Gender Incongruence: Puberty Suppressing Hormones
(3 weeks, 2 days ago)
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Rebecca Paul (Reigate) (Con)
I beg to move,
That this House has considered the potential impact of puberty suppressing hormones on children and young people with gender incongruence.
It is a pleasure to serve under your chairmanship, Ms Lewell. I am pleased to have the opportunity to shine a light on this important topic, one that impacts the health and wellbeing of some of the most vulnerable children in our country. This debate must be led by science, data and evidence, not by ideology, bias or belief. I will do my best to do that today.
The number of children and young people presenting to the UK NHS with gender distress has increased year on year since 2009, with an exponential rise in 2014. What is behind the increase among Generation Z is unclear and the reasons are likely to be multifaceted. It is speculated that the factors may include 24/7 internet access, increased acceptance of trans identities, or even peer, social and cultural influences.
Over the last 20 years we have seen groups such as Stonewall and Mermaids call for better access to treatment and increased rights for trans people. Large corporates have gone big on diversity and inclusion to boost their brands, impactful TV dramas centring trans stories, such as “Butterfly”, have been widely viewed, and the public sector, from the NHS to the police, has been flying the progress flag at every opportunity. So it can be no surprise that gender identity is at the front of young people’s minds in a way that it simply was not when I was growing up.
In 2009, only 51 patients were referred to GIDS—the NHS gender identity development service for children—of whom two thirds were male. In 2016, there were 1,766 referrals and two thirds of them were female. That is quite the change. There has been an overall surge in the number of children suffering gender distress, but the increase is especially notable among girls; we also see over-representation of neurodiversity, mental health issues and trauma in this group. To put it another way, these children are much more likely to have been in care, to suffer with anxiety and depression, to be autistic and to have been abused. It is a group of incredibly vulnerable children.
GIDS was established in 1989. Its main approach to treatment at that time was therapeutic—referred to as watchful waiting. Early studies from the 1980s showed that in around 85% of cases, the gender incongruence or distress ceased in the child after going through puberty. Later studies reached a similar conclusion, with between 67% and 90% desisting after puberty. Only a small cohort of children continued to experience gender dysphoria or incongruence after puberty, and it was that small group who would likely adopt a permanent trans identity in adulthood.
Everything changed with the emergence of the Dutch protocol, which involved the use of puberty blockers from early puberty. Puberty blockers are gonadotropin-releasing hormone analogues, which supress oestrogen production in girls and testosterone in boys. They are licensed for use in children with precocious puberty—when puberty starts much too early and it is beneficial to suppress it until a more normal developmental time and age—but in the case of gender dysphoria they are used to delay or even indefinitely stop natural pubertal development and maturation, and it is important to note that puberty blockers are not licensed for that purpose.
The original rationale for using puberty blockers to treat gender dysphoria was to press pause on puberty and give children time to think, but for some the aim was also to increase the chances of a child passing as a member of the opposite sex in adulthood. GIDS started trialling puberty blockers in the UK after 2011. The preliminary results in 2015-16 did not demonstrate psychological benefits, with some of the females suffering a worsening of symptoms, including higher incidence of wanting to hurt or kill themselves. The results of the study, which were not formally published until 2020, demonstrated no statistically significant improvement in gender dysphoria or mental health outcomes.
It is also important to remember the early studies that told us that in the majority of cases, going through puberty could relieve gender distress. It follows, therefore, that stopping or delaying puberty using medication could derail that natural desistence, essentially locking in or prolonging the gender distress, rather than allowing it to naturally resolve.
One would think that, in the absence of any evidence of benefit from puberty blockers, the NHS would have stepped back from using them after the trial. Furthermore, the high numbers of autistic, traumatised, mentally unwell and same-sex attracted youth in the group of children referred should have rung alarm bells loudly, but no; instead, puberty blockers and cross-sex hormones were routinely made available to an even broader group of children, including those with neurodiversity and complex mental health presentations.
An independent systematic review of published studies on puberty blockers, of which there were 50, was undertaken by the University of York as part of the Cass review. It was found that puberty blockers do indeed suppress puberty effectively. It was also found that, given that most children progress on to cross-sex hormones after starting puberty blockers, the main objective of pausing development is not achieved. No reduction in gender dysphoria or improvement in body satisfaction was demonstrated, and there was limited evidence of positive mental health outcomes.
Worryingly, bone density in those taking puberty blockers was compromised, and height gain may lag behind normal. In the case of biological males, it can make vaginoplasty more difficult in future, due to insufficient penile growth, forcing the use of gut tissue instead. The Cass review reports:
“There seems to be a very narrow indication for the use of puberty blockers in birth-registered males…in order to stop irreversible pubertal changes. Other indications remain unproven at this time.”
I take that to mean that those drugs have been given to young girls, not because they benefit them specifically, but because they might benefit a very small group of males. Professor David Bell, a retired consultant psychiatrist at the Tavistock, and Dr Sinead Helyar, a clinical trial nurse, also warned of the potential harms in a recent article.
