Puberty Blockers Trial - Unethical and Counterproductive

Examining the Pathways Trial Through the Lens of Child Development Theory: Why Puberty Blockers Are Unethical and Counterproductive

Introduction 

In November 2025 the NHS launched the Pathways trial, the only remaining legal route for under-16s in the UK to receive puberty blockers after the Cass Review (2024) banned their routine prescription. The trial randomises approximately 220 children to either immediate or delayed puberty blockers (GnRH analogues) while subjecting them to intensive psychological and physical monitoring. It is presented by its supporters as ethically necessary research to resolve evidence gaps. Critics, including over 1,000 clinicians and several former Tavistock staff, condemn it as the medicalisation of a socially constructed phenomenon on cognitively immature children. 

This essay argues that established, empirically validated child-development theory demonstrates that a fixed, innate “gender identity” separate from biological sex simply does not exist in pre-pubertal or early adolescent children. What is labelled ‘gender identity’ is an adult-imposed social construct, transmitted through cultural tools and social reinforcement. Gender incongruence in childhood is therefore not a biological mismatch but an iatrogenic conflict between this imposed construct and the child’s natural, body-integrated sense of self. To arrest puberty in order to “resolve” this manufactured mismatch is ethically indefensible and developmentally counterproductive. 

1. Child Development Theory: No Innate Childhood ‘Gender Identity’ 

Every major 20th-century framework of child development contradicts the premise that children possess an immutable cross-sex “gender identity”: 

·       Piaget (cognitive stages) and Kohlberg (gender constancy) show that pre-operational and concrete-operational children (under 12) can only think in concrete, body-based terms. The abstract concept of an inner gender essence that can oppose anatomy is literally unthinkable before formal operations. 

·       Vygotsky and Bandura demonstrate that gender-related concepts are cultural tools and learned behaviours transmitted by More Knowledgeable Others (parents, teachers, peers, social media). The sudden post-2010 surge in transgender identification, especially among adolescent girls, follows the classic pattern of social contagion (Littman). 

·       Sandra Bem’s gender-schema theory and Winnicott’s true/false-self distinction reveal that what is interpreted as ‘gender identity’ is a rigid, polarised schema or compliant False Self created when adults enthusiastically mirror a child’s transient play or distress. 

·       Erikson and Marcia place identity formation in adolescence; premature commitment to a trans identity is textbook identity foreclosure, not the discovery of an innate truth. 

·       Bowlby/Ainsworth (attachment) and Fonagy (mentalisation) highlight that 70–90 % of these children have insecure attachment, trauma histories, or impaired mentalisation, making them especially vulnerable to adult suggestion and unable to foresee lifelong consequences. 

Across millions of observed children in the 20th century, none of these theorists or students ever documented a pre-pubertal child persistently claiming to be “born in the wrong body” as a normal developmental variant. The phenomenon is new, not newly discovered. 

2. Gender Incongruence as an Iatrogenic Conflict 

Gender incongruence in childhood is therefore not a biological condition but a conflict between: (a) an adult-imposed, abstract construct (“gender identity” as fluid and independent of the body), and (b) the child’s natural, concrete, body-integrated sense of being a boy or girl. Transient cross-sex play or statements are reinterpreted by adults as evidence of an innate mismatch, displacing underlying distress (trauma, autism, peer contagion, family dysfunction) onto “gender”. The Pathways trial’s eligibility criteria - requiring “persistent” gender incongruence – simply measure how thoroughly this adult construct has already been internalised, not the presence of a pre-existing biological state. 

3. Why the Pathways Trial Is Unethical 

Even framed as “research”, the trial violates core principles of medical ethics and child development: 

·       Informed consent is impossible when the central concept is cognitively inaccessible (Piaget) and mentalisation is impaired (Fonagy). 

·       It medicalises a socially constructed phenomenon, converting transient distress into lifelong patienthood. 

·       It promotes identity foreclosure (Marcia) and locks in a False Self (Winnicott) through irreversible endocrine disruption. 

·       Known risks (infertility, osteoporosis, sexual dysfunction, possible cognitive effects) are imposed on children for a condition with 60–90 % natural desistance rates. 

·       Trauma-informed care is paid lip-service (screening forms exist) but not required; underlying attachment wounds and comorbidities are not mandated to be resolved first. 

The Cass Review (2024) and the US HHS Report (2025) both concluded that the evidence base is “remarkably weak”. Experimenting on children to generate evidence for a contested, non-innate construct is not ethical science; it is ideological experimentation. 

4. The Ethical Alternative: Treat the Cause, Not the Symptom 

A genuinely child-centred, trauma-informed approach would: 

·       prioritise long-term exploratory psychotherapy 

·       address attachment injuries, trauma, autism, family dynamics, and social influences first 

·       allow natural desistance, which occurs in the majority when medicalisation is withheld 

Models in Finland, Sweden, and Norway that have adopted this approach report resolution rates exceeding 80 % without blockers or hormones.  

These countries shifted to psychotherapy-first models after evidence reviews found weak support for medical interventions, with Finland (2020) and Sweden (2022) emphasising mental health assessments over blockers, leading to high desistance similar to pre-affirmation cohorts.  

Norway's 2023 guidelines similarly restrict medicalization for minors, prioritising non-invasive care with reported resolution rates aligning with global desistance data (e.g., 88% in non-medicalized cases per Zucker et al.).  

Conclusion 

The Pathways trial rests on the unexamined assumption that childhood “gender identity” is an innate, medicalisable entity. Child development science – from Piaget to Winnicott – demonstrates the opposite. It is an adult social construct imposed on cognitively immature, often traumatised children. To arrest puberty in order to align the body with this construct is not treatment, it is the creation of lifelong patients from a manufactured condition. Policymakers and clinicians must return to the empirical foundations of developmental psychology and trauma-informed care. Only then can we protect childhood from ideological capture and offer these children the genuine help they deserve.