NHS

by

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.

by

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?

by

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.

by

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.

by

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.
by

Amplify trans youth

This morning I logged into instagram and watched, transfixed in amazement and worry, as a young person scaled the walls of the Department for Education.

The aspiring spiderman is part of the activist group Trans Kids Deserve Better. At the time of writing they are staging a multi-day protest at the Department for Education building in London, for the right to a safe and inclusive education.

Watching the video, I fear for Squirrel, the anonymous activist who is genuinely risking their life to stop government employees from taking the group’s banner. It’s very apparent that Squirrel is a skilled climber who knows what they are doing – equally, one wrong move could result in a deadly drop to the concrete pavement. This is not safe.

But of course, the entire reason this protest is happening is because young trans people are not safe.

Trans Kids Deserve Better launched their campaign for youth autonomy, safety, respect, and inclusion in July, from a dramatically high ledge of an NHS England building. In an interview with Jess O’Thompson for Trans Writes, the emergency doctor and children’s TV presenter Dr Ronx Ikharia argued that “our young people deserve better than suffering, and shouldn’t be scaling walls”. But they added that for this to happen, trans kids must be “believed, supported, affirmed, and loved”.

And this is the crux of the issue. Under the Conservative and Labour governments, we have seen a policy environment in which teachers, doctors, therapists and parents are actively discouraged or prevented from believing, supporting, affirming, or loving young trans people. Instead, families face prison sentences for supporting young people’s continued access to medication, NHS England is expanding the provision of state-funded conversion clinics, and a growing number of schools are refusing to allow even the discussion of trans experiences.

Trans kids are not safe because they have been entirely failed by the adult world. They have been failed by politicians, failed by civil servants, failed by the NHS, failed by the voluntary sector, failed by researchers, and in many cases also failed by their doctors, teachers, and parents or carers. This is why the activists from Trans Kids Deserve Better are literally scaling walls in their fight for an actual future.

Looking at the challenges facing young trans people, it can be easy to lose hope. But the actions of Trans Kids Deserve Better show that there is a better way. Doomerism helps nobody. The successes of successive liberation struggles have come about because people have continually dared to believe that a better world is possible, and fight for it. The young people currently sat outside the Department of Education are not bemoaning what they have lost: they are insistently demanding change.

Image from Trans Kids Deserve Better

What can we do? In their conversation with O’Thompson, activists from Trans Kids Deserve Better explained that while trans adults often want to “protect” trans youth, they would rather we “amplify” them: “we don’t need sympathy, we need support”. This is a call to action, with a focus on solidarity, rather than trying to speak for young people or bemoan their situation.

Many adult trans people and allies have complained about the lack of mainstream media coverage for the actions of Trans Kids Deserve Better. But we should not simply wait for the papers or news programmes to start caring. It’s up to us to talk about what’s happening. Today’s queer and trans communities only exist at scale because we made our own media, told our own stories, and forced the mainstream to catch up.

So I encourage everyone who reads this to share the story of what is happening. Share it on social media, share it with friends and family, share it in conversations at work and in bars and in cafes and in parks and at gigs and festivals. A few days ago I was at a pub in Bath, fresh from Pride, still holding a placard that read “Ban Wes Streeting” (copied shamelessly from someone else in Glasgow a couple of weeks prior). Someone asked what Wes Streeting had done, so I told her. She was appalled, but grateful to have learned what is happening, and better informed to act. Information spreads when we spread information.

Trans Kids Deserve Better are also hoping that more people will contribute to their actions. You can sign up as a supporter, stay updated from their Instagram account, or contribute to their fundraiser.

If you, like me, would rather not see young people risking life and limb by climbing public buildings, it is time to fight with them, not “for” them. Together we can build a safer world.

by

Out now in Scientific American: “The U.K.’s Cass Review Badly Fails Trans Children”

I have co-authored an article with Cal Horton for the science magazine Scientific American. We take a concise look at what the Cass Review is, what it found, why the methods used were troubling, and how it is being used to harm young people.

You can read the article here. I hope it will be helpful as a basic explainer for why trans community groups, academic experts, and clinical specialists are so concerned about the Cass Review.

