all about the way the question is framed. If NICE had asked ‘Do puberty blockers prevent further progression of the secondary sex characteristics that occur during and after puberty?’ the response would have been a resounding yes.

Instead the question they seem to want answered is whether there is enough good evidence that blockers can safely reduce gender dysphoria and improve outcomes. However, there are so many other facets that impact that outcome.

We know that puberty blockers are effective at blocking puberty. As a secondary effect, they may indeed allow a young person more time, and ease the distress caused by the body’s development, but on their own they cannot be expected to fully ease gender dysphoria. The pain and distress in adolescents who face prejudice and barriers to living in their authentic gender identity cannot be alleviated by a three-monthly injection alone.

If this review of the existing research results in access to this essential component of gender-affirming medical intervention being restricted, it would be a travesty, tantamount to child abuse inflicted by those whose role it is to care for children.

The use of puberty blockers is standard practice in centres of excellence across the world. While new, ethically-grounded research data is always welcome, when assessing how best to help transgender children the NHS must seriously consider the right questions to ask. Failure to do so merely serves to perpetuate the hysteria.