Gender Incongruence: Puberty Suppressing Hormones

John Hayes Excerpts

Wednesday 30th April 2025 Westminster Hall

[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.

--- Later in debate ---

[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.

--- Later in debate ---

[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.

[Sir John Hayes]

Will the Minister give way?

[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.