Blog

An application for a judicial review of the Secretary of State’s decision to ban puberty blockers but not cross-sex hormones was heard in the High Court on 21^st May. The case was brought by Keira Bell together with two parents. NHS England was an interested party.

Although the Court refused permission for a judicial review, the outcome of bringing the application was a victory for the claimants: the Secretary of State, Wes Streeting, has established a working group to review the prescription of cross-sex hormones to minors by private providers. A decision on whether to impose a ban on cross-sex hormones will be announced in July.

Keira Bell said she was “relieved that the Secretary of State is now actively considering a ban on cross-sex hormones outside of the NHS” despite this being “long overdue”.

“These powerful drugs should not be given to children and young people. Not only are the drugs life-changing at a time when so much is uncertain and changing, but so many children and young people are struggling with trauma and are experiencing confusion during their development.

“The safety of vulnerable children and young people should be a first priority. It now looks like that is beginning to happen.”

The court case

The claimants brought the case on the basis that it was irrational and unlawful for the government to ban puberty blockers but not impose a similar ban on cross-sex hormones when the safety profile and inadequate evidence base was the same for both. The Cass Review had also made it clear that children were put at risk through access to both blockers and hormones from private and overseas providers.

The initial response from the Department of Health and Social Care (DHSC) was that it remained “neither necessary nor appropriate” to ban cross sex hormones. But this changed on receipt of the expert reports of Professor Riittakerttu Kaltiala from Finland and Professor Jovanna Dahlgren from Sweden.

The grounds for the defence then changed from the claim that the application for the JR was unreasonably delayed, (as it was made nearly three months after the decision to ban blockers) to the claim that the application was premature and academic, as the Department was still carefully considering what action might be appropriate in the case of cross-sex hormones. In court the DHSC barrister Iain Steele said that a working group of NHS clinical specialists had been established on 28 April to review the issue and advise government.

The application for a judicial review was therefore dismissed by Lady Justice Whipple, on the grounds that “the case had moved on substantially” following the establishment of the new working group.

So what was the new evidence that motivated the DHSC to change their position?

Expert evidence

The expert evidence in witness statements submitted by the claimants took the form of answers to specific questions. Some of the evidence would already have been familiar to NHS England through the Cass Review, for example this response from Professor Dr Riitakerttu Kaltiala of Tampere University and Tampere University Hospital, Finland:

Is cross sex hormone treatment safe and effective in the treatment of gender dysphoria for natal males and females under the age of 18 years old?

13. Research to date has not been able to verify the assumed psychosocial and mental health benefits of cross-sex hormones initiated during developmental years. Actually, deterioration can occur.

21. Finally, there is the emerging issues around individuals discontinuing CSH treatments that were intended lifelong, detransitioning from adopted cross-sex identity after irreversible bodily changes have taken place, and experiencing regrets. It was long assumed that very few patients embarking on medical gender reassignment regret their choice and seek to reverse it.

From the 1970s to the 2010s, estimates of those regretting their initiated gender reassignment were only in the region of 2% (Dhejne et al., 2014; Wiepjes et al., 2018). However, alongside the increase in the number of people accessing medical gender reassignment, reversing the initiated transition seems to be increasing (Hall et al., 2021). In recent samples, 20-30% of those who initiated hormonal gender reassignment discontinued hormonal treatment in four to five years (Boyd et al., 2022; Roberts et al., 2022).

This underlines the uncertainty related to stability of identity particularly during developmental years.

The following response is specifically critical of the service specification the NHS failed to review and update:

Is the treatment of young people with gender dysphoria aged 16-18 with cross sex hormones safer than providing the same treatment than for children under the age of 16 years old ?

26. Based on the existing research it is not possible to claim that this treatment initiated at ages 16-18 would be safer than if initiated at ages < 16. It is not safe to any minors. I have seen the NHS Clinical Commissioning Policy Prescribing of Gender Affirming Hormones which implies that CSH treatment has been evidenced as safe for treatment for over 16-year-olds. The evidence relied upon in the policy does not support that conclusion.

