Cass Review

Wednesday 17th April 2024 Lords Chamber

Statement

The following Statement was made in the House of Commons on Monday 15 April.

“With your permission, Madam Deputy Speaker, I would like to make a Statement on the Cass review of gender identity services for children and young people. May I say how pleased I am that we are joined by parents of children who have been affected by some of the issues raised in this review? I hope all of us will bear the sensitivities of this debate in mind as we discuss it this afternoon.

This review strikes hard and sure at an area of public policy where fashionable cultural values have overtaken evidence, safety and biological reality. This must now stop. As recently as 2009, the NHS’s sole gender identity development service at the Tavistock and Portman NHS Foundation Trust received fewer than 60 referrals for children and young people, and just 15 for adolescent girls. Since then, demand has surged. By 2016, over 1,700 children and young people a year were referred—a 34-fold increase. More than half were teenage girls. In 2022, more than 5,000 children and young people were referred to gender identity clinics, and almost three quarters were female.

This exponential increase in demand is not a coincidence; it has been driven by a number of factors which I will come to later, but at its heart it was driven by a myth. This myth was that for children and young people grappling with adolescence who were questioning their identity, their sexuality or their path in life, the answer to their questions was inevitably to change gender to solve their feelings of unease, discomfort or distress.

That near-uniform prescription was imposed on children and young people with complex needs without full and thoughtful consideration of their wider needs, including, as is set out in the report, conditions such as neurodiversity, experiences such as childhood trauma or mental health conditions, or indeed discovering who it is that they may one day fall in love with. Indeed, the response from some of the people who should have protected them—some of the clinicians in charge of their care at the Tavistock clinic—was almost always to put them on an irreversible path: blocking puberty, then prescribing cross-sex hormones, and on to surgery as an adult. In other words, such professionals were not asking the right questions of themselves or of their patients.

That is why in 2020, with the support of my predecessors, my right honourable friends the Members for West Suffolk, Matt Hancock, and for Bromsgrove, Sir Sajid Javid, NHS England commissioned Dr Hilary Cass to examine the state of services for children questioning their gender. I would like to start by thanking Dr Cass and her team for undertaking a considered, comprehensive and courageous review into an extremely contentious area of healthcare. Since NHS England commissioned the review in 2020, they have meticulously unpicked what went wrong, what the evidence really shows and how to design a fundamentally different service that better serves the needs of children.

I must also thank those who raised the alarm and contributed to the review over the last four years: the clinicians who spoke up against their peers to blow the whistle about what was happening at the Tavistock clinic, even though it risked their careers; the journalists, academics and activists who listened to their stories and investigated further, even when they were derided as bigots and transphobes; the parents who were just trying their best to support their children, but were so badly let down by a service that vilified them for questioning whether the interventions offered were right for their children; and, of course, the young people themselves who have shared their experiences, including those who have gone through the pain of de-transitioning only to find out that the so-called ‘reversible’ treatments they were offered are not in fact reversible.

The Cass review makes for sober reading. It is extremely thorough, so I will not attempt to cover all its recommendations today, but I genuinely encourage all Members to read the report in full. It should concern every single Member of this House that part of our public space—the NHS—was overtaken by a culture of secrecy and ideology that was allowed to trump evidence and safety. We say enough is enough; our young people deserve better, and we must do whatever it takes to protect them.

Since the publication of Dr Cass’s interim report in 2022, a series of important changes have been made, and I put on record my thanks to NHS England’s chief executive, Amanda Pritchard, and all those at NHS England who have worked hard with Dr Cass to implement them. On 31 March, the Tavistock clinic finally closed, having stopped seeing new patients a year earlier. Two new regional hubs have been opened, in partnership with the country’s most prestigious children’s hospitals, to ensure that children are supported by specialist, multidisciplinary teams. Indeed, another hub will follow in Bristol later this year.

In the past few weeks, NHS England made the landmark decision to end the routine prescription to children of puberty blockers for gender dysphoria. On the day of publication of Dr Cass’s final report, it announced that it is stopping children under 18 from being seen by adult gender services with immediate effect, and an urgent review on clinical policy for cross-sex hormones will now follow without delay. I also welcome NHS England’s plans to bring forward its full review of adult services, including Dr Cass’s recommendation for a follow-through service for young people up to the age of 25.

