Puberty-suppressing Hormones

With permission, Madam Deputy Speaker, I shall make a statement on puberty blockers.

At the outset, I wish to make clear the principles that drive the Government’s approach to this issue. First, children’s healthcare must always be led by evidence. Medicines prescribed to young people should always be proven to be safe and effective. Secondly, evidence-led, effective and safe healthcare must be provided to all who need it, when they need it. Thirdly, this Government believe in the dignity, worth and equality of every citizen, and recognise that trans people too often feel unsafe, unrecognised and unheard, and that must change. None of these simple ambitions has been achieved in recent years. Medicine has been provided with insufficient evidence, and young people have been left to go without the support and care that they need. This Government are determined to change that.

The Cass review made it clear that there is not enough evidence about the long-term effects of using puberty blockers to treat gender incongruence to know whether they are safe or beneficial. That evidence should have been established before they were ever prescribed for that purpose. It is a scandal that medicine was given to vulnerable young children, without proof that it was safe or effective, or that it had gone through the rigorous safeguards of a clinical trial.

Following the Cass review, the NHS ceased the routine use of puberty blockers to treat gender incongruence in children. In May, the previous Government issued an emergency order to extend these restrictions to the private sector. In Opposition, my party and I, as shadow Health and Social Care Secretary, supported those decisions. Since coming into office, I have renewed this order twice, continuing restrictions until the end of this year. That was done jointly with the Health Minister in Northern Ireland, and I updated the House via a written statement.

While the temporary ban was in place, I asked the Commission on Human Medicines to look at the current environment for prescribing puberty blockers, and we launched a targeted consultation. The commission is an independent body, made up of leading clinicians and epidemiologists, that advises on medicine safety. It took evidence directly from clinical experts, consultant paediatric endocrinologists and patient representatives, including representatives of trans people, young people and their families. After thoroughly examining all the available evidence, it has concluded that prescribing puberty blockers to children for the purposes of treating gender dysphoria, in the current prescribing environment, represents “an unacceptable safety risk”. Of particular concern to the commission was whether these children and their families were provided with enough time and information to give their full and informed consent. The commission found that children had received prescriptions after filling out online questionnaires and having one brief Zoom call with prescribers from outside the UK.

Consequently, the commission has recommended that the Government extend the banning order indefinitely, until a safe prescribing environment can be established for these medicines. On the basis of those findings, I am acting on the commission’s advice and putting in place an indefinite order to restrict the sale or supply of puberty blockers to under-18s through a prescription issued by either a private UK prescriber, or a prescriber registered outside the UK. This is on the advice of expert clinicians, the independent Commission on Human Medicines—advice based on the best available evidence—and follows the cautionary and careful approach recommended by Dr Cass. The legislation will be updated today, and will be reviewed in 2027, when there will be an updated assessment of the safety of the prescribing environment for these medicines.

We are working to grow a thorough evidence base for puberty blockers. The National Institute for Health and Care Research is working closely with NHS England to establish a clinical trial on puberty-supressing hormones. The NIHR is now contracting the team that will deliver the study and is working tirelessly towards recruiting the first patients by spring. The trial is the first of its kind the world over. It will help us better understand the effects of puberty-suppressing hormones on young people, providing the robust evidence required.

The Cass review also made clear recommendations to the Government and NHS England on improving healthcare services for children with gender dysphoria. I will now provide an update on the progress made. NHS England has published its implementation plan, which will transform its services. It has also published a new services specification, to ensure that children and young people experiencing gender incongruence have an appointment with a paediatrician or mental health professional before being referred to specialist services. Dr Cass was clear on the need for the model of care to change and take account of children and young people’s holistic needs.

Since April, NHS England has opened three new gender identity services—in the north-west, in London and in Bristol—with a fourth expected in the east of England by the spring. That puts us on track to open services in every region by 2026. These services offer a fundamentally different clinical model. They bring together clinical experts in paediatrics, neurodiversity and mental health, so that care can be tailored to patients’ needs. At first, the new services were prioritising patients registered with the old Gender Identity Development Service, but I am delighted to report that the north-west and Bristol services are now taking patients off the general waiting list.