“Current known and potential harms of puberty blockers are multi-fold and include a reduced bone density and early-onset osteoporosis, brain swelling and concerns around impairment of future sexual functioning and ability to form emotional relationships. A recent review of the impact of suppressing puberty on neurological function highlighted that adolescence is a critical window of neurodevelopment and puberty plays a critical role in this process. The author concluded that suppression of puberty impacts brain structure and the development of social and cognitive functions, in which the effects are complex and often sex specific.”
The over-representation of same-sex attracted girls and boys in the group of children being treated with puberty blockers is particularly worrying. In a study in the Netherlands of 70 patients given puberty blockers between 2000 and 2008, 89% were same-sex attracted, and most of the rest were bisexual. The same pattern was seen in most of the other trials, with the majority of the children growing up to be same-sex attracted adults. A paper from GIDS in 2016 reported 89% of the biological girls being either same-sex attracted or bisexual.
Why would same-sex attraction be over-represented in that way? Could gender distress be symptomatic in some cases of struggling with sexuality? Is sufficient emphasis put on reassuring those young adolescents about their sexuality, to establish if the gender distress is linked or separate; or is our society’s hyperfocus on gender identity and gender conformity putting them on an unnecessary medical pathway to change their body? Keira Bell, who has now detransitioned, says,
“I became attracted to girls. I had never had a positive association with the term ‘lesbian’ or the idea that two girls could be in a relationship. This made me wonder if there was something inherently wrong with me. Around this time, out of the blue, my mother asked if I wanted to be a boy, something that had not even crossed my mind.”
The Cass review received several reports from parents of biological females that their child had been through a period of trans identification before recognising that they were, in fact, a lesbian. That begs the question: why are so many young lesbians being medically transitioned?
Before I move on to my questions to the Minister, it is important to note that almost all the children and young people who take puberty blockers go on to take cross-sex hormones. I raise that because it links the two treatments. The impact of puberty blockers cannot be looked at in isolation, because cross-sex hormones may lead to further surgeries, lifelong medication, and loss of fertility and sexual function. These are catastrophic impacts. How can a prepubescent child really understand what never experiencing an orgasm means and the impact that could have on their future relationships, or indeed what losing the opportunity to have children could mean?
It is very apparent that the lack of solid long-term data on outcomes for patients who are treated with puberty blockers is problematic. No doctor should prescribe something in the absence of strong evidence of its effectiveness and a clear understanding of the side effects. In May 2024, the previous Government temporarily banned the use of puberty blockers for the treatment of gender incongruence and gender dysphoria in under-18s, following the Cass review’s findings of insufficient evidence to show they were safe and effective, and this ban was made permanent by the current Secretary of State for Health and Social Care in December 2024. In the light of everything that I have set out today, I fully support that decision: it is sensible, has full regard to the data, and puts the safety and wellbeing of children first.
It is also important to note campaigners’ claim that suicides among young patients with gender dysphoria increased due to puberty blocking drugs previously being restricted, following the High Court decision in the Bell v. Tavistock case, has been disproved by Professor Louis Appleby’s investigation and report, published on 19 July 2024, in which he confirmed that the data did not support such assertions. He concludes that:
“The way that this issue has been discussed on social media has been insensitive, distressing and dangerous, and goes against guidance on safe reporting of suicide. One risk is that young people and their families will be terrified by predictions of suicide as inevitable without puberty blockers.”
At the same time that the Secretary of State announced the permanent ban on puberty blockers, he announced that a clinical trial would be set up in 2025 to examine the use of puberty blockers, in order to establish a clear evidence base for the use of this medicine in gender incongruence. The £10.7 million trial, called Pathways, will be carried out by a team at King’s College and is due to run until 2031. Over two years, it will track:
“the physical, social and emotional wellbeing”
of young people who want to delay puberty, and whose parents and the gender service agree with this treatment option.
I will be grateful to the Minister for an update on the trial and how she intends to ensure that children are not physically or psychologically harmed. A trial of this nature of a drug that is unlicensed for gender incongruence raises many ethical concerns. In the words of Professor David Bell and Dr Sinead Helyar:
“The first duty of any clinician inside or outside of a clinical trial is to ‘do no harm.’”
Can there ever be a situation where it is ethical to run such a trial when the harms could be significant? It is important to remember that the children who would participate in this trial are physically healthy children who stand to have worse health by the end of it. This trial is in no way similar to a clinical trial for a cancer drug, where the patient is seriously unwell at the beginning of the trial.
Secondly, approximately 9,000 children and young people were treated by GIDS over the years, which provides a plentiful supply of data about the long-term outcomes for those who took puberty blockers and those who did not. Would the Minister please clarify matters and explain why a new trial is needed, given this abundance of data? Will she please provide an update on the exercise that is currently under way to obtain more data?