I also share Dr Cass’s concerns that clinicians who subscribe to gender ideology will try to use private providers to get around the rules. Let me give a very clear warning: prescribing is a highly regulated activity, and the Care Quality Commission has not licensed any gender clinic to prescribe hormone blockers or cross-sex hormones to people under the age of 16. Any clinic that does may be committing extremely serious regulatory offences for which its licence can be revoked and its clinicians can be struck off. My officials have been in contact with the CQC following the final report to ask that it looks again at the age thresholds in its licensing conditions.

The CQC has also reassured us that it will incorporate Dr Cass’s recommendations into its safe care and treatment standards for all care providers. That means that all new providers will be asked if their practices respect the Cass review, and all existing providers have to meet the same rigorous standards when they are reviewed by the CQC. My officials met the General Medical Council over the weekend, and will do so again in the coming days, to understand how it will ensure that every clinician on its register follows its code of practice and implements the wider findings of the Cass review.

It is morally and medically reprehensible that some online providers not registered in the UK have stated their intention to continue to issue prescriptions to children in this country. I am looking closely at what can be done to curtail any loopholes in prescribing practices, including legislative options. Nothing is off the table, and I will update the House in due course as we progress that work at pace.

Dr Cass also found that there was a lack of robust data on what happened to the 9,000 children who were treated by gender identity services between 2009 and 2020. Many went on to continue their treatment at adult clinics, and the University of York had been due to research the long-term consequences of treatment they received as children, so that we can properly support them through their journey into adulthood. It was expected to provide important insights into the clinic’s work, including how many patients de-transitioned and how many were also diagnosed with a mental health condition or an autism spectrum disorder.

This Government took the unprecedented step of changing the law to make it possible for adult gender clinics to share medical data with the university. All bar one of the adult gender clinics refused to co-operate with this vital research. To quote Dr Cass, that is ‘unacceptable’, but I would go even further: I think it is deplorable and a dereliction of their professional duty. I am pleased to update the House that following the publication of Dr Cass’s report, I have been informed that all seven clinical leads for the adult gender services now intend to fully participate in this important work.

Dr Cass also concludes that a cultural shift alone ‘does not adequately explain’ the huge growth in young women being referred to gender services. She paints an alarming picture of digitally engaged young women who are frequently exposed to pornography involving violent, coercive, degrading and pain-inducing acts. Is it any wonder than more and more of them are looking for ways to opt out of becoming women? That is deeply troubling and, as Dr Cass makes clear, we have a duty to support those young women with considered, evidence-based care.

Our children deserve healthcare that is compassionate, caring and careful. Their safety and well-being must come above any other concern, and anyone who threatens it must be held to account. I will work with NHS England to root out the ideology that has caused so much unnecessary harm, to support those who have already received life-altering treatment, to give the next generation access to holistic care, and to protect our children’s futures. Anything less would be neglecting our duty to the next generation. That will not happen under this Government, and it will not happen under my watch”.

19:45

[Baroness Merron (Lab)]

My Lords, Dr Cass and her team are to be thanked for their rigour and their care with this report, in which they have navigated many complex and sensitive issues. This review into the NHS’s gender identity services concludes that children and young people have been let down by inadequate research and evidence on medical interventions, and they have been failed by inadequate services amidst a debate which has, sadly, been marked by extreme toxicity.

At the same time, at the heart of the complexity around gender identity services are two aspects that are simultaneously true. There are trans adults who have followed a medical pathway and say that, for all the pain and difficulty involved, it was not just life-affirming; it was life-saving. There are also people who followed a medical pathway and say that it has ruined their lives irreversibly and ask how anyone could let that happen. For those children, young people, and now adults, but particularly those who are being referred into gender identity services today, there is a duty to get this right.

The Cass review refers to many scandals, which exposes both the inordinate amount of time that children and young people are waiting for care while their wellbeing deteriorates, and medical interventions that have been made on what could be called shaky evidence. Can the Minister say how it came to be that NHS providers refused to co-operate with this review? How was it allowed that adult gender services would not share data on the long-term experience of patients? What accountability does the Minister feel that there should now be?

