This article is taken from the October 2024 issue of The Critic. To get the full magazine why not subscribe? Right now we’re offering five issues for just £10.

---

Before the 19th century, doctors were feared rather than trusted. Their brutal, ineffective methods earned them nicknames like quack, leech and sawbone. Their ignorance of how infections spread meant they carried illness and death wherever they went.

That changed with the discovery of microorganisms and the invention of vaccines, antibiotics, anaesthetics and all the other weapons with which doctors now fight disease, save lives and ease pain. Few women die in childbirth any more; most children survive into adulthood. And doctors get the credit. Polls around the world routinely rank them as the professionals people trust most.

Underpinning this trust is the scientific method, especially the clinical trials that weed out promising ideas that don’t work, or that do more harm than good. The profession’s continuing failures, such as the millions of women worldwide fitted with vaginal mesh for prolapse before the rate of complications became too high to ignore, gain so much attention precisely because they are the exception rather than the rule.

But not in gender clinics, which offer a post-truth charade that relies on the signs and symbols of evidence-based medicine — consultations, diagnoses, drugs and surgeries — whilst subverting its spirit. They trade on the trust hard won by the medical profession at large, like counterfeiters who pass fakes in a market that has been lulled into a false sense of security by the sophisticated anti-forgery measures those counterfeiters have worked out how to circumvent.

◉ ◉ ◉

In the final report of her government-ordered review of child gender medicine, published in April, Dr Hilary Cass came close to calling a quack a quack, albeit in professionally modulated tones. The field was operating on “remarkably weak evidence” she concluded: junk, in other words.

Of 50 studies of puberty blockers identified by her research team, 24 were too weak to be included in the systematic reviews they carried out. Just one was judged as high quality.

On Dr Cass’ recommendation, the NHS has stopped prescribing puberty blockers. The Conservative government banned private prescriptions as well, a measure Labour, now in power, has upheld. NHS researchers are preparing to recruit young people to a clinical trial, with potentially thousands of under-16s eligible to take part. The aim is to start it early next year.

By now you’re probably nodding along, thinking what everyone thinks when they learn that something serious is happening without evidence to support it, namely, that “further research is needed”.

This phrase is such a staple of policy analyses and scientific papers that it’s commonly referred to by its acronym, FRIN. Very often it’s a reasonable acknowledgement of the uncertainty that bedevils real-world decision-making. More cynically, researchers like it because it implies a need for further research funding.

But with puberty blockers, what’s needed isn’t more research, it’s more courage: the courage to admit that their rationale rests on a false premise and to abandon attempts to delay the inevitable reckoning. To understand why, you need to understand the limitations of clinical trials, which questions they can and can’t answer and humans’ seemingly limitless capacity to circumvent self-imposed rules intended to limit self-deception.

The best sort of clinical trial is the “randomised controlled trial”, or RCT. It’s the nearest researchers can get to both treating and not treating the same person without having access to a time machine. In an RCT, researchers divide participants into separate groups at random, giving the treatment to one group and using the other as a “control”. If there are enough participants, any difference in outcomes can be attributed to the treatment rather than chance.

Ideally, neither researchers nor patients know who is in which group, in order to eliminate optimism bias and the placebo effect. This precaution, known as double blinding, is impossible with puberty blockers, because it would be obvious whose development had been arrested and who was progressing normally towards adulthood.

◉ ◉ ◉

The first doctors to block children’s puberty — in Amsterdam around 1990 — could have done an RCT, albeit without blinding. They didn’t. By then clinics elsewhere had realised that the tiny number of children who asserted a cross-sex identity almost all stopped doing so once they hit puberty. But the Dutch clinicians somehow believed they were able to identify the exceptions.

Forcing any of these “child transsexuals” through the wrong puberty, they thought, would be unethical. So they treated them all and checked how they were doing a couple of years later. One had died after genital surgery from complications caused by puberty blockers, and the long-term impact on bone strength, cognition, sexuality and fertility would not be known for decades. Even so, they declared the treatment a success.

By failing to do an RCT, the Dutch researchers sidestepped the central question: whether puberty blockers lock in gender distress that would otherwise have resolved on its own. The entire edifice of paediatric gender medicine worldwide has been built on that unjustified professional arrogance.

For many years now puberty blockers have been presented to young people as a panacea

Now an RCT is impossible. They’re only appropriate when researchers are in “clinical equipoise” — a balanced state of neutrality about which treatment is best. But when it comes to puberty blockers, no one feels like that any more.

Clinicians who accept the premise that people have “gender identities” think, like the early Dutch researchers, that it would be unethical to withhold puberty blockers from children who feel their gender identity doesn’t match their sex. Clinicians who reject that premise think it’s unethical to give them to anyone.

As for the potential participants, for many years now puberty blockers have been presented to young people as a panacea. Those randomly selected into the control group — that is, not to receive them — would be more likely to drop out. If too many did, the trial would collapse.

Instead, the plan seems to be to compare outcomes for the puberty-blocked children with a comparator group — children matched in other important respects, such as health and socioeconomic status. Such a study may be able to tell whether interrupting puberty causes immediate harm to brains and bones, and whether it alters adult sexuality. But it can’t compare what happens to gender distressed youngsters who receive puberty blockers with those who don’t.

◉ ◉ ◉

All this is to say that I wouldn’t start from here. But then, I wouldn’t have started at all. The gender doctors did start, however. Should they finish? The trouble is that whatever they do now is unlikely to shift many people’s positions.

Suppose the trial reaches the most glowing verdict possible given its design limitations. Suppose puberty-blocked youngsters stop feeling gender-distressed, become much more mentally healthy and don’t display immediate side effects such as falling IQ or lower bone density. I’d still want the researchers to go back 20 years later and ask how they now feel about the impact on their genitals, their sex lives and having been put on a path to sterility in their teens.

I’d want to ask 30 years later about their careers and earnings, and 40 years later about brittle bones and early-onset dementia. I’d want to know how they’ve coped through their lives in bodies that were radically reshaped in service of an idea that has long since ceased to be fashionable, as I fully expect it will.

As for the proponents of gender medicine, they already believe in its benefits without evidence of benefit. There’s no reason to think that evidence of harm will change their minds.

◉ ◉ ◉

Fundamentally, the hypothesis that arresting children’s physical development can treat mental distress doesn’t deserve to be dignified with a clinical trial of any kind. It’s an example of what Harriet Hall, a long-time proponent of better decision-making in science who died last year, memorably called “tooth-fairy science” — studying a phenomenon before establishing that it even exists.

In principle, you could run trials to answer all sorts of tooth-fairy-related questions. Do bigger teeth earn bigger payouts? Does it help if the child writes a note? It’s all nonsense because there is no tooth fairy. Yet once the results come in, you would analyse them, and out would churn new hypotheses and demands for “further research”.

Maybe older children get bigger payouts, for example. Is that because the tooth fairy likes back teeth better, or perhaps because she doesn’t like the whining six-year-olds are more prone to? Sticking a spanner in a teenager’s mental, physical and sexual maturation to make them feel better about an unchangeable aspect of the human condition isn’t quite as absurd, but it’s close.