Thirdly, the current trial only proposes to look at outcomes over a two-year period. To put that into context, a child who starts puberty blockers at the age of 13 will only have their outcomes followed and assessed until the age of 15. That is not long enough to understand medium and long-term outcomes. A positive result for a 15-year-old might look very different for a 25-year-old, when physical health, sexual function and fertility are likely to be more important and relevant to them than when they were 15. Does the Minister agree that two years is not a sufficient timeframe to properly evaluate the impact of puberty blockers on physical and mental health? If this trial goes ahead, will she commit to funding and ensuring that there is long-term follow-up of these children into adulthood?
Fourthly, how many children will the trial be limited to, and what criteria will be used to determine which children are eligible and which are not? Is it possible that all eligible children will be included and prescribed puberty blockers as part of the trial? How many children in total does the Minister expect to take part in the trial over its duration? How will the trial establish an appropriate control group? Fifthly, given that gender nonconformity sometimes correlates with same-sex attraction in adulthood, how will the trial safeguard those children who may simply be uncomfortable with their sexuality rather than experiencing true gender distress?
Sixthly, given the high rates of progression to cross-sex hormones following puberty blockers, will only children who agree not to progress to cross-sex hormones be accepted on to the trial, so that the impact of the puberty blockers on outcomes can be seen in isolation? If the answer is no, given the corresponding likelihood of impaired sexual function and loss of fertility, which are monumental ramifications, how will the children taking part in the trial be able to give consent?
Finally, will the Minister please provide details of other trials that have been approved for paediatric medical interventions with equivalent or similar diagnostic uncertainty, to reassure the public that moving forward with a trial in this situation has precedent? I look forward to hearing the Minister’s answers and thank everyone for attending this debate.
Emma Lewell (in the Chair)
I remind Members that this debate will run until five past 6. I will be calling the Front Benchers at 5.45 pm, so I ask Members to keep their contributions to five minutes.
Tim Roca (Macclesfield) (Lab)
It is a pleasure to serve under your chairship, Ms Lewell. I wanted to speak today because, as has already been said, this is a really important debate—one that must be had in a respectful and open manner. I am particularly grateful to the hon. Member for Reigate (Rebecca Paul) for opening the debate in precisely that way.
There needs to be a space to debate these topics openly and to engage with each other constructively because ultimately this issue is about the safety and wellbeing of young people. These are some of the most vulnerable, and often frightened, people in our schools and medical settings. They deserve a debate based on fact, open to new ideas and evidence, and respectful of their choices and identities.
The Cass review—an important review—did not find that puberty blockers cause harm in young people. Dr Cass made it clear that puberty blockers could, in the right circumstances, be effective and valuable in helping young people. That is absolutely why we need a rigorous, safe and scientific trial to determine, once and for all, the efficacy of puberty blockers in treating gender dysphoria.
I am grateful that the review also made clear that gender dysphoria is a diagnosable, recognisable and treatable condition. It is not about boys and girls being confused, nor is it caused by the media or by playing with the “wrong” toys; it is something that has been studied, proven and diagnosed. Ultimately, we are also talking about the trans community, which I think we all agree deserves dignity and respect.
I have to say that I am not a scientist, doctor or expert, and I expect that many other hon. Members are not either. It is therefore incumbent on us all to listen to experts of all kinds who have welcomed the call for a substantial clinical trial into puberty blockers. That would not be the first trial, as many in the UK and internationally have found favourable evidence. However, I will never not be in favour of more evidence and in particular of a rigorous UK trial.
An outcome of the review was that a trial into the use of puberty blockers for those with gender dysphoria was welcomed, as I say, and that that trial
“should be part of a programme of research which also evaluates outcomes of psychosocial interventions and masculinising/feminising hormones.”
I am proud that the Government support a holistic approach to the treatment of gender dysphoria, with proper psychological and physical support as well as treatment. I urge all hon. Members to listen to that call for more evidence. The Cass review made that point strongly and expressed regret that a controlled study was not delivered in 2011, specifying:
“There are many reports that puberty blockers are beneficial in reducing mental distress and improving the wellbeing of children and young people with gender dysphoria”.
It went on to say:
“Importantly some children within this group who remain gender incongruent into puberty may benefit from puberty blockers and will be able to enter the specialist component of the service and access the puberty blocker trial in a timely way”.
The review did not rule puberty blockers out of hand completely, but wanted to ensure that there was a decent evidence base, because ultimately we are talking about young people. As we debate this issue, we should agree that more facts and evidence help, whereas conjecture, opinion and speculation only muddy the waters. I am very keen to see the framework for the trial as soon as possible—I think the hon. Member for Reigate makes some good points—so that we see the results as quickly as possible in a safe way. If they demonstrate that puberty blockers are beneficial for young people with gender incongruence, I hope all those who claim to want to protect and support young people accept that fact.