The Minister will know that the discussion around the substance of the review has been highly toxic. People have felt silenced, and it has required investigative journalism to prompt this review to take place. Tribute should be paid to journalists, including Hannah Barnes, and to the whistleblowers, who together helped shine a light on the Tavistock clinic. It is concerning to note that Dr Cass said that the

“toxic, ideological and polarised public debate has made the work of the review significantly harder”,

and that will

“hamper the research that is essential to finding”

a way forward. This particularly vulnerable group of children and young people is at the wrong end of the statistics when it comes to mental ill health, suicide and self-harm. They have been badly let down, so we owe it to them to approach this discussion with the sensitivity it demands.

Parts of this report today will sound very familiar: services unable to cope with demand; significant staff shortages; a lack of workforce planning; and unacceptably long waits for the mental health support and assessments that children and young people need, such that in some cases children become adults before they even get a first appointment with the gender identity services. To this point, the Cass review recommends a follow-through of services up to the age of 25, to ensure continuity of care. Will the Minister indicate how long it will take to establish these services, and could the Minister set out what plans there are to cut waiting times for assessments for mental health and neuro- developmental conditions?

Last month’s decision by NHS England to stop the routine prescription of puberty blockers to under-18s is welcome. However, the loophole that exists for private providers risks illegal trading. In the other place, the Secretary of State said that she expected private clinics to follow the report’s recommendations to follow the evidence. I underline our support for these expectations on compliance. Does the Minister consider that further regulation might be needed to enforce the recommendations? Could he say something more about the timescales involved in making progress, both for the CQC to incorporate the recommendations into its safe care and treatment standards and for NHS England’s urgent review on clinical policy for cross-sex hormones?

Children’s healthcare should always be led by the evidence and be in the best interests of their welfare. Dr Cass’s report has provided the basis on which to go forward. This report must also provide a watershed moment for the way in which society and politics discuss this issue. There are children, young people and adults, including trans children, young people and adults, who are desperately worried and frightened by the toxicity of the debate. There are healthcare professionals who are scared to do their job and make their views known. I hope that we can now put children’s health and well-being above all else.

[Baroness Burt of Solihull (LD)]

My Lords, I believe that the Cass review is an extremely thorough summary of where we are now and of the pathways available to young people that we need to explore. Most importantly, this report gives a way forward for young people and their clinicians who feel anxious and frightened because they find themselves at the centre of a political maelstrom.

Interestingly, the most balanced response I have seen to the report came from Stonewall, which was consulted by Cass, and I have used some of its points here. Cass says that these youngsters have been sorely neglected by the NHS, which sidelined them away from mainstream care to services that have fallen short. She points to how we can start the process of making it up to them, by giving them the holistic care that they need and deserve.

Despite the way in which the report was received by certain gender-critical individuals, it does not question trans identities or recommend rolling back healthcare access. It does not say that puberty blockers are unsafe or dangerous. It does say that there is insufficient and inconsistent evidence about some of the effects of puberty suppression. In addition, it notes that cross-sex hormones are well established and have transformed the lives of trans people, and supports their use from the age of 16. Importantly, it does not, at any stage, suggest a ban on social transition for any age of child or young person, but recommends that this be done with the support of parents and clinicians.

Cass says that gender incongruence is a result of a complex play between many biological, psychological and social factors, of which sexual orientation can be one. There are many factors, and no simple answer. For example, saying that such young people are simply confused gay people, unhappy teenagers, or that it is all the fault of social media, is all too simplistic. Regrettably, this has not stopped the Government spinning their own version of who is to blame.

For example, this week’s Statement by Secretary of State Victoria Atkins said that Tavistock clinicians “almost always” put children on an irreversible path of blocking puberty, then prescribed cross-sex hormones and on to surgery as an adult. This is not my understanding of the situation. In 2019-20, only 161 under-19s were referred by gender identity development services for puberty blockers. It was estimated that only around one in six GIDS patients ended up being prescribed puberty blockers. Is not the picture bad enough, without painting something even worse?

There are currently more than 5,000 children on the waiting list for treatment. The NHS has confirmed that everyone currently on puberty blockers via the NHS—fewer than 100 children—will be able to continue on them. These children, and any new recommendations for puberty blockers, will not be prescribed unless they agree to take part in a clinical trial to test the effectiveness of puberty blockers properly. How long does the Minister estimate that it will take for this clinical trial to be set up? Speaking of waiting lists, I understand that it currently takes three years for a child on the list even to be seen. How will the trial ever be set up, except for the few now on puberty blockers, while the rest languish for years on waiting years while their puberty seeps away? Does the Minister not agree that it is time to make up this shocking treatment which has, or rather has not, been given to children by the NHS and put them immediately on a par in priority with other NHS services?