Furthermore, the Cass Review’s conclusions were informed by reviews conducted by the National Institute for Clinical Excellence (NICE). The conclusions of both NICE reviews (PB and CSH) was that all the evidence was “very low certainty” for both PB and CSH. This is the lowest level of the evidence. It’s definition is that the results reported by the studies are likely substantially different from the truth.

It is not possible to conclude that treatment with cross sex hormones is safe for under 18- year-olds, and having reached age 16 makes no difference to this. There is no reliable evidence upon which that conclusion can be reached.

27. Another issue is a young person’s ability to make decisions on this type of medical treatment, as well as the possibility that starting these treatments earlier may mean that it is more likely that they will come to regret that choice and seek to de-transition.

(Not only 16-18-year olds but also young people from 18 to about mid-twenties are still in developmental years regarding brain maturation, personality and identity consolidation, and social roles (Bogaerts et al., 2021; Klimstra et al., 2013; Kroger et al., 2010; Luyckx & Robitschek, 2014).)

The next response reflects the conclusions of the Cass Review and should be used to inform government if the proposal for a ‘trans inclusive’ conversion practices bill is put forward again:

What is the appropriate clinical intervention for young people under the age of 18 with suspected gender dysphoria?

29. Comprehensive and holistic assessment is the first clinical intervention needed with young people under the age of 18 with suspected gender dysphoria.

30. Such assessment requires time and several personal encounters with the young person and their parents / guardians with follow-up of the young person’s development over time, because a comprehensive understanding of an adolescent’s mental health, functioning, adolescent development and such complex issue as identity development cannot be obtained in a single meeting, by meeting the young person alone, by remote contact, or by assessing the young person without any follow-up.

32. For gender-distressed young people who do not currently present with psychiatric needs, appropriate first line intervention is psychosocial/ psychotherapeutic intervention aiming at encouraging and promoting identity exploration across the different facets of identity. The aim of this intervention is not to reach any given gender identity, but to help the young person to increase understanding of themselves and to promote their agency and autonomy when responding to any gender-related distress they may be experiencing.

The following should be absolutely clear to both NHS and government by now:

Do you consider the treatment approach of GenderGP to be appropriate in terms of safety for young people under the age of 18 years old ?

35. No I do not. It is inappropriate throughout. Based on the information I reviewed about its services from information on its own website

e. and it is intentionally providing disinformation that may mislead young persons and their parents to believe in the safety and positive effects of the cross-sex hormone treatment for feelings of gender dysphoria regardless of the mental health, developmental and psychosocial situation and the identity development of the young person.

36. I consider it unsafe and irresponsible, and it is deeply concerning that adolescent children are able to access its services, apparently free from any official regulation or oversight.

The government also needs to consider the activist groups that are similarly intentionally providing disinformation to schools and through children’s literature, and take strong action to protect children from accessing this harmful messaging.

The expert evidence from Professor Dr Jovanna Dahlgren of Department of Paediatrics, University of Gothenburg, similar to the HHS report we wrote about here, lists the permanent risks and harms of cross-sex hormones on male and female bodies. This was information missing from the Cass Review, but it should be common knowledge for our national health service. It also should be common-sense for even those who are not medically trained that giving opposite-sex hormones to children will have damaging effects on developing bodies, and raises ethical concerns about children’s capacity to consent.

We reproduce Dr Dahlgren’s evidence with permission here.

What are the consequences of prescribing cross sex hormones to young people under the age of 18 years old? Please differentiate between natal males and females

9. The consequences of prescribing cross sex hormones in individuals under the age of 18 years are that the body and the brain are permanently marked/changed with both known and more unforeseen consequences.

10. In natal females, the consequences of treatment within the first year (already after 1-6 months) are masculinization with deepening of voice with male pitch, fat redistribution to a more male-like pattern. The clitoris becomes enlarged and the vagina atrophic. The libido increases. The menses become irregular and then they disappear within one year.

