18:59 - The House divided: - Ayes: 112 / Noes: 283 - Question accordingly negatived.
The Secretary of State for Health and Social Care (James Murray)
I know what a sensitive, emotive and difficult issue this is. As I said in the House yesterday, I have myself struggled with the profound challenges this subject raises. We all, as adults, owe a duty of care to every child and young person in this country. That is a responsibility I bear, both as a citizen and as Health Secretary, with the utmost seriousness and sincerity. It is why, in all my deliberations on this matter, my consideration is to protect the safety and wellbeing of children and young people. Children’s healthcare must always be evidence-led, safe and effective. The way to ensure that is to follow expert clinical advice, which is what the Government are doing.
Dr Hilary Cass, the clinician who I think has more respect in this space than any other, has spoken about the importance of this trial in recent days. I remind the shadow Minister that it was her party that commissioned the Cass review and accepted its findings, which included the Pathways trial. I have been clear to the House that this is a challenging area. I accept and welcome the scrutiny of Members, but I encourage us to keep in mind Dr Cass’s request to consider the issues sensitively and cautiously. She says:
“Polarisation and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse, and in the long run will also hamper the research that is essential to finding the best way of supporting them to thrive.”
I do not think that there is any question that a few years ago, children’s safety and wellbeing was not being protected when it came to gender incongruence. From around 2009, the number of children and young people being referred for NHS support around their gender identity increased rapidly. Stories subsequently emerged of young people struggling after undergoing radical and permanent transition surgery at an early age, of children rushed into taking medication without adequate therapy beforehand, and of clinicians disregarding conditions such as neurodiversity and mental health issues. As such, there was rightly deep concern about the vulnerability of these children and young people, the care and treatments they were receiving, and the surge in referrals. And so, in 2020, NHS England commissioned the leading paediatrician, Dr Hilary Cass, to carry out a review into NHS gender identity services for under-18s.
What Dr Cass uncovered was shocking and scandalous, and she made a series of recommendations for how children can be better protected and supported. It was, in my mind, unquestionably wrong for children and young people to be routinely prescribed puberty blockers for gender dysphoria without any clear evidence on their benefits or risks. The situation then was out of control and so I fully supported the indefinite ban introduced by my predecessor, my right hon. Friend the Member for Ilford North (Wes Streeting), which followed the temporary ban brought in by the previous Government.
In considering what to do next, Dr Cass identified that treatment for gender incongruence was
“an area of remarkably weak evidence”.
She found that even clinicians working in the field were divided on the best way to support, treat and care for young people suffering from gender dysphoria. Where there is strong divergence of medical opinion on treatment, the two possible responses are either to continue with uncertainty—and with that, conflicting opinions and advice—or to undertake a trial. It is only by doing that that we can ensure that children with gender-related distress get the same access to and standards of care as everyone in the NHS.
Gregory Stafford
There is a third option, which is to get NHS England to motor ahead with the data-linkage study, so that we can use the data that has already been collected to find out the answers to the questions that the Secretary of State is posing. Only then, if the information is not there, should the trial go ahead. Why is he not pushing that third way?
James Murray
The hon. Gentleman’s question allows me to address that matter directly. The data-linkage study will not provide clear evidence of the risks and benefits of puberty-suppressing hormones, which is needed to guide future clinical practice for this cohort. The type of information that would be available in a linkage study is much more limited than the detailed information that the research team will collect about the relative benefits and harms of puberty-suppressing hormones when accessed alongside a holistic model of care.
Harriet Cross (Gordon and Buchan) (Con)
For clarity, are Scottish children going to be included in the trial, either by being able to travel south of the border or via NHS Scotland directly?
James Murray
I have responsibility for NHS England as Secretary of State for Health and Social Care, and I am setting out the protocol agreed in relation to this trial, as it is a subject that is arousing a lot of questions in the Chamber, which is fair. [Interruption.] I will come back to that point, if the hon. Member for Gordon and Buchan (Harriet Cross) allows me to make a little progress.