Screenshot of Scientific American website.

Writing for Scientific American was a really interesting experience. It was of course radically different to publishing in a peer-reviewed journal: we put the piece together in a matter of weeks, and it was not scrutinised by academic experts from our specific field of study. At the same time, there was an extremely rigorous editorial, fact-checking, and copyediting process that also made it very different to publishing in most magazines or newspapers.

I was deeply impressed with the sheer amount of time and care the Sci Am editors put into this piece. On one hand, their contributions ensured the piece is written in accessible language, with an international (and especially US-based) readership in mind. On the other hand, we had extensive discussions to ensure that all points made in the article could be rigorously evidenced, including some very detailed exchanges about the specifics of UK law, and what exactly the Cass Review document does and does not have to say about exponential growth over different periods of time. We had to be able to strongly back up any even slightly contentious point.

It was a challenging experience, but one I felt very held by as an author committed to consciencious research practice. Publishing this piece in Sci Am definitely ensured that it was as good as it could possibly be.

by

Understanding Trans Health on Philosophy Tube

My book Understanding Trans Health is cited prominently in the new Philosophy Tube video on complaint, systematic inflexibility, and England’s NHS trans health crisis.

It’s a great video, which manages to capture the sheer horror of NHS failings while still delivering silly jokes, ridiculous costumes, and a strong analysis. In addition to drawing on my work, Philosophy Tube’s Abigail Thorne consulted me on the script for this episode, and I appreciated the opportunity to use my research in this way.

I am personally more optimistic than Abigail about the opportunities offered by the four NHS England ‘pilot’ clinics. These are beginning to slash waiting times, and several are now effectively run by trans people, for trans people. However, I do think it’s important to still critique the very logic that underpins many trans healthcare systems, especially the highly questionable ways in which the medical diagnosis of ‘gender dysphoria’ is constructed, and used to try and control us.

You can buy Understanding Trans Health directly from Policy Press here. It’s also available from all major booksellers, plus many independent queer book stores (e.g. Leeds’ brilliant The Bookish Type). I have also written to my publisher for permission to put a chapter of the book online for free – watch this space! In the meantime, free links to much of my other academic writing can be found here.

by

“Living as a woman” – MPs take on the Real Life Test

I’m currently writing up a section of my thesis that describes trans people’s experiences of navigating the public health system in the UK. A large part of this is related to the “real life test”, a stage of treatment which patients are required to live for a period of time in their “acquired gender” in order to demonstrate that they are suitable candidates for hormone therapy and/or surgery.

This requirement (which, incidentally was absent from the latest version of the international World Professional Association for Transgender Health Standards of Care) has a lot of issues. These include the prioritisation of cisnormative standards, little-to-no recognition of non-binary identities, white-centric cultural insensitivity, and the frequent demand that patients hold down “an occupation” as part of the test (particularly pernicious in a time of high unemployment).

It was therefore very interesting to see MPs questioning the idea of the real life test during the fourth and final session of the UK Parliament Women & Equalities Committee’s inquiry into transgender equality earlier this week. The conversation, in which MPs quizzed Ministers and NHS England representative Will Huxter, went as follows:

Jess Phillips MP:
“I think I’d like to go back again to this idea of living in one gender identity: I wonder if you can tell me – clinically – what ‘living like a woman’ – or alternatively, man – actually means?”

Will Huxter:
“I’m not a clinician I can’t tell you what that’s – ”

Jess Phillips MP:
“Do you think that there is a clinical way to live as a woman? Or a man?”

Will Huxter:
“The point I am making is that we are guided by specialists who work in this area, the clinical consensus among gender identity specialists about how services should operate. We are absolutely open to looking at how that might change, but I’m not in a position to make a change to the way in which those services are commissioned without having gone through a clinical process”.

Maria Miller MP:
“Mr Huxter, sorry, I think we’re going to have to press you on that. Is – this is just factual, we have read that people have to ‘live like a woman’ or ‘live like a man’, we as a committee have struggled to know what that looks like in a day and age where men and women live in very similar ways. What do you – factually – what does that mean?”