Then after one year there is also evidently more facial/body hair, rougher face, increased muscle mass of the chest and extremities. The treatment has also effects on bone mineral density, left-ventricular posterior wall thickness and several structures of the brain such as hippocampus, globus pallidum and cortex with impact on several crucial networks. The treatment will in other words influence processing, emotions, consolidation of information and spatial memory. Secretion of insulin-like growth factor 1 and insulin increases on testosterone treatment. Less desired effects are more acne, oiliness of skin, scalp hair loss. Many of these symptoms are irreversible even if the individual stops the treatment.

11. In natal males, the consequences of estrogen treatment within the first months (1-6 months) are less spontaneous erection and less libido. Within 6 months it is also seen breast growth, redistribution of fat in a more female pattern and decreased testicular volume and sperm production. In more detail the treatment leads to smaller seminiferous tubules with heavy hyalinization and fibrosis, impairing sperm quality and thus fertility. Estrogen and anti-androgen treatment causes higher proportions of sperm abnormalities (i.e. low total sperm count, low sperm concentration, poor sperm motility) or azoospermia. Less desired effects are lower insulin-like growth factor 1, decrease in muscle mass and strength.

12. The treatment with cross sex hormones is lifelong. Over longer time the visceral fat is increased in both genders with signs of the metabolic syndrome (high blood pressure and blood lipids as well as lower insulin sensitivity). If the treatment is started in young years, many years with daily treatment with cross sex hormones will increase the risk of cardiovascular disease such as cardiac infarction and stroke. Therefore, during treatment it is recommended to avoid development of overweight, to stop smoking and increase physical activity. Moreover, monitoring of remaining breast tissue, prostate, uterus and ovaries for cancer prevention is recommended every second year. The hormone treatment can decrease fertility, impair liver function and increase the risk of cancer in both genders, but long-term data is lacking.

What are the risks of treatment with cross sex hormones for natal males and females under the age of 18 years old?

13. We know that cross sex hormone treatment has a huge impact on most cells and especially on the genetic material in the DNA. Both testosterone and estrogens are steroid hormones that penetrate the cell membrane and is translated to the cell nucleus

14. From experiments in mammals being exposed for cross sex hormones in young age, they develop besides brain structural changes also the metabolic syndrome with high blood pressure, lower insulin sensitivity/type 2 diabetes and dyslipidemia (high LDL[1]cholesterol and lower HDL-cholesterol)

Natal males (Transfemale) were found to have a substantial higher incidence of VTE, ischemic stroke and myocardial infarction.

18. Alzahrani et al. found an increased risk for myocardial infarction in natal females on cross sex hormone treatment

Are the risks of treatment with cross sex hormones for natal males and females greater if treatment is commenced prior to conclusion of puberty?

19. Yes, the risks of treatment are greater if treatment commences prior to the conclusion of puberty. Most important, cross sex hormones accelerate bone maturation. If the child has not fulfilled the pubertal progression to Tanner stage 4 or 5, then the potent sex hormones will accelerate the bone age influencing adult height. Studies show that if the patient is treated with puberty blockers and then testosterone, then they may have normal adult height, but with only testosterone there is a shortness of adult height

20. Moreover, the pubertal years (normally 4.5 years from starting puberty) as in analogy with the critical infancy is a period for both mental maturation, brain and other organ development. These periods are seen as critical windows of opportunity for optimal stimuli. If the pubertal period is accelerated with higher sex hormones or delayed such as pubertal arrest, then the required ordinary process of successive maturation is impaired.

21. The irreversible effect of cross sex hormone treatment despite stopping treatment are the voice with male pitch, the bald headed and decreased fertility for natal females. In natal males, it is the breast development (gynecomastia), lower bone mineral density, atrophy of gonads and decreased fertility. Moreover, also the redistribution of fat mass and the metabolic disadvantages of visceral fat can be difficult to reverse after stopping cross sex hormone treatment.

