Health

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Open letter to Yvette Cooper on dangerously flawed NHS research

In May this year I was one of 85 expert signatories to an open letter to James Palmer, NHS England’s National Medical Director for Specialised Services. The letter, organised by Trans Actual, raised serious concerns about the NHS evidence reviews of hormone therapy for trans youth, the subsequent prescribing policy (i.e. a ban on NHS hormone therapy for young trans people aged under 18), and an associated public consultation.

Three months later, Palmer responded. Unfortunately, he dismissed our concerns, and outright ignored most of the evidence we presented regarding the methodological and ethical flaws in the NHS England evidence reviews.

At this stage, we have no confidence in receiving an adequate response from Palmer. My personal view is that both Palmer and NHS England as an organisation have chosen to prioritise political convenience over both good research practice and patient safety (there is a longer history to this too). Following a consultation with signatories, Trans Actual therefore took the decision to escalate the matter to the current Secretary of State for Health and Social Care, Yvette Cooper.

I have reproduced the letter below – you can also read Trans Actual’s press release and the fully-referenced, signed version sent to Cooper here.

Dear Secretary of State,

We write regarding the series of evidence reviews commissioned by NHS England into masculinising and feminising (MAF) hormones for under-18s with gender dysphoria. Based on these reviews, NHS England has consulted on a policy proposal that would make these hormones for under-18s no longer part of the clinical commissioning policy.

In May 2026, a joint letter to Professor James Palmer was signed by 85 clinicians, researchers and academics raising significant ethical, methodological, and procedural concerns with these evidence reviews and the resulting policy proposal.

In August 2026, Professor Palmer responded to our letter (attached), but a number of concerns raised were not addressed to our satisfaction.

We now write to you directly to highlight the significant issues that remain, namely: the lack of clear rationale for these reviews, the significant methodological issues and risk of bias that is evident, and lack of any plan to monitor the impact of this denial of healthcare on young trans people.

1. Lack of clear rationale

Palmer was asked to clarify the exact rationale for these 2025 under-18 evidence reviews, given that NHS England had already updated the relevant clinical commissioning policy in 2024 in response to the findings (Recommendation 8) of the Cass Review of Gender Identity Services for Children and Young People, which included the systematic evidence review of hormones for under-18s conducted by the University of York.

In his response, Palmer explained that evidence reviews are commissioned as part of standard policy development, but provided no indication of any specific impetus for reviewing this policy just one year after it had already been updated.

Following a related FOI request to your own Department of Health and Social Care (FOI-1720493), we have determined that the most likely trigger for these under-18 reviews was in fact the out-of-scope and unvalidated concerns regarding adult services raised by Baroness Cass in her May 2024 letter to John Stewart and Professor James Palmer (see also para 19.34 of the Final Cass Review).

On the basis of these unevidenced concerns, John Stewart and James Palmer decided to “define the role of gender affirming hormones through the development of a new evidence based national clinical policy which will cover all people over the age of 16.”

We note that this work was launched outside of the already-commissioned Levy Review of adult services, which did not report any such concerns regarding hormone prescribing.

In the course of developing the scope of this “all ages” national clinical policy, the Policy Working Group “deemed [it] necessary” in April 2025 to split the evidence reviews into separate children and young people (CYP) and adult policy documents, due to “the significant variation in dosage of MAF between adult and CYP populations”.

At this point, it should have been recognised that:

  • a comprehensive evidence review of CYP hormones had already been carried out as part of the Cass Review;
  • NHS England had already produced an updated CYP hormones clinical commissioning policy following that Review;
  • an ongoing living evidence review into under-18 hormones had been commissioned by NHS England and was already funded and underway.

Instead, NHS England embarked on a redundant and duplicative review of the clinical commissioning policy for MAF hormones in under-18s, overriding and ignoring both the findings and original recommendations of the Cass Review, its own 2024 CYP policy update, and the funded EPPI living review.

We are extremely concerned that Palmer was not able to give us a clear answer as to the impetus for these 2025 under-18s reviews, and that as a result of this confusion, NHS England has spent valuable time and resources duplicating and overriding work it had already commissioned and / or completed.

2. Methodological issues and risk of bias

We are further alarmed by multiple methodological decisions taken in the commissioning of the under-18s evidence reviews.

In particular, we raised in our initial letter our concerns with the decision – taken not by the independent researchers, but the policy working group – to split what is effectively two interventions in under-18s (masculinising and feminising hormones) and at most two treatment populations (those seeking masculinisation and those seeking feminisation) into 10 separate PICOs.

While we agree with the statement in Palmer’s response that Cochrane advocates for a balance between overly-narrow and overly-broad search criteria when conducting evidence reviews, Cochrane also specifically emphasises (2.5.3) that review criteria may require modification in response to initial search results, particularly when dealing with sparse data:

“The ability to address the review questions will depend on the maturity and validity of the evidence base. When few studies are identified, there will be limited opportunity to address the question through an informative synthesis. In anticipation of this scenario, review authors may build contingencies into their protocol analysis plan that specify grouping (any or multiple) PICO elements at a broader level; thus potentially enabling synthesis of a larger number of studies.”

In our view, the fact that 6 out of the 10 PICOs returned zero (0) relevant studies should have been a strong indicator that the PICOs needed to be reconsidered, and that the initial protocols had erred far too far in the direction of “splitting”.

We also note that Cochrane differentiates between (2.3.1) review PICOs, and PICOs for comparisons between interventions or groups. NHS England appears to have entirely misunderstood or ignored this distinction.

Rather than beginning with one review PICO that would naturally be broad in scope, NHS England began with ten different PICOs already limited to specific sub-treatments (masculinising vs feminising, with or without concurrent GnRH analogues) and sub-populations (male, female, non-binary) – yet we note that NHS England has not generated 10 different clinical commissioning policies, only one.

This confirms that NHS England should have commissioned a far broader initial review PICO reflecting the actual review question — namely the safety and clinical effectiveness of MAF hormones for under-18s. Instead it appears that NHS England started with 10 different review PICOs, six of which resulted in zero studies being found due to their extremely narrow scope.

This leads on to one of the most unjustifiable methodological decisions made by NHS England in these evidence reviews.

Professor Palmer’s reply to us confirms:

“The use of GnRH analogues in this cohort is not routinely commissioned in England; therefore, any hormone regimen that could be commissioned cannot be based upon evidence of people who have already been treated with GnRH analogues because the treatment effects of masculinising or feminising medicines may be different for those who have received previous treatment with
GnRH analogues.”

Palmer uses the same justification to explain why dozens of studies that were included in the Cass-commissioned University of York evidence reviews were excluded from NHS England’s 2025 evidence reviews.

The law criminalising access to puberty blockers in England has been used by NHS England as a reason to exclude from its evidence reviews any and all international studies of masculinising and feminising hormones in which patients also received this treatment at any point prior.

This is despite the fact that puberty blockers followed by gender-affirming hormones has been a standard protocol globally for at least three decades, and as Professor Palmer himself admits: “many study populations include those who have received puberty suppression.”

We also note that, according to the March 2025 meeting minutes for the Policy Working Group, “Multiple members shared concerns raised of only having masculinising and feminising medicines (MAF) rather than the usual PSH [puberty suppressing hormones].” These concerns were seemingly overruled.

