November 2025, and the NHS has finally launched the PATHWAYS trial. Two hundred and twenty-six children, most only just into puberty, will be randomised: half get triptorelin to switch puberty off today, half are told to wait a year while their young bodies do what maturing bodies do. Everyone receives the new psychosocial package. Everyone receives the puberty blockers eventually. Two years of questionnaires, bone scans, and optional brain MRIs later, we are promised definitive answers about puberty blockers. The Great and the Good of the Science Media Centre dutifully declared the trial “robust” and “essential”.
Forgive me if I remain unimpressed.
I said in February that this trial risked harming more than it helped, and I asked in the previous July what an ethical trial would even look like. Nothing I have seen since has shifted that view. In fact, the more one digs, the clearer it becomes that PATHWAYS is less a scientific endeavour than an expensive piece of theatre designed to keep puberty blockers on the table while performing a pantomime of clinical trials.
Start with the Tavistock scandal that now appears to be forgotten. We already have outcomes for at least 9,000 children referred to the Tavistock GIDS clinic and several hundred who actually received blockers. That data sits in NHS desk drawers. Cass repeatedly asked for adult-clinic data linkage between child and adult service so detransition and long-term health could be tracked. The clinics refused, citing spurious answers like “data-protection concerns” that have never withstood scrutiny. PATHWAYS is therefore £10.7 million spent to partially re-create some of that data we already possess but have deliberately chosen not to examine. We are putting more children at risk to avoid confronting activist therapists. The evidence that does exist is in papers that were systematically reviewed and found to be so flawed, under-powered and selectively reported that the Cass Review found no high quality results.
Next, the diagnosis itself. Ethical trials require a clear intent to answer a scientific and clinical question that can inform future treatment decisions. It is hard to see what that question is. The trial is formally to test a treatment for “gender incongruence”. But this is not a clinical diagnosis. Activists insist this means the child is “trans”, that they possess an internal gender essence incompatible with their body, and that the only “remedy” is to alter the body to somehow match this ineffable feeling. There is no scientific evidence that such an intrinsic thing called a “gender” exists. This is postmodernist claptrap: the reification of abstract ideas about the sexes in society. Gender is a social concept built on sex stereotypes: boys must be tough and sporty, girls must be pretty and gentle, and both must be heterosexual. Many (if not most) adolescents feel they fall short of these stereotypes; some feel it acutely. Puberty sharpens the discomfort. In the overwhelming majority the discomfort resolves without any intervention as puberty progresses. To pathologise this entirely normal process, label it a medical condition, and treat it with powerful endocrine disruptors is not progressive healthcare; it is regressive, cruel, and inherently unscientific.
The trial’s design guarantees we will learn almost nothing useful about puberty blockers themselves. Every single child (treatment arm and delayed arm) receives the same new package of psychosocial support: therapy, family work, psycho-education, regular clinic visits, the full comforting apparatus of being “in the system”. The only variable that changes is whether a child receives triptorelin injections now or in twelve months’ time.
That single difference in treatment timing is the sole thread we have to pull on if we want to isolate the specific effect of the drug. Yet the thread is buried under a dozen powerful confounders: the therapeutic alliance, the placebo effect of finally being believed, the nocebo effect in the delayed group who feel cruelly denied, the natural maturation that happens to every teenager over two years, regression to the mean, and the simple passage of time away from whatever acute crisis brought them to clinic in the first place.
Because the psychosocial support is constant and the drug is the only thing that moves, any observed change in mood, self-harm, or quality-of-life scores can be attributed to the counselling just as plausibly as to the hormone suppression. The trial has no mechanism for disentangling the two. It is rather like testing a new analgesic by giving every patient in the study the drugs and a daily massage and then wondering if the massage or the pills reduce the pain. The protocol may produce reams of numbers, but it is structurally incapable of telling us what the blockers actually do.
Any improvement in quality-of-life scores can therefore be attributed to the counselling, to placebo effects, to regression to the mean, or simply to the relief of finally being taken seriously. We will never know which. The delayed arm, meanwhile, starts the study believing they have been denied life-saving treatment. Nocebo effects and off-protocol self-sourcing of blockers are inevitable. The trial cannot separate these confounders any more than a non-blinded homeopathy trial can separate the effects of sugar pills from the therapist’s reassuring smile. Puberty blockers are a dramatic intervention that is bound to create a psychological response in those who wish them to improve their lives. A chiropractor’s crack is also dramatic, but drama is not the same as effectiveness and prudence.
The follow-up in the trial is just two years. Yet, the major questions are about what happens to children as they mature into young adults and further. Peak bone mass is not reached until the late twenties. Fertility outcomes, late cognitive effects, and long-term cancer risks will remain unknown. The promise of “registry linkage pending further funding” is not a plan; it is an admission that the most important clinical questions have been postponed indefinitely.
