In the more hyperbolic echo chambers of social media, the decision was cast as a lifeline withdrawn for no other reason than state-sanctioned bigotry and transphobia, possibly as part of a covert programme of eugenics.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.

Gids had been established in 1989, to help distressed teenagers navigate their feelings of gender dysphoria, but changes in leadership along the way led to a dramatic shift in its clinical approach. In recent years children routinely found themselves on a medical conveyor belt before the psychological effects of early adverse experiences were fully explored. Much has been written about the blanket application of an “affirmation-only” approach to a complex caseload, which too often put children on a single pathway to life-long medicalisation. By 2020, Gids had prescribed puberty blockers to more than a thousand children. 

In most academic discourse, a “no-debate” approach, such as the one described at Gids, will be stifling and unproductive — but in medicine, it will inevitably result in harm. All clinical practice should be centred around the careful consideration of competing possibilities. It is unsurprising that children were harmed at Gids when a single-minded certainty usurped clinical curiosity.

One year on, Gids remains open, although it no longer accepts new referrals. The plan is to replace the moribund service with regional hubs offering the holistic care required by young people struggling with their gender identity. The promised new services are still taking shape, but before they have even opened their doors to the ever-accumulating backlog of referrals — last rumoured to be upwards of 8,000 young people — concerns have been raised about history repeating itself. Some of the senior clinicians from Gids have seamlessly transferred into new leadership positions, despite appearing to have learned little from its terminal failings.

In April 2023, Prof Gary Butler, the lead endocrinologist at Gids and a clinician appointed to a leadership role in its replacement service, questioned any need to rethink the model. He told a conference audience that Gids was already working in “exactly” the way that Dr Hilary Cass had called for in her thorough review of services for children and young people with gender incongruence. It is difficult to see how anyone could reconcile the service described in Time to Think — BBC Newsnight reporter Hannah Barnes’s careful and balanced account of the failings reported by multiple Gids clinicians — with the holistic approach recommended by the Cass Review.

Its recommendations tear down the exceptionalism that allowed things to go so wrong at Gids; evidence-based practice will be the bedrock of the new service, just as it is in every other NHS clinic.  Those working within the new services will be contractually committed to follow Dr Cass’s recommendations, which place a new emphasis on integrated models of care and evidence-based treatments, recommendations that should be as uncontroversial as motherhood and apple pie.

But, then, motherhood and apple pie aren’t quite as uncontroversial as they used to be. And an evidence-based practice may not be quite the unifying foundation if the clinicians involved cannot agree on the evidence base.

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Doctors have failed detransitioners

By Sallie Baxendale

Earlier this month, a group of 21 eminent clinicians working across nine countries in the field of gender distress wrote an excoriating open letter in response to a bold claim from Stephen Hammes, president of the Endocrine Society. In a letter to the Wall Street Journal, Hammes had stated that more than 2,000 studies had provided a clear picture that gender-affirming care improved the well-being of gender diverse people and reduced the risk of suicide; if that were true, it would be very reassuring and closer to certainty than we often get in many medical specialities. The authors of the response, who included Dr Anna Hutchinson and Dr Anastassis Spiliadis, two of the original whistleblowers at Gids, noted that this claim had been contradicted by every single systematic review of the evidence, not least one published by the Endocrine Society itself. They noted that recommendations for clinical practice should be aligned with the best available evidence, rather than a position that exaggerated the benefits and minimised the risks.

Not all evidence is equal. There are hierarchies of evidence in science, often represented as a pyramid. The lowest level is “expert consensus”, which is barely evidence at all. Who decides who is an expert? The process of reaching a consensus can result in a compromise where lots of people agree collectively what nobody actually believes individually. Consensus may have nothing to do with empirical truth. Expert medical consensus can be very wide of the mark, sometimes disastrously so: in the early 1900s, it was expert medical consensus that smoking cured asthma and other lung diseases. It is well within living memory that the expert consensus for treating back pain was bed rest and plenty of it. We now know this is likely to increase pain and prolong recovery.