Adopting this bizarre exclusion criterion, based entirely on NHS England’s own unique and controversial policy position, inevitably led to the finding that there was a “lack of evidence” for masculinising and feminising hormones for under-18s, because so many studies were excluded.

All of this contributes to the exaggerated conclusion that there is an extreme lack of evidence regarding the use of MAF hormones in under-18s. This overstated scarcity has then been leveraged by NHS England to advocate for the removal of this aspect of gender-affirming care.

3. The appropriate response to “lack of evidence.”

Even setting aside the inconsistent rationale and significant methodological flaws we have highlighted above, there is the even more critical issue of how the purported “lack of evidence” is being used to justify the outright denial of care to trans people.

According to meeting minutes from 22nd January 2025, members of the Policy Working Group were assured that “in the absence of evidence, it is possible for specific policy areas to be informed by evidence-based decisions.” Despite this assurance, the proposed withdrawal of under-18 hormones appears to have been based solely on “absence of evidence” and, further, did not follow best practice approaches to evidence-based decision making.

We highlight statements from the BMA’s evaluation of the Cass Review regarding how evidential uncertainty is interpreted and actioned. While their points are in reference to the provision of puberty blockers, we believe they apply equally, if not more so, to the provision of under-18 hormones:

“The evidence base is limited and uncertain, with signals of both benefit and harm … A precautionary approach is consistent with this uncertainty. However, precaution in medicine typically involves risk mitigation alongside maintenance of care, rather than withdrawal of … treatment. … Alternative approaches (e.g. continued access with safeguards) are also consistent with the same evidence base.”

Instead of the precautionary approach and continued access originally recommended by Cass and adopted by NHS England on the basis of robust research, NHS England have now – for no good reason – overridden this, and are once again proposing a blanket withdrawal of treatment for trans people.

We also note that they are proposing to do so before any plans have been offered to monitor or mitigate the impact of treatment withdrawal, or develop any alternative systems of care.

4. Impacts of Treatment Withdrawal

In response to our concerns about the impact of treatment withdrawal, Palmer’s reply takes no account of patients currently on waiting lists or planning to seek referral to gender services in the hope or expectation that this might provide access to gender-affirming hormones.

As NHS England’s own Equality and Health Equalities Impact Assessment for this policy update makes clear:

“Patients who are already under the care of the NHS Children and Young People’s Gender Service and who have previously been advised that they would be referred for consideration of MAF hormones – but whose eligibility has yet to be clinically determined under the current policy – would no longer be eligible. This would mean that an existing aspiration for treatment will no longer be available for some individuals.”

The EIA also states that:

“Some stakeholder groups have previously suggested that withholding MAF hormones will lead to an increase in emotional and psychological distress, leading to risk-taking behaviour amongst children and adolescents.”

We remain extremely concerned about NHS England’s lack of articulated plans for monitoring the effect and impact of the proposed withdrawal of MAF hormones on young trans people.

Instead they have made the bizarre claim that “adoption of the policy [removing access to hormones] would in itself be a risk mitigation measure” “because of a lack of sufficient evidence relating to the safety and clinical effectiveness of MAF hormones for children and young people with gender dysphoria.”

In other words, without evidence, NHS England has adopted the blanket assumption that hormone treatments for under-18s are harmful, and therefore that the very act of denying this care reduces “risk”.

5. PATHWAYS Trial

We also note that if the decision is made to withdraw gender affirming hormones for under 18s from routine clinical commissioning, this will inevitably raise significant issues for the PATHWAYS (puberty blocker) research trial that is already underway.

The inability for young transgender patients to transfer onto cross-sex hormones with a reasonable time scale after beginning puberty blockers has already been a significant question raised in discussions of the ethical viability of this trial.

To date, we have been given no assurances as to how these issues will be addressed.

6. Expert statements

On reading Palmer’s response to our letter, Simona Giordano, a Professor of Bioethics at University of Manchester Law School, responded:

“One of the major concerns raised in our letter was that NHS England adopted review criteria that excluded a substantial proportion of the existing literature. In doing so, it risks repeating a longstanding methodological error in this field: attempting to separate the effects of puberty suppression and gender-affirming hormones as though they were entirely distinct interventions. In practice, many young people received these treatments sequentially as part of a single clinical pathway. This was especially true in England, where treatment with GnRH analogues was typically a prerequisite for access to masculinising or feminising hormones. Excluding studies involving such patients removes a large and clinically important part of the evidence base and may create a misleading impression about the amount of evidence available.”

Simona notes that Palmer’s response “does not adequately engage with several of the substantive concerns raised in the original clinicians’ and researchers’ letter, particularly those regarding the rationale for commissioning a further evidence review, the methodological choices underpinning the review process, and the implications of those methodological decisions for the evidence base considered.”

Chris Noone, a lecturer at the University of Galway who also read Palmer’s response, said:

“Guidance development and evidence reviews in Poland, France, Germany, and the Netherlands have all concluded that Gender Affirming Hormones are safe and effective as part of the care provided by gender services for young people. Furthermore, a recent paper in The Lancet (Doyle & de Vries, 2026) that considers the 13 systematic reviews that exist on this topic concludes that ‘gender-affirming medical treatment for adolescents does what it is intended to do—it shapes physical gender presentation in line with the affirmed gender of the adolescent. Research also indicates that gender-affirming medical treatment for adolescents is effective in terms of stabilising and improving the primary psychological target: gender incongruence (or gender dysphoria)’.”

He concludes that “the withdrawal of this intervention (1) does not follow from the existing evidence, and (2) does not consider the evidence on the risks of withdrawing this intervention.”

7. Conclusion

Our fundamental concern is that the provision of trans healthcare, including healthcare for under-18s, continues to come under immense external pressure from anti-trans actors, as well as being influenced by individuals within public institutions who approach policy and evidence-gathering from the presumption that gender-affirming care is inherently harmful.

In light of the above, we are calling on you as Secretary of State to:

  1. Meet urgently with James Palmer to seek answers to the unresolved ethical and methodological concerns raised in this and our initial letter, and ensure that these concerns are adequately addressed before any proposed change to the provision of MAF hormones for under-18s is finalised.
  2. Meet with trans healthcare clinicians and researchers and work with NHSE to ensure that future commissioning policy changes resulting from evidence reviews – like the forthcoming evidence reviews into MAF hormones for adults – are informed by a high respect for the expertise of clinicians, the autonomy of patients to seek care that reflects their goals and preferences, and a recognition of the risk of harm to trans patients of denying gender-affirming care.

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New article: Pathologising Legacy Measures and over-assessment

I have a new peer-reviewed academic article out in the International Journal of Transgender Health, co-authored with my colleagues Cal Horton, Jaimie Veale, Lou Kerley, and Ken Pang.

Pathologising Legacy Measures and over-assessment:
reconceptualising ethical assessment and data collection practices in trans children’s healthcare

The article looks at a range of questionnaires which are in common use internationally in trans youth healthcare. These are designed as a type of data collection tool known as “Patient Recorded Outcome Measures”, or PROMs, in which patients are asked direct questions about their feelings and experiences, to track the outcome of specific treatments.

PROMs are common across healthcare and mental health interventions more generally. You may have experienced this yourself if you have ever seen a therapist, for instance. A widely-used example is GAD-7. This invites patients or clients to use a numerical scale to rate how often they have felt bothered by particular problems, such as “feeling nervous, anxious or on edge”, or “feeling afraid as if something awful might happen”.