James Murray
I will make a little progress, and then I will be open to more interventions. We need to be clear about who we are talking about. As Dr Cass said, the vast majority of children and young people who question their gender will resolve it without needing any support other than their friends and family. For many young people, questioning their identity, on many different fronts, is a normal part of growing up, and we should simply let them be. A small number of those young people, however, need greater support because of the level and longevity of discomfort that they feel, and that can often involve counselling or therapy.
For a very small number of young people, it is possible—and I emphasise the word possible—that medical treatment would help improve their quality of life and mental health and reduce their gender-related distress. That is why Dr Cass recommended a trial to study the effects of puberty-suppressing hormones on young people’s physical, social and emotional wellbeing, and to establish how best to support children and young people suffering gender incongruence.
Iqbal Mohamed
On that point, in normal clinical trials, the active substance and a placebo would be used, and the impact, changes or benefits that each cohort experienced would be checked. If children have a psychological leaning and are emotionally feeling that they are in the wrong body, is there not value in having a cohort that takes a placebo and seeing if that improves their mental health?
James Murray
The hon. Gentleman raises an important question around how the clinical trial is designed. In this case, the young people involved in the trial, of whom there will be around 226, will be split into two groups; one half will have the puberty blockers from the start, the other half will receive them after a year.
My understanding of this matter, having interrogated the detail carefully, is that a placebo would not be appropriate for this trial because the subject will be able to know the impacts of having the puberty blockers; they will be aware of whether they are having the medication. What is important, however, and what I hope will set this Pathways trial in a wider context, is all the other work that is being done to study the incidence of gender incongruence and the responses to that among young people, which will go beyond the trial we are talking about to look at children and young people questioning their gender through talking to them, understanding their mental health and their approach to that. All that will happen alongside this trial, which is one part of a much wider study to understand how best to support young people who are facing these gender-related issues.
John Glen (Salisbury) (Con)
I acknowledge the serious way that the Secretary of State is approaching this. I think many people will be concerned that, as the shadow Minister has said, there is no objective blood marker for these individuals; I think they will be concerned that a group of people will be taken forward in this trial when a whole range of influences could have governed how they have got to that point, given that the implications of taking these drugs are quite profound for their life and further development. How does one reconcile the fact that there is no way of verifying the suitability and the way that these individuals have been selected for the trial? Perhaps he could help me to understand it better.
James Murray
I thank the right hon. Gentleman for the tone he took in asking an important question, which I am pleased to be able to respond to. The bar for getting on to this trial is set extremely high, with strict eligibility criteria: parental consent, alongside the young person themselves consenting or assenting; a diagnosis of gender incongruence for at least two years; and consent from both the NHS care team and a national multidisciplinary team, including a wide range of disciplines, to understand all aspects of a young person’s health, context and situation. The level of approvals and scrutiny that young people will have to go through to participate in the trial will, therefore, set the bar extremely high.
James Murray
I will give way one more time, and then I will make some progress.
Dame Harriett Baldwin
I am grateful to the Secretary of State for giving way. He mentioned parental consent—what would happen in a situation where the child was in the care of the state? Would they be included or excluded from this trial?
James Murray
If a child is looked after under a care order, the local authority has parental responsibility, so it would need to be part of the consent process as the corporate parent.
I turn to the points raised by the right hon. Member for Salisbury (John Glen) about young people becoming involved in the trial and the checks that are in place to enable that to happen. As I set out earlier, as the trial involves children, it comes with a responsibility to interrogate and understand its design. As Health Secretary, I have sought the most detailed assurances possible from my clinical advisers as to how children taking part in the trial will be protected.
