Puberty Blockers Trial: Consent
Debate between Baroness Merron and Baroness Cass(1 month, 2 weeks ago)
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Baroness Merron (Lab)
My noble friend is quite right about the use of these drugs. It is important to note that we banned their use indefinitely for gender dysphoria outside of research settings because of the immense concerns about safety. That ban has been in place since January 2025. She is also right that the issue will not go away. The right way to protect children, as I have said, is to act on clinical evidence and opinion, and to make that decision with a cool head. That is why, despite the difficulty of such a decision, the Secretary of State has made it. He is doing the best he can to protect children in this situation.
Baroness Merron (Lab)
Although I am keen to be helpful to the noble Baroness, my comments yesterday related to trials and insurance provisions. I do not know what research has been undertaken since then. I would be pleased to write to her; I cannot promise the detail she seeks, but I will seek to be helpful.
Baroness Cass (CB)
My Lords, I have spoken to my clinical colleagues about the issue of age at enrolment and they expect enrolment at 11 or 12 to be vanishingly rare. However, I ask noble Lords to consider the case of a child I will call Jo, who was a biological male socially transitioned at two and a half by his parents. At 11, she—I say this advisedly, because the chances of her reverting to her biological gender are vanishingly remote—has been in stealth and will not go to secondary school because she is so afraid of being outed in that environment. She is now refusing to come out of her room except very rarely and has weak bones, not as a result of puberty blockers but through inactivity. Should her subsequent treatment be decided by politicians or by the clinicians looking after her?
Baroness Merron (Lab)
The noble Baroness brings her expertise to the subject and I am grateful to her. This is not a political matter. As I have said, it must be driven by clinical evidence and focus on the safety of our young people. The example she gave is deeply disturbing and is a result of not taking action that is evidenced.
PATHWAYS Study: Puberty Suppression
Debate between Baroness Merron and Baroness Cass(1 month, 2 weeks ago)
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Baroness Merron (Lab)
I understand the point that the noble Baroness is making but, in answer to her first question, this is not outwith any trial or intervention because there always has to be the clinical evidence and the approach to make sure that we are always seeking benefit, not harm. I am glad that the noble Baroness acknowledged the extensive safeguards. I hope that would reassure your Lordships’ House. Indeed, for children and young people who do take part in the trial, there will, for example, be repeated follow-up physical checks, questionnaires, blood tests, bone density scans and cognitive testing, all at the relevant time points. There will be psychosocial care throughout the trial. Importantly, the protocol also clarifies that, where there are significant concerns—again, I know this is a matter of concern about psychological well-being—that case then has to be promptly reviewed by the right clinician.
As for the future, I think we should wait for what the trial says. I am not going to speculate. I point out that we are not waiting, in terms of NHS care and support. Three services for children and young people have already opened in north-west London and in the south-west for those with gender dysphoria. NHS England will aim to deliver service provision in each region of England by the end of 2026-27. Again, that programme of work, rightly, was started under the previous Government. I think we all acknowledge that there are young people with gender dysphoria. They are to be seen, supported and dealt with in the most caring, appropriate and scientifically evidenced way possible.
Baroness Cass (CB)
My Lords, this is complex, and people across both sides of the House share one objective: to be cautious, careful and protective of children and young people. It is not my place here to answer many of the perfectly valid questions that have been raised, but I am developing a briefing based on proceedings in the Commons yesterday and I am listening carefully today, so I will not pick up on issues around the linkage study. I will refer to the Minister on one or two things.
The noble Baroness, Lady Cash, is right to say that the vast majority of children and young people desist, but the noble Baroness, Lady Barker, is also right to say that some do not. The clinicians working in the new centres are gaining considerable experience and working holistically to try to determine which young people—a tiny number—they feel may benefit from these medications.
I am not worried about the children in the trial but I am seriously worried about the children not in the trial. Approximately 240 children who have come to the new clinics have admitted to being on an extraordinary cocktail of medications, including testosterone from age 11, with facial hair at 13. Why are they doing this? They are not being perverse: we have told them for 15 years that these drugs are safe, effective and even life-saving, so is it any surprise that they will now go to any lengths to get them? They are not foolish, and they say they want to know the answers on that. We as the medical profession have created this issue, so it is on our heads to solve it. Does the Minister agree with me that the children in the trial will be at considerably less risk than the ones we know about who have come to the NHS and the very many more we are aware of who are not coming to the NHS but are going straight to rogue providers?