If a patient or client fills out a questionnaire such as GAD-7 both before and after receiving a treatment or therapeutic intervention, the care provider can – in theory – test how successful their intervention has been.

In trans healthcare, PROMs have historically been used by clinicians for research purposes, as well as for tracking individual outcomes. This has often been problematic, especially when patients are presented with a great many questions, or where these questions are experienced as pathologising or intrusive. For example, in the mid-2010s the Nottingham Centre for Transgender Health notoriously subjected new patients to 27 pages of apparently mandatory questions, including about seemingly random topics such gaming. This caused a great deal of stress and confusion for people seeking care at the clinic.

However, with specialist trans healthcare provision increasingly facing political threats, many clinics currently present PROMs as necessary to demonstrate the benefits of the care they provide. With this in mind, Cal Horton set out to examine 36 PROMs used in trans youth healthcare, assessing them according to four aspects of pathologisation (authenticating transness, intrusion, delegitimisation, and transnormativity) as well as over-assessment. They then brought their findings to our research team, and we wrote them up collectively. We found that both pathologisation and over-assessment were widespread across a majority of these PROMs. For example:

“Tool BI2 asks children to rate how happy they are with 26 body parts, asking which body parts they would like to surgically change, including body parts that cannot be changed through medical intervention (e.g. hands). These questions do not adopt a trauma-informed approach, and many may be experienced as abusive. Tool BI1, for example, asks how children like to pee and how they feel about looking at their body naked, questions which are clinically unnecessary and likely to be experienced as a significant intrusion of privacy by service users.“

The central argument of our article is that numerous commonly-used PROMs are impacted by a wider legacy of pathologisation in trans health, in which young people especially were treated as objects of clinical curiousity, rather than subjects of care. Since these PROMs are well-established and scientifically “validated”, they continue to be used in clinics which profess to practice forms of affirmative care. We therefore named these “pathologising legacy measures”, and caution against their continued use.

We do recognise that many clinics continue to use pathologising legacy measures out of a genuine desire to evidence necessary, life-saving care in an increasingly hostile political environment. Our ultimately question to these clinics is: at what cost?

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Open letter to NHS Director for Specialised Services on trans youth hormone ban

I am one of the 85 signatories to an open letter to James Palmer, NHS England’s National Medical Director for Specialised Services. We are raising serious concerns about the recent NHS evidence reviews of hormone therapy for trans youth, and subsequent prescribing policy and public consultation.

The letter has been published and sent to Palmer by Trans Actual – you can read more about it on their site here. In my signature, I note that I was a 2023 recipient of the NHS England LGBT+ Advisor Award. Unfortunately, in subsequent years, NHS policy on LGBT+ healthcare seems increasingly shaped by ideology and political pressure, rather than patient experience, expert advice, and evidence. In meetings I attended with Palmer in the early 2020s, I personally heard him share various forms of disinformation about young trans people, such as the factually inaccurate claim that recent cohorts of adolescents presenting with gender dysphoria represent a distinct population from young people referred to the same clinics in earlier years.

For a longer and more detailed critique of the NHS evidence reviews, see this excellent analysis by Kim Hipwell: A Medical Mess: An Analysis Of The NHS’s Proposal To Ban Hormone Therapy For Trans Youth.

The public consultation is open until 7 June, and you can submit a response here.

Dear James Palmer,

We are a group of clinicians, researchers, and academics working in gender care, paediatrics, and related fields of healthcare, medicine, and science.

We are writing to lay out our serious concerns with NHS England’s recently-published evidence reviews into the use of gender-affirming hormone therapy (GAHT) by children and adolescents.


1. Lack of Clear Rationale

The Cass Independent Review previously commissioned a systematic evidence review into GAHT for under-18s.

Based on this peer-reviewed and published analysis, Dr. Cass recommended that “NHS England should review the policy on masculinising/feminising hormones. The option to provide masculinising/feminising hormones from age 16 is available, but the Review would recommend extreme caution.”

In 2024, NHS England reviewed and updated their GAHT policy accordingly.

A “living systematic review” – also recommended by Dr. Cass – is now underway, to consolidate the evidence base and keep it up-to-date. This work is being conducted by EPPI-Centre and others, funded by the National Health and Care Research Institute (NIHR), and includes an ongoing review of evidence for GAHT for under-18s.

Therefore, it remains entirely unclear why – having previously wholeheartedly accepted the Cass Report – NHS England has now launched a separate evidence review that was never recommended by Dr. Cass and which duplicates other research already commissioned and underway.


2. Lack of Peer Review

None of the NHS England evidence reviews have been peer reviewed or written to meet publication standards. Instead, NHS England released the reviews only as part of a public consultation process and has asked the general public to “check that draft policies are well evidenced” and to determine whether “all of the relevant evidence [has] been taken into account”.

Consultation is not a substitute for formal academic review, and risks conflating technical evaluation with public opinion.


3. Methodological Limitations and Risk of Bias

Rather than address a single, clinically meaningful research question, NHS England subdivided the GAHT for under-18s evidence review into 10 separate and extremely narrow PICOs (population, intervention, comparison and outcome search parameters).

We have confirmed that this methodological decision was made by NHS England’s “Policy Working Group”, prior to instructing the “independent” researchers, Solutions for Public Health (SPH).

This methodological approach explicitly goes against the gold-standard guidance outlined in the Cochrane Handbook, which cautions that fragmentation of PICOs is likely to result in “sparse” evidence and “could be chosen by review authors to produce a desired result.”

As a result of these overly-narrow search parameters, the researchers had to exclude some of the most significant studies on gender-affirming care for young people, such as Chen et al., 2023, the largest NIH-funded prospective study of trans youth ever conducted.

Ultimately, the researchers could find only 11 eligible studies across all 10 PICOs, with 0 (zero) studies found for 6 of the 10 reviews. In contrast, the University of York evidence review commissioned by Dr Cass found 53 studies, 34 of which were assessed as moderate- or high-quality.

As an example, studies were deemed “out of scope” if participants had received GnRH analogues in the context of puberty suppression prior to receiving gender-affirming hormones (despite the fact that this was the standard treatment protocol internationally for many years, including in the UK).

According to the published reviews, as a result of this methodological decision alone at least 38 studies were excluded that would otherwise have been eligible (and potentially many more at title/abstract stage). These studies could, at the very least, have provided information on the risk profile of GAHT, a factor which NHS England claims to be central to their policy decision making.

NHS England has published no rationale at all for this – and other– methodological decisions. In response to an FOI request, NHS England indicated that studies involving GnRHa puberty suppression “cannot be included” in the PICOs because of “legal issues”, an “ongoing research trial in this area” and “lack of new evidence” – reasons that we find scientifically unsound.

Additionally, in contexts where limited evidence is available for a paediatric intervention, it would be typical for researchers to consider extrapolating data from research into adults, something that NHS England again chose not to do.

In effect, NHS England has adopted a methodological approach that predictably minimises the available evidence base, then cites this manufactured scarcity as a justification for restrictive policy conclusions.


4. Misreporting and Misapplication of Findings

Especially in paediatrics, clinical policy and decision-making is commonly based on evidence considered limited and/or “low-quality” as recognised under the GRADE system. There is therefore no reason why the purported lack of evidence reported in these reviews should automatically lead to the policy position that gender-affirming hormones are so unsafe and/or ineffective for 16- and 17 year olds that they must be immediately withdrawn.

