Imagine, for a moment, that the NHS unveiled a clinical trial for children who believed they were ugly: a programme of experimental “pre-cosmetic” injections designed to make them better candidates for breast enlargements or pectoral sculpting in adulthood. If it emerged that these injections were already known to disrupt brain development, weaken bones and eliminate sexual function, there would be national outrage. We would call it grotesque and anti-medical, a parody of care in which children were harmed to deliver an imagined future aesthetic to get rid of an imagined future dysmorphia.

Yet this is ultimately logic which underpins the newly-approved Pathways puberty-blocker trial. This week, three claimants — detransitioner Keira Bell, psychotherapist James Esses, and the Bayswater Support Group — launched a High Court challenge to stop the £10.7 million study. They argue that far from being a scientific inquiry, Pathways is a fresh round of experimentation on vulnerable children, without the evidence required to justify the risks.

Barely a year after puberty blockers were withdrawn from routine NHS use, ministers have authorised a trial that will give them to children as young as 10. Around 230 participants will be assigned either to receive blockers immediately or to wait a year. There is no placebo group. The primary outcome is a 10-question wellbeing form that asks children whether they felt energetic or sad in the previous week.

The Cass Review, which exposed the failures of the Tavistock model of gender-affirming care, could not have been clearer. The evidence base for blockers is “remarkably weak”; the long-term outcomes and the rationale for early suppression remain “unclear”. Cass also noted that the vast majority of children who start on blockers proceed straight to cross-sex hormones. By her own admission, the claim that blockers “buy time to think” is unsupported by evidence. If anything, they appear to strap children onto the medical conveyer belt.

And yet Cass has lent her support to Pathways. The charitable explanation is pragmatism: the NHS wants to keep distressed young people away from private prescribers and black-market hormones, and believes it must be seen to be offering something.

But to understand why this is a feeble basis for a paediatric drug trial, we must confront the real appeal of blockers. Early suppression of male puberty makes it easier for boys to look more like women in adulthood. Without the testosterone surge, they grow into adults with narrower shoulders, softer faces, no Adam’s apple and voices that never fully break.

These are aesthetic effects, and of course a person’s psychological self-perception is deeply intertwined with how they look. But they are not solely aesthetic — they are biological and not without hormonal and functional complications. This approach concerns the future adult, not how to rectify the child’s distress. As Cass herself noted, one rationale offered by proponents of early suppression is to prevent pubertal changes that might later make it harder for a young person to “pass” in their intended gender role.

This is part of the fiction sold to vulnerable teenagers: that altering their bodies early will guarantee a future identity which “passes” under the gaze of others. It is a strange logic, according to which appearance eclipses wellbeing and the cosmetic is prized above any holistic concern for the child’s development.

Once this is acknowledged, the structure of the trial becomes easier to understand and harder to defend. The focus of the trial is short-term self-reported feelings in a group already convinced that blockers will help. Those who receive the drugs immediately will feel affirmed; those who must wait are likely to feel rejected. Any difference between the groups risks measuring expectation, not efficacy.

What the trial avoids is even more revealing. Around 2,000 under-16s were referred for blockers at the Tavistock Clinic. A national data linkage study to track their adult outcomes was approved and ready to proceed, then stalled when adult gender services refused to release the necessary information. Instead of insisting on that essential evidence, the NHS has pressed ahead with a new cohort of children.

As Keira Bell told the BBC: “Puberty does not happen in a vacuum. It is your brain sending signals to your body. I did not understand any of that. There are children who have already been down this pathway. Why are we not following them up?”

The High Court claimants are right. The Pathways trial is the institutional repetition of a mistake we already made. If the health service refuses to learn from the children it has already harmed, the courts may have to ensure it does not harm thousands more.

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Josephine Bartosch is assistant editor at The Critic and co-author of Pornocracy.

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