Puberty blockers: The medical controversy Scotland's experts don't want to talk about

After days of saying very little, the Scottish Government left health leaders to do the talking. Prescriptions of puberty blockers for gender-questioning young patients were to be paused for any new cases; under-18s would not be referred for gender-affirming cross-sex hormones. 

The news was broken not by a minister but on the web page of the Young People Gender Service at the Sandyford clinic in Glasgow, Scotland’s answer to London’s controversial Gender Identity Development Service (GIDS) at the Tavistock. Dogged by staff shortages, the Sandyford is the only clinic in the country to provide specialist assessment and support for children and young people seeking help with their gender identity. Waiting lists run into years rather than weeks or months, with around 1,000 patients holding on for first appointments at the turn of the year. From there, some are referred on to hospital endocrinology teams in the Glasgow and Lothian regions for puberty-blocking drugs to stop the development of secondary sex characteristics, or either masculinising or feminising hormones to otherwise rewrite their body chemistry.

Or at least that was the case until Thursday, when a suspension of endocrinology referrals was announced for all but those already receiving the treatment. In a joint statement, NHSGGC, which runs the Sandyford, and NHS Lothian said the decision had the backing of the chief medical officer, Sir Gregor Smith. Later, health secretary Neil Gray said he supported it too. “I remain clear that it is right that those most impacted by this change were the first to hear about these changes, sensitively and from the services caring for them," he said. "They are who should be at the centre of our thoughts when we discuss this issue.”

The move was met with condemnation from LGBTQI+ campaigners at the Equality Network and Scottish Trans, who said it will “harm trans children and young people”. “We’re saddened that this change will result in some young people being unable to access the care they need at all, or having to wait even longer for it,” Scottish Trans manager Vic Valentine said. “We want every child or young person to get the individualised care that’s right for them at the time that’s right for them. We don’t think this decision will make that possible.”

The pause followed the final publication of the 400-page Cass Review, which asks big questions about gender identity services for children and young people. Written for NHS England by the world-renowned paediatrician Dr Hilary Cass, the final report was four years in the making and makes more than 30 recommendations aimed at addressing deficiencies in diagnosis, waiting times, long-term care, regional services and treatment methods. 

Clinicians are “fearful” amid “polarised” debate, Cass wrote, and this area of medicine is conducted on “remarkably weak evidence”. Results of studies are “exaggerated or misrepresented by people on all sides of the debate to support their viewpoint” on transgender rights, she found, and “the reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress”. 

None of this is helpful to the children at the centre of this febrile debate around sex and gender

On that basis, Cass recommended “extreme caution” in the prescription of cross-sex hormones and said that while there is “no evidence” that puberty blockers in adolescence really do give children “time to think”, as suggested by some advocates, there is evidence that they compromise bone density. The prescription leads some onto a medicalised pathway that takes them onto adult hormone treatments, which may not ultimately be appropriate for them, it is claimed.

“Too often this cohort are considered a homogenous group for whom there is a single driving cause and an optimum treatment approach, but this is an over-simplification of the situation,” Cass wrote. “Being gender-questioning or having a trans identity means different things to different people. Among those being referred to children and young people’s gender services, some may benefit from medical intervention, and some may not. The clinical approach must reflect this.”

Before the review was published in full, a decision had been taken by NHS England to bar the use of puberty blockers for children with gender incongruity, outwith clinical trials. That was after the initial findings were released in an interim report two years ago and led to questions about what would happen for Scotland’s children. It now turns out that NHSGGC and NHS Lothian deferred starting new patients on hormone treatments in mid-March this year, based on clinical advice, but the move was not made public.

At the same time, an information vacuum followed the publication of the report, with questions asked of exactly what the Scottish Government and health services were doing about an area relating not only to child health and wellbeing but also safeguarding, service design, clinical practice and equalities. Few answers were given, with First Minister Humza Yousaf and public health minister Jenni Minto stating that the matter was one for doctors. It would not be “appropriate to respond quickly” to the review, Minto said, and that must be done “in the appropriate time so we understand exactly what the implications are of the Cass Review to gender identity services within Scotland”. Attempts to bring about a ministerial statement on the matter were voted down and George Adam, Minister for Parliamentary Business, told the chamber that “the Cass Review deals with services in NHS England, not in NHS Scotland” and “it is therefore clearly not the responsibility of the Scottish Government to respond to it: it is for the UK Government to respond with ideas for its NHS”.

A source close to Cass disagreed, telling Holyrood that “it’s pretty straightforward, this is not just a report about England”. “The evidence looked at was international. The papers that were reviewed came from a wide range of countries. Really that is the point – you would have to argue that children in Scotland were somehow different to children anywhere else.”

In the days that followed the publication of the Cass Review, Holyrood sought answers on that and other points from the chief medical officer, the commissioner for children and young people, children’s minister Natalie Don, LGBT Youth Scotland, Scottish representatives at the Royal College of Paediatrics & Child Health (RCPCH) and the Royal College of Psychiatrists (RCPsych). All either declined to be interviewed or to answer questions, or failed to respond to our approach.

Adam’s comments were made on Tuesday, two days before the Sandyford decision emerged, while Minto’s remarks came on the eve of the news. Before First Minister’s Questions, Scottish Conservative deputy leader Meghan Gallacher, who sought the ministerial statement, expressed confusion. “I wish to convey my utmost dismay at the utter shambles that has unfolded this week over the Scottish Government’s handling of the Cass Review findings,” she said.

“We’ve been told repeatedly this week that the minister and the government needed sufficient time to carefully consider its findings, so I’m wondering, did the Scottish Government develop the skill of speed reading overnight? Because if the government was going to announce this anyways, why didn’t the SNP and Greens vote for my statement yesterday? That would have allowed the government to have announced that puberty blockers were to be paused in parliament and for MSPs to ask questions.”