Even when looking only at the 11 studies included in this NHS England evidence review, we believe the overall pattern of evidence suggests that the benefits of GAHT for under-18s outweigh any harms. We believe this is also the case in the University of York review.

We have also found that at least one of the studies included in the SPH reviews that apparently found evidence of “harm” (Grannis et al., 2003) was entirely misreported. The evidence review states that those taking oestrogen had significantly higher depression, suicidality and social anxiety scores than those not on hormones. In fact, Grannis et al. found no statistically-significant differences on these measures.


5. Impacts of Treatment Withdrawal

As far as we are aware, NHS England has no plan to monitor the impact of this withdrawal of gender-affirming healthcare on patient outcomes. This is despite evidence that removal of gender-affirming care is associated with adverse mental health outcomes, including increased suicidality among trans youth.

A decision to withdraw a treatment must consider what alternatives will be provided. Psychotherapy or psychosocial support alone – all that is currently available via the NHS – has not been demonstrated to be an effective treatment for those with a diagnosis of gender dysphoria. Nonetheless, as far as we know, NHS England has no plans to conduct a similar evidence review of
this intervention.


6. Conclusion

In summary, a drastic and potentially devastating policy change that runs counter to international standards of care has been advanced:

  • without any clear rationale,
  • on the basis of a methodologically-flawed process,
  • in the absence of peer review,
  • and without plans for monitoring impact or mitigating harm.

We therefore urge NHS England to:

  1. pause and reverse implementation of any policy changes arising from this flawed review process,
  2. publicly acknowledge and take into consideration the existing University of York systematic review into gender-affirming hormones and the existing EPPI-Centre study,
  3. ensure any clinical commissioning policy on gender affirming hormones for under-18s reflects established international best practice,
  4. and incorporate patient and clinician consensus and testimony into any decision about transgender healthcare.

A full list of signatories can be found here.

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Crowdfunder: help a Black trans kid afford care

I’m currently helping to raise money for Isaac, a young trans man I know, and his family.* In the face of enormous NHS failings, they need your help to afford trans healthcare.

Share or donate:
Help a Black trans kid afford care


There is of course already a lot of fundraising for healthcare within trans communities. This is inherently unfair for several reasons. Firstly and most importantly, it’s wrong that people struggle to receive the care they need from state-funded providers, and pretty much all trans people across the world are discriminated against in this regard (whether or not we are talking about medical transition).

Secondly, research shows that crowfunding tends to favour individuals with more existing social capital. People trying to raise money for their care benefit from factors such as being older, transmasculine, white, and/or well-connected on social media.

For these reasons, I try to support collective fundraising where possible. Some examples of this include the Glasgow Transfem Electrolysis Project, and the gig I was DJing at just this week for Trans Healthcare Access Glasgow.

However, there are cases where we simply don’t have the infrastructure or resources in place (yet?!) to support collective fundraising. A good example of this is all minors: young trans people who are more likely to face heightened discrimination and legal barriers both to accessing care in the first place, and in attempting to circumnavigate these barriers.

I do not have the capacity to make a habit of running fundraisers. In this instance, I have known both Isaac and his family for a long time. I know that they are systemically disadvantaged due to economic factors, an inability to go public and put a face to their crowdfunder, and the intersection of transphobia, racism, and various other forms of structural oppression.

Here’s some of the blurb from the crowdfunder page about why you should support Isaac:

Isaac’s story

Isaac is a Black trans kid living in England. He is an expert baker of chocolate chip cookies, loves painting and drawing sharks, and has a budding rock collection. He’s obsessed with highland cows, and knows all the words to Hamilton.

Isaac has a very supportive family who want to help him access healthcare. However, they are in low income work, and are on universal credit.

They therefore need your help to afford care for Isaac.

Stylised drawing of a young man, with white and pink chalk on black paper.

NHS failings

Isaac received a diagnosis of gender dysphoria from the NHS England Gender Identity and Development Service (GIDS). However, the clinical timelines were so slow at GIDs that this diagnosis came too late for him to access any medical treatment before the clinic closed in 2024.

Like many of young people, Isaac has found the new NHS trans healthcare clinic for under-18s – the Children and Young People’s Gender Service  – to be traumatic and abusive. He also has no hope of being prescribed medication there.

For more information on young trans people’s terrible experiences at NHS clinics, see Dr Cal Horton’s article, “The worst thing I ever experienced”

How much money does Isaac’s family need?

We are aiming to raise up to £8000. This is to cover the cost of the following for up to three years:

  • Diagnostic appointments
  • Subscription to a private clinic
  • Medication costs
  • Blood tests

Isaac’s family may save on some of these costs if they can find a GP who will provide shared care and blood tests. However, this is not guaranteed.

If Isaac’s treatment costs less than the money raised, any remaining donations will go towards a top surgery fund for when he is an adult.

If there is still remaining money not spent on Isaac’s healthcare, the family will donate this to fundraisers for other trans kids and/or other trans people of colour.



*Isaac, of course, is not his real name. However, the image for this campaign is a self-portrait of his future self that he drew when much younger. Isn’t it amazing?

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Gig: There Will Be Blood! Glasgow fundraiser

I’m super hyped to announce I will be doing a DJ set at Stereo on 2nd March 2026 – performing for the first time as ROGD.

This will be at a gig for Trans Healthcare Access Glasgow. They are raising money to provide free blood tests for trans people who have otherwise been denied healthcare by the NHS.

You can buy your tickets here.

Poster for the There Will Be Blood gig by Trans Healthcare Access Glasgow. The text of the poster reads as follows. Raising funds for trans blood tests. At: Stereo! Monday 2nd March 2026. Door 7pm. Artists: Sersi, Deep Filff, Comfort, Ruth on the Goddamn Decks. Tickets: £10, £12, or £15. The poster features cut and paste imagery relating to medical care and a deck of cards, with the King and Queen of Hearts.


Much like the Glasgow Electrolysis Project (who are now running a successful clinic in the city) the very existence of Trans Healthcare Access Glasgow is both an indictment of the NHS and a credit to our community organisers. It’s depressing that the UK’s state healthcare system has so profoundly failed trans people that many GPs are now refusing to even monitor the safety and efficacy of NHS-prescribed medication. But it is also truly excellent that we are building our own new networks of medical support, which offer an alternative to the cis-led medical systems that have abused and exploited us for decades. Through the work of harm reduction groups such as Trans Healthcare Access Glasgow, we are collectively less reliant on these systems than we have ever been.

Meanwhile, I have a long history as a rock DJ but don’t get behind the decks too often these days. While I’m hoping to perform a bit more often again going forward, there’s no guarantee – so snap up those tickets while you can!

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Some thoughts on the Levy Review

On 18 December, NHS England quietly published the report of Dr David Levy’s review of adult gender clinics. The report’s official title is the massively dry Operational and delivery review of NHS adult gender dysphoria clinics in England, but it’s commonly referred to the “Levy Review” within community spaces.

Prior to its publication, there were some concerns about the Levy Review being a sort of Cass Review for adults, leading to further massive restrictions in trans people’s access to healthcare. I witnessed active catastrophising in some quarters, with social media posts calling medication stockpiling. I don’t think this kind of rollback was ever on the cards with Levy, but I do understand why people were concerned. Trans people’s trust in the NHS and political processes is – justifiably – at rock bottom.