There are a number of important safeguards. As I have said, children can participate only with the consent of a parent or guardian, and the child themselves must consent or assent. They can participate only if they have had a diagnosis of gender incongruence for at least two years, have received psychosocial support through the NHS and are of stable physical and mental health. They can participate only if they are not subject to any safeguarding concerns and if they and their parents demonstrate sufficient understanding of the nature of the treatment, including its possible advantages and disadvantages. They can participate only if the treatment has been deemed clinically appropriate by both the NHS care team and the national multidisciplinary team and if they are already accessing NHS gender services. On eligibility, the bar is extremely high.
The number of young people who would expect to qualify for the trial will be low and the safeguards to ensure their safety and wellbeing will be rigorous. I have sought and had an assurance that, once they are involved in the trial, participants may be withdrawn at any point. We are not proceeding with the previous, now decommissioned, model of care overseen by the Conservatives when they were in government. We are proceeding cautiously, with rigorous safeguards in pursuit of the evidence, as Dr Cass recommended.
Last Thursday, the independent MHRA approved an updated protocol that significantly strengthened the objective criteria for withdrawing children from the trial, which is a change that I welcome. Signs of greater risk to participants will now trigger increased monitoring, clinical review or their automatic withdrawal from the trial. All participants will be monitored before, at the start of, every three months during, and after the trial. Before and during the trial, information will be collected about mental health, quality of life, self-harm and suicidality, body image, cognition, puberty stage, physical health and side effects.
I have been determined to ensure that the oversight of this trial is as rigorous and robust as it possibly can be, so I have requested monthly updates on its progress. That will include my being notified of any emerging risks.
This trial is rightly one of the most scrutinised UK clinical trials of recent times. We should expect nothing less when we are talking about the health and wellbeing of some of the most vulnerable children in our country. Yet, as Dr Cass has made clear, we have to build the evidence base to show whether the treatments are safe and whether they produce the positive outcomes that young people and clinicians want from them.
The Opposition’s motion would prevent us from following expert clinical advice, when proceeding with the trial is the most appropriate way forward. I say that not because I am suggesting that we should feel instinctively comfortable in doing so but because I have arrived at that conclusion after considering the clinical evidence and receiving robust assurances on the safeguards that are in place.
Sir John Hayes (South Holland and The Deepings) (Con)
I know that the Secretary of State has agonised over this matter—he made that clear in his statement to the House last night and again today—but what is not in doubt is the harm that these drugs do. It is an established medical fact. He is determined to be driven by the evidence. That is evidential. We know that the drugs have harmful effects, so in essence what he is saying is that we are prepared to wear those harmful effects on the off-chance that the drugs may have a beneficial set of effects, when there is no evidence to suggest up until now that they do.
James Murray
The MHRA has introduced additional safeguards. As a result of its dialogue with the trial sponsors, the amended protocol published last week increases the level of safeguards. That means that if the regular monitoring, which will happen at least every three months—it can be more regular during the trial—shows any sign of increased risk of harm, that will lead to increased monitoring, clinical review and, when considered against objective criteria, automatic withdrawal from the trial.
It is a question of monitoring this trial, possibly more closely than any trial before—the level of scrutiny is very great indeed—to ensure that at the first sign of any increased risk of harm, action will be taken. That is the assurance that I have sought in interrogating this matter carefully in recent days, and that is the basis on which I am talking to the right hon. Gentleman and others in the House today.
We must come to a fair and settled conclusion on this matter to move forward as a country, and I believe that we should follow clinical advice and establish the clinical evidence gathered in a highly scrutinised trial with all the safeguards in place that I have described. Only that approach will give us the confidence about where we settle on this matter in the future. On that basis, the Government oppose this motion.
Madam Deputy Speaker (Caroline Nokes)
I call the Liberal Democrat spokesperson.
The Minister for Care (Stephen Kinnock)
I would like to start by declaring an interest, because my son Milo, of whom I am extremely proud, is a trans man.
I have listened to colleagues very carefully over the course of our proceedings. There have been some truly heartfelt speeches, and this strength of feeling is certainly warranted wherever children are concerned. The Government welcome this scrutiny, and I want to thank Members from all sides of the House for the constructive tone and substance of this debate.
