Puberty blockers ‘given to children without proper checks’

Governance of Scotland’s puberty blocker services for children is “complex and unclear”, an independent report for the NHS has concluded.
Scottish doctors stopped prescribing the contentious drugs to new patients in April after a review of paediatric gender services in England by Dr Hilary Cass.
Children who were already taking the medicines — which Cass said were not yet proven to be safe or effective — have been allowed to continue their treatment. However, an investigation ordered by health officials has revealed confusion over exactly who is accountable for the service the children are receiving.
• Puberty blockers halted for children in Scotland after Cass review
All the young people were initially assessed by a single clinic, the Sandyford in Glasgow. Specialists there assessed the children’s “gender dysphoria/incongruence” and then referred on to child hormone specialists — endocrinologists — in either NHS Greater Glasgow and Clyde or NHS Lothian where puberty blockers could be prescribed.
A report, dated March 2024 and carried out by Rhoda Macleod, head of adult sexual health services at Glasgow City Health and Social Care Partnership, highlighted confusion over whether NHS Greater Glasgow and Clyde was responsible for Sandyford patients who lived in other parts of the country.
According to the report, NHS GGC did not have governance information about the medication and monitoring of children it referred to Edinburgh with gender issues.
In the west of Scotland, where the care is provided entirely within NHS GGC, the report said the assessment, prescribing and monitoring of under-16s with gender incongruence was not included in the governance of other paediatric services.
• Sandyford whistleblower warns of doctors’ ‘fear of challenge’
The report says: “There is currently lack of clarity and understanding about where clinical governance accountability lies for this small but important patient group across Sandyford services, GGC, acute services in GGC and acute services in NHS Lothian. Currently none of these services have responsibility for the risks above and mitigations to reduce these.”
It is not the first time questions have been raised about who is overseeing care of this group of patients. In October 2022, Jennifer Armstrong, medical director of NHS GGC, and Tracey Gillies, medical director of NHS Lothian, raised the issue in a letter to Scotland’s chief medical officer, Sir Gregor Smith, saying they had asked for a review of “clinical governance arrangements”.
The retired merchant banker Sir Ewan Brown — a vocal critic of Scottish governance arrangements — said there were “aspects of George Orwell” in the report, referring to apparently conflicting statements about which part of the Scottish NHS should be overseeing their care.
According to the report, there are 43 young people attending NHS clinics in Scotland who are receiving the treatment.
Brown said he considered the conclusions of the report “serious” because the area of healthcare concerned was complex, sensitive and controversial. “I would put it up very high in the category of things that a board should be on top of,” he said. “As Glasgow clearly has been given the responsibility they have got to discharge it.”
One NHS consultant, with an interest in the field, questioned whether all patients on the drugs were being monitored appropriately.
“In view of the concerns I am surprised they aren’t reviewing all patients currently prescribed puberty suppressing hormones to see if they were appropriately prescribed in the first place,” he said.
In a statement, NHS Greater Glasgow and Clyde said it was committed to providing the best possible clinical care for people accessing gender services. It added: “Clear clinical governance arrangements are now in place between NHS GGC and NHS Lothian in relation to patients attending NHS Lothian paediatric services.”
Puberty blockers have become increasingly contentious in recent months. Cass recommended they no longer be prescribed — and governments on both sides of the border agreed.
• GPs ‘scared off’ treating children over gender identity, says Cass
Scrutiny of 50 studies found most suggested the treatment might affect bone health and height, but no conclusions could be drawn on the likely impact on gender dysphoria or mental health.
Smith, in his response to the Cass review, said that access to gender identity services for young people should be “via clinician referral” in the same way as all other child and adolescent specialist services.
Many referrals to the Sandyford had been by parents of children who said they were experiencing gender identity issues, rather than by doctors.
The Scottish government said the ban on self-referrals would “ensure both services have any clinical information they need prior to a patient’s first appointment and the referring clinician will also be able to make sure that the person referred receives care for any other health problem they may face”.