There were also a minority who hoped that the Levy Review might result in significant improvements to how trans people are treated by the NHS in England. I don’t think that was ever realistic either.

In reality, Levy does acknowledge some of the problems with English gender clinics, focusing especially on capacity issues, inefficiencies, and long waiting times. It offers a series of recommendations relating largely to the practical operation and delivery of gender services (the hint is in the title!) QueerAF asked me what I thought about it for their coverage of the Levy Review, and I told them this:

“Faced with the sinking Titanic of trans healthcare in England, the Levy Review suggests we rearrange the deckchairs,” Dr Ruth Pearce, a transgender health expert and Senior Lecturer in Community Development at the University of Glasgow, tells QueerAF. Levy's report offers a limited, technocratic response to the ongoing crisis, recommending a range of bureaucratic measures to improve the efficiency of the current system.


These measures may still result in a few improvements. NHS England hope Levy’s recommendations will contribute to “clinical effectiveness, safety, and experience”. I am not entirely convinced. But perhaps the waiting lists can be a bit shorter and fairer, especially with the opening of new clinics and introduction of a national waiting list.

Why is the Levy Review like this?

Levy did not truly seek to understand, let alone confront, the real scope of the problem in trans healthcare services, sticking instead to the very narrow scope of the brief provided by NHS England. Deeper issues he ignored include open discrimination from healthcare practitioners, as well as gatekeeping, pathologisation, and dehumanisation baked into the design of the gender clinics. These all harm patients, while also wasting clinical time and resources.

When I started my PhD on trans healthcare in 2010, such issues were not widely understood outside of certain trans community settings. That is no longer the case.

There have been multiple reviews and consultations undertaken by NHS England over the past 15 years, including in 2012, 2014-2015, and 2017-2019. There was also a review undertaken by the House of Commons Women and Equalities Committee in 2015.

Then there’s the research I undertook for that PhD, later published in my book Understanding Trans Health. Here, I argued that long waiting lists for gender clinics are not simply a result of underfunding or bureaucratic inefficiencies, but also an inevitable outcome of the gatekeeping system. By positioning trans healthcare as a specialist matter, and forcing patients to prove over and over again in psychiatric evaluations that they are “really” trans, you create unnecessary roadblocks and bottlenecks for care.

There have been a lot of other studies undertaken since. The most notable might be the massive, rigorous, and extremely detailed final report of the Integrating Care for Trans Adults (ICTA) project, published in 2024. This was funded by the UK government through the National Institute for Health Research, and has been roundly ignored by NHS England.

There are also a growing number of popular analyses: blog posts, news stories, podcasts, and video essays. One prominent example is I Emailed My Doctor 133 Times: The Crisis In the British Healthcare System, by Philosophy Tube, which has been seen by over 2.5 million people to date.


All this research and commentary highlights those same problems ignored by Levy: discrimination, gatekeeping, pathologisation, and dehumanisation.

My feeling is that neither NHS England nor Levy were interested in these issues. In fact, they are not really interested in understanding trans people at all.

It is therefore no surprise that Levy not only ignores widely-documented problems, but also repeats factually inaccurate claims, such as that the growth in patient demand for gender clinics is “not well understood”. Quite aside from what we have learned from all of the research and commentary noted above, this growth was forecast back in the 2000s by the education and advocacy organisation GIRES, in a study funded by none other than the Home Office.


The really bad stuff (and how to protect your data)

For all the limits of the Levy Review, I feel most of the recommendations are somewhat positive and may help people a bit. On balance, it’s mostly okay.

However, there are a few real points for concern.

Firstly, Levy argues that a first assessment for medical interventions should always be undertake by a psychiatrist or clinical psychologist. As all the research on trans healthcare services has shown time and time again, this is both unnecessary and unhelpful. It compounds the pathologisation of trans people, wrongly positions trans healthcare as a “specialist” matter, and creates expensive bottlenecks for treatment.

Secondly, Levy insists that gender clinic patients should be referred by GPs, and should not be able to self-refer. This is intended to help with the problem of patients ending up on a waiting list with no information for clinical staff on who they are, what they are looking for, and what their healthcare needs might be. However, the recommendation ignores the widespread issue of transphobic GPs refusing to provide referrals, as well as the fact that not everyone will have a GP (see, for example, the fact that trans people disproportionately experience homelessness, or that we are more likely to avoid healthcare providers due to justified fears of abuse). The problem Levy is trying to address could have been tackled in a more sensitive way, for example through NHS England providing a short referral form that prospective patients can fill in when seeking an appointment at a gender clinic.

Finally, there is the issue of future research. Citing Alice Sullivan’s transphobic report on sex and gender, Levy calls for more data collection on patient outcomes. Here Levy fails to acknowledge the urgent need to build trust before trans patients can be confident the NHS will not misuse our data. Moreover, as Trans Safety Network have noted, NHS England have committed to addressing this through expanding the role of the National Research Oversight Board for Children and Young People’s Gender Services. Trans Safety Network report that the board includes members associated with anti-trans medical groups, including the Society for Evidence-Based Medicine (SEGM), who are listed as a hate group by the Southern Poverty Law Center, and CAN-SG. It’s little surprise therefore that the National Research Oversight Board has recommended that clinicians working with young trans people attend SEGM and CAN-SG conferences, ensuring the further spread of transphobic disinformation, pseudoscience, and hate.

Trans Safety Network therefore recommend that trans patients in England opt out of their healthcare data being used for research. They provide the following advice on opting out:

This can be done via the following links, the first to stop GP records being shared and the second to stop secondary care records being shared.

We also suggest you email your GIC the following to ensure your opt-out is clear and ask to have a note of this added to your care record. I do not give my permission for any aspect of my patient data to be submitted to, or collected for, the purpose of any research or non local audit without my express permission in writing being obtained in advance.

Emails should include your name, DOB and NHS Number to assist your GIC admin in finding your record. If you have been referred but not been seen by a GIC, you can still contact the GIC you were referred to.


Could it be better?

The failings of the Levy Review are not inevitable. There are numerous international models of better practice. For a strong example, see the Professional Association for Transgender Health Aotearoa’s 2025 Guidelines for Gender Affirming Care in Aotearoa New Zealand. This recommends treatment under an “informed consent” model. Here is some of their guidance on this for adult patients:

Being transgender is not a mental illness, and it does not impair capacity to consent to treatment. If a doctor or nurse practitioner has sufficient knowledge, skill and professional scope to initiate GAHT [gender-affirming hormone therapy] in an adult patient:

– There is no requirement for all people to be assessed by a mental health professional prior to starting GAHT

– For many transgender adults, GAHT can be initiated in primary care, without the involvement of secondary or tertiary care.

But we need not even look overseas for better. The Welsh Gender Service has seen a growing shift towards the provision of hormone therapy for trans people in primary care settings, supported through close collaboration with community organisations and GP practices. This has proven to provide a better experience for trans patients and has improved the efficiency of the service from an NHS perspective. The ICTA reportdescribes what this looks like in practice.