These are our children. They, and the clinicians who want to treat them, have been intimidated by the toxic environment that we have all helped to create. I have heard the Cass report described as a rock that we can now all cling to. We will never all agree about some quite fundamental issues regarding trans and the nature of trans, but we must never make our children suffer for it; we must never make them pawns in a zero-sum game. We must rise above it and argue well, with more light than heat, to protect our children, who, after all, must be at the centre of all we seek to do.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)]

I thank the noble Baronesses for their important points and for their sensitivity.

First, I echo the Secretary of State’s gratitude to Dr Cass and her team for undertaking a considered, comprehensive and courageous review into an extremely contentious area of healthcare. Officials have described this to me as probably the best report they have seen, in its excellence, thoroughness and sensitivity. Since NHS England commissioned the review in 2020, it has meticulously unpicked what went wrong, what the evidence really shows and how to design a fundamentally different service that better serves the needs of children.

Noble Lords and Baronesses will be aware of why this review was commissioned, but it is worth repeating here. The statistics are startling. As recently as 2009, the NHS’s sole gender identity development service at the Tavistock and Portman trust received fewer than 60 referrals for children and young people, with just 15 being adolescent girls. Since then, demand has surged. In 2022, more than 5,000 children and young people were referred to gender identity clinics, almost three-quarters of whom were female. The near uniform prescription of an irreversible medical pathway on the basis of sometimes very minimal evidence was imposed on these children and young people with complex needs without full and thoughtful consideration of their wider needs, including neurodiversity, trauma, mental health conditions or who they loved.

In her Statement in the other place, the Secretary of State outlined the immediate priorities for taking forward the recommendations from Dr Cass’s report. This includes looking closely at what needs to be done to curtail loopholes in the prescribing practices of private or online providers to ensure that they fall in line with Dr Cass’s recommendations. In answer to the noble Baroness, Lady Merron, the CQC is on this, and made it clear to all providers straightaway. We hope that legislation will not be required, but we are prepared to table it if necessary, because we need to send out a very clear message.

Private providers have been put on notice. Prescribing is a highly regulated activity and the CQC has not licensed any gender clinic to prescribe hormone blockers or cross-sex hormones to people under the age of 16. Any clinic that does may be committing extremely serious regulatory offences, for which it can have its licence revoked and its clinicians struck off.

On the point made by the noble Baroness, Lady Merron, I share the view of Dr Cass and the Secretary of State—I know that noble Lords share it, too—that it is completely unacceptable that all bar one adult gender clinics refused to co-operate with the University of York research into the long-term consequences of treatment received at the Tavistock centre. To be completely honest, I do not understand how they could be allowed to do that and I think we all are united in saying that that is simply not acceptable. That is why we have gone back so strongly on exactly that point.

Since the publication of Dr Cass’s interim report in 2022, NHS England has made a series of important changes. On 31 March, the Tavistock clinic finally closed, having stopped seeing new patients a year earlier. To answer the points made about new services, two new regional hubs have been opened in partnership with the country’s most prestigious children’s hospitals to ensure that children are supported by specialist multidisciplinary teams, and another will follow in Bristol later this year. In the last few weeks, NHS England has made the landmark decision to end the routine prescription to children of puberty blockers for gender dysphoria. On the day of publication of Dr Cass’s final report, NHS England announced it was stopping children under 18 receiving adult gender services with immediate effect, and an urgent review on clinical policy for cross-sex hormones will now follow without delay.

Children are at the heart of this debate. Dr Cass’s report demonstrates that they deserve healthcare that is compassionate, caring and careful. Their safety and well-being must come above any other concern. That is why the Government will work with NHS England to root out the ideology that has caused so much unnecessary harm, and to give the next generation access to holistic care and protect our children’s future.

I turn to the other points raised. In addition to the three clinics mentioned, eight regional clinics will also be set up to make sure we can provide services on this. Within all that, the point about providing continuity of care up to 25 will be a key part of that. On mental health treatments generally and helping people on that, that is what the £2.3 billion investment has all been about in terms of developing the hundreds or thousands of extra places.