On the waiting list, Dr Cass’s review painted a picture of a service unable to cope with demand. Children and young people face unacceptably long waits for care, with some children passing into adulthood before their first appointment, leaving them facing a dangerous cliff edge. I am pleased to tell the House that NHS England is working with potential partner organisations to explore establishing a much-needed follow through service for 17 to 25-year-olds, as Dr Cass recommended. Young people’s distress or needs do not vanish when they turn 18, and neither should their healthcare.

We do not yet know the risks of stopping pubertal hormones at this critical life stage. That is the basis on which I am making decisions. I am treading cautiously in this area because the safety of children must come first. There are some who have called on the Government not to go ahead with the clinical trial recommended by Dr Cass. Others on the opposite side of the debate want the Government to ignore the recommendations of the independent expert Commission on Human Medicines. We are taking a different approach. The decisions that we take will always be based on the evidence and the advice of clinicians, not on politics or political pressure.

Finally, there are many young people in this country who are desperately worried and frightened by the toxicity of this debate. This has not been helped by some highly irresponsible public statements, which threatened to put vulnerable young people at risk. In the past few months, I have met young trans people, who either have been, may be, or will be affected by the decisions that I and my predecessor have taken. I have listened to their concerns, fears and anxieties, and I want to talk directly to them. I know it is not easy being a trans kid in our country today. The trans community is at the wrong end of all the statistics for mental ill health, self-harm and suicide. I cannot pretend to know what that is like, but I do know what it is like to feel that you have to bury a secret about yourself, to be afraid of who you are, to be bullied for it, and then to have the liberating experience of coming out. I know it will not feel like it, based on the decisions that I am taking today, but I really do care about this, and so does this Government.

I am determined to improve the quality of care and access to healthcare for all trans people. I am convinced that the full implementation of the Cass review will deliver material improvements in the wellbeing, safety and dignity of trans people of all ages, and the Government will work with them to help them live freely, equally and with the dignity that everyone in our country deserves. I commend this statement to the House.

I call the shadow Secretary of State.

I thank the Secretary of State for advance sight of his statement, and for his courtesy in coming to the House to make an oral statement, which gives hon. Members the opportunity to ask him questions.

When the Secretary of State is wrong, we will challenge him robustly and hold him to account, but when he is right, we will support him. That is responsible opposition. In what he sets out today, he is right, and he has my support for what he is doing. Protecting children is one of the most important priorities that a Health Secretary can have. My predecessor, my right hon. Friend the Member for Louth and Horncastle (Victoria Atkins), worked tirelessly to do just that. She set out that it was her priority to protect children and young people from risks to their safety from the prescription of puberty blockers, given the lack of an evidence base. I welcome the Secretary of State’s continuing the work started under the previous Government, and I welcome his support at the time and all that he has done since, including in his statement on 4 September. I associate myself with the three principles that he enunciated when he opened his statement.

With increasing numbers of young people questioning their gender identity, NHS England, with the support of previous Conservative Health Secretaries Matt Hancock and Sir Sajid Javid, commissioned Dr Hilary Cass to examine the state of services for children questioning their gender. That historic review cut through the noise and ideology to lay bare the clear facts, so that we as policymakers can seek to make decisions based on evidence, safety and biological reality, and create a service that better serves the needs of children, as the Secretary of State set out. In the review, Dr Cass made it clear that not enough is known about the lifelong impacts of using puberty blockers on young minds and bodies to be sure that they are safe, and that the robust evidence base was simply not there. In March, NHS England made the landmark decision to end the routine prescription to children of puberty blockers for gender dysphoria. With the support of the then Government, it announced that it was stopping children under 18 from being seen by adult gender services with immediate effect.

I thank the shadow Secretary of State for the constructive way in which he has responded to the statement, and for the tone with which he has approached the issue. It is worth everyone bearing in mind that every word of statements in this House, and indeed online, are often hung upon by a particularly vulnerable group of children and young people. Many of them feel afraid about the environment in which they are growing up, as do their families. Establishing an environment in which we can discuss issues with their welfare and wellbeing at its heart is therefore the right way to approach these issues. As I have said many times before—and I am sure the shadow Secretary of State agrees—we need less heat and more light, and we can show leadership together in trying to provide that climate.

I am absolutely committed to the full implementation of the Cass review. The shadow Secretary of State asked about the implementation of new children and young people’s services on gender incongruence. As I said, the north-west London and Bristol services are now open. A fourth service is planned in the east of England for spring next year. We want a specialist gender service in every region by 2026, and of course I will keep him and the House updated on that.