The history of medicine is littered with these examples, and there are treatments we are recommending now with the full blessing of expert consensus that will eventually prove to be ineffectual at best, fatal at worst. But perhaps the biggest problem with consensus, particularly in the area of gender medicine is the chilling effect it has on debate. As Michael Crichton, the physician and author of Jurassic Park, said: “The claim of consensus has been the first refuge of scoundrels; it is a way to avoid debate by claiming that the matter is already settled.”

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Why the Tavistock had to fall

By Kathleen Stock

Fortunately, most branches of medicine now rely on more rigorous forms of evidence to inform their practice. Further up the “evidence pyramid” are case reports and studies that compare the outcomes in patient groups before and after treatment, with and without control groups. Close to the top of the evidence pyramid are the results from randomised controlled trials. All of these kinds of research can provide valuable information (some more than others) but no study is perfect and no study design can control for all of the biases that might have influenced the results. So sitting right at the top of the evidence pyramid are the meta-analyses and systematic reviews. These studies systematically evaluate the quality and quantity of all of the relevant evidence that has been published in peer-reviewed journals. These independent reviews summarise what we really know and how confident we can be in that knowledge. Bodies such as the National Institute for Health & Care Excellence (Nice) produce the gold standard in clinical practice guidelines based on these kinds of independent meta-analyses.

In 2020, Nice examined the evidence for puberty blockers. They concluded that “the results of the studies that reported impact on […] outcomes of gender dysphoria and mental health (depression, anger and anxiety), and […] body image and psychosocial impact (global and psychosocial functioning), in children and adolescents with gender dysphoria were of very low certainty”. In other words, there is no good quality evidence supporting the use of these drugs on these outcomes.

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You can't be born in the wrong body

By Ellen Pasternack

It seems likely in the heated debates that surround gender medicine that many people are confusing “expert consensus” — the evidence right at the bottom of the pyramid — for the gold standard in clinical practice guidelines, which are based on evidence and right at the top.

This conflation appears to have been responsible for the mutual bafflement in the heated exchange between Republican Dan Crenshaw and Dr Meredithe McNamara earlier this month, in a debate in the US House Committee on Energy and Commerce on gender-affirming care. While Dr McNamara insisted trans healthcare was based on “standards of care”, the senator countered with the stark lack of evidence from any systematic reviews. Both appeared exasperated with the failure of the other to grasp the importance of their incontrovertible evidence. Just as not all evidence is equal, neither are all clinical guidelines or standards of care. They can be developed from evidence at the top of the pyramid (as in Nice guidelines), but more often come from the bottom and simply represent expert consensus with all its inherent flaws and biases. The stamp of approval from a learned society does not trump the rigours of a Nice review.

Since no high-quality evidence for the benefits of puberty blockers has been found in systematic reviews, it is unsurprising that even the doctors who work in this field have described themselves as building the plane while flying it. With mounting concerns for the possible harms associated with medical pathway of puberty blockers and cross-sex hormones (including reduced bone density, disruptions to neurodevelopment, impaired sexual function and infertility) — not to mention the growing numbers of detransitioners for whom this was never an appropriate treatment pathway, one might extend their aviation metaphor as an attempt to build a plane while flying it while someone else throws out all the parachutes and sets an engine on fire.

Who would put any children on that plane? Or volunteer to pilot it?

The only rational response in such a situation would be to ground the plane immediately. The interim recommendations of the Cass Review combined with the upcoming closure of Gids effectively do this, but the pressures on a new service to immediately take to the metaphorical skies again will be significant.

However, there is another way. Practice guidelines based on expert consensus cannot be mistaken for those based on systematic reviews. Where the systematic reviews indicate little evidence for benefit and potential for significant harm, the service should proceed with the caution that would be applied in any other branch of medicine.

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What if you regret transitioning?