Case Study 4 in Chapter 4 reports on the establishment and initial development of regional primary care clinics, spread across Wales, which take responsibility for prescribing and monitoring HRT for trans adults following assessment at the specialist gender clinic. This is the most significant initiative we studied to address lack of integration between an assessing gender service and arrangements for prescribing and monitoring HRT. The key features are as follows. Their effectiveness and efficiency would appear to be of wider relevance to other gender services and NHS primary care commissioners.

The regional clinics were largely staffed by GPs, located within established GP practices and funded by the local NHS. They took responsibility for prescribing hormones, monitoring blood tests and titrating doses immediately following assessment, aiming to pass service users on to their usual practice after around 12 months, on the basis that their doses and prescriptions would by then be stable. This arrangement avoids the costly and damaging difficulties in communication between GICs and primary care practices over blood tests and dosage changes, experienced by many people attending other GICs. It also frees up gender specialists to devote more time to assessments, rather than review appointments for people already on hormones. Local clinicians, however, worked in an integrated way with their specialist colleagues, attending joint training on trans health care, and holding regular joint clinical consultations.

Further advantages emerging from this arrangement include the regional clinics rapidly becoming established as having GPs confident in prescribing under shared care with a GIC, whether based on a full GIC assessment or on the basis of a ‘harm reduction’ bridging prescription. These more knowledgeable GPs can then advise and educate colleagues in their own and neighbouring practices. Above all, both service users and GPs involved in these regional clinics were enthusiastic about how they brought HRT for trans people into the mainstream of primary care. Doctors in the regional clinics helped service users deal with a range of health issues, and hormone therapy came to be experienced as part of primary care, rather than something specialised, difficult, or in any way stigmatised.

The Welsh model is still far from perfect. However, it proves that there is no need for NHS England to keep asking the same tired questions and presenting the same tired answers. Yes, we deserve better than the Levy Review: but more importantly, positive change is both realistic and possible.

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Podcast: Who Who Is Wes Streeting and Why Is He Like That?

Last month I returned to the fabulous Red Medicine podcast to talk all things Wes Streeting. I joined the socialist writer Jonas Marvin and host Sam Kelly to discuss the UK Secretary of State for Health and Social Care’s political background, possible motivations, and current challenges.

Red Medicine always offers a great deep dive into health-related topics of the day. Streeting’s alignment with transphobic pseudoscience and conversion proponents means that obviously I had a lot to say about his impact on trans healthcare. However, our conversation was offered a great opportunity to grapple with the wider context of Streeting’s ideology and actions, discussing wider matters such as class, party politics, and trade unionism: highly relevant given current discourse around the proposed strike by resident doctors! I also talk a little about my encounters with Streeting in the 2000s, back when I was a campaigner with the National Union of Students’ LGBT and Women’s Campaigns.

You can listen to Red Medicine through all the major podcast platforms – or through the link below.


You can also hear me talking about the Cass Review on a previous episode of the podcast in June 2024.

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Reject Trans Doom-Posting

This week I took the long train down to the south of England for my friend Robyn’s funeral. She died very suddenly three weeks ago, aged just 32.

Robyn gave so much love to the world, and was so loved in turn. Around a hundred and fifty people crammed into a small building for the service. There weren’t enough seats for everyone, so many stood at the back and sides of the room. I sat on the floor. More attended online.

We shared stories from Robyn’s life, learned from each other, cried together. Like many funerals, especially for young trans people, it was absolutely gutwrenching. It also helped move us towards closure. It was good to be in community together, to think and speak not just of Robyn’s past, but of our collective futures. Robyn lived life to the absolute maximum. Surely we could take inspiration from her example.

Photo of a punk crowd having a good time. In the centre of the image, a white butch woman exclaims and points with delight.
Robyn at Manchester Punk Festival 2024. Photo by Chris Bethell for The Guardian(!)


After the funeral, I stayed the night with queer friends in rural Surrey. We went for a curry, toasted Robyn, caught up about our lives. We talked about work and about books and about art and about holidays we wanted to take. That evening I felt tentatively more at peace with the world.

And then I looked at my phone. And I learned that another young friend, Jessica, had also just died.

***

It’s a shit time to be trans. Many people are saying this.

But then again, when has it not been a shit time?

Eight years of moral panic have taken an enormous toll. In the UK, as in many other countries, our civil rights and our access to public services, public spaces, and public life are all being rapidly rolled back. Politicians and influencers fall over themselves to promote anti-trans violence and praise one another’s incendiary takes. We are less safe at work, at home, in hospitals, in schools, and in the streets.

Trans people often die young, including too many of my friends. Sometimes (all too often) we die by suicide, driven to despair in a world full of hate and malice. Sometimes (mercifully less often in the UK) we are murdered, usually in incredibly violent ways. Other times, it’s more complicated. I think of Denise, who died a sudden death from melanoma. I think about Elli, who died of Covid-19. And now I also think about Robyn and Jessica, who each died suddenly of apparently natural or accidental causes.

These days, the high rate of untimely trans death can feel like a consequence of the trans panic. Certainly I believe it’s making things worse. However, this phenomenon pre-dates the current political situation. Trans people disproportionately died young in the 2010s, at the time of the so-called “tipping point“. Trans people disproportionately died young before this too. Sociological theory can tell us why.

A decade or so ago, I worked for a couple of years in Warwick Medical School. I was there to teach medical students about social determinants of health. The basic concept is that our general health is affected enormously by the context in which we live. This includes factors such as the resources and services we do and do not have access to, and barriers we might face in attempting to access healthcare services or otherwise look after ourselves

So, it’s not a coincidence that – for example – life expectancies are shorter in poorer neighbourhoods, or that Black women are more likely to die in childbirth. There is nothing inevitable or biological about any of this, something intrinsically different about poor people or Black people. The issue is that entire groups of people are more likely to experience particular kinds of illness, and more likely to die of things others might survive. This is because of the social disadvantages they face, and because of the discrimination they experience at the hands of bigoted doctors and nurses.

There is a massive scientific literature on social determinants of health. I’ve contributed to it myself, co-authoring a recent study showing an association between transphobic microaggressions and poor mental health among trans people. For this reason, I know it’s no coincidence that so many of my trans friends have died untimely deaths. Trans people are more likely to have worse health because of transphobia. They are less likely to receive timely and effective treatment because of transphobia. This means when trans people are seriously ill, we are on average less likely to survive. I see this when I look at the academic literature, and I see this every day in the lives trans people I know.

I see the impact of transphobia when I look at Robyn’s life and death. Her health deteriorated significantly in her final years. She was afraid to seek help from doctors though: and for good reason, given the discrimination she and many of her friends experienced in NHS services. I wrote my entire goddamn PhD thesis on this problem.

Things were even worse for Jessica. I witnessed so many organisations and institutions in her home city of Coventry failing her time and time again. I could fill whole books with accounts of the violence done against her. She was failed by her school, her church, a political party she gave so much energy to, the council, the local hospital, the psychiatric ward, the housing association. Just last year I sat helplessly on the other end of the phone while she attempted suicide, doing the best I could in this moment to ensure that she was not alone.

The institutional failings experienced by Robyn and Jessica and so many others are the result not just of ignorance, but of actively malicious transphobia and transmisogyny. I believe these factors contributed significantly to their untimely deaths.

How can any of us expect to find hope and purpose in the face of such violence?