The epigenetic changes in the cell nucleus may also be irreversible leading to increased risk for cancer, but these long-lasting effects are not completely elucidated as the treatment in young ages has not been in use for so many decades. No other medical field performs irreversible treatments before the age of 25 years in Sweden (for example to have a sterilization performed, you need to be 25 years of age for decision making).

Can you please compare the risks associated with cross sex hormones treatment with the risks associated with puberty blockers and provide the Court with your view as to which poses the greater risk and why?

23. The puberty blockers deteriorate development, impairing mental maturation as well as organ development leading to impact on cognition and bone mineral density. This seems to be in part reversed when puberty is allowed to proceed.

24. However, cross sex hormones have greater risk with its potent and continuing impact on all cell nucleus and DNA, mostly through epigenetic mechanisms. This effect is exerted on estrogen receptors through increased methylation by testosterone treatment in natal females, whereas the androgen receptor has increased methylation due to estrogen treatment in natal males. These changes correlated with body composition as well as metabolic and hormonal parameters increasing the risk for developing the metabolic syndrome  and by that increasing the risk for cardiovascular disease. Epigenetic changes of these receptors have also impact on several different brain regions including serotonin neurons, a system that regulates affective status and thus may lead to depressive symptoms, sleep and wakefulness.

What are the necessary clinical procedures that have to be undertaken prior to and during treatment to ensure that it is as safe as possible?

25. The clinical procedure prior to treatment is after a proper diagnosis of gender dysphoria without other severe psychiatric comorbidities, that the patients understand in depth the consequences of irreversible changes of cross sex hormones. The irreversible nature of the treatment raises critical ethical concerns about consent, autonomy, and bodily integrity.

What other medical conditions are cross sex hormones prescribed for in young people under 18 years old? For example, what conditions would testosterone be prescribed for in natal females under the age of 18 years old?

27. I am not aware of any such condition that needs cross sex hormone treatment. However, some disorders of sex development (DSD) may need complementary sex hormone treatment and then a discussion can emerge on what gender to mimic.

Do you consider the practice of GenderGP in relation to prescribing cross sex hormones to be safe for young people under the age of 18 years old?

30. No, today a more cautious and thorough management is recommended within a complete multidisciplinary high specialized gender dysphoria team following yearly the young patient under the age of 18 years. The human rights of the child as non-autonomous should be strongly taken into account as children must be protected from harmful or irreversible practices. The patient needs unbiased information about the potential long-term risks, benefits, and alternatives to cross sex hormone treatment.

31. Moreover, the prescription of cross sex hormone treatment by a digital GP or center far away from the child is the opposite to good clinical practice, non-evidence-based and should be prevented by the authorities.

32. The practice at GenderGP would not be permitted in Sweden. It is very unsafe and exposes children to a significant risk of harm.

What we learned

Some interesting facts have emerged from this case. Part of the evidence for the claimants came from a previous judicial review brought by activist group TransActual in April 2024 challenging the puberty blockers ban. It showed that the position of the previous Secretary of State was that “a full Order could also include cross-sex hormones, subject to clinical advice.” We had written to Victoria Atkins, the former Secretary of State, in March 2024 asking for the inclusion of cross-sex hormones in the ban.

Subsequently the previous government took action on puberty blockers as a priority in May 2024 but this was no reason for the current government not to consider a similar ban on cross-sex hormones after taking office following the General Election in July.

It was also revealed that the NHS clinical commissioning policy review for cross-sex hormones is underway. An updated policy is expected to be in place by April 2026.

We are glad to hear this but it should have been done at the same time as the puberty blockers review and public consultation following the Cass Interim Report in 2022. So much time has been lost. There was no reason not to do it at the same time as the puberty blockers review, as we wrote about here and here. We wrote to NHS Engagement to ask whether a review of hormones was being done but received no reply so we asked Dr Cass who had also heard nothing from NHS England on this issue.

