Puberty blockers paused for children in Scotland after Cass Review

Referrals for puberty blockers have been paused in Scotland following publication of the Cass Review into gender identity services for children. 

The Sandyford sexual health clinic in Glasgow has announced that referrals for the prescription of puberty-suppressing hormones have been "paused for any new patients assessed at" its Young People Gender Service.

"Gender affirming" cross-sex hormones will also be limited to those aged 18 and over.

The steps affect new patients and a full review of the treatment pathways for young patients is to take place.

The NHS Greater Glasgow and Clyde (NHSGGC) clinic is the only one in Scotland to provide the specialist service and has a waiting list running into years, with around 1000 young patients on the list for appointments as of the start of the year.

Those referred on for the prescription of puberty blockers, which prevent the development of secondary sex characteristics, are sent on to paediatric endocrinology departments at NHSGGC and NHS Lothian hospitals.

The treatment is said to buy time for young people who are questioning their sex and gender.

But the Cass Review – a landmark report into services for gender-questioning young people in England – found evidence that the hormones harm bone density.

And Dr Hilary Cass, a leading paediatrician, found there is no proof that the blockers 'buy time' for patients in practice, with the majority going on to take masculinising or feminising cross-sex hormones.

She recommended "extreme caution" in the use of the drugs.

Scottish ministers have this week said it will take time to consider the Cass Review and whether its findings apply to Scotland.

Now the Sandyford clinic has announced action of its own in a decision which has the backing of Sir Gregor Smith, the chief medical officer for Scotland.

A statement on its website said: "Referrals from the Sandyford Sexual Health Services to paediatric endocrinology for the prescription of puberty suppressing hormones have been paused for any new patients assessed by our Young Persons Gender Service.

"Patients aged 16 to 17 years old who have not been treated by paediatric endocrinology, but who are still seeking treatment for their gender incongruence, will no longer be prescribed gender affirming hormone treatment until they are 18 years old.

"If you are already being treated by paediatric endocrinology and being prescribed either of these medications, you will have been contacted and advised that there will be no change to your course of treatment. You will also have been informed that you can contact your clinician if you have any concerns.

"This service update follows research from NHS England and the publication of the Cass Review while we work with the Scottish Government to engage in research with NHS England that will generate evidence of safety and long-term impact for therapies.

"We are committed to providing the best possible clinical care for young people accessing and understand the distress that gender incongruence can cause.

"While this pause is in place, we will continue to give anyone who is referred into the Young People Gender Service the psychological support that they require while we review the pathways in line with the findings."

NHSGGC and NHS Lothian deferred placing new patients on the treatments in mid-March in response to the position taken by NHS England, which has banned the use of puberty blockers for gender-questioning young people.

Dr Emilia Crighton, NHSGGC director of public health, said: "The findings informing the Cass Review are important, and we have reviewed the impact on our clinical pathways. The next step from here is to work with the Scottish Government and academic partners to generate evidence that enables us to deliver safe care for our patients."

She went on: "We understand the distress that gender incongruence can cause and, while all referrals to endocrinology are paused, we will continue to give anyone who is referred into the Young People Gender Service the psychological support that they require while we review the pathways in line with the findings."

Tracey Gillies, executive medical director at NHS Lothian, added: "The Cass Review is a significant piece of work into how the NHS can better support children and young people who present with gender dysphoria. Patient safety must always be our priority and it is right that we pause this treatment to allow more research to be carried out."

Cass, who called for an end to the "toxic" debate around gender identity services for children, has been accused of transphobia over the findings, which are based on evidence gathered from around the world.

Health Secretary Neil Gray said: "We have been clear it is for clinicians and health boards to make decisions about clinical pathways, and that these decisions should be made carefully and based on the best evidence available. This is what both health boards have done, and their position is supported by the chief medical officer.

"More broadly, the Cass Review's final report and findings are being closely considered by both the Scottish Government and health boards, in the context of how such healthcare can be best delivered in Scotland.

"We agree with Dr Hilary Cass when she highlights that 'increasingly toxic, ideological and polarised public debate' does nothing to serve the young people accessing this care, their families and the NHS staff working hard to care for them. 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. They are who should be at the centre of our thoughts when we discuss this issue."

Scottish Conservative deputy leader Meghan Gallacher commented: "This long overdue decision should have been taken weeks ago when NHS England put a pause on the prescribing of puberty blockers.

"The SNP government have been dragged kicking and screaming towards taking the necessary action to safeguard vulnerable youngsters after days of shameful silence and dithering in response to the Cass Review – presumably to placate the gender zealots in the Scottish Greens.

"Humza Yousaf repeatedly passed the buck – insisting it was up to clinicians to decide on the efficacy of puberty blockers and saying he wouldn’t be rushed in to responding to Cass – when it was clear decisive action was required."

However, Scottish Trans and the Equality Network called it "the wrong decision", saying it will "harm trans children and young people".

The organisations said it is "incredibly rare for children or young people to be prescribed puberty blockers" in Scotland, with fewer than 90 patients prescribed them between 2011 and 2023. 

Vic Valentine, manager of Scottish Trans, said: "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. 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.

"We note that the announcement mentions the potential for further research into the use of puberty blockers, in partnership with NHS England. There is widespread concern that neither the research programme, nor how it will be designed, are finalised yet. We call on the Young People Gender Service and the Scottish Government to urgently prioritise resourcing high quality, ethical research, to make sure that no child or young person is denied the care they need."