By Julie Bindel

Cass has emphasised that just as there are many pathways into gender dysphoria for young people, so there could be many ways out. For some, that may still be a medical pathway, with its unevidenced outcomes and multiple inherent risks. The new teams will be tasked with explaining these uncertainties in uncompromising detail to ensure the truly informed consent of those who wish to embark on this experimental approach. Fortunately, the new service model means that other treatment pathways will now also be available.

Bringing gender distress firmly back into the fold of mainstream mental health services for children and adolescents means that these vulnerable children can finally begin to benefit from the therapeutic input and safeguards they have been denied for far too long. It can’t begin soon enough.

Trepanning (drilling a hole in someone’s skull) has been conducted for millennia, with evidence of the oldest procedure dating back several thousand years. Archaeological finds of skulls with multiple holes in various states of repair indicate that at least some of our ancestors survived these treatments and came back for more. Opening a space to let the demons out of someone’s head makes sense, if you believe the pesky things have taken up residence and are running amok inside. At least this treatment was in the right anatomical ballpark, according to our current understanding of epilepsy as a neurological condition. Less than 130 years ago, surgery for epilepsy had “advanced” (or regressed) to the extent that the head was no longer the sole target of the surgeon’s scalpel.

They had branched out to recommend limb amputation. The rationale was straightforward: if someone’s arm keeps shaking, what more effective cure than to cut it off? Other surgical approaches to epilepsy in the 1890s included clitoridectomy and castration — both attempts to curb the immoral sexual appetites that were “well known” to cause epilepsy at the time. For the squeamish patients who wished to retain their sexual organs, alternative treatments included admonitions to avoid coffee, chocolate and amorous love songs. Late Victorian treatments for epilepsy were nothing if not eclectic.

Into the mid-20th century, people with epilepsy were once again the unwitting participants in a dark era of medical experimentation. In an enterprising spin-off, the radical surgical techniques developed in the Forties’ psychosurgery movement were trialled as treatments for epilepsy. All undergraduate psychology students (and fans of the film Memento) will be aware of Henry Molaison, better known by his initials. In October 1953, Mr Molaison underwent surgical excision of the right and left temporal lobes of his brain. In a short paper delivered six weeks after the surgery, his surgeon reported that the operation had resulted in no real changes, “with the exception of a very grave recent memory loss”; H.M. was unable to remember where his room was in the hospital, or how to find the toilet.

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Why the Tavistock won't talk to me

By Hadley Freeman

H.M.’s profoundly disabling amnesia persisted for the next 55 years, until his death in 2008. He became the most famous neuropsychological case study in the history of the profession. But he was not the first person to undergo this procedure and suffer this devastating outcome. Scores of others were discovered in a retrospective review, triggered by Mr Molaison’s case. His memory loss could have been anticipated and prevented if the outcome of this procedure had been fully evaluated in his predecessors. More shocking still is that a similar fate was allowed to befall a number of other patients after his amnesia was discovered. Ignorance is one thing, inertia something entirely different.

The lessons from this sobering history are clear. When doctors fundamentally misunderstand the cause of a condition and treat the symptoms instead, and fail to properly monitor outcomes, and modify their practice in response to known adverse outcomes, our patients suffer — often greatly and for the rest of their lives — if indeed they survive. These fundamental errors underpin the depressingly regular scandals that punctuate the history of medicine. (The stakes are particularly high if surgery is involved.)

It is naïve to think that all these scandals are in the past. Our descendants will look back at some aspects of our current medical practice and wonder that we could have been so stupid. They will shudder at how barbaric and crude some of our current treatments are. So where might the next medical scandal be brewing?

The increasing visibility of detransitioners suggests it may lie in wait in gender-affirming medicine. Many detransitioners are young women who underwent treatment for psychological distress that has left them with irreversible, life-long changes to their bodies: a deep voice, a beard, and compromised sexual function. Some have had their breasts surgically removed; some may be infertile. Others are young men who have been castrated.