***

In recent months I have noticed an uptick in trans doom-posting. By this I mean trans social media posts, blog posts, and videos which dwell entirely on negative feelings and convey a sense of hopelessness.

A prominent example is Shon Faye’s recent essay, well, it’s over, which she describes as “a brief eulogy for the ‘trans rights’ movement”. Shon observes that powerful transphobic movements in the USA and UK are succeeding in many of their aims. They have spread fear and disinformation far and wide, made allies of mainstream politicians and media platforms, and enacted bans on trans healthcare. Now they are attempting to criminalise our very existence, as part of a campaign to eliminate us altogether.

Shon’s conclusion appears to be: well, that’s it. We’re all fucked.

“Today I doubt I will see another progressive measure (either in legislation or healthcare policy) put in place for trans people in my lifetime. Who knows what may yet be taken away.”

I very much empathise with her account of trying to talk about this in any way with cis friends and family:

“their instinct is to try and generate hope or minimise despair [which] typically minimises the gravity of the situation and the depth of my grief and exhaustion and fear – increasing my resentment.”

Shon concludes that she doesn’t want to hear “fucking platitudes” – “there’s time for hope later”. For now, she wants time to grieve. I’ve seen similar sentiments shared by other authors on various social media platforms, including posts from extremely popular trans meme accounts.

I understand intimately where all of this is coming from. Just look at everything I said earlier about social determinants of health. I recognise the violence we are subject to, and its costs. This post too is written from a place of deep grief.

But there is also the question of where and how we grieve. We do need space to vent and to despair. But we also need space to process, and figure out what happens next. Ideally, we need places and times we can do this collectively, rather than just being isolated as individuals. Robyn’s funeral offered this.

I’m not saying we shouldn’t talk about what is happening to us. What I am concerned about is the individualising effect of public platforms, and the parasocial relations we hold with high-profile accounts. We tend to consume doom-posting on our own, on a phone. We often have no-one to process it with, and little context beyond the content in front of us. In this way, doom-posting offers only a partial account of reality, and no way out from despair.

And there is a way out. We find it in community.

***

Look, I have a great deal of respect for Shon Faye. I have a hard enough time navigating the consequences of my own very minor microcelebrity. Shon has to tackle a great deal more attention: from trans people looking for someone to idolise and/or tear down, from cis readers who project heroic expectations onto her, and from haters who see her as the antichrist or something. She’s great on camera, and a brilliant writer. I would recommend her book The Transgender Issue to literally any cis reader. I also recognise that her blog post comes from a place of incredible pain.

At the same time, I am concerned that many trans people and allies are putting way too much energy into engaging mainstream institutions and liberal systems on their own, individualistic terms, rather than looking to the alternative power and support we can build in our communities. Notably, a lot of Shon’s post talks about civil society, legislation, lobbying, and the role of organisations such as Stonewall. This is definitely a realm in which “trans rights” face a seemingly terminal decline. But it is also not the first place I would look for real, grounded hope.

You can find a similar energy in Jules Gill-Peterson’s dire essay Reject Trans Liberalism, which is referenced by Shon. Jules’ piece simultaneously criticises the trans liberation movement for being about more than transition, while also insisting that preparing ideologically sound documents for the US supreme court is a radical act. It posits a false and ahistorical dichotomy between transsexuals (good, pure, radical) and transgenders (bad, elitist, liberal). The essay does not consider how gender diverse people might work together or support one another across our differences. This contrasts with existing critiques of trans liberalism already advanced by activist-scholars such as Nat Raha and Mijke van der Drift. Again, don’t get me wrong, I’m a huge fan of Jules’ previous work. But as trans people, and especially as trans women, we owe each other so much more than this.

Now, I’m hardly without fault. This very blog is replete with examples of myself and others putting untold hours into lobbying politicians, participating in public consultations, advising the National Health Service and so on and so forth. In her post Stepping Over The Line, Josie Giles, who once again I admire greatly (look, I just fucking love trans women) argues that:

“Theoretically, an army of well-resourced energetic activists could simultaneously engage in state-centred advocacy and also do grassroots politics. In practice, it doesn’t happen. In practice, state-centred pseudo-organising dominates the social media feeds and the limited energy reserves of an already depleted community, and absorbs what little money is available to pay for the salaried self-licking ice-cream cone of the lobbying profession.”

Sick burn!

Meme depicting two femme white women. One is labelled "trans NGOs", and is holding the other woman firmly by her hair. The second woman is labelled "broke trannies facing a highly funded segregation movement". The first woman is force-feeding the second woman a bottle of milk, labelled "email your MP".
Meme acquired via one of them social media platforms we’ve all heard so much about.


I do disagree with Josie a little. Unlike Shon and Jules and also Josie, I transitioned in the early 2000s. This was well before the tipping point, and before most trans civil rights even existed in law. I remember how we fought successfully for changes that genuinely improved many people’s lives. I feel it will always be worthwhile to use what levers we can to minimise the harm caused by those who have power over us. Lobbying is the most accessible form of activism for some people. I still have an auto-reply on which encourages every damn cis person who emails me at work to contact their MP.

But Josie is completely right that many if not most trans people can and should be putting a lot more of our energy into grassroots politics. This must necessarily involve re-imagining what our worlds could look like, using what we already have as a basis from which to build. I know from lived experience that we can not only survive in the absence of certain civil rights and recognition, but also see material improvements in our lives when we come together. I met Jessica because we built trans-led community services in Coventry from the ground up.

Similar points are made by Roz Kaveney, who first came out over 50 years ago. In her criminally underrated 2022 poetry collection, The Great Good Time, Roz does reflect on the violence faced by young trans women in her youth. However, she also details the vibrant lives they lived together, the joys they experienced, how they shared housing and clothes and had each others’ backs. In a short forward to the book, she notes:

“I observed a lot of bleakness creeping into trans social media and thought it my job as a community elder to remind young people that things have been, if not worse, then at least as bad in different ways”.

As Josie states in Stepping Over The Line, white, middle-class trans people in particular need to understand in this current moment that we are as disposable to the ruling classes as any other minoritised individual. Our strength lies in practical solidarity with others subject to the violence of corporations, fascist movements, and the state. To once again reiterate the point, we need to be in community with one another.

Both Robyn and Jessica’s lives offered perfect models for this.

***

Every single speaker at Robyn’s funeral talked about how much time and energy she put into punk and folk music, building and fixing things, and caring for others. She was a loud, proud butch who was incredibly committed to sustaining community wherever she went. When she saw a need, she sought to meet it. Many of us only wished that she was better at asking for or accepting help herself.

If a trans person needed somewhere to stay, Robyn would put them up. If a trans person needed to move house, or was being evicted or was fleeing a violent relationship, Robyn would turn up with a van. If a trans person was having trouble at work, Robyn would show up online or in person with sensible advice. This attitude inspired Robyn to volunteer with groups such as Reading Red Kitchen, a grassroots project which provides a social foodbank and free community meals for asylum seekers experiencing food poverty. For Robyn, radical politics could never simply be about slogans and demonstrations: it was about cooking, connecting with others, and washing the dishes.

None of this is to say that Robyn was never found at a protest: quite the opposite. When I lived in the south we co-founded Trans Liberation Surrey, a collective which worked to oppose transphobia in a county hardly known for its activist movements. My most treasured memory of Robyn is from this time, when we attended a small anti-fascist demonstration in Wokingham. A coalition of neo-nazis, anti-vaxxers, and climate conspiracists descended on the town to protest a drag queen storytime event for young children. Robyn and I joined other locals outside the library to wave rainbow flags and play upbeat music, enabling families to attend the event without disruption.

