James Murray
MP for Ealing North · Labour (Co-op) · United Kingdom
“I wonder whether any other Members might say that they have the most pubs in their constituency, or whether the hon. Lady has done her research. [Interruption.] I hear her saying that hers are the best pubs, a claim that even more Members may challenge in the Chamber. Although the hon.”
“The hon. Gentleman has some cheek, given the number of pubs that closed when his party was in government. The Labour party is making sure that the business rates system is set right for the future.”
“I think the hon. Gentleman’s point is that the price of fuel is linked to international events, which, as I said earlier, I very much agree with. That is why it is important that we de-escalate the situation in the strait of Hormuz, which is the best way to bring down the cost of fuel.”
“I know my hon. Friend is a great champion of pubs in her constituency. In fact, she has brought together people for her pub politics events, including at the Willy Wicket, the Beaufort Arms, the Baileys Court Inn—which I have been to—and the White Lion, where people come to talk about issues that matter to them.”
“I thank the hon. Gentleman for talking about the Station House in his constituency; I am sure we all have pubs in our own neighbourhoods that we feel are at the heart of the local communities that we represent. The 20% business rates cut that we announced was a down payment on further reform.”
“I agree with the hon. Lady about the importance of providing breathing space for families, which is a priority for us as a Government, and she mentioned her plans. I have set out what we have done since the general election to reduce fuel prices by 11p per litre compared with what they would have been otherwise.”
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“The Opposition’s motion would prevent us from following expert clinical advice, when proceeding with the trial is the most appropriate way forward. I say that not because I am suggesting that we should feel instinctively comfortable in doing so but because I have arrived at that conclusion after considering the clinical evidence and receiving robust assurances on the safeguards that are in place.”
“Before and during the trial, information will be collected about mental health, quality of life, self-harm and suicidality, body image, cognition, puberty stage, physical health and side effects. I have been determined to ensure that the oversight of this trial is as rigorous and robust as it possibly can be, so I have requested monthly updates on its progress. That will include my being notified of any emerging risks. This trial is rightly one of the most scrutinised UK clinical trials of recent times. We should expect nothing less when we are talking about the health and wellbeing of some of the most vulnerable children in our country. Yet, as Dr Cass has made clear, we have to build the evidence base to show whether the treatments are safe and whether they produce the positive outcomes that young people and clinicians want from them.”
“I have sought and had an assurance that, once they are involved in the trial, participants may be withdrawn at any point. We are not proceeding with the previous, now decommissioned, model of care overseen by the Conservatives when they were in government. We are proceeding cautiously, with rigorous safeguards in pursuit of the evidence, as Dr Cass recommended. Last Thursday, the independent MHRA approved an updated protocol that significantly strengthened the objective criteria for withdrawing children from the trial, which is a change that I welcome. Signs of greater risk to participants will now trigger increased monitoring, clinical review or their automatic withdrawal from the trial. All participants will be monitored before, at the start of, every three months during, and after the trial.”
“They can participate only if they have had a diagnosis of gender incongruence for at least two years, have received psychosocial support through the NHS and are of stable physical and mental health. They can participate only if they are not subject to any safeguarding concerns and if they and their parents demonstrate sufficient understanding of the nature of the treatment, including its possible advantages and disadvantages. They can participate only if the treatment has been deemed clinically appropriate by both the NHS care team and the national multidisciplinary team and if they are already accessing NHS gender services. On eligibility, the bar is extremely high. The number of young people who would expect to qualify for the trial will be low and the safeguards to ensure their safety and wellbeing will be rigorous.”
“If a child is looked after under a care order, the local authority has parental responsibility, so it would need to be part of the consent process as the corporate parent. I turn to the points raised by the right hon. Member for Salisbury (John Glen) about young people becoming involved in the trial and the checks that are in place to enable that to happen. As I set out earlier, as the trial involves children, it comes with a responsibility to interrogate and understand its design. As Health Secretary, I have sought the most detailed assurances possible from my clinical advisers as to how children taking part in the trial will be protected. There are a number of important safeguards. As I have said, children can participate only with the consent of a parent or guardian, and the child themselves must consent or assent.”