I am working closely with my counterparts in the devolved Governments. I particularly welcome the engagement I have had with my counterpart in Northern Ireland and his predecessor, the hon. Member for South Antrim (Robin Swann), who is within my line of sight. I appreciate the way we have been able to work together on this and many other issues. The shadow Secretary of State asked about loopholes. I will keep the matter under close observation and review.

With regard to sanctions, penalties and enforcement, it is worth pointing out that breach of the order is a criminal offence under the Medicines Act 1968. It is a criminal offence to supply these medicines outside the terms of the order. That means pharmacists who dispense medicines against prescriptions that are not valid may be liable to criminal prosecution. It is a criminal offence to possess the medicines where the individual had responsible cause to know the medicine had been sold or supplied in breach of the terms of the order. There are fines and penalties associated with that, including case-by-case and regulatory enforcement by the General Pharmaceutical Council.

I thank the Health Secretary for his statement and for the manner in which he continues to handle this important issue. I welcome the fact that the Government are following clinical evidence, particularly in relation to children and young people, whose wellbeing and protection are paramount—that is the right approach. Given that the Cass review found insufficient evidence on whether puberty blockers are safe, and highlighted their potential harms, there are understandably concerns about the risks of trialling them. Can the Secretary of State reassure me that the upcoming trial will have robust safeguards, and will he continue to be led by the wellbeing and safety of children?

I can certainly give my hon. Friend that assurance. Better-quality evidence is critical if the NHS is to provide reliable and transparent information and advice to support children and young people, and their parents and carers, in making potentially life-changing decisions. That is why we support the setting up of the study into the potential benefits and harms of puberty-supressing hormones as a treatment option. The study team’s application for funding is going through all the usual review and approval stages ahead of set-up—including peer review, consideration by the National Institute for Health and Care Research funding committee, and ethical approval processes. We want the trial to begin recruiting participants in spring 2025. I am confident in the robust, appropriate and ethical way in which the trial is being established.

I call the Liberal Democrat spokesperson.

I thank the Secretary of State not only for the content of his statement, but for its tone and his recognition of the importance of such a tone in this place. 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 increasingly toxic public debate.

Before GIDS closed, more than 5,000 young people were stuck on the list for an appointment and waited, on average, almost three years for their first appointment. For teenagers going through what is often an incredibly difficult experience, three years must feel like an eternity, so change is desperately needed.

The Liberal Democrats have long pushed to ensure that children and young people can access the high-quality healthcare that they deserve. We welcome the NHS move to create multiple new regional centres, but those centres must get up and running as quickly as possible. Will the Secretary of State outline what steps the Government are taking to ensure that happens in every region, and will he give a timetable for that work? Tackling waiting lists and improving access to care must be priorities.

I understand why today’s news is causing fear and anxiety for some young trans people and their families, who have been badly let down for so many years—not least those I have met in my constituency, who have highlighted the catastrophic mental health impacts of the situation. It is crucial that these sorts of decisions are made by expert clinicians based on the best possible evidence. Will the Secretary of State publish all the evidence behind his decision, including the results of the consultation, to give those families confidence that this is the right move for them?

We welcome the announcement of a clinical trial. We need the NHS to build up the evidence base as quickly as possible, and the Government to provide certainty that they will follow evidence and expert advice on behalf of those children.

I thank the Liberal Democrat spokesperson for her approach to this matter. I can certainly respond to her questions. We want all those regional centres to be up and running by 2026, and we are working with NHS England to achieve that outcome.

The hon. Lady mentioned the waiting lists. To give people a sense of the challenge, the latest figures show that 6,237 children and young people are on waiting lists for gender services, so we have seen growth in the waiting list in the time that she mentioned. As with all NHS waiting lists, I want to see those numbers fall. It is particularly important to note, in the context of children and young people’s services—be they gender identity or other paediatric services—that a wait of many years can represent a school lifetime. I know that for that group of children and young people, time really does feel of the essence, so we owe it to them to get the waiting lists down faster.

We are also working to implement the recommendation on the follow-through service for 17 to 25-year-olds. I know that there is some anxiety about that issue—some people have interpreted it as an extension of children’s services up to the age of 25, but that is not what we intend. It is about a transitional service from children’s to adult services, which I think will lead to better care.