I am not the Minister who is responsible for leading on this policy in the Department for Health and Social Care. Nevertheless, I feel a great deal of responsibility for the health and wellbeing of children in our country. As the Minister of State for Care, I am, for example, responsible for making sure children at end of life are receiving the right palliative and end-of-life care. And tooth decay, for example, has an appalling effect on children’s wellbeing. When it comes to gender incongruence, I cannot help but think of those children suffering in great distress, who may even be watching our proceedings this evening, and I want them to know that all of us in this Chamber want what is best for them. We might disagree about how we get there, but I do not doubt the sincerity of anyone who has spoken today.
Fundamentally, our approach on this side of the House is to be led by the evidence, and on this I pay tribute to Dr Hilary Cass, who has taken on one of the most sensitive and polarising issues of our times with such courage and professionalism.
The shadow Minister, the hon. Member for Sleaford and North Hykeham (Dr Johnson)—I hugely respect her expertise as a paediatrician—has said that our decisions could be motivated by “fear and hostility”, but that is not a charge that anyone could level at Dr Cass, who has shown the utmost courage and professionalism from the moment that she was appointed. It was on the strength of her independence and integrity that the previous Conservative Government, of which the hon. Lady was of course a member, accepted her recommendations. One of those recommendations was for a regulated, robustly safeguarded trial. Yesterday, Dr Cass said that she is
“absolutely convinced that more children will be harmed if we don’t do the trial than if we do.”
Alex Sobel (Leeds Central and Headingley) (Lab/Co-op)
I commend the Minister on an excellent and brave speech. When the Cass report came out, I was criticised for not accepting it in full, and now the very same people who said that to me are not accepting the Cass report in full. Does he agree that that is hypocrisy, and that those people should stick to their word?
Stephen Kinnock
I know that feelings on these matters are strong and heartfelt. If the Conservative party has changed its position and is putting forward its arguments with sincerity and honour, that is a perfectly acceptable position to take, but I simply remind the House of the journey that the party has been on.
Rebecca Paul
The Cass review also suggested a clinical trial for cross-sex hormones. On that basis, will the Government launch a clinical trial on cross-sex hormones as well?
Stephen Kinnock
This is a debate about hormones for suppressing puberty, and is related to the matter that the hon. Lady raises, but it is important that we get the sequencing right. Let us look at the trial and the evidence. That is part of the process of understanding the milestones and the forks in the road faced by children who are experiencing gender incongruence. Let us do this one step at a time.
We are proceeding carefully, cautiously and under the mantra that the safety and wellbeing of children are non-negotiable, and with clarity that a robustly scrutinised trial with rigorous safeguards is the only way of establishing a robust evidence base for puberty-suppressing hormones.
Many hon. Members have asked about safeguards, so let me remind the House what they are. A child can participate only with the consent of a parent or guardian and the child’s own consent or assent, and only if they have had a diagnosis of gender incongruence for at least two years; if they are of stable physical and mental health; if they are not subject to any safeguarding concerns; if they and their parents demonstrate sufficient understanding of the nature of the treatment, including its potential advantages and disadvantages; if they have been deemed clinically appropriate by both their NHS care team and the national multidisciplinary team; and if they are already accessing NHS gender services, including participation in a tailored package of psychosocial care.
Sir John Hayes
Will the Minister at least commit to looking again at the experience of Finland and Denmark, whose evidence has led them to now emphasise counselling rather than medical intervention?
Stephen Kinnock
A little later, I will go through all the different work that is going on. This is absolutely not happening in isolation; we are taking into account a range of other studies.
Some colleagues have raised the work of the MHRA in strengthening the safeguards for young people involved in the trial. The MHRA has been engaged in a scientific dialogue with the trial sponsors, and it was the outcome of that process that led the MHRA, as an independent body, to publish the updated protocol last week. We welcome the changes, because they show that the MHRA is taking its job seriously and that the system is working as intended. We cannot cut corners when it comes to the safety and wellbeing of children, and the safeguards are now in place to guarantee greater monitoring and clinical reassessment, including objective criteria for withdrawing children and young people from the trial entirely. I remind colleagues that the bar to qualify for the trial is extremely high, with only a small number of young people expected to meet the strict criteria.