“That is the assurance that I have sought in interrogating this matter carefully in recent days, and that is the basis on which I am talking to the right hon. Gentleman and others in the House today. We must come to a fair and settled conclusion on this matter to move forward as a country, and I believe that we should follow clinical advice and establish the clinical evidence gathered in a highly scrutinised trial with all the safeguards in place that I have described. Only that approach will give us the confidence about where we settle on this matter in the future. On that basis, the Government oppose this motion.”
“The MHRA has introduced additional safeguards. As a result of its dialogue with the trial sponsors, the amended protocol published last week increases the level of safeguards. That means that if the regular monitoring, which will happen at least every three months—it can be more regular during the trial—shows any sign of increased risk of harm, that will lead to increased monitoring, clinical review and, when considered against objective criteria, automatic withdrawal from the trial. It is a question of monitoring this trial, possibly more closely than any trial before—the level of scrutiny is very great indeed—to ensure that at the first sign of any increased risk of harm, action will be taken.”
“Thanks to the strengthened criteria now in place for monitoring children’s wellbeing and withdrawing them from the trial, there is now intense scrutiny, and there are robust mechanisms to prevent harm from coming to the young people who take part. It is on that basis that I believe we should follow the advice of clinical experts and seek the clinical evidence that will give us the confidence to know that where we settle on this matter in the future is right. I commend this statement to the House.”
“Members are also wrestling with this dilemma—and, as we debate this issue today, I hope that we will keep in mind Dr Cass’s ask to consider the issues sensitively and cautiously. As she said: “Polarisation and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse, and in the long run will also hamper the research that is essential to finding the best way of supporting them to thrive.” I will not pretend that I do not continue to feel discomfort and unease, but I believe that the only way for us all to come to a fair and settled conclusion on this matter—to move forward as a country on this difficult and sensitive issue—is on the basis of clinical evidence in which we trust.”
“After considering the matter closely over the past few days, I have requested monthly updates on the progress of the trial, including on any emerging risks. Pathways is rightly one of the most scrutinised UK clinical trials of recent times—we should expect nothing less when we are talking about the health and wellbeing of some of the most vulnerable children in our country. Yet, as Dr Cass has made clear, we have to build the evidence base to show whether the treatments are safe and whether they produce the positive outcomes that young people and their clinicians want from them. My view is that proceeding with the trial is, on balance, the most appropriate way forward. This has not been easy—I am sure many hon.”
“On cognition, while there are no established scientific reports proving a cognitive effect, the new protocol sets out strict definitions for investigation and automatic withdrawal of young people from the trial. The new criteria for increased monitoring or withdrawing children from the trial will mean that, at the first sign of negative impacts, action will be taken. These criteria will stop short-term harm, and the view of the National Institute for Health and Care Research is that that means any long-term harm should not occur or go unnoticed. Those reassurances about preventing harm to the children who take part in the trial, and taking clear action if any risks appear to increase, are critical.”
“All participants will be monitored before, at the start of, every three months during and after the trial. Before and during the trial, information will be collected about mental health, quality of life, self-harm and suicidality, body image, cognition, puberty stage, physical health and side effects. On bone health, puberty is normally a time of rapid bone gain, so if changes in bone density are identified, that will lead to a reassessment of whether the participant should continue in the trial, with set criteria for automatic withdrawal. On fertility, there is no published scientific evidence of irreversible changes, but that will be proactively addressed, with every participant offered repeated counselling and a range of options to preserve their fertility.”
“The number of young people who would expect to quality for the trial will be low, and the safeguards to ensure their safety and wellbeing are rigorous. I have sought and had reassurance that once participants are on the trial, they may be withdrawn at any point. As hon. Members will know, the Medicines and Healthcare products Regulatory Agency raised new concerns at the beginning of this year, and the start of the trial was delayed so that they could be fully scrutinised. On Thursday last week, the regulators approved an updated protocol that significantly strengthened the objective criteria for withdrawing children from the trial. I welcome that change. Signs of greater risk to participants will now trigger increased monitoring, clinical review or automatic withdrawal from the trial.”