Finally, in the context of a statement that focuses on puberty-suppressing hormones, it is worth pointing out that they are not the only treatment for children and young people in this area. I think there is a danger that the focus on that treatment—because of an inevitable but necessary political process—means that it is held up as the gold standard, so some children and young people and their families feel that if they miss out on it, they are missing out on all treatment. That is not the case. Indeed, for many trans people of all ages in our country, puberty blockers have never been considered an appropriate intervention. We must see all the treatment options in the round, which is why I support the holistic approach to supporting children and young people with gender incongruence, as Dr Cass outlined in her excellent report.

I thank the Secretary of State for addressing the points in my letter to him, particularly on the holistic approach to the health of trans young people. In his statement, he said that the order would

“restrict the sale or supply of puberty blockers”

to under-18s through private prescriptions. Can he assure me that that will apply to all under-18s, not just those with gender dysphoria? Otherwise, it will be used as an attack on trans young people, as he well knows. Is the order universal rather than targeting trans young people in particular?

The order relates to the use of puberty blockers by that particular group of patients for that particular purpose, where the evidence base is not sound and for which the Commission on Human Medicines has described the current prescribing environment as representing an “unacceptable safety risk.” Puberty blockers are safe and proven for use among children and young people for other conditions, including precocious puberty. Where we lack a sound evidence base and a safe prescribing environment, and where that medicine represents an unacceptable safety risk, is in relation to its use for that particular purpose for that particular group of patients.

I welcome the statement and commend the Secretary of State for putting the safety and wellbeing of children first. The use of puberty blockers to treat gender dysphoria is—I will not mince my words—nothing short of a medical scandal, in my view, so I very much welcome his approach. He said that it is important that young people receive the right care from paediatricians and mental health professionals. Does he agree that no child should ever be told by a health professional that they were born in the wrong body?

It is important, particularly with this group of children and young people, that clinicians ask a range of questions to identify the nature of a child’s needs, and respond appropriately by providing holistic and evidence-based healthcare. That is the best way of turning around the horrendous statistics on the effects of gender dysphoria on children and young people, and it is how we will achieve better, healthier and happier outcomes for that cohort of patients.

I wrote to the Secretary of State this morning, before his statement was announced, to highlight that a Council of Europe report notes that gender-affirming hormone therapy for trans minors in the UK is almost impossible to access, and that the total withdrawal of access to healthcare outside of a research trial may breach the

“fundamental ethical principles governing research”.

The restrictions on puberty blockers remove the clinical expertise from medical decision making, which significantly impacts on young trans people and their families, and I am hugely disappointed by the content of the statement. Will he read that Council of Europe report, and will he agree to meet me, as a UK delegate, to discuss it?

I am certainly happy to continue meeting my hon. Friend on this issue. With great respect to the Council of Europe and the authors of the report that she mentions, I have to take decisions about the welfare, wellbeing and safety of children in this country based on clinical evidence. When our own Commission on Human Medicines says that there is an “unacceptable safety risk” and an unsafe prescribing environment, I have to take that seriously. When one of our country’s leading paediatricians says that there is insufficient evidence about the long-term effects of the use of this particular drug for this particular purpose for this particular cohort of children and young people, I have to take that seriously.

I know there are people who will be deeply disappointed by this decision, including many trans people and their families. Thinking about some of the young people I have met in recent weeks and months, I have taken to heart what they have said, and I know this will be deeply upsetting to them. I do not take that lightly, but to anyone challenging me to do something else, I ask them quite sincerely whether if they were standing in my shoes as the Secretary of State for Health and Social Care, looking at recommendations from clinicians in our country—including the Commission on Human Medicines—saying that there is insufficient evidence for the use of medication in children and young people for this purpose and an unacceptable safety risk arising from the current prescribing environment, they would really take a different position.

I am extremely worried and fearful about this decision to continue the blanket ban, and I want to ask the Secretary of State about his reliance in the terms of reference and reasons for this decision on the purpose for which these drugs are being prescribed—that is, being trans—when they are safely used by young people for other conditions, as he acknowledges. Does he understand that this is, at heart, discriminatory?

I do not agree with the hon. Member’s characterisation. A whole range of medicines are prescribed for a whole range of uses among a whole range of patient cohorts that may well be unsafe, inappropriate or ineffective for use by other patients with other conditions. That is a basic fact of medicine and, if I may say so, the hon. Member’s intervention is why we should listen to clinicians, not politicians.