Jim Shannon (Strangford) (DUP)
It is a pleasure to serve again under your chairship, Ms Lewell. I think this is the third time this afternoon, and it is always a pleasure. I commend the hon. Member for Reigate (Rebecca Paul) for raising this imperative issue, which we talked about yesterday, and for setting the scene so well, with detail and knowledge. She and I are on the same page on this one—I share her concerns, as others will.
Medical professionals have raised with me their concern about the lack of knowledge and the impact on the most vulnerable people; they recognise and welcome the recent developments in Great Britain that have led to a significant policy shift, effectively banning access to puberty blockers for the purpose of transitioning young children. That decision has been driven by comprehensive reviews, scientific fact, and emerging evidence that questions the long-term safety and efficacy of such drastic treatment for minors. It is the right thing to do. The hon. Member for Macclesfield (Tim Roca) spoke about having time to look at these things and to understand and explore them in the necessary detail, and that we are right to do that. That is the way I feel as well.
No long-term studies have been carried out on the long-term administration of puberty blockers to children, because puberty blockers have historically been used only for specific reasons regarding rare conditions in the short term—never for what is primarily a lifetime choice. Given those concerns, and indeed the potential implications for the health and wellbeing of children, I wrote to the Health Minister in Northern Ireland to understand what steps were being taken by the Department of Health, and the Executive, to prevent Northern Ireland from being used by gender ideologists as a back door to those drugs, and to bring Northern Ireland into line with the rest of the United Kingdom.
I looked back at the statement that the Minister, Mike Nesbitt, made on 11 December 2024. He said:
“Following recommendations from the Commission on Human Medicines (CHM), it is now intended that we”—
that is the Northern Ireland Assembly and Department for Health—
“will replace the UK’s existing temporary restrictions with an indefinite ban, subject to review in 2027.”
The Northern Ireland Assembly has made its choice. I represent Northern Ireland in Westminster, and I want to represent the viewpoints of my constituency—by the way, Mike Nesbitt represents the same constituency as me: he is the Member of the Legislative Assembly for Strangford, and I am its Member of Parliament.
The welfare of children is of the utmost importance, particularly those in the age category approaching puberty, so those age 12 and under. It is crucial that Northern Ireland maintains high standards of medical practice that prioritise safety and wellbeing. Aligning our policies with evidence-based practices will help to ensure that we provide the best possible care for our young children, and protect them from decisions being made “for them and about them” by adults, when they are at such a vulnerable time and age in their lives. It is important that those in the Northern Ireland Assembly back home follow the same logic as there has been here. I know that the Minister has a particular interest in Northern Ireland and she travels there regularly. She will be aware of all these things, so I just want to put that on the record.
In conclusion, concerns have been expressed to me by medical professionals who want to solidify our position and ensure that no backward steps are taken. I look to the Minister for that confirmation. Our children—I say this with great respect—are not test dummies, and no risk should be taken with their health and future. We must have this locked down in legislation.
Westminster did the right thing. The Northern Ireland Assembly has followed that solution, and the arrow is pointing in that direction—we are doing the same. We must have all the information in front of us. We must be able to make these decisions and most of all we need to protect our children. I am a grandfather of six young children, so the issue is really important to me. I have a role to play on behalf of my grandchildren, and as an MP I have a role to play for my constituents, who feel the same way as I do.
Sir John Hayes (South Holland and The Deepings) (Con)
It is a pleasure to serve under your chairmanship, Ms Lewell, and I am grateful to my hon. Friend the Member for Reigate (Rebecca Paul) for securing this debate. Everyone, regardless of their particularities, deserves dignity, but that open-mindedness has in recent years been supplanted by an ideology-driven series of harrowing episodes involving, in this case, both medical policy and clinical practice. That led me, in 2019, to raise the issue of the Tavistock clinic when a number of the professionals there drew attention to the fact that they were
“often under pressure to refer young people for life-altering treatment even though they did not believe that it was in the individual’s best…interests…experimental treatment is being done on children who have experienced mental health difficulties, abuse and family trauma.”—[Official Report, 11 April 2019; Vol. 658, c. 479.]
Those kinds of concerns led to the review by Hilary Cass, and Cass was clear, when she published her report, that there was a lack of evidence on the long-term effects of using puberty blockers to treat gender incongruence to know whether they were safe or beneficial. Later, I had an exchange with the current Health Secretary—the previous Government having taken action latterly—in which he assured me that he would be implementing the Cass report in full. It is right that he should, because of the tragic history of the prescription of drugs that even those involved in that process regarded with such concern that they gave up their professional lives.
We have altered young people; we have warped them, and that is a result of a policy that was adopted without proper consideration and of clinical practice that did not have its basis in scientific fact. Given that the Health Secretary has seen most of that and acted upon it, it is important to consider what happens next. We know that the Tavistock clinic has been closed and we now know that there is a new series of measures to deal with these matters. There will be six new regional gender identity clinics for children and young people by 2026.