“They can participate only if they have received psychosocial support through the NHS. They can participate only if they are of stable physical and mental health. They can participate only if they are not subject to any safeguarding concerns. They can participate only if they and their parents demonstrate sufficient understanding of the nature of the treatment, including its potential advantages and disadvantages. They can participate only if they have been deemed clinically appropriate by both the NHS care team and the national multidisciplinary team, and they can participate only if they are already accessing NHS gender services. So, when it comes to eligibility, we are talking about a very small subset of a very small group.”
“The trial seeks to gain evidence on whether those potential benefits are real, alongside evidence on whether such treatment comes with the risk of harm. It is right that this Government are guided by expert clinical advice and a clinical, evidence-led approach, but as this study involves children, and therefore comes with a particular responsibility, as Health Secretary I have sought the most detailed assurances possible from my clinical advisers about how children taking part in the trial will be protected. There are a number of important safeguards. Children can participate only with the consent of a parent or guardian, and the children themselves must consent or assent. They can participate only if they have had a diagnosis of gender incongruence for at least two years.”
“That can often involve counselling or therapy. For a very, very small number of young people, it is possible—I emphasise the word “possible”—that medical treatment would help to improve their quality of life and mental health, and reduce their gender-related distress. That is why Dr Cass, whose approach until recently commanded cross-party consensus, recommended a trial to establish how best to support children and young people suffering gender incongruence. That is the Pathways study. It has four main parts, one of which is the clinical trial to study the effects of puberty-suppressing hormones on young people’s physical, social and emotional wellbeing. The Pathways trial, which is being led by King’s College London and the South London and Maudsley NHS foundation trust, was initially approved last November.”
“Where there is strong divergence of medical opinion on treatment, the two possible responses are to continue with the uncertainty—and, with that, conflicting opinions and advice—or to undertake a trial, not just to resolve a dispute but to make sure that children with gender-related distress get the same standards of care as everyone else in the NHS. As Dr Cass has said, the vast majority of children and young people who question their gender will resolve it without needing any support other than that of their friends and family. For many young people, questioning their identity on many different fronts is a normal part of growing up, and we should simply let them be. For a small number of young people, though, greater support is needed because of the level and longevity of the discomfort that they feel.”
“Friend the Member for Ilford North (Wes Streeting), which followed the temporary ban brought in by the previous Government. I do not think there is anyone with more respect as a clinician in this space than Dr Cass, and my predecessors in this role recognised that too. Dr Cass identified treatment for gender incongruence as “an area of remarkably weak evidence”. She found that even clinicians working in the field were divided on the best way to support, treat and care for young people suffering gender dysphoria.”
“In 2020, NHS England commissioned leading paediatrician Dr Hilary Cass to carry out a review of NHS gender identity services for under-18s. What Dr Cass uncovered was shocking and scandalous, and she made a series of recommendations for how children could be better protected and supported. I remind the House that those recommendations were accepted in full by both the Conservative Government of the time and my party in opposition. It was, in my mind, clearly wrong for children and young people to be routinely prescribed puberty blockers for gender dysphoria without any clear evidence on their benefits or risks. The situation was out of control, and I fully supported the indefinite ban introduced by my predecessor, my right hon.”
“I do not believe that children’s safety and wellbeing was being adequately protected just a few years ago. I think it would be helpful to remind Members how we arrived at that point. For several years before the turn of the decade, the number of children and young people being referred for NHS support around their gender identity increased rapidly. Stories subsequently emerged of young people struggling after undergoing radical and permanent transition surgery at a young age, children being rushed into taking medication without adequate therapy beforehand, and clinicians disregarding conditions such as neurodiversity and mental health conditions. As such, there was rightly deep concern about the vulnerability of these children and young people, the care and treatment they were receiving and the surge in referrals.”
“With your permission, Madam Deputy Speaker, I shall make a statement on the Pathways trial. I know what a sensitive, emotive and difficult issue this is. I myself have wrestled with, and at times struggled with, the profound challenges that this subject raises. In all of my consideration and deliberation over this matter, my bottom line has been to protect the safety and wellbeing of children and young people. The way to do that is to follow expert clinical advice and take an evidence-led approach, which is what this Government are doing. As adults, we all owe a duty of care to every child and young person in the country. It is a responsibility that I—both as a citizen and as Health Secretary—bear with the utmost seriousness and sincerity.”
