The UK Pathways Trial for puberty blockers has set a minimum participation age of 11, revised up from no minimum at all after the MHRA paused proceedings in February 2026. That is broadly welcome. What is not welcome is Hilary Cass calling private providers charlatans, when the real failure has been the absence of timely NHS care for children left in distress.

What has actually happened

The Pathways Trial was paused earlier this year after the Medicines and Healthcare products Regulatory Agency raised safety concerns, including the absence of any lower age limit. The research team, based at King's College London, has now agreed a revised protocol: a minimum age of 11 for children registered female at birth, and 12 for those registered male. Parental consent remains a requirement. Children must also demonstrate they understand the intervention and its possible risks, including effects on bone density, brain function, and fertility. Recruitment is not expected to begin until after 1 August, partly to allow ongoing legal proceedings brought by clinicians and campaigners to run their course.

The trial was originally approved by UK regulators and ethics experts in November 2025. Its aim is to examine the physical, social, and emotional impact of puberty-suppressing hormones on children under 16 who are distressed about their gender and are already accessing gender services. That is a reasonable thing to study, and adding safeguards in response to legitimate regulatory concern is exactly how research should work.

The children behind the numbers

Stonewall has said that many young people have been left in limbo since puberty blockers for under-18s were banned in 2024, living with emotional and physical distress as their bodies change in ways they find deeply painful. Nobody who has spent any time listening to these young people, or to their parents, could read that and feel nothing. The whole point of having a trial is to generate evidence that might eventually restore access to care. The whole point of having evidence is to help real children, whose adolescence is happening right now and will not wait.

I hear from families in this situation. The distress is not abstract. A child watching unwanted puberty progress while adults argue over trial protocols is not a statistic; that child is a person, and the time being lost cannot be given back.

Where Cass went wrong

Hilary Cass has told the BBC that it is vital the trial goes ahead, or, in her words, "we're going to have ongoing charlatans just handing out inappropriate drugs." She was pointing to the private sale of puberty blockers, particularly online.

The framing matters.

The ban on puberty blockers for under-18s created a void. Children who had been assessed, who were in distress, who had clinical need, suddenly had no NHS pathway. Some families turned to private providers. Some turned to providers abroad. Some obtained medication online with no clinical oversight whatsoever. That last group is the genuine concern, and it is a real one.

But the word charlatan means a fraud, a quack, someone without the knowledge they claim. Applying it as a blanket description of private providers is not accurate, and it is not fair. Many of the clinicians who continued to provide puberty blockers privately were working to the World Professional Association for Transgender Health standards of care, the Endocrine Society guidelines, and the same international frameworks used by gender services across Europe and North America. They did not become charlatans because the NHS stopped commissioning their work. They continued to provide the care they were trained to provide, to young people who had nowhere else to go.

If the primary concern is children obtaining medication with no clinical oversight, the solution is not to smear specialist providers: it is to restore a regulated, accessible care pathway so that families do not have to seek one out privately in the first place. The ban created the very problem Cass is now citing as a reason to rush the trial. That is a circular argument, and it places the blame in entirely the wrong direction.

What the trial should not become

A clinical trial is not a substitute for a care pathway. Children who are eligible and consenting can participate, and that is genuinely valuable. But the trial will not help every child who needs care now. It cannot. Trials have eligibility criteria, site limitations, timelines, and legal obstacles that mean large numbers of young people will remain without any formal NHS route even if it recruits on schedule.

The risk is that the trial becomes the answer to every question about trans youth healthcare, when it is really only one part of a much larger picture. The question of how we provide safe, evidence-based, timely care to gender-questioning children in this country has not been answered by setting a trial age of 11. It has only been deferred again.

What good care actually looks like

The international evidence base for gender-affirming care, including puberty blockers used at the right clinical moment, is endorsed by the World Health Organisation, the Endocrine Society, WPATH, the American Academy of Pediatrics, and many others. That evidence base did not collapse because of the Cass Review. What collapsed was one country's political willingness to act on it.

Good care means assessment, information, consent, monitoring, and follow-up. It means listening to the young person and their family. It means giving weight to the risks of withholding care, not only the risks of providing it. Delay causes harm: unwanted pubertal changes are not reversible in the way puberty blockers are. That is the asymmetry that gets lost when every conversation focuses on the risks of intervention and treats inaction as neutral.

The clinicians who maintained care for trans young people through the ban, within proper clinical and ethical frameworks, deserve acknowledgement, not a label that implies they were doing something dishonest. The families who sought that care out, often at significant personal expense and stress, deserved better than a system that offered them nothing and then looked down on them for finding something elsewhere.

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Dr Helen Webberley is a Gender Specialist, Medical Educator, writer, and advocate, and the founder of GenderGP. She writes about gender diversity, trans healthcare, and the lives at the centre of both.