Baroness Merron (Lab)
I agree with the noble Baroness and I thank her for the offer of the briefing, which I mentioned earlier, and for her observations. I associate myself with what she said about the complexity of the matter, which is why I take it so seriously. The fact is that this situation exists. I am exercised about those who are accessing puberty blockers in an unregulated fashion. It is extremely concerning, which is another reason for this trial, as well as the services being set up. That is why we indefinitely banned the sale and supply of puberty blockers via private prescriptions, taking effect from January 2025. If offences are committed then those involved will be brought to justice, and rightly so.
NHS Adult Gender Identity Clinics
Debate between Baroness Merron and Baroness Cass(3 months, 3 weeks ago)
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Baroness Merron (Lab)
My Lords, we are indeed committed to developing services for 17 to 25 year-olds, and I certainly recognise that this is a potentially very vulnerable time in a young person’s journey, as was clearly outlined in the report by the noble Baroness, Lady Cass. I can say to the noble Baroness that we recognise changing patient demographics, and therefore a holistic biopsychosocial assessment framework is being developed for use across all services, including a complexity measure to support understanding of the impact of any co-occurring conditions, as the noble Baroness refers to.
Baroness Cass (CB)
My Lords, we know that the 18 to 25 year-olds have many of the same complex problems as the under-18s and, as the Minister has said, they need similar holistic wraparound care, although that is not necessarily yet in place. However, Dr Levy’s review had a narrower remit than mine, focused on quality improvement rather than the model of care, so as a next step would the Minister agree to ask departmental and NHSE colleagues to convene a group, which should include independent experts, representatives of professional groups and representatives of the new children’s and young people’s services as well as service users, to consider how we best understand and, importantly, improve clinical outcomes for this group of young adults?
Baroness Merron (Lab)
My Lords, I remain grateful to the noble Baroness for her work and her expertise in this area, which I know has been acknowledged both by the previous Government and this Government. I will certainly take on board what she has said and ask my officials to discuss this further with NHS England.
Puberty Suppressants Trial
Debate between Baroness Merron and Baroness Cass(7 months, 3 weeks ago)
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Baroness Merron (Lab)
I thank the noble Lord. Before participants enter the trial—and it is an extremely high bar, as it should be; there will be at least 226 participants required, but that is not a target and there will be no drive to get up to that number—certainly any possible impacts such as those the noble Lord describes will be fully discussed and mitigations will be explained and made available, particularly in terms of fertility. I absolutely take the point that the noble Lord raises.
Baroness Cass (CB)
My Lords, we are faced with a situation where, for 15 years, clinicians in this country have told children and young people that these medications are safe, fully reversible and indeed life-saving. Last year, they were rightly banned from clinical practice. However, the upshot is that now, of the 75 children a month who are coming to the new services, about 20% are getting these medications and, worse, testosterone and oestrogen from unlicensed and unregulated sources—and those are the ones we know about. In addition, referrals to the new services have dropped from 200 a month to only 30 a month, so we think that a large number of those young people are also being harmed through those mechanisms.
We are concerned about this much broader harm; children are voting with their feet now. Does the Minister agree with me that, for the very tiny number of young people who clinicians believe will ultimately have a long-standing gender incongruence and will therefore be eligible for this trial, it is better that they get their medication under careful clinical supervision rather than on the dark web? Secondly, does she think that this trial will be a way of attracting that broader group of young people back into the NHS who do not need medical treatment but need holistic wraparound care?
Baroness Merron (Lab)
Let me first say to the noble Baroness how grateful we are for her continued professional attention and sensitivity in dealing with this. There was a cross-party approach to the Cass review, and I pay tribute to Sir Sajid Javid, the former Health Secretary for seeing the need for this. We have always been supportive of the Cass review. I agree with both points that the noble Baroness has made. The fact is that this is about the need to face up to what the review found: shocking levels of unprofessionalism, a lack of clinical oversight and puberty blockers being prescribed to children without sufficient evidence. That was not safe and not beneficial and it could not go on.