“As I set out, I feel uncomfortable and uneasy when considering this matter, but I think that the right way for us to move forward is to have the clinical evidence on which to base decisions. I have received reassurances about there being the highest possible level of scrutiny and protection from harm for young people involved in the trial, and that is the basis on which, on balance, I think it is right for it to proceed.”
“As I set out, there is intense scrutiny, and there are robust mechanisms to prevent the children involved from being harmed. She mentioned the MHRA recommendation for the lower age limit. Initially, there was no lower age limit, but a scientific dialogue between the MHRA and the trial sponsor led to publication last week of the updated protocol, which recommended the minimum ages of 11 and 12. The gateways to younger people and children becoming involved in the trial are significant. There must be not just consent or assent from the children, and consent from their parents or guardians, but approval from the NHS care team, the national multidisciplinary team and others before anyone can be involved.”
“I agree with the shadow Minister that most children and young people who are questioning their identity and gender are likely to resolve those questions on their own, and I think Dr Cass would agree with that. As I said in my opening remarks, for the majority of children who question their gender, we should let them be; they will resolve the matter through their friends and family and their own development. We are talking here about a small subset within a small group of children who need further support. I also agree with the shadow Minister that the situation before Dr Cass did her review—the situation that had developed in the last few years before the turn of the decade—was totally unacceptable, and we should be clear that that was wrong. The shadow Minister asked about protecting the young people involved in the trial from harm.”
“As my hon. Friend will know, the recommendations in Dr Hilary Cass’s review set out how to establish better services for young people in the future. The focus of today’s statement, the clinical trial, is just one part of the wider work on how best to support young people who need extra support in this situation. It was welcome that there had been, at least until recently, a cross-party consensus that Dr Cass was finding the right way through this difficult matter.”
“As I said, a decision to withdraw is triggered by the participant meeting set objective criteria related to the risk of harm.”
“As I said earlier, I welcome the changes that it has brought forward to strengthen the criteria, which will lead to greater monitoring and clinical reassessment, and to setting objective criteria for withdrawing children and young people from the trial entirely. The MHRA has been engaged in a scientific dialogue with the trial sponsors, and it was the outcome of that process that led the MHRA, as an independent body, to publish the updated protocol towards the end of last week. Now that that is in place, we have greater reassurance about the safeguards. The trial is expected to involve around 226 children and young people over five and a half years, with each participant potentially being offered puberty blockers for up to 24 months.”
“I welcome the fact that the hon. Lady agrees with the Government that we should base our decisions about whether and how to provide support for children, particularly in the case of the treatment that is at the centre of this clinical trial, on clinical evidence and the expert advice of clinicians. There can be no one in this field more widely respected than Dr Hilary Cass, whose recommendations form the basis of the decision that we have taken as a Government. The hon. Lady asked about the work of the MHRA since early this year to strengthen the safeguards for young people involved in the trial.”
“I absolutely agree with my hon. Friend about the importance of following clinical evidence and taking a clinically led and evidence-based approach to this decision. As I said, I have felt uncomfortable and uneasy about some of the challenges raised by this matter, but for me, the right way to move forward is to follow the clinical advice, and to base future decisions on clinical evidence, given that I have received the most robust assurances about the safeguards that are in place to protect young people involved in this trial from harm.”
“That is why, although my starting principle is that clinical evidence is the right way to approach such a matter, I wanted that extra reassurance. That is why I asked for the most detailed possible assurances from my clinical advisers, to ensure that those robust safeguards are in place in the way the trial is now designed.”
“I am sure that the hon. Lady will agree that this is now one of the most heavily scrutinised clinical trials in this country in recent history, and rightly so—it is right that it is so heavily scrutinised and that we all seek assurances about the safeguards in place. It is right that, as Health Secretary, I made sure that I got those detailed safeguards before coming to the House to set out the Government’s position today. The hon. Lady asked how usual it is for the MHRA to work with the sponsors of trials. My understanding is that the MHRA routinely works with trial sponsors to iterate the protocols in relation to those trials. Because this trial involves children and young people, for me, the bar should be exceptionally high, to ensure that those safeguards are in place.”