However, alongside the decision to ban the prescription of puberty blockers for under-18s, the National Institute for Health and Care Research is sponsoring a clinical trial, and I have a number of questions for this Minister about that trial. The trial will be run by a team at King’s College London, led by Professor Emily Simonoff. According to The Times, the study will involve monitoring
“the well-being of children who attend a network of new NHS gender clinics for children, including those not on”
puberty blockers, and
“whether puberty blockers affect young people’s thinking and brain development, using various activities and brain scans.”
All that is disturbing, it seems to me, and that view has been argued by David Bell, who has suggested that other kinds of research could be adopted, other measures put in place. He refers to long-term follow-up studies of those who have undergone such treatment, qualitative research into the experiences of the growing numbers of detransitioners, and further animal studies to understand the biological impact of these drugs on adolescent brain development.
That view has been reinforced by the Clinical Advisory Network on Sex and Gender, which is calling for the Government and NHS to pursue alternative research options to the proposed clinical trial, including evaluating the effects of puberty blockers on children treated by the Tavistock clinic.
It seems to me that, after our having made the mistake that led to Tavistock and then having commissioned the Cass review, which led to its closure, the risk is that we now make another mistake, not out of ill will but out of a concern expressed by some of the people I have mentioned going unheeded. I hope the Minister will heed those concerns. They are not only mine, as I have made clear.
There was an ideological aspect to this situation that we must not understate. There was a belief, on some people’s part, that rather than accepting that young people as they grew might be homosexual, their sex should be altered. That is a chilling perspective, but it did hold sway in a number of cases, with medical intervention to support it. I hope this Government do not perpetuate that distorted view of humankind, and I am immensely grateful to my hon. Friend the Member for Reigate for giving us the chance to explore just that.
Helen Morgan (North Shropshire) (LD)
It is a pleasure to serve under your chairmanship, Ms Lewell. For too long, children and young people who are struggling with their gender identity have been badly let down by low standards of care, exceptionally long waiting lists and an unacceptably toxic public debate. That is why Liberal Democrats have been arguing for much better specialist healthcare services for children and young people who find themselves in this distressing situation. The old system, a single clinic, with a shockingly long waiting list and rated “inadequate” by the Care Quality Commission, was clearly failing vulnerable young people at the most difficult time in their lives. Before GIDS closed, more than 5,000 young people were stuck on the list and left waiting for an average of almost three years for a first appointment. For vulnerable teenagers and pre-teens, going through what are often incredibly difficult experiences, those three years must have felt like an eternity.
Liberal Democrats have consistently campaigned for action to tackle appallingly long wait times across the NHS, whether for cancer treatment or mental health, and it is right that we do so for gender identity services as well. It is clear that change is needed. That is why we have long been pressing the Government to establish new specialist services and recruit and train more specialist clinicians, so that children and young people can access the appropriate, high-quality healthcare that they need. The move to create multiple new regional centres is, therefore, a very welcome one, but only two are open now—in London and the North West—leaving those who have already been stuck on waiting lists for years to wait even longer. There is no sign yet of when the other centres will open. Would the Minister be able to give us an indication of when they might?
Unless the Government show far more urgency in getting these centres up and running properly, more and more children will be denied the care they need as they languish on those long waiting lists. While it is right that treatment is largely based on talking therapies for both the child and their parents to give all gender-questioning young people the time and space to make clear and informed decisions about their future, that has got to mean that people starting their talking therapy when they need it, not after years of delay.
Following the Cass review, the Secretary of State announced that the NHS would be conducting clinical trials on the impact of puberty blockers. That is due to begin very soon. I would appreciate clarification from the Minister about the current status of the trials and the terms of reference under which they will be conducted. The announcement of the trial came alongside an indefinite ban on the prescription of puberty blockers as a treatment for young people with gender incongruence or dysphoria, unless they are part of that trial. Numerous organisations, including the Council of Europe, have raised concerns about the potential ethical implications of only offering a treatment to a small group of patients taking part in a clinical trial. I believe that the Secretary of State confirmed at the Dispatch Box that the trial would be uncapped when he gave a statement on puberty blockers to the House in December 2024. Would the Minister confirm whether that is the case?
The ban has caused fear and anxiety for some young trans people and their families, who have been so badly let down for so many years. I have met with families in my own constituency who have highlighted the severe mental health impacts that uncertainty over treatment can have. It is crucial that any clinical decisions are made by expert clinicians based on the best possible evidence, not politicians with a point to make.
Tracy Gilbert (Edinburgh North and Leith) (Lab)
Are the Liberal Democrats supportive of the views in the Cass review? I do not think that that has been stated on the public record as yet.
Helen Morgan
I have met with Dr Cass. We have considered the Cass review, and we are in support of the clinical trial that she has recommended. That is why I am asking the Minister to clarify some of the points that have been made as that trial progresses.
When that decision was made to indefinitely ban puberty blockers, it obviously caused some concern and uncertainty for the families that are affected. Would the Minister commit to publishing the supporting evidence, including the results of the consultation, to give those families confidence in the decision to ban their prescription?