This is important because part of the DHSC’s defence was consideration of the response of NHS England to the Cass Review and the different approach taken to puberty blockers compared to cross-sex hormones. We believe that the NHS failed to respond to the Cass Review’s findings about hormones with the same warranted degree of seriousness and urgency as they took to blockers.

If NHS England thought it was adequate not to review the use of hormones, but to retain the pre-Cass, out-of-date clinical commissioning policy (albeit with a few tweaks to reflect the new policy on blockers) then who can blame a Health Secretary for assuming that hormones do not need the same level of scrutiny?

The damage caused

Having failed to properly review the 2016 clinical commissioning policy in 2022, NHS England should have made a clear statement in response to the Cass final report that cross-sex hormones were no longer available as routine treatment on the NHS until such a review had been completed.

Nevertheless, the announcement of the belated review by NHS England, following publication of the final Cass Review, should also have been enough for the government to ban private prescriptions. Instead we have a mess of mixed messages regarding cross-sex hormones.

NHS England is following the Cass recommendation for ‘extreme caution’ (and apparently no child has been referred for hormones since the policy has been in place) but they are still using an ideologically-based, WPATH-influenced service specification that contradicts Cass’s advice. The government has banned blockers but not hormones.

While it’s good news that these issues are finally being addressed, in the meantime children have continued to be harmed by private providers and doctors who have continued to supply these drugs outside the safeguards established by Cass.

One example of this is transgender doctor Sam Hall at the WellBN clinic in Brighton. who prescribes cross-sex hormones to adolescents. At the end of last year an application for a judicial review was launched by a Brighton father after his 16 year-old was given cross-sex hormones by the clinic. Last week an announcement was published on the clinic’s website stating that the clinic has been forced to stop prescribing hormones to minors under threat of being shut down by NHS England.

As of 11th April 2025, NHS England and NHS Sussex has forced us to temporarily pause initiating new NHS prescriptions for gender affirming care to anyone under the age of 18. This includes a ban on taking over prescriptions from the private sector. They did this by threatening to close us down altogether if we did not comply.

The Trans Health Hub team at WellBN described this as an ‘injustice’ and signed off the statement ‘With solidarity and rage.’

It has since been reported that NHS England has started a “rapid investigation” into the clinic, in partnership with the Sussex Integrated Care Board.  

The evidence

In the Bell v Secretary of State case it was the witness statement and supporting evidence from the Bayswater support group that demonstrated the extent to which unregulated private providers, specifically Gender GP and Imago, are continuing to supply teenagers with cross-sex hormones without parental knowledge. Bayswater had also written to the DHSC outlining the concerns of parents in this position.

The issue was raised in a meeting of stakeholder groups in July 2024 and, as part of their response to the subsequent stakeholder consultation, Bayswater included the risk that the puberty blockers ban could lead to private clinics switching to cross-sex hormones, and they followed it up with another letter.

(In our response to the consultation we also included the warning from Andrew McFarlane, President of the Family Division, that adolescents were at risk of accessing cross-sex hormones from off-shore, online, unregulated private clinics).

The claim by DHSC barrister Iain Steele that there was no evidence that there had been an increase in prescriptions for cross-sex hormones, conversely, was not backed up with any evidence.

It was Bayswater who supplied the evidence that this was going on, but it seems that it is the evidence from experts that is instrumental in motivating the NHS and the government to review policy. While activists have been allowed to dictate clinical policy based on unevidenced claims, very low quality evidence and anecdotal ‘lived experience’, changing it has taken a four-year independent review.  

Despite the Cass Review and its findings there seems to be continuing resistance to making all the changes necessary to protect children from the harms of ‘gender affirming care.’ This is why these court cases are so important. There is nothing like the threat of legal action to motivate the NHS and the DHSC to take action on the concerns that parents have been raising for years.