“My hon. Friend raises an important point about the relationship between politics and clinical evidence and clinically led decisions. Being led by clinical advice and clinical evidence is a decision that I and this Government stand behind. In this case, it is a matter where in considering some of the issues raised, I have felt uncomfortable and uneasy, but that commitment to clinical evidence, particularly recommended by someone as widely respected as Dr Cass, is the basis on which we can move forward. As I mentioned in response to the Chair of the Health and Social Care Committee, because this involves children and young people, I wanted to receive extra assurances that the clinical advice was robust and that the safeguards would be as robust as possible.”
“The hon. Lady refers, apparently with some certainty, to what she considers to be the clinical outcomes of these puberty blockers on young people. I have to say, with all due respect, that I would trust Dr Cass’s conclusion more than the hon. Lady’s, which is that there is not evidence about the risks or benefits of these medications. That is exactly why Dr Cass was so clear in recommending a trial to find that clinical evidence, because that is the basis on which we can take those decisions.”
“As a result of the work that the MHRA has been doing with these trial sponsors in recent months, there are now objective set criteria against which children and young people involved in the trial would be automatically withdrawn. Those criteria, as I set out earlier, will stop the short-term harm, and the view of the National Institute for Health and Care Research is that this means any long-term harm should not occur or go unnoticed. It is important that we ensure that the appropriate safeguards are in place for this trial. That is why I welcome what the MHRA has done in recent months, because it strengthens those safeguards, which are important in any clinical trial but, in this trial, could not be more important.”
“The hon. Lady is right to draw attention to some of the gateways that children and young people will have to go through before being accepted on to the trial. That will involve not just the child assenting and the parents giving consent, but the NHS care team and a national multidisciplinary team, which will take into consideration all the different aspects of a child’s life that I set out in my earlier remarks about their health, but also the wider context that the children are coming from. The importance here is to ensure that there is an exceptionally high bar for children and young people taking part in this trial, and that is the process that has now been established.”
“Let me be absolutely clear, for the avoidance of all doubt, that the Government’s clear expectation is that all relevant organisations will provide the data required to complete the study.”
“My hon. Friend asks about the data linkage study, and I apologise to my hon. Friend the Member for North Northumberland (David Smith), who a few seconds ago also asked about that—I did not respond then but can now address both questions together. It is important to understand that the information in the linkage study is much more limited than the detailed information that the research team will be able to collect about the relative benefits and risks of puberty blockers. NHS England is, however, committed to delivering the data linkage study. NHS England, since assuming responsibility for that study, has taken time to ensure that the data is shared by relevant organisations.”
“Gentleman and I agree on how unacceptable that situation was, and I put on record my thanks to Sir Sajid Javid for commissioning the work by Dr Cass, because it has been such an important piece of work not only to expose what was happening before, but to provide a way forward.”
“I thank the right hon. Gentleman for his comments, and although he and I come to a different conclusion on this, I do not doubt for a second the sincerity of his motivation in wanting to protect children and young people. I actually agree with him, as I said in my earlier comments, that most young children who are questioning their gender will resolve it on their own—let them be to resolve it. But there is a small subset of children who will need extra support, and within that there is a question about whether for a very small subset of them there might be a benefit to having treatment, and that is what this trial seeks to conclude. I would add that the right hon. Gentleman refers to what happened in the Tavistock clinic and the stories that led to Dr Hilary Cass being commissioned. I think the right hon.”
“My hon. Friend rightly points out that the clinical trial—the Pathways study, which is the subject of this statement—is just one part of the wider work being done to make sure that the support is there for children and young people who are questioning their gender and who might, or might not, need support in order to feel well about themselves. The Pathways horizon is an observational study of all children and young people attending NHS children and young people’s specialist gender services. Pathways connect is a brain-imaging study. Pathways voices will interview young people. Horizon intensive is about making sure that there is a comparison group of 300 participants who are expressing gender incongruence but not receiving puberty-suppressing hormones, as my hon. Friend suggested.”
“I thank the hon. Lady for her remarks, and for her tone and approach to this sensitive matter. Sadly, we have waiting lists across many different parts of the NHS. This Government are determined to deal with that so that everyone can receive the appropriate treatment. There are wider questions, which we could debate at another time, about the support that children who are questioning their identity might need. The focus of today’s statement is specifically on the clinical trial, and it is right that we let that happen. The trial will last five and a half years and it is right that we do that thoroughly, because I do not want this country to be taking decisions in future that are not based on the most solid evidence.”