With regard to clinical trial timings, that is a difficult one. I think all noble Lords agree—this was very much a feature of the round table we held after we had the question on gender identity—that there is a general feeling that of course you do not want to settle on any course of treatment for a young person while they are still at that stage of life, in terms of puberty, where they have not had a chance to discover their own feelings. We all know that it is a complicated time and so, more than anything, we want to make sure that people are not set on a course of action that is irreversible before they really know their own minds and bodies and what is appropriate in that situation. That is why we are so firm in trying to follow the Cass guidelines to make sure that that is not available in those circumstances. To be open and honest on that point, I am not absolutely sure whether those clinical trials are compatible with that, but I will come back in more detail on that point. I hope that that answers the points for now, and I look forward to answering other points raised.

20:04

[Baroness Bottomley of Nettlestone (Con)]

My Lords, this is a deplorable situation. It is a formidably good report and I commend the Government on their firm action following its publication. I question why it took the NHS quite so long to stop the routine prescription of puberty blockers to children under 18—that seems rather slow off the mark.

However, I have a more important point. I fear that one of the great damages from all this is to one of our national and international centres of excellence. The Tavistock clinic has been in existence for over 100 years. It was started by Hugh Crichton-Miller for the treatment of soldiers with shellshock. It has been the home of John Bowlby, Lily Pincus and RD Laing. It has done incredibly important work in terms of mental distress, mental health and emotional well-being. It is a national and international centre of training, with about 2,000 students a year. If I may take up the Minister, for whom, as he knows, I have an inordinate regard, I think he said that the Tavistock clinic had closed. It has not closed; the gender reassignment clinic has closed for ever. I ask the Minister and everyone in this House to try to help reclaim the reputation and the respect that the Tavistock clinic rightly deserves.

[Lord Markham (Con)]

Yes, absolutely, and I thank my noble friend for correcting me and giving me the opportunity to correct that. Again being very honest, this shows that part of the challenge in setting up the new services is that this has become such a difficult, toxic space, and finding and recruiting staff who want to work in this area is a real challenge as well.

[Baroness Hayter of Kentish Town (Lab)]

I thank the Government, the Minister and indeed the Opposition for their very robust response and welcome to the report. I am really sorry that the Lib Dems have chosen to use Stonewall’s briefing in what we have heard tonight; I hope that is not the whole of the Lib Dem position.

I note that the Government have already met with the GMC over the weekend, and they have been in contact with the CQC. However, just last month, the Royal College of General Practitioners tried to cancel a conference posing exactly the questions covered by Dr Cass in her excellent report. It allowed this conference—it was called “First Do No Harm” and I had the privilege to open it—only after an enormous amount of persuasion; it did it under duress, with bad grace and some hostility. That was the Royal College of General Practitioners.

Will the Government also meet the Royal College of General Practitioners and indeed the Royal College of Psychiatrists, the Royal College of Nursing, the Professional Standards Authority and all the other regulators, many of which seem to have been blind when all this was going on, and ensure that they all engage with the conclusions and the recommendations of Cass, whether those professionals over which they have oversight are working in the NHS or in the private health sector? These puberty blockers were being prescribed years after we knew they were irreversible, when Stonewall still said they were reversible, and when the doctors should have known but still prescribed them. Will the Government therefore engage with all those regulators to ensure that Cass is implemented in full?

[Lord Markham (Con)]

Yes, and that is an excellent point. Again, I thank the noble Baroness in this area. The questions that she raised earlier in the year in terms of some of the language from the GMC really added to the debate and represented a step forward. Therefore, although I am sure it is happening already, I will doubly check that it is.

[Lord Sandhurst (Con)]

My Lords, my focus is on the misuse of drugs for unlicensed purposes. It is perfectly proper and sensible that drugs are used for unlicensed purposes in the right circumstances. For example, in the case of children, drugs are not tested on them; they have been tested and licensed for use on adults, and they are used quite properly—it is called “off-label”—for children for the same purposes. However, in this case, as Cass has found at paragraphs 20.11 and 20.12 of her report, in the case of puberty blockers there was what she describes as a “system weakness” in that off-label use. It went beyond the usual level of permissiveness in extending use to a very different indication. So she has recommended, in recommendation 32:

“Wider guidance applicable to all NHS services should be developed to support providers and commissioners to ensure that innovation is encouraged but that there is appropriate scrutiny and clinical governance to avoid incremental creep of practice in the absence of evidence”.