Health and Social Care: Winter Update
Debate between Baroness Merron and Baroness Cass(1 year, 6 months ago)
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Baroness Merron (Lab)
I am grateful to the noble Lord. These things do not just happen; we are here because of a failure to reform, a failure to invest and a failure to get the right productivity and results that we need. Indeed, there has been a failure over a number of years to do exactly what the noble Lord spoke about. I could not have put it better myself. The noble Lord came up with the most marvellous advert in his comments for the central pillars, to which I referred, of the 10-year plan, which will soon be available, following the biggest ever consultation in the history of the NHS.
The noble Lord talked about community. One of the things that we will be ensuring will happen in the NHS is a movement of focus from hospital into community. The noble Lord talked about digital. We will move from analogue to digital. He also talked about services being around the patient. I have frequently said that we need to get the services around the patient, not the patient around the services. There is also the move from sickness to prevention. All these three pillars will completely transform the National Health Service.
The noble Lord also referred to the third sector, including charities. We could not deliver much of what we deliver without them, and charities often are extremely well-placed to do things that statutory services cannot, so they are part of the equation and I offer all respect to them.
Baroness Cass (CB)
My Lords, the investment described in additional GPs is really welcome, as are the other reforms in primary care. However, one of the challenges in previous recruitment drives into primary care has been losing people from the other end and not being able to retain. Therefore, will the Minister tell us about retention strategies and how they will counteract that really troubling trend?
Puberty-suppressing Hormones
Debate between Baroness Merron and Baroness Cass(1 year, 7 months ago)
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Baroness Cass (CB)
My Lords, I echo the thanks given to the Secretary of State for his careful and scientific approach to this issue and for his very sensitive Statement in the other place.
It might be helpful to elaborate on just one or two of the points that have been raised, particularly the use of puberty blockers for precocious puberty—that is, for children who enter puberty too early—which is a licensed use of these drugs. We are confident about that use because we have many years of experience, and because it is a very different situation from prescribing for young people with gender dysphoria. The difference is that children with precocious puberty have an abnormal hormone environment, which we normalise, whereas in young people with gender dysphoria we are taking a normal surge in pubertal hormones and disrupting it. That is why it is much less clear what the long-term impact of that intervention is, and why we need careful clinical trials.
The second thing it would be helpful to clarify is the appropriate question, asked by the noble Baroness, Lady Walmsley, about children and young people who are already on puberty blockers from private or overseas sources. In addition to the comments made by the Minister, it is important to know that NHS England has set up a telephone number that young people and families can ring to receive a mental health triage. Young people’s mental health services have been forewarned and are on hand to provide that triage for that small group of young people who may be in significant distress because of fear of interruption of their supply of puberty blockers. There is provision that, in those circumstances, and where the clinician thinks it is in the best interests of that young person to continue on puberty blockers, an NHS prescriber is allowed to continue the prescription. We hope that those in distress will come forward and contact NHS England and therefore be supported through the system.
One of the other misunderstandings about puberty blockers is that they have become totemic as the main treatment or entry-point treatment for young people who want to transition, or who may in the longer term be trans but may not go on to a medical pathway. Young adults have said to us that they wish they had known when they were younger that there were more options for them than a binary medical transition, and that there were many more ways of being trans—that they could remain gender fluid, continue to be non-binary, or in the longer term continue to be a cis adult, as some do, and not go through any medical interventions at all.
Having a multidisciplinary team that can support young people in that decision-making without necessarily rushing them into a medical pathway is crucial, and that is what the new services have now embarked on doing.
Baroness Merron (Lab)
I thank the noble Baroness for bringing her expertise directly into the Chamber. We are very glad that she is in the House to do so, and she has actually answered a number of the points better than I ever could.
I will emphasise one point that I am particularly interested in, because I know it has been raised a lot, about why the legislation is being laid in respect of the use of medicines just for gender dysphoria. The noble Baroness, Lady Cass, referred to this. It is really important to emphasise that the medicine might be the same, but the fact is that it is not licensed for gender incongruence or dysphoria—that is the key point. These medicines have not undergone that process, which means that safety and risk implications have not yet been considered. It is true that there are licensed uses of the medicines for much younger children or for older adults, but the issue here is about adolescents, and it is an entirely different situation.