Some other colleagues—I turn now to the point made by the right hon. Member for South Holland and The Deepings (Sir John Hayes)—have queried the need to have a clinical trial when a number of children have already taken puberty blockers and information is already available. However, Dr Cass concluded that there is not enough evidence about the risks and benefits of those medications. That is why she was so clear in recommending a trial to find that clinical evidence, because that is the basis on which we can take those decisions.
The information in the data linkage study is much more limited than the detailed information that the research team will be able to collect about the relative benefits and risks of puberty-suppressing hormones. NHS England is, however, committed to delivering the data linkage study and has taken time to ensure that the data is shared by relevant organisations.
Esther McVey
I have been listening to the debate and have not yet heard what the Government will deem to be a measure of success of this puberty blocker trial before it goes ahead. What are the criteria, the measurements, the percentages and the numbers, and what are the timelines over which they will be measured? Can the Minister explain what those are? If someone is unhappy, can they sue the Government?
Stephen Kinnock
As the right hon. Lady will know, a lot of this is about the distress and the tremendous mental health pressure that young people going through gender incongruence feel. Clearly, one of the outcomes that we will look for from the trials is an alleviation and an amelioration of those significant mental health issues and distress. Those are the kind of outcomes we want to see to help some of those young people who often end up in awful situations, leading to self-harm and other terrible situations.
Some colleagues have asked about the wider support we are providing for children and young people with gender dysphoria and incongruence. I am pleased that the Pathways study is just one part of the wider work being done to ensure that the support is there. For example, Pathways Horizon is an observational study of all children and young people attending NHS children and young people’s specialist gender services. Pathways Connect is a brain imaging study, Pathways Voices will interview young people, and Horizon Intensive is about ensuring that there is a comparison group of 300 participants who are expressing gender incongruence.
Furthermore, NHS England has opened three new children and young people’s gender services in the north-west, London and Bristol, with a fourth planned for the east of England this year. I can confirm that the Government aim to have a service in every region of England in the coming years. These services use a different model with multidisciplinary teams, including mental health support and paediatrics, within specialist children’s hospitals to provide holistic care. The new services will increase clinical capacity and reduce waiting times so patients can be seen sooner and closer to home.
I can update the House that waiting lists for children and young people’s gender services have come down since this Government took office. As of April, nearly 3,000 fewer children and young people were on the waiting list compared with September 2024.
This Government stand by the principle that we will always be led by clinical advice and clinical evidence, but that does not mean we take these decisions lightly, and it does not mean that we are abdicating our responsibilities either. My right hon. Friend the Secretary of State has requested monthly updates on the progress of the trial, including any emerging risks. Throughout this process, he has immersed himself in the detail, scrutinised the issue and sought the strongest assurances from his most senior clinical advisers. We have received those assurances and are proceeding on the basis of evidence, not ideology.
I end with regret that it appears that the cross-party consensus on Dr Cass’s expert review has been lost, but also with hope that colleagues can get behind Dr Cass’s work again. We will move forward on the basis of taking decisions based on the expertise of clinical and medical professionals, and acting within clearly defined safeguards and robust oversight, including in this House, to provide the best quality of healthcare and support for all children and young people to access what they need.
On one level, this is a specific debate about a specific issue, but when we zoom out, we see that it goes to the heart of what our NHS is about, which is how best to do the greatest possible good for the greatest possible number of people. When we look at this through that basic ethical prism, there can be no doubt that this Government’s position is the right one. A small cohort of vulnerable children are struggling, and it is our job to help them—it really is as simple as that. I therefore urge colleagues to oppose the Opposition’s motion.
Question put.