Photo of people with placards around a banner labelled Trans Lib Surrey.
Trans Liberation Surrey, at Surrey Pride 2021.


Jessica was also extremely motivated to help others, in spite of her own difficult circumstances. Like Robyn, she was a committed trade unionist. For many years she was also involved in a small political party, before eventually being ejected for challenging the leadership. Her motivation for this was a genuine belief in the possibility of positive political change, and in the potential for people to come together and make that change happen. Later in life she would rediscover her Christian faith as alternative vehicle for community action.  

After hearing of Jessica’s death, our mutual friend Charlotte reached out, and we asked one another how we knew her. It turned out Charlotte had also been a member of that political party, and reconnected with Jessica several years later as they both sought new ways to make a difference in the world. In turn, I explained how Jessica and I met while lived in Coventry, and was myself involved in organising trans community social events, meals, and punk nights. Charlotte and I also both knew Robyn. “Christ Ruth,” said Charlotte, “trans lives are so entangled and we often don’t even realise”.

So it is. Right now, Jessica’s Facebook wall is replete with people thanking her for being there as a friend, for providing them with advice, for helping them come out.

In a hostile world, we are everything to one another. In the face of the most horrific hate, our love is so powerful. Such love survives death.

Selfie photo taken by a white woman with shoulder-length brown hair. She is wearing colourful clothes and a cross around her neck, and smiling at the camera.
Selfie taken by Jessica.

***

This is where I find hope. At protests and demonstrations, sure, but more importantly in the contexts where we give each other’s lives meaning.

I find hope in community meals, mutual aid, queer bars and queer bookshops and queer gigs. I find hope in small parties, in big Pride events, in quiet meetings at work, in food pantries. I find hope in housing projects and healthcare projects, and in the Glasgow Electrolysis Project, which has created actual jobs for trans women and a vital new service for hundreds of us across the city. We know we are failed constantly by mainstream institutions: rather than seek incremental change, is it not time to re-imagine the clinic, re-think the workplace? Our problems will not be solved by refusing to engage with existing services, nor by creating trans charities that replicate existing hierarchies. We need to find ways to build something new entirely.

I find hope in the fact there are more of us out than ever, more connected than ever. These collective endeavors are all so much more important than anything I personally might write, any research I might do, and certainly any “progressive” policy I might influence.

Doom-posting and finger-pointing cannot deliver any of these things. We need to take the time to connect with one another, especially outside the internet. Yes we need to grieve, but we need so much more than this. We need to actively look after one another, and provide space for rest and recuperation. We need to have each others’ backs. We need to connect across difference, and not (re)create hierarchies of oppression or need.

These are no fucking platitudes. This is my life. This is the lifeblood of our shared communities. This is how we create better social determinants for our goddamn health.

Long may we live together.  

Photo of a butch white woman playing a banjo next to a Scottish loch.
Robyn in the Highlands. Photo by Elaine O’Neill.

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Free resources: Perinatal care for trans people

On 8 February 2021, Brighton and Sussex University Hospitals NHS Trust published a series of groundbreaking resources on perinatal care for trans people, written by their Gender Inclusion Midwife team. As of March 2025, the Trust no longer exists, the midwives in question work elsewhere, and the resources page was sadly taken down – a sadly all-too common experience with NHS guidance for working with marginalised peoples.

Given the importance of these materials, for which I was part of a large team of expert reviewers, I am reproducing them on my website today for Trans Day of Visibility 2025, alongside some related resources.

I hope these will be of interest and use to anyone interested in improving perinatal care for trans people, including midwives, nurses, doctors, policymakers, commissioners, advocacy groups, and of course also families and prospective parents.

Professional guidance and protocols by the Gender Inclusion Midwives

Perinatal Care for Trans and Non-Binary People

Gender Inclusive Language in Perinatal Services


Information, forms, and materials for birth parents by the Gender Inclusion Midwives

Support for trans and non-binary people during pregnancy, birth and the postnatal period

Referral to Gender Inclusion Midwives

My language preferences

Pronoun stickers

Poster: Gender Inclusive Perinatal Care


Additional materials

It’s been a long four years since the Gender Inclusion Midwives resources were published. Here, therefore, are a few additional materials that may be of help to people working in this area.

National Maternity Survey data on trans birth parents
Since 2021 the Care Quality Commission has collected data on gender modality as part of its annual National Maternity Survey. The most recent findings indicate a significant rise in the number of men and non-binary people giving birth since 2021, with 1.58% of 2024 respondents indicating a gender that differs from the sex they were assigned at birth. This shows that hundreds of trans people are giving birth in England every year. See: Open data > 2024 Maternity survey National tables > page g9.

Inclusive language statement from the Royal College of Midwives
2022 statement affirming both that a majority of RCM members and service users are women, and that diverse gender identities should be recognised in midwifery.

Improving Trans and Non-Binary Experiences of Maternity Services (ITEMS)
2022 report published by the LGBT Foundation, looking at the findings of an English study on the experiences of 121 trans people who conceived and gave birth. It found that many trans birth parents do not feel safe sharing their identity in perinatal services, with a large proportion not feeling comfortable to access any support at all from an NHS or private midwife.

Trans Pregnancy Project website
I reviewed the Gender Inclusion Midwives resources as part of my work on the Trans Pregnancy Project, which was an international study of trans people’s experiences of pregnancy and childbirth. This year we launched a new website. This includes links to all our peer-reviewed publications, on topics including conception, pregnancy loss, midwifery, gender and embodiment, domestic violence, racialisation, and media representation.

Caring for Everyone: Effective and Inclusive Communication in Perinatal Care
One of the key recommendations of the Gender Inclusion Midwives’ guidance on Gender Inclusive Language in Perinatal Service is the adoption of “additive” language. This approach acknowledges male and non-binary birth parents alongside mothers, rather than simply replacing woman-centred language with a gender-neutral approach. This 2025 academic article by Matthew Cull, Jules Holroyd, and Fiona Woollard provides advice on a “pluralist” approach to language, which builds upon the additive model by offering a more contextual approach. It includes clear examples of what best practice can look like.

Image of poster on gender inclusive perinatal care. For version accessible to text reader, see download link above titled Poster: Gender Inclusive Perinatal Care.
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Building our own power: the Glasgow Transfem Electrolysis Project

Last year I joined the Glasgow Transfem Electrolysis Project, a super cool initiative which is raising money to train and equip two community members as electrolysists. Building on the example of Electrolysis by Siobhan, who opened her service off the back of a similar project in Manchester, the project’s aim is to ensure affordable and safe hair removal for trans women and non-binary people.

In an era of continued NHS failings and civil rights rollbacks, it’s important to be reminded of the power that lies in coming together as a community and working towards a common goal in our collective interest. Hateful policymakers and journalists can never take that away from us.

You can donate to the fundraiser here. We are also running LOVE ELECTRIC, a gig at Mono in Glasgow on Thursday 13th February, with pop, folk, punk, and drag artists. If you’re local, please come by to learn more about the project, and see some incredible live performers! I’m really excited for what’s going to be an amazing night.

Gig tickets are available here.