“Dr Cass has raised that point a number of times, particularly when she has spoken in public and been interviewed on her concerns about young people accessing equivalent drugs through an unregulated source—through online sources that are not carefully controlled and where there is no monitoring of the effects on young people. That is part of her motivation for recommending the approach that she proposes. As I said earlier, I and the Government want the decisions about what role, if any, such treatments play in the future to be based on the clinical evidence, with the highest possible safeguards in place for children involved in the trials.”
“Those are the specialisms represented in the national multidisciplinary team, which means that those aspects of the child’s wellbeing are all being considered in that process.”
“I thank the hon. Lady for her question, which highlights the importance we all place on making sure that vulnerable children are protected in the way that the trial proceeds. Perhaps I can offer her some detail which might reassure her by explaining who is on the national multidisciplinary team. As I mentioned earlier, the national multidisciplinary team will have to give permission for young people to be involved in the trial, as will the NHS care team. That national multidisciplinary team has an independent chair and its membership comprises senior clinicians from a range of clinical backgrounds: paediatric endocrinology, general paediatrics, child and adolescent mental health, clinical nursing, safeguarding, adolescent medicine, allied health and service leadership.”
“I share my hon. Friend’s disappointment that the cross-party consensus that was in place about the way to approach the issue does not currently seem to be holding. I urge Opposition Members who are not aligned with that cross-party consensus to reconsider their position, because that is the best way forward for our country.”
“I reassure the hon. Lady, as I set out in my responses to earlier questions, that while my starting point is that clinical evidence should be the basis for our way forward, I have taken the responsibility to interrogate that with the highest level of scrutiny in order to ensure that the conclusions are as robust as possible. That has involved my ensuring that my clinical advisers at the Department for Health and Social Care and the other bodies associated with the Department have provided me with the highest level of detail and reassurance about the safeguards in place. Although I stand behind the principle of following clinical advice and basing conclusions on clinical evidence, I feel that it is important for me, as Health Secretary, to have an extremely high bar for a decision of this magnitude.”
“Member for South Holland and The Deepings (Sir John Hayes) recognised, and we must never go back to a position where the situation is out of control in the way that it was then. In working out how to move forward, I believe that, as uncomfortable as it may make myself and others on an individual basis, focusing on the principle of following clinical evidence, demanding the highest possible safeguards and protections for the children involved, and setting objective criteria for them to be withdrawn or for action to be taken if the risk of harm increases, is the balanced and correct way to proceed.”
“Despite our different conclusions on this matter, I respect my hon. Friend. Part of taking decisions as Health Secretary involves sometimes approaching issues where one might feel uncomfortable on a personal level, but none the less being guided by the right principles in order to take decisions for other groups of people in the country and for the country as a whole. I am not in any way disputing how difficult a matter this is; it is one where I, as Health Secretary—and my predecessors—have had to carefully consider how we ensure that the clinical basis for any future decisions is robust and that we can point to it as a foundation for where this matter settles. Before Dr Cass did her review, the situation at the Tavistock clinic was totally unacceptable, as the right hon.”
“Although the hon. Gentleman comes to a different conclusion from the one that I and the Government have come to, he poses the right question when he asks what harm do we need to protect against while getting clinical evidence. If we are to be led by clinical evidence, it is important to have that evidence in a way that we can rely on, but particularly because it involves children and young people, it is incumbent on us to ensure that the level of protection against the risk of harm is exceptionally high. That is why the strengthening of the protocol announced by the MHRA last week provides that higher level of assurance that I have sought to interrogate and to ensure is there in as robust a way as possible. That gives us the confidence that those safeguards are in place as the trial proceeds.”
“The number of expected participants in the trial is 226. That is not a firm target—it does not have to be exactly that number—but that is the number at which statistically significant conclusions can be drawn. The 226 will fall into two camps: one will access the medical treatment immediately and the other will access it after one year. In that way, we will have clinical evidence from which we can draw conclusions and on which we can base future decisions. The number has been chosen so that the evidence can be relied on in the future to take decisions about whether, and if so how, to continue the use of these treatments.”