Withholding treatment with puberty blockers doesnt save young trans people from making irreversible decisions, writes Sage Brice It just denies them the chance to explore their natural doubts and uncertainties in a safe and supportive environment.

I recently interviewed Jacob, a young transmasculine dad, about his experience of pausing his testosterone treatment to conceive a child with his husband.

Reproductive futures can be a painful topic for trans people. Its also a popular focus for anti-trans campaigners, who argue that gender-affirming medical treatment denies trans young people the right to have genetically-related children later in life.

In a recent case brought against the Tavistock Trust the only NHS service providing gender-related care to young people in England High Court judges ruled that children under 16 were unlikely to be able to give informed consent for medical treatments relating to their gender.

The centres gender identity development service, which has just been rated inadequate by the Care Quality Commission (CQC), has long been struggling under an unmanageable caseload with insufficient funding and resources. Now it is caught between critics from both sides trans advocates claim it is not doing enough to help trans young people, while so-called gender critical campaigners are doing everything they can to stop it in its tracks.

The fear that young people might make hasty, irreversible medical decisions which could harm their future ability to have children makes for a compelling and relatable story. Its easy for an uninformed reader to pick up this concern without thinking to question the reality behind it.

But treatment with puberty-blockers (see box-out) is safe and reversible, and far from being a conveyor belt, the assessment process is already not only rigorous, but hampered by severe delays.

Adding additional legal obstacles to this process will make timely treatment even less accessible. Children and families have been plunged into despair since this unexpected ruling on the Tavistock Trust took away their hope of access to medical care.

Under NHS policy, young people who experience gender dysphoria, and who have begun puberty, may be prescribed puberty blockers as one stage in a therapeutic process, following a period of assessment and exploration. These are temporary, reversible treatments which are routinely prescribed for children and young people experiencing premature and distressing puberty.

For trans young people facing what feels like the wrong puberty, it can seem like the clock is ticking too fast. Blockers buythem some time to mature, explore, and make informed decisions about their futures without undergoing lasting, irreversible changes. From the age of 17 onwards, they can choose to stop treatment allowing delayed puberty to occur as normal or progress onto feminising or masculinising hormones. These, too, are partially reversible, but the decision has implications for parenting, because a person cannot become fertile and conceive if their body has not gone through a puberty that aligns with their reproductive anatomy.

Read more about puberty blockers:

I spoke to Jo Maugham of the Good Law Project who is supporting a teenage boys legal challenge to the NHS over unethical delays, which can range from 18 months to four years for a service, which should legally be provided within 18 weeks.

Withholding puberty blockers, or imposing a long waiting time is like having a five-month waiting list for abortion, Jo told me. Its not delaying treatment, its effectively denying it.

Linking this case to wider questions of reproductive justice is not mere speculation. The lawyer acting against Tavistock has a substantial portfolio of anti-abortion cases, including a failed legal challenge to prevent pregnant under-16s accessing abortion without parental knowledge.

The key thrust of the Tavistock case, however, is the argument that gender-questioning young people who go on from puberty-blockers to cross-sex hormones or surgery might hypothetically, later in life, regret their transition and their inability to conceive.

Underlying this approach is an unspoken belief that being trans is not a real thing, but a fad which society collectively should not indulge, Jo stresses. And that assumption is fundamentally transphobic.

Jos fear is that by not providing a supportive and well thought-through pathway, the NHS risks driving young people to self-administer medication procured from poorly-regulated suppliers, and without access to therapy, monitoring for safety and potential side effects, or the opportunity to make informed choices about their reproductive futures.

In this scenario, young people end up making difficult decisions alone, unsupported, and more quickly than they might have done with appropriate guidance.

If we are concerned for reproductive futures, then obstructing access to gender-affirmative healthcare is counterproductive. In practice, creating a hostile environment for trans healthcare destroys the parenting dreams of many trans people and their partners, of all ages.

For one thing, trans people frequently lack access to timely and accurate health information when starting out on our various journeys. As Ailbhe emphasised in a previous interview, medical information and support should be available to us so that we can live our lives and not continue to feel alienated, pathologised, and dysphoric.

In most cases, we end up educating our healthcare providers, rather than the other way round. For example, many GPs dont know that in certain circumstances they can prescribe temporary hormone treatment to trans people waiting for their GIC diagnosis.

This is a problem when what we dont know can hurt us as is sometimes the case with reproductive side effects of transition. Trans people are often required to live openly in their preferred gender for a year or more before doctors will consider medical treatment such as hormone management. To fulfil this requirement, many trans women and transfeminine people, for example, tuck our genitals so as to prevent a visible front bulge.

This can be necessary in order to feel safe, comfortable and dignified under public scrutiny, or to alleviate feelings of dysphoria. What many women dont know until too late, however, is that the process can significantly impact fertility.

NHS guidelines acknowledge that hormone management can compromise fertility, and recommend that trans women should be able to access cryopreservation of gametes (sperm or eggs) prior to treatment. In practice, this service is rarely authorised by local funding bodies.

Madeleine, a freelance stage manager in Bristol, was refused cryopreservation when she was 17. Although she eventually accessed an alternative service, this meant a ten-month delay to starting hormones, at a critical time in her life. Sian, a student, ended up going private for cryopreservation, which was not only expensive but involved coming off hormones, with a long delay while she searched for a (relatively) affordable clinic.

Even where this policy is respected, however, a formal diagnosis is required to access the treatment on the NHS. Even in the best case scenario (that is, disregarding the years-long delays currently affecting GIC services), this effectively ensures that a trans woman will likely have incurred damage at least a year prior to becoming formally eligible for treatment.

For trans men and transmasculine people, the prevailing medical approach has long assumed that medical transition automatically involves a hysterectomy (removing the womb). While for some this surgery is a desired outcome, for others it is an unnecessary invasive operation that makes pregnancy impossible.

Underlying this approach is an unspoken belief that being trans is not a real thing, but a fad which society collectively should not indulge

There is no medical imperative to remove the dormant uterus unless a complication develops a relatively rare occurrence. Instead, this unofficial policy seems to arise from outdated binary ideas about sex and gender.

The growing number of trans fathers who like Jacob choose to carry and birth their own children shows that this is nonsense. It is important for trans and non-binary people to be supported in reviewing all options and making informed choices when considering medical transition. This applies, regardless what age a person begins their transition journey.

In fact, if young peoples reproductive futures are the priority, then making life difficult for those who want to access gender-affirming medical care may have the opposite of the desired effect. Creating a hostile, suspicious environment for trans young people puts excessive pressure on them to take up and defend a definite, fixed and binary position about their identities and desires for the future.

Knowing its going to take all youve got to fight for access to healthcare may be a deterrent for the fainthearted, but for most of us all it does is deny us the chance to explore our natural doubts and uncertainties in a safe and supportive environment.

This is part of the Struggle for trans healthcare equality mini-series, looking at issues affecting local transgender, nonbinary and gender-diverse (trans) communities, driven by peoples lived experiences.

Read more:
'Puberty blockers are safe and reversible. So why do campaigners want to deny access to them?' - The Bristol Cable

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