I have two questions. What steps are the Government taking to implement this important recommendation as a matter of urgency? It will not just be puberty blockers; there will be drugs used in a range of fields. Who will be charged with the responsibility for creating this guidance and then implementing it?

[Lord Markham (Con)]

With the wonders of modern technology, I hope I can answer two questions in one. On the previous question, yes, the regulators have been communicated with about making sure that it is very clear. On that point, I say to my noble friend that the regulators have been charged with making sure that very clear guidelines are put out on the drug use that he mentions; those are being set right now. While I am clearing stuff up, to be clear and to save me correcting it later, it will be eight clinics in total when they are all there; I might have said that it was eight additional clinics.

[Lord Young of Norwood Green (Lab)]

My Lords, I too pay tribute to the Government, and to Dr Cass especially, for a magnificent report that took both determination and courage; let us not underestimate that. She has achieved a huge amount: we now have four clinics up and running with people who understand the need to counsel young people. What we do not know is how many thousands of lives have been wrecked by the indiscriminate use of puberty blockers and hormones; it may eventually be uncovered. I also pay tribute to our party and our shadow Health Minister Wes Streeting for unequivocally backing the Cass report and committing the next Labour Government, should that be the case, to an evidence-based situation.

I put it to the Minister that puberty is not something that ends at 18. Dr Cass rightly defines it as a process that could go up to 25. She recommends that those services should include that kind of counselling, and I would welcome some confirmation from the Minister that that will be the case. There is still more work to be done on this. I have said on previous occasions that this is a cult that has invaded a lot of the institutions of government and other institutions. It is not going to just lie down quietly; there will be attempts to evade this legislation, and we should be on our guard against that.

I want to end on a positive note. I welcome the Statement. I pay a further tribute to Dr Cass, a woman who came out of retirement and was probably looking for a nicer and easier thing than this to deal with. This Chamber owes her and her civil servants a real debt of gratitude.

[Lord Markham (Con)]

I remember that it was the noble Lord who, in the round table that we had on this, made very clearly the same point I was making earlier about puberty and age. It is only when you are right the way through it that you really are in a position where you start to know your own mind and your own body. I agree with the noble Lord that it can be as late as 25, and that is why that is definitely the intention behind the eight clinics that are being set up—that they can provide that continuity right up to the age of 25, given that there is such a state of flux in a young person’s life.

[Baroness Finlay of Llandaff (CB)]

My Lords, I thank the Government for giving us this opportunity. Dr Cass’s report is incredibly important. She has taken a scientific, as well as a kind, humane and humanitarian, approach to the children affected and to the way the report is written. In the recommendations, as well as the discussion over puberty blockers there is the importance of ongoing research, research capacity and data. One finding that emerged for her was that there was a lack of consistent collection of data, which means that for many of these children, the people who were looking after them were, in effect, flying blind. That cannot be allowed to continue in future.

Her recommendation 17 is that:

“A core national data set should be defined for both specialist and designated local specialist services”.


Recommendation 18 is that:

“The national infrastructure should be put in place to manage data collection and audit and this should be used … to drive continuous quality improvement and research in an active learning environment”.


My question to the Government is whether, among the organisations listed, there are also discussions with the Royal College of Surgeons, because there is also surgical intervention undertaken in some of the processes. Without a database of the numbers that undergo a surgical intervention, the type of intervention and the complication rates, and monitoring the effect of that surgery on quality of life, we risk carrying on flying blind with clinical treatments that are literally life changing.

[Lord Markham (Con)]

I thank the noble Baroness. She is absolutely right: it is only in that lack of data environment that, dare I say it, ideology can fill in the vacuum and start to drive the sorts of behaviours that we see. Data is always the best way to cut through and provide light when there is a lot of heat in an argument. She makes an excellent point about the Royal College of Surgeons. I am sure that it has been contacted along with all the other bodies, but we need to make sure that is covered off. As ever, I will come back in detail in writing to all noble Lords who have raised points. I will make sure that point is addressed as well.

[Baroness Deech (CB)]

My Lords, my gratitude to Dr Cass is that the report has given the rest of us the strength to challenge something that we knew was irredeemably harmful. I have two questions for the Government. First, will they remind the NHS of the law? Gillick competence—I am abbreviating it—states that:

“Children under the age of 16 can consent to their own treatment if they’re believed to have enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment”.