This is the same weary playbook Stanislaw Burzynski has been running since the 1980s: an implausible treatment (in his case, peptides extracted from urine) surrounded by fervent belief, wrapped forever in the protective cloak of “ongoing clinical trials” so that no definitive negative result ever has to be published, no licence ever granted, and the patients keep paying millions while the clock runs on. PATHWAYS is simply the NHS’s £10.7 million, state-sanctioned version of the same quack trick.
Picture a 12-year-old girl who starts blockers under PATHWAYS this winter. By the time she is 30 she may never know what an orgasm feels like and will certainly never carry a pregnancy. That is not a rare side-effect from what we know already; it is the intended physiological outcome of the treatment this 12 year old is being invited to “consent” to.
A majority of the children in such clinics arrive with autism, histories of trauma, depression, or eating disorders. Almost all cannot yet imagine adult sexual relationships or parenthood. To ask them to consent to a pathway that carries a substantial risk of permanent infertility and anorgasmia is to ask them to consent to something they cannot meaningfully understand. The consent forms may be legally watertight; they are ethically threadbare.
So what sort of results can we expect? Allow me to take a punt. The children who receive blockers immediately will, on the whole, report being “happy”. The children forced to wait a year for the treatment they have been told is life-saving will, on the whole, report being “sad”. The headline conclusion will be that puberty blockers must be offered as early as possible because they improve wellbeing. The two-year follow-up is conveniently too short for the serious skeletal, sexual, and fertility harms to become undeniable, so the treatment will be declared “safe and well-tolerated”. Critics who point out the blindingly obvious methodological flaws will be dismissed as bigoted, hateful, or “anti-trans”. This trial could not have been better designed if the brief had been: “Produce the most quack-friendly trial methodology possible while retaining a veneer of scientific respectability.”
If PATHWAYS had been submitted to the Cass Review as one more observational study it would have been graded low quality and filed under “inconclusive”. Instead it has been granted the status of the definitive trial, the one that will finally settle the matter. It will do no such thing. At best it will generate numbers that can be spun either way. At worst it will provide a veneer of scientific respectability for continuing to offer puberty suppression to children on the basis of ideology rather than science and evidence.
Ten million pounds and two hundred childhoods, spent not to discover whether puberty blockers “work”, but to postpone the moment when the NHS finally has to admit they never did and never could.
I remain, as ever, watching.
If the trial does go ahead (it may even have already started recruiting), the kids on the immediate treatment arm are essentially lost. They will suffer tragically and unnecessarily for this ideology. The gender cult will claim them as their own.
There is the hope that at least some of those on the delayed arm (or their parents) will come to realise that they do not want to be harmed, they do not want to take opposite-sex hormones, they don’t want to be sterilised.
But the only way to stop any of these 226 kids from being harmed is to stop this trial before it really gets going.
Thanks, this is very helpful and please keep watching!
Does the trial ‘psychosocial’ support entail the child participants’ peer groups being involved too (providing ‘social transitioning’)?
Thank you a very good article
Pseudoscience from top to bottom.
This is good. I’ve had the same thoughts myself but not so cogently expressed or organised
The *only* difference between the two groups in the cohort is the time when the PBs are given – this is astonishing. If there is any difference in outcomes, all it will tell us is that it might be good/bad to give PBs sooner/later….and the tiny length of follow-up will essentially tell us nothing about that.
Thanks for the analysis. What do you make of the claims that PATHWAYS TRIAL is one strand of the wider PATHWAYS programme, so the challenges re disentangling PB effects can be done by looking at and comparing with
-PATHWAYS HORIZON (observational study of 3600+ kids attending services for Children and Young Person’s Gender Service- annual mental health & quality of life assessments by questionnaire),
HORIZON INTENSIVE (more detailed study of 300 CYPGS patients from PATHWAYS HORIZON not receiving PBs, matched as far as possible to the trial participants, and given nearly all the same assessments),
PATHWAYS CONNECT (250 participants (150 from TRIAL, 100 from HORIZON INTENSIVE) receiving intensive biological (MRI scans) and neurognitive testing to study the effects of PBs on brain development, and
PATHWAYS VOICES (participants from the other four studies will be given repeated qualitative interviews to understand their experiences of GD and treatment)
I’m not a scientist myself, but it seems that these at least answer some of the criticisms above?
These other cohorts are not randomised or blinded will so always be subject to non-specific effects impossible to disentangle. The kids in these other cohorts will always have significant differences from the TRIAL cohorts.