With any medical treatment, especially for children and young people, it is most important that the clinical professionals follow the evidence on safety and effectiveness. I welcome the Government’s support for the research to improve evidence on the safety and efficacy of potential treatments; that research must take into account the direct personal experiences of those who have used those services in the past. More broadly, Liberal Democrats believe that all trans and non-binary people should have access to the high-quality healthcare that they deserve, and that Government should prioritise tackling unacceptable waiting times by expanding the provision of appropriate and timely specialist healthcare through NHS child and adult services for trans and non-binary people, ensuring that trans people have access to high-quality healthcare on the same basis as we would expect for all patients, with medical decisions made by patients and doctors together, informed by the best possible evidence, and supporting research using international best practice to improve evidence on the safety and efficacy of potential treatments.
For puberty blockers specifically, it is for expert clinicians to build the evidence base and determine whether they are safe and effective. I do not think any politician, such as me, who does not have that clinical experience or evidence to hand should be making pronouncements on whether or not they are. We need the NHS to act on building up that evidence base, and for the Government to provide certainty that they will follow the evidence and expert advice when that is available.
Children and young people with gender incongruence are uniquely vulnerable, potentially facing an identity crisis, difficult relationships at home and social isolation at a very young age. It is extremely important that they are treated respectfully, safely, quickly and in the way that is best for their long-term health and personal development. It is unlikely that the same treatment will be appropriate for every individual in that situation, but when it comes to any individual medical interventions, Liberal Democrats believe it is right that those decisions are made by clinicians and patients together, informed by the best possible evidence, as is the case in all areas of healthcare.
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
It is a pleasure to serve under your chairmanship, Ms Lewell. I start by making a declaration of interest as an NHS consultant paediatrician and a member of the Royal College of Paediatrics and Child Health. My work in the NHS at times involves looking after children who may have gender dysphoria, although it is not specifically for that purpose. I congratulate my hon. Friend the Member for Reigate (Rebecca Paul) on securing this important debate, and on her excellent speech.
Hippocrates’ dictum, “first do no harm”—although it does not actually appear in the Hippocratic oath—captures a core medical ethic, and is an important guiding principle in policymaking. When it comes to children and young people expressing gender dysphoria, we must take a compassionate but firmly evidence-based approach. The causes of gender incongruence are not fully understood, but they are likely to be multifactorial and influenced by both biological and social factors. It is of huge concern that diagnoses of gender dysphoria have risen over fiftyfold, and that vulnerable and same-sex attracted children are over-represented.
There are legitimate licensed uses for puberty blockers, such as in cases of children who enter puberty very young, and in the treatment of certain malignancies. However, using puberty blockers for young people with gender dysphoria represents a significantly different context, both medically and ethically. With most children with gender dysphoria, symptoms resolve without treatment, with many finding that the natural process of puberty leads to a resolution to their distress.
The Gender Identity Development Service began trialling puberty blockers for adolescents with gender dysphoria back in 2011. Preliminary findings in 2015-16 showed no psychological benefit from the treatment and, alarmingly, a deterioration of wellbeing in some children, particularly some girls. The Cass review, published last year, showed that there is insufficient evidence on the long-term effects of using puberty blockers to treat gender incongruence. I ask the Minister: why does the planned trial not look at long-term outcomes?
The Cass review made the risks of these drugs explicit. Puberty blockers can seriously compromise bone density and can lead to adverse long-term neurodevelopmental effects. As for the purported benefits, the review added that,
“no changes in gender dysphoria or body satisfaction were demonstrated.”
The often repeated justification that blockers are for “time to think” was not supported by the evidence, with concern that they may instead alter the developmental trajectory of psychosexual and gender identity.
In May 2024, the last Government passed emergency legislation to temporarily ban puberty blockers for new treatments of gender dysphoria. The current Government have renewed that order twice, continuing restrictions until the end of this year. However, that does not affect cross-sex hormones. Does the Minister plan to commission research on the outcome of masculinising and feminising hormones on young people? Do the Government plan to extend the ban to cross-sex hormones in the fullness of time?
We heard in February that the NHS has announced plans to start offering puberty blockers as part of a clinical trial. There are questions about this trial. Given that most children’s symptoms will resolve anyway, and that the Cass review clearly states there is no method of proving in advance which children will have improved symptomatology and which will not, the trial will be essentially treating a whole cohort of healthy children with drugs to see the effect on the around 15% whose symptoms may not resolve in adulthood. Former Tavistock clinicians, including David Bell, have said that they would not refer patients to the clinical trial.
The Government are taking direct control of NHS England, so it is now the Secretary of State’s responsibility to ensure that any such trial is properly conducted. The gold standard for a medical trial is the double-blind randomised controlled trial. Will the Minister confirm that if the trial goes ahead there will be a control sample? The trial still requires ethical approval from the Health Research Authority. Will the Minister provide an update on when that decision is expected, clarify how the Government are ensuring the impartiality and safety of the decision-makers, and clarify whether provisions are in place to pause or suspend the trial if safety concerns arise?
