CAN-SG welcomes the recent news that the Health Secretary, Wes Streeting, has set up a working group to review the private prescription of cross-sex hormones to young people under 18, due to report at the end of July 2025.
The New Statesman reported 27 May that an application by Keira Bell and others for judicial review of government’s failure to ban the private prescription of cross sex hormones to under 18s when it banned puberty blockers last year was rejected by the judge because the government had just instituted an expert review body to look into the matter and it would be premature to judicially review a process that had not yet completed.
The JR application included witness statements from two international experts on the lack of evidence and risks of cross sex hormones in under 18s and it was reported that this persuaded the government to set up an expert panel to review the risks of unregulated hormone prescribing.
Expert witnesses testify on lack of evidence and risks
Professor Riittakerttu Kaltiala, professor of adolescent psychiatry in the University of Tampere, Finland and Professor Jovanna Dahlgren, paediatric endocrinologist, University of Gothenburg, Sweden who have both worked directly with hundreds of gender-questioning children, hold leading positions in their specialties and have researched and published widely on youth gender medicine gave witness statements that evidence of beneficial effects of cross sex hormone treatment of gender dysphoria in minors (oestrogen in males and testosterone in females) was practically non-existent and warned of serious long term health problems such as increased incidence of heart attack and stroke.
Seemingly most relevant to Wes Streeting’s decision-making, is the outlined additional danger of starting hormone treatments while still in childhood. “If the treatment is started in young years, many years with daily treatment with cross sex hormones will increase the risk of cardiovascular disease… and stroke… [and] can decrease fertility, impair liver function and increase the risk of cancer in both genders,” hormone expert Dahlgren wrote. She also noted the lack of long-term data: “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.”
Hannah Barnes New Statesman
NHS England dragging its feet
The appointment of an expert review body is an important step forward in protecting young people from the harm of unregulated prescribing of cross sex hormones to 16 and 17 year olds, but as it is limited to private prescribing it will not evaluate the risks and benefits of prescribing these same hormones within the NHS.
Given the high level of concern about these hormones – with the University of York systematic review showing no evidence of benefit, and increasing concerns about risk highlighted in the Cass Review – one would have expected a review of cross sex hormone use in this age group by now.
Instead NHS England has dragged its feet and according to Court documents the NHS hormone clinical policy review won’t report until at least mid 2026.
Hormones still recommended for under 18s on the NHS
In the meantime NHS England has published a draft service specification for the new youth gender clinics which still contains the option of referral for hormones and links to an out of date hormone commissioning policy.
The approach for onward referral to a paediatric endocrinology clinic for the purpose of assessment for suitability for exogenous hormone intervention is described in NHS England’s published clinical commissioning policy.
NHS England Draft Service specification:
NHS Children and Young Peoples Gender Service 18 March 2025
NHS hormone policy out of date and not evidence based
The clinical commissioning policy for “masculinising or feminising hormones as part of the children and young people’s gender service” is dangerously out-of-date and lacks evidence. Published on 21 March 2024 it recommends use of cross sex hormones in 16 and 17 year olds and suggests there is evidence for their safety. This is at odds with the Cass Review published a few weeks later on 10 April 2024.
The NHSE hormone clinical policy claims to be evidence based:
In creating this policy NHS England has reviewed this clinical condition and the options for its treatment. It has considered the place of this treatment in current clinical practice, whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources.
None of the above claims is true. There was no review of the scientific research on benefits or risks. The policy cites no up-to-date evidence to support its recommendations. It ignores the considerable body of research on safety and efficacy, including multiple systematic reviews, since the previous policy recommending cross sex hormones for under 18s was published in 2016.
NICE SR found no evidence of hormone benefit
In particular the 2024 clinical policy does not reference the NICE 2020 systematic review of gender affirming hormones which showed no evidence of benefit.
This evidence review found limited evidence for the effectiveness and safety of gender- affirming hormones in children and adolescents with gender dysphoria, with all studies being uncontrolled, observational studies, and all outcomes of very low certainty. Any potential benefits of treatment must be weighed against the largely unknown long-term safety profile of these treatments. (NICE 2020)
Nearly a decade of evidence ignored
Having ignored nearly a decade of accumulated evidence, including the NICE SR, and knowing the Cass Review and the University of York systematic reviews were about to be published, it seems odd that NHS England did not wait a few weeks so it could base its updated hormone policy on the latest evidence and recommendations. Instead they said this was something they would do later, giving no time scale.
Extreme caution
The Cass Review, published just three weeks after the NHS England clinical hormone policy that couldn’t wait, made a strong recommendation regarding cross sex hormones.
Recommendation 8:
Cass Review
NHS England should review the policy on masculinising/feminising hormones. The option to provide masculinising/feminising hormones from age 16 is available, but the Review would recommend extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18.
The recommendation was informed by the University of York systematic review of masculinising and feminising hormone interventions for adolescents experiencing gender dysphoria or incongruence which showed no evidence of benefit, and mounting concern about the medium and long term risks of cross sex hormones, including their irreversible effects.
Hormone review group should widen its remit
The recommendation of “extreme caution” in the Cass Review suggests a degree of urgency in reviewing the use of cross sex hormones in under 18s. We shouldn’t have to wait until the middle of next year: the evidence is there already. NHS England’s approach seems lackadaisical, considering it is an issue that carries considerable risks to the health of young people, and the government should be pressing for the review to be completed as soon as possible.
Perhaps Wes Streeting could widen the remit of the group he set up to look at non NHS prescribing of cross sex hormones in under 18s and ask it to review prescribing in the NHS too. That shouldn’t be difficult as much of the same evidence (or lack of) will apply to both situations, and NHS England should already have been working on this.
Hormone policy for under 18s should be withdrawn
In the meantime, as there is no clear clinical rationale for their use, NHS England should remove referral for cross sex hormones from its new youth gender service specification, which is expected to be put out for consultation soon, and the March 2024 clinical hormone prescribing policy should be withdrawn.