The kids in HORIZON INTENSIVE will be matched to ones in TRIAL on variables thought likely to affect the prognosis. _Large_ differences in outcomes at least will be difficult to explain away as being due to unknown confounders. The nocebo effect remains, of course: other girls and boys are already on the train to manhood and womanhood respectively. It is not only trial participants who will be harmed.
A significant proportion of the 3600 kids recruited from HORIZON may be prescribed puberty blockers and will have the option of joining the trial. But of course, they may NOT opt to join the trial because of the chance of being randomised to the delayed prescription. If I were a kid convinced PBs were the answer to my problems, in this position I would not join the trial, but I would join HORIZON and try to get an immediate PB prescription. I may have misunderstood, but this seems like yet another loophole to allow kids to be given PBs
Your reasoning is incorrect as nobody other than the 226 trial participants can be prescribed puberty blockers not least because it would be illegal.
It would be good to have some skeptics respond here to either agree with your criticism of the trial or give their view of the protocol.
An excellent explanation. It helpfully explains the issue in detail but without jargon.
There’s one editing error. The paragraph beginning “This is the same weary playbook…” is in the wrong place amd splits in half the preceding and subsequent paragraph (at least on my device). Could you correct this?
Thanks again for a very helpful column.
Ah thanks! I had been fiddling!
This is a terrific article. Thank you for writing it.
Just come across this so I don’t know the protocol details for the trial. As someone who has designed clinical trials and know the massive amount of details required for ethical approval I’m confused. For there to be any interpretable meaning from this trial the “delayed” group needs to be treated with placebo in a double-blind manner during the first year. As the “efficacy” of treatment has not been previously demonstrated this should be ethically acceptable.
Congrats on this piece of writing- it nails the flaws in this trial. It is deeply concerning that the reason we ‘need’ this trial is because of mishandling of previous trials/data. This study will tell us nothing useful, so I fear that more kids will be subjected to similar ‘research’ in the future. Looking on X, I can why we are in the mess we are in. There are doctors/academics celebrating this trial. Criticisms of the trial are met with arrogance or accusations of transphobia with very little engagement with the valid arguments. Most worrying was the tweet from Professor Howard, who will very likely be the next President of the Royal College of Psychiatrists:
“Brilliant explaining/discussing thread from @RichardBentall on the PATHWAYS study. I agree with him that this is a high quality, ethical and needed piece of research. Good luck to the research team and participating families. Only people who are afraid of data would oppose this.”
Yes. Only those ‘afraid of data’ would oppose it; it has nothing to do with children being exposed to the lifelong side effects from drugs issued for something that can usually be resolved by puberty. Unfortunately, psychiatry has been a bit of a blindspot for the skeptic movement. I’ve noticed that some VERY well respected UK psychiatrists have a nasty habit of rubbishing any research that shows that psychiatric treatment is less effective or more harmful than first thought, with quotes to journalists that would embarrass a homeopath. Worse still, they might produce retaliatory ‘research’ that gets marketed at invite-only press conferences via the SMC- the ‘limited hangout’ stops dissenting academics asking awkward questions in front of journalists.
I fully expect that the same tactics will allow the clinicians running the trial to spin the ‘findings’ as some great breakthrough that the press will faithfully report. It will then become ‘settled science’ and, as in psychiatry, those who study the harms will be smeared as cranks.
You know, I’ve been reading some of your stuff (not just this article that happens to be the most recent), and while you galivant claiming that you are just “defending science” or some other bullshit, and how this isn’t about attacking a marginalized community that is under attack on multiple fronts, I’ve noticed that you haven’t actually seemed to clarify anywhere that you are against transphobia and that you support trans rights. You complain about how what you write would be attacked as transphobic, but you never seem to try to actually deny transphobia. Respectfully, are you averse to the existence of trans people, or are you just married to outdated rigid definitions of biological sex?
What “trans rights” are you asking me to support? Can you be specific about a right that is either under attack or has not been granted that you wish me state my support for?
I also do not knwo what “outdated rigid definitions of biological sex” you think I am “married” to? I have several blog posts where I explicitly look at what we mean when we say an animal has a sex. Do get back to me if it is not clear.
Hey, Kenneth, re your last sentence, you ask,
“…are you averse to the existence of trans people or are you just married to outdated rigid definitions of biological sex?”
If you were directing your questions at me, I’d wonder why you were offering only two possible alternatives, as if they were mutually exclusive and there were no others.
I don’t kid myself for a moment that you care about the opinion of an actual woman – this is for the benefit of anyone else reading- but my answer would be, “I am not averse to the existence of anyone as long as they do nothing to negatively impact on the rights, safety and wellbeing of others. Also, I’m not ‘married’ to any definitions of anything and if you can provide sound reasoning for redefining sex, other than that it doesn’t suit the agenda of a tiny number of people who are already one of the most privileged demographic,” I’d be all ears. 🙂