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Why I stopped being a good girl

By Hadley Freeman

This is not an argument about the pros and cons of these treatments for trans-identified young people. Nor is it an argument about the percentage of people who may “regret” undergoing these procedures. The existence of just one detransitioner suggests that an individual was not offered the correct treatment for their condition by the doctors charged with their care. It is a clear case where the medical profession caused harm. We are ethically bound to learn, and widely disseminate, the lessons from these cases.

For many detransitioners, the cause of their distress as a teenager was misattributed by their clinicians to the notion that they had been born in the wrong body, and that they would be helped by the surgical creation of the “correct” body. Regardless of the validity of this treatment for some — on which I make no comment — this assumption was incorrect in the case of many detransitioners. Once these fundamental errors of misattribution had been made by the treating clinicians (who in the case of GIDS were primarily psychologists, and not medically qualified), surgeons and endocrinologists embarked on a procedure akin to that of limb amputation for epileptic seizures. The detransitioners’ discomfort with their body was a symptom of psychological distress, not a cause, but their medical team prescribed treatments with an irreversible impact and surgically removed healthy tissue in an effort to cure their symptoms.

In most other fields of surgery, this would be classified as a “never event”, and an exhaustive investigation would be launched. But in the case of many detransitioners, their treating medical team has failed their patient at every stage. They have fundamentally misunderstood the nature of the condition the patient has presented with and have treated the symptom rather than the cause. The astonishing failure of the Tavistock & Portman NHS trust to monitor even primary outcomes were laid bare in the original trial of Bell vs Tavistock, with further shocking details subsequently presented in Hannah Barnes forensic account of the collapse of the service. This failure means there is no opportunity to modify practice in response. It is unsurprising that the results have been catastrophic for some.

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However, in the case of detransitioners, there is an additional, darker layer to this cascade of medical errors. The patients themselves are being held responsible, by the very doctors who made them. The term “post-treatment regret” appears to abrogate any responsibility on behalf of the treating clinicians for these outcomes. Some argue that there is some degree of regret associated with every medical procedure. However, there is a fundamental difference between patients who are unhappy with the outcome of elective treatments recommended for their condition, and those who have been misdiagnosed, and have had healthy tissue surgically removed as a result. Many detransitioners were given the wrong treatment for their condition. These people are not experiencing post-treatment regret, they are responding appropriately to the consequences of a grave medical failure.

Advocates of gender-affirming care argue that “no one can know whether post-treatment regret will occur; therefore what matters ethically is whether an individual has a good enough reason for wanting treatment”. This is a remarkable position to take. Surely what matters ethically is that the medical profession offers appropriate, evidence-based treatment to patients who will benefit from them. Others argue that young trans people have “the right to be wrong”. They do indeed; doctors, less so, particularly when they are wielding a scalpel. Just as trans youth deserve access to the very best in evidence-based medicine, so doctors have a fundamental duty not to offer harmful treatments to young people who will not benefit from them. It is not good enough to shrug and say, “no one knows whether this will occur”. We know that poor outcomes do occur, and are duty-bound to find out as much as we can about these in order to predict and prevent them.

Since 2014, there has been a phenomenal increase in young women referred to specialist services for gender dysphoria. There is, therefore, a greater number of people who are at potential risk of receiving inappropriate treatments. To respond by creating a “fast-track” to medical transition is to ignore everything history has to teach us. Meticulous assessment of a young person’s symptoms is not transphobic, nor does it invalidate anyone’s identity. It is good medicine, and ensures that the right treatment is given to the right patient.

No branch of medicine can be exempt from rigour. Exceptionalism lies at the heart of many medical scandals. That way catastrophe lies and, as ever, it will be our patients who suffer. This is not hypothetical: detransitioners stand before us as living, breathing examples of people who have been harmed. To change nothing as the result of their experience — or, even worse, to make changes that mean similar errors could potentially harm even more people — is immoral. Upholding scientific principles is the least we can do to protect our current patients and honour the thousands who have been failed by the medical profession in the past. The history of surgery can teach us that much. It is our responsibility to take note.