It is simply impossible for any child under the age of 16 to understand what is meant by sex change or puberty delay. They cannot get their heads around it or possibly comprehend what it will mean for them in future, so Gillick competence has to be remembered.

Secondly, will the Government also remind the NHS that young people and others are confused and possibly endangered by the ridiculous use of phrases saying that “people who have ovaries” or “people who have cervixes” should come forward for treatment and so on? Can we please restore the word woman, or indeed girl, when it comes to medical treatment?

[Lord Markham (Con)]

To take the second point first—it was also made by the noble Baroness opposite—that is absolutely right; it can be a real danger. People with English as a second language might not understand that a “person with ovaries” refers to them. It needs to be very clear. It is fundamental that the first description has to be “male” or “female”; you can then put additional parentheses after that.

The noble Baroness’s first point is exactly right. Until young people are through the age of puberty and its effects, they are not in a real position to make up their own minds. That does not mean that they should not be supported during that process, but it does mean that we should not be doing anything irreversible.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I watched the Secretary of State’s introduction to this Statement on Monday, live from my office. She asked the other place to

“bear the sensitivities of this debate in mind”.—[Official Report, Commons, 15/4/24; col. 55.]

I am afraid that it is clear from the printed record before us, and was even clearer watching the Secretary of State speaking, that it was delivered in a triumphalist, dogmatic tone, which meant that she did not follow her own prescription.

The Statement speaks of “myths” but fails to acknowledge the agency and lived experience of children and young people. I have two questions for the Minister. Can he reassure me that we are not going to lose, in this ideological debate, the need for massively more investment in services for children and young people in the NHS? The noble Baroness, Lady Burt, referred to the huge waiting lists that are behind the report we are discussing today.

The Statement also did not mention—and I think we have to acknowledge this—that hate crime against transgender people hit a record high in figures out last October. I hope that the Minister will agree with me that children and young people seeking gender identity services should not have to live in a society where their experiences are used as a political football. They should not be treated as a weapon in the culture war. They should not have to live in a hostile society.

[Lord Markham (Con)]

First, I think I speak for the whole House in agreeing that no one, under any circumstances, should feel that they live in a hostile society —whatever case it is, whether it is transgender, race, sex or whatever. I totally agree with the noble Baroness there. I will absolutely clarify this in the follow-up in writing, but I know that, in this specific area, the NHS has already committed £18 million in this space. Of course, this is quite separate from the £2.3 billion that I mentioned before in the mental health space generally, which, from memory—and I will absolutely clarify this—is the provision of 350,000 extra places for young people, because we know how much the demand is out there.

[Baroness Jenkin of Kennington (Con)]

My Lords, I am grateful to the Noble Baroness for clarifying the Lib Dem position because, unfortunately, the page on the website has disappeared this afternoon. May I ask my noble friend whether the Government acknowledge that a conversion practices Bill would have a detrimental effect on the recruitment of clinicians to the new children’s services, as highlighted in the Cass Review?

[Lord Markham (Con)]

I must admit that I am not sure that I quite understood the question from my noble friend.

[Baroness Jenkin of Kennington (Con)]

There are a number of conversion practices Bills currently in play, and Cass has said that such a Bill would have a detrimental effect on the recruitment of clinicians, because they would feel a chilling effect before they would apply.

[Lord Markham (Con)]

Understood. Again, I will come back in detail on that point. One of the points made to me about the difficulties of trying to recruit to these eight new services was that, when this is such a toxic space, how do you get good-quality people? I think we agree we need that more than ever, because it is such an essential and sensitive area. So I will take that back and make sure that nothing we are doing, such as that legislation, should have that sort of chilling effect.

[Lord Allan of Hallam (LD)]

My Lords, if I could add to the Minister’s correspondence list, this is really following up the point made by the noble Baroness, Lady Finlay. Dr Cass rightly highlights that we need data about all the young people who present to the services—what service they received and what happened to them over time. Can the Minister include in his letter the measures that the Government will be taking to encourage those young people to participate? If they feel intimidated or that the data is going to be used against them, they are going to opt out, and then we are not going to have the dataset we need to understand the best treatment.

[Lord Markham (Con)]

That is an excellent point—yes.