Sir John Hayes
Might my hon. Friend add to her list of questions and ask about the experience of other countries that have looked at these matters? For those countries that have used alternatives to having children in trials, how effective have such alternatives been?
Dr Johnson
My right hon. Friend raises important questions that I hope the Minister will answer. It is important to look at the data that we already have. That was the next part of my speech—my right hon. Friend is, as usual, reading my mind.
Given that these drugs have been used on hundreds of patients at GIDS alone, why not look at that data, rather than conduct new experiments on further children? Despite the last Government legislating to ensure that data could be made available for research, several NHS trusts refused to participate fully in the Cass review. What are the Government doing to retrieve that data and to ensure that NHS trusts, which are now more directly controlled by the Government, comply with data-sharing requirements in the future? If the trial does go ahead, how will the Secretary of State ensure the genuine impartiality of those conducting the trial so that we can rely on the results?
In conclusion, this debate is about the wellbeing of young people. Gender-questioning children are not solely defined by their gender incongruence and gender-related distress; they are whole individuals. They deserve holistic care and the same rigorous evidence-based care as any other young patient.
The Minister for Secondary Care (Karin Smyth)
It is a pleasure to serve under your chairmanship, Ms Lewell. I congratulate the hon. Member for Reigate (Rebecca Paul) on securing this debate, on the constructive tone in which she has engaged with me and my Department, and on the way that she opened the debate.
The Government’s approach is governed by three principles. First, the health and wellbeing of children and young people is our primary concern—a point made by the hon. Member for Strangford (Jim Shannon). Secondly, evidence-led, effective, ethical and safe healthcare must be provided to all who need it, when they need it—a point well made by my hon. Friend the Member for Macclesfield (Tim Roca). Thirdly, this Government believe in the dignity and equality of every single one of His Majesty’s citizens.
Since the election, we have been calmly and cautiously guided by the evidence. We take children’s healthcare extremely seriously. That is why we remain committed to implementing the Cass review, and ensuring that children and young people who are looking for support in relation to their gender receive the highest quality of care, as one would expect of any other child health service in the NHS.
Tracy Gilbert
Dr Cass was clear in her review that the model of care for people with gender incongruence, and particularly for children and young people, needs to be changed to take into account their holistic care needs. Will the Minister update us on her Department’s progress in implementing those findings?
Karin Smyth
I thank my hon. Friend for that intervention; I hope to get on to that subject in my speech. It is important that people are aware of that progress.
I know that many people are concerned about the ethics of this research, as the hon. Member for Reigate and the right hon. Member for South Holland and The Deepings (Sir John Hayes) both noted. I assure hon. Members that the UK has, as we know, extremely rigorous and robust ethical approval pathways, and that no clinical trial can proceed without the necessary independent scientific approvals.
We already regularly use those processes to consider clinical trials in children so that we can evaluate new treatments for a whole range of conditions, including cancer, depression, respiratory infections, or any illness. Many aspects of the methodology of this trial are still being looked at, such as how long it will follow children, how many children will be on the trial and how the demographics of the trial will be constructed. That is all still to be confirmed and approved; many hon. Members asked about those points today. All participants in the trial will also be part of the ongoing observational study.
Following the decision by the Secretary of State for Health and Social Care about puberty blockers, which was based on the evidence, we needed to make sure that we got on with helping scientists, researchers and clinicians to do their jobs. Some people have called for the Government to stop those experts from pursuing this line of inquiry, and we have heard such calls again in this debate. They have argued that the decision to halt the sale and supply of puberty blockers should be the end of the matter, and that young people should not have access to this medication, come what may. That would be to ignore the distress and real experiences of young people, and the Government have no doubt that it would drive people towards possible illegal and underground routes, shutting off young people’s access to conversations with professionals and the opportunity to pause and consider other options.
Instead, as Dr Cass suggests, we can set out a proper path to treatment that involves young people, their parents, clinicians and mental health professionals. Knowing that they are on a path will reassure young people that they are being taken seriously. The cautious process that they will have to work through before joining a trial means that young people will have access to support and counselling, which may result in them deciding against joining the trial and pursuing a medical route. That is an approach entirely missing over recent years.
We all agree that treatment should be offered based on the best available evidence, and clinical trials in the UK are considered to be the gold standard for evaluating healthcare interventions. The Cass review found:
“The evidence base underpinning medical and non-medical interventions in this clinical area must be improved.”
That is why we have commissioned the PATHWAYS programme of research, one aspect of which includes the world’s first clinical trial designed to help us to better understand the relative benefits and potential wider effects of the use of puberty blockers in affected children.
