England to Launch Large Observational Study Of Gender-Incongruent Kids
The 6-year study, which plans to recruit 3,000 gender-incongruent youths, is expected to be complemented by a study of puberty blockers—one that has yet to receive regulatory and ethics approvals.
England’s National Health Service will soon launch what it hopes will be the world’s largest observational study of children with gender incongruence. The study, which has just received the requisite regulatory and ethics-board approvals from the NHS, is slated to recruit 3,000 minors and follow them for the next six years.
The plan is to provide the young people with routine surveys and to track their emotional and physical well-being over time as they receive care from the NHS’s new system for treating gender-incongruent children. The NHS hopes the study will yield important new insights about how best to care for a cohort of youths whose psychiatric profiles are often extraordinarily complex.
The study, called PATHWAYS Horizon, is slated to be the largest of a four-pronged study. The other three PATHWAYS arms, including a much-anticipated trial examining the impacts of puberty blockers among minors, are still pending approval.
Critics have suggested that the $13.9 million puberty blocker study will be unlikely to advance the already weak evidence base backing pediatric gender-transition treatment.
As for the Horizon study, Dr. Emily Simonoff, a professor of child and adolescent psychiatry at King’s College London and the chief investigator of the study, said in a press release that it “will provide a stronger evidence base to allow young people and their families who have support needs related to gender incongruence to make more informed decisions in future, based on what is likely to give them the best wellbeing and health in the longer term,”
Overall, these studies are the outgrowth of a sweeping overhaul that NHS has undertaken over the past 16 months in its approach to caring for the burgeoning population of minors across the United Kingdom who harbor distress about their gender. The NHS-commissioned Cass Review—a four-year effort overseen by renowned pediatrician Dr. Hilary Cass that was published in April 2024—sent shockwaves across the UK and around the world when it concluded that the increasingly widespread practice of prescribing puberty blockers and cross-sex hormones to treat gender-related distress in minors was based on “remarkably weak evidence.”
At the core of the Cass Review was a set of over 30 recommendations for reforms in how the NHS provides care for this vulnerable population of young people.
Accordingly, the NHS shuttered its long-standing pediatric gender clinic, the Gender Identity Development Service, or GIDS. Given criticism that GIDS had focused too narrowly on gender-related issues, the NHS has begun launching a network of satellite clinics, called the the NHS Children and Young People’s Gender Services, that focus on treating gender-distressed children more holistically. In other words, they provide psychological treatment but no blockers or cross-sex hormones—which has been cold comfort to many youths who have come too see obtaining these drugs as a matter of life and death.
The NHS also instigated a policy that forbade its physicians from prescribing puberty blockers for gender-related distress outside of a planned clinical trial. That trial was slated to begin early this year. But like most matters to do with the NHS’s work on this issue, it has been delayed.
On the political front, the outgoing conservative government in Parliament last year placed an emergency ban on private physicians prescribing puberty blockers for gender-related distress. (A slim minority of medical care in the UK is provided by private physicians as opposed to by the NHS.) The new Labour government in turn made that ban permanent.
These policies have left 16 and 17 year-old Britons with cross-sex identities still technically able to access cross-sex hormone treatment. However, in her report, Dr. Cass advised that physicians observe strong caution in providing this age cohort with such drugs. Plus, UK health secretary Wes Streeting is considering banning hormone prescriptions for these youth as well.
For supporters of open access to gender-transition medications by minors, these changes have amounted to a devastating denial of what they insist is live-saving care for transgender youth.
However, the claim that these treatments prevent suicide death in particular is not supported by evidence. Only a single study, conducted in Finland and published in February 2024, has ever directly assessed whether such treatment is associated with an independent, statistically significant difference in the suicide death rate among young people. The large study, which relied on Finland’s robust national health records, found no such association. It further found that while suicide deaths were elevated among youth attending gender clinics in the Scandinavian nation, these tragic outcomes were nevertheless rare.
The PATHWAYS Horizon study will soon begin recruiting youths attending the NHS Children and Young People’s Gender Services, seeking 3,000 participants in total. This would make the study at least an order of magnitude larger than all other observational studies of gender-distressed youths. By comparison, a major National Institutes of Health study in the United States of such young people, which has produced a 2023 paper assessing their outcomes after two years on cross-sex hormones, has followed 315 participants.
A major criticism levied at GIDS during the years that preceded the troubled clinic’s ultimate collapse was that its administrators gathered almost no data about the approximately 9,000 youths it directly cared for between 2011, when it first launched a program to provide gender-transition drugs to minors, and its shuttering 13 years later. (Some 6,000 young people were on GIDS’s waiting list by the time it closed.)
Additionally, the NHS’s adult gender clinics refused to provide the Cass Review with de-identified data on former GIDS patients. Consequently, Dr. Cass was unable to conduct any analysis on the long-term outcomes of adults who had received care for gender-related distress as children, including assessing how many of them detransitioned.
Commissioned and funded by NHS England along with the National Institute for Health and Care Research, the PATHWAYS Horizon study will be led by King’s College London and cosponsored by the college and the Maudsley NHS Foundation Trust. The NIHR sought a review of its methodology by an independent group of scientists.
Youth who agree to participate in the study will be provided with annual questionnaires, as will their caregivers. The study will also seek families’ consent to access the youths’ heath and school records, which will be de-identified to protect privacy.
The study’s design team sought input from gender-incongruent youths regarding outcomes that they would like to see measured in the research. The study will assess how the youths feel about their bodies, their mental and physical health and their capacity to engage in education and other everyday outlets.
In a release about the study, the administrators acknowledged that the profile of the youth presenting at gender clinics has changed dramatically in recent years. Historically, such youths were predominantly natal males who began expressing cross-sex identification at a very young age. Now the patients are predominantly natal girls who only first expressed distress about their gender after puberty’s onset and who have high rates of psychiatric conditions and autism.
Consequently, the study authors assert that new research is necessary to better understand the needs and outcomes of this contemporary cohort and that older research does not necessarily apply well to such youth seeking care in the present day.
Waiting in the wings for regulatory and ethics approval are three other PATHWAYS studies, which apparently will overlap with or otherwise complement the Horizon study:
PATHWAYS Trial will assess the impacts of puberty blockers on gender-incongruent youth, examining their physical, social and emotional health. Young people can be enrolled in the study if their parents and the NHS Gender Service agree it is a good option for them.
PATHWAYS Connect will fill in the considerable gaps in scientific knowledge about changes in brain development among children receiving puberty blockers, comparing them with youth who are not on the drugs.
PATHWAYS VOICES will be a qualitative study examining the experiences of gender-incongruent youth receiving care from the NHS system, and will also seek input from staffers about what they think helps these young people.
I am an independent journalist, specializing in science and health care coverage. I contribute to The New York Times, The Guardian, NBC News and The New York Sun. I have also written for theWashington Post, The Atlantic and The Nation. Follow me on Twitter: @benryanwriter and Bluesky: @benryanwriter.bsky.social. Visit my website: benryan.net
It will be another 7 years or so before finally results of these studies are released. Who knows how much this field will change by then. We could be in an entirely different world.
No child should have their puberty blocked.
Where were all of these children 15 years ago?