“We should know if this decision has been taken as a result of any Scottish Government intervention, if [the first minister] and his government is supportive of a wider acceptance of the recommendations within the Cass Review after the poor, indeed woeful, answers we received in this chamber yesterday,” Labour’s Carol Mochan echoed.

Yousaf said Gray “or, indeed, ministers” will give an update on the government’s position “next week or in the coming weeks”. “There is a process of review that is very much underway,” he went on. “When it comes to the treatment, when it comes to the care that’s provided to these young people, those should be matters that are made by clinicians and decided upon by clinicians, not entirely by politicians.”

According to Professor Alexis Jay, who led the Independent Inquiry into Child Sexual Abuse in England and Wales, we need to talk. Jay said parallels have been drawn between aspects of the findings of the Cass Review and what she found in Rotherham, where fear and the toxicity of the debate combined to fail vulnerable children. “None of this is helpful to the children at the centre of this febrile debate around sex and gender, and may serve to confuse the issues even further,” she told Holyrood. 

“All organisations, public institutions and politicians need to be clear in their approach to these difficult decisions that the ‘paramountcy’ principle prevails in law, policy and practice across health, justice, and children’s services, amongst others. Nothing should be done except in the child’s best interests and welfare. That must involve, as Dr Cass has stated, a holistic understanding of the child or young person’s needs, supported by robust evidence of the effectiveness of any interventions the various parties concerned recommend.”

Indeed, heat must be taken out of this debate – how else can rational, evidence-led decision-making take place? The Cass Review comes on the heels of a procession of bills relating to equalities and legal reforms – the Gender Recognition Reform Act, the hate crime act, the proposed criminalisation of misogyny – which have for years kept our politics in a kind of Groundhog Day in which the same arguments around sex and gender are heard in a seemingly endless loop. The review could move an element of that argument on, providing an authoritative new perspective for the care of one of the most complex and vulnerable cohorts cared for by the NHS. But the atmosphere remains charged.

Every now and again a report comes along that makes you stop and just think

Responding to the Sandyford news, a protest was organised in Glasgow, with organisers sharing a graphic bearing the words “stop killing trans kids”. On the Cass Review itself, Green MSP Ross Greer reshared a post on X calling it “a straight-up transphobic and conservative document”. The Rainbow Greens, which represent LGBTQIA+ members of the Scottish Greens, described the Cass Review as a “social murder charter”. And the newly elected chair of Scottish Labour students, Emma Russell, posted on social-media platform X that “the Cass Review is a methodologically flawed, ideologically-led study that isn’t worth the paper it’s printed on”.

“Every now and again a report comes along that makes you stop and just think, and I think the Cass Review fits that,” said former children and young person’s commissioner Tam Baillie. “It’s made me stop and think, where is all this going? It’s a compassionate review focused on the needs of children, young people and families.”

Baillie, who hailed the publication of the review as a watershed moment, particularly supports the suggestion in the report that services should be available on a regional rather than centralised basis, and highlights the emphasis given by Cass to the need to improve mental health services for children and young people who may also be reporting gender issues. “There are children in Scotland who are suffering because of their gender incongruity and we need to get services and help to them, but I’m also supportive of the expanded services and bringing with it the extreme caution it recommends on the administration of medication. For any medication, people should be cautious, but how can you make informed consent when you don’t know what the evidence base tells you? That’s really challenging.

“I would see this report as being a positive lever for trying to improve our general mental health services for children and young people and about expanding services on a regional basis.” 

The current commissioner, Nicola Killean, is less certain. While her office told Holyrood that it had no statement on the “complex report”, and nor was Killean able to take questions, when she appeared before the Education, Children and Young People Committee, the commissioner said her office had not worked on the “specific issue” of the safety of puberty blockers. “I don’t have a fixed view on that,” she said. “What we would say is the Scottish Government are looking at this and actually decisions that are independent medical care should continue to be made by medical professionals.”

It can be difficult for those professionals to speak publicly, and the Scottish Government said the CMO, whose chief responsibility is to provide policy advice to ministers on healthcare and public health, was not available for interview.

puberty blockers and hormone therapies are major, life altering interventions

Meanwhile the Royal Colleges, who provide a voice for individual specialisms, are being sparing with their words. RPsych said its UK-wide operation was working on a “fuller response” once senior doctors “had time to consider the entire report”. RCPCH, whose motto is “leading the way in children’s health”, told Holyrood it was “not currently doing interviews” but the principles of its statement referring to the Cass Review and NHS England could also apply to NHS Scotland, agreeing that the name of one service could be substituted for that of the other in this statement by its president, Professor Steve Turner: “It is essential that NHS England now provides the necessary additional guidance and support needed for paediatricians and the wider child health team to undertake their important role of caring for children who are gender questioning or experiencing gender dysphoria. We will continue to engage with NHS England, our members and children and young people on this matter as the new services develop.”

The former UK health secretary Sajid Javid, who called for the Cass Review in the first place, was less choice in his words on its publication: “When I was briefed on the NHS GIDS for the first time, I knew this was not just another policy area but a child-protection issue and huge medical scandal in the making.” Similarly, an editorial in The British Medical Journal said: “Offering treatments without an adequate understanding of benefits and harms is unethical... puberty blockers and hormone therapies are major, life altering interventions.”

Opinions continue to be polarised and yet, with the future lives of young people at stake, a careful, considered approach to this issue is crucial. So too are leadership, evidence-base, and authoritative voices. Without them, the hot takes lighting up social media, fuelled by and fuelling yet more polarisation, will continue to burn.