We must look at the most appropriate medical and non-medical approaches to support physical, emotional and psychosocial health. That is why the trial forms just one component of a wider study and a growing portfolio of research, jointly hosted by NHS England. That includes looking at the experiences of the 9,000 adults who, as children, were cared for under a previous model of NHS care, which I know the hon. Member for Reigate has described as a “medical scandal”. Dr Cass was clear in her review that both a clinical trial on puberty blockers and a data linkage study, which many hon. Members have raised today, are important to improving the evidence base on gender incongruence in children and young people.
Regardless of individuals’ views on the practices of the Tavistock, I hope we can all agree that learning from the experiences of those thousands of people who have accessed puberty blockers is important; it will provide different and separately valuable information from the clinical trial. That data alone, however, will not provide the answer as to whether we should—or should not—consider routinely prescribing these drugs in the future, or continue the ban indefinitely.
The adult gender services have now committed to sharing their data, a point also raised by hon. Members. I acknowledge that we need to move quickly, and I expect to be making progress on this soon. We will consider all data that is relevant to puberty blockers, including from the adult gender clinics.
As with all clinical research, the team leading the trial must ensure that approval is obtained from the regulatory authorities, including one of the Health Research Authority’s independent ethics committees and the Medicines and Healthcare products Regulatory Agency. Those are all standard steps where the research receives full scrutiny. Once approvals are granted, the study protocol will be finalised and published, and only then can the trial commence. I am not able to comment on the finer details of that today, but we will issue further updates when they are available, and I commit to keeping Members updated.
I assure hon. Members that entry into the trial will be guided by strict eligibility criteria. It will involve only young people under the care of the NHS children’s gender services who have received a full assessment, where other appropriate forms of support have been offered and where their clinician supports a referral to the trial. Under the law, if a child is under 16, a parent will have to consent to their participation, and the child also needs to agree.
I am repeating myself slightly, but that level of caution was entirely missing over recent years. This is a more considered and evidence-based approach. In the past, puberty blockers were presented as the magic pill that young people needed to access; this trial will give children and young people the support they need to make these major decisions.
As we have heard today, we are currently in a situation where some people think it is unethical not to provide these treatments, and some think it is unethical to provide them. The reality is that we do not have definitive evidence. When that happens, we routinely ask for the study to be checked by an independent ethics committee. We spell out the uncertainty to young people and their parents, so that they can balance any such risk against their desire to join the trial before deciding whether they wish to participate.
Karin Smyth
I am sorry, but I am tight on time.
Uncertainty is common to many new treatments, but through that process, we ensure that those treatments are no longer used in the absence of such evidence. During the trial, an independent committee checks whether new results have emerged from other countries around the world—a question that was raised several times—and, if those results provide evidence that the benefits or risks are clear, such that we could issue clinical guidelines based on them, the trial would be stopped.
We need better-quality evidence to support the NHS in providing reliable and transparent information and advice to children and young people, and their parents and carers, in making important treatment decisions. That is exactly what NHS England and the National Institute for Health and Care Research programme will provide.
I was asked to provide an update on implementing the Cass review, which, beyond that research, we are absolutely committed to doing. From what we heard this afternoon, I am not entirely sure what the Liberal Democrat position is, but we are very clear that we will continue to work on that in lockstep with NHS England. We have opened the three services, and a fourth is planned in the east of England from this spring.
Those services operate under a fundamentally different clinical model, where children and young people get the tailored and holistic care they need from a multidisciplinary team of experts in paediatrics, neurodiversity and mental health. At first, those services saw patients transferred from the now-closed gender identity development service at the Tavistock, but I am pleased that all the services now take patients from the national waiting list. NHS England aims for there to be a service in every region of England by 2026. That will help to reduce the waiting list and bring the services closer to the homes of the children and the young people who need them.
Rebecca Paul
I will speak only briefly. I want to say a massive thank you to everyone who has spoken. To echo the words of the hon. Member for Macclesfield (Tim Roca), I appreciate the respectful and constructive tone. There have been some different ideas—not everyone is entirely on the same page—but we have all approached the debate in a way that is evidence-based and about sharing facts. It is very clear that everyone in this Chamber wants the best for our children. We absolutely share that objective.
I thank the hon. Member for Strangford (Jim Shannon) for his thoughtful contribution. We always tend to be on the same page about such issues. My right hon. Friend the Member for South Holland and The Deepings (Sir John Hayes) and I are also very much aligned in our thinking on this point. This is a really important debate. Very vulnerable children are affected by the issue, so it is important that we get it right.
I thank the spokespeople, the hon. Member for North Shropshire (Helen Morgan) and my hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson), for their contributions. I also thank the Minister, who has taken a huge number of questions from me. She and her Department were very constructive in advance of the debate.
This debate is not political; it is about doing the right thing for our children. I am absolutely here to work with the Government and to support what they are doing to get us to that right position. If I can do anything to help, they should not hesitate to let me know. I thank the Minister for going through the questions, and I look forward to hearing the detail. I appreciate that some of the detail is not available yet, but will be forthcoming.
Question put and agreed to.
Resolved,
That this House has considered the potential impact of puberty suppressing hormones on children and young people with gender incongruence.