Will Huxter:
“Well in terms of what is required by the clinic I’d be very happy to provide some details from clinical colleagues after this because it’s not – I don’t deliver the services nor am I a clinician. I feel I could give a better representation to the committee if I provided that outside.”

Maria Miller MP:
“Is the Minister comfortable with the fact that the government requires this information to be available, or that individuals have to live ‘like a man’ or ‘live like a woman’ in order to be able to change their identity?”

Jane Ellison MP:
“Well, I mean, put as you put it to us, I mean obviously you know it gives cause for concern in a sense that, you know, who wouldn’t have sympathy for someone put in that situation etc , clearly the committee has heard I know some really difficult evidence and I quite understand why you wish to reflect that. I mean I think that as Will has said you know there is actually currently a review going on anyway about this very issue, which is essentially about looking at the current guidelines, about understanding that represents current better practice, about giving some challenge to that. There are a number of – compared to even five years ago – there wasn’t a mechanism for the NHS to receive that sort of, you know, feedback from critical friends or otherwise. Those now exist, the transgender network has been set up, the various stakeholder groups that are, you know, really locked into the process. So I think what I’m saying is I don’t think there is ever, you know, clinical understanding of situations is rarely completely frozen in time, I mean this one particularly isn’t, because for a lot of people this is a very new speciality, and therefore I would imagine over the next ten years for example, the next few years, you will see an evolution. And that process is underway, which is exactly why the NHS is consulting and is looking at, particularly at its clinical, you know, specification. That process is actually going on at the moment and, as Will has said, very open to the committee’s recommendations being fed into that. But I know I’m not a clinician too, and I know from other areas of my portfolio perhaps better than this one because I’ve been doing it longer, I do know that you do need to test. Because once you commission to a standard, once you’ve got that, you know you do, you need to make sure you’ve tested your views, and that you actually capture a clinical consensus, because that’s the only way you can move forward. But that consensus will evolve.”

Jess Phillips MP:
“Okay, I just – from the Minister – just, I suppose, what I’m looking to hear, is that you recognise that there is not a single list of attributes that represents what it is to be a woman and/or a man; and therefore, there cannot be a clinical list of things that a person can be told to do by a doctor in order to tick those boxes. Do you recognise that fact?”

Jane Ellison MP:
“Well I understand what you’re saying and I think that it would be very helpful if we – subsequent to this hearing – write to the committee with some – with an example from a clinician operating in the field as to what they would mean by that, because obviously you know people are sitting down with individual people and saying, you know, requiring them to do that and they must have an idea of what that requirement is, what that looks like. So I think we should ask the question of clinicians and supply the committee with some, perhaps some examples, obviously anonymised, of where that’s already happening in clinical practice, and what that looks like.”

You can watch the footage here.

women and equalities

All of this is relevant to the law – in addition to clinical practice – because of the current functioning of the Gender Recognition Act. In order to gain “full” legal recognition as female or male (non-binary options aren’t available) people who have transitioned are required to apply for a Gender Recognition Certificate (GRC). In addition to £140, a whole load of paperwork and scrutiny from the national Gender Recognition Panel (no, really), individuals wishing to acquire a GRC need clinical approval. It’s no wonder that many trans people simply refuse to play along, leading to consequences such as the Tara Hudson case.

As it turns out, there is an answer to be found in the clinical literature. Charing Cross GIC clinical lead James Barrett has the following to say on the subject of the real life test in his book, Transsexual and Other Disorders of Gender Identity: A Practical Guide to Management:

“The question immediately arises of what constitutes ‘success’ in a chosen gender role. In essence, ‘success’ amounts to occupation, sexual, relationship and psychological stability. Of these, the first can be measured by whether or not the patient can manage to hold down a full-time (or equivalent part-time occupation in the chosen role for a year, in the course of the real life experience […] ‘Success’ in an occupation is achieved if the patient is treated by most others as if they are of the assumed sex. It is not necessarily that those around the patient believe that they are that sex […] Rather than being believed to be the assumed sex, the goal should be taken as an treated as that sex.”

[…]

“Some patients fiercely maintain that they do not care what others think of them, and that their own conviction of their gender is what matters. This position is at odds with the philosophy of a real life experience and if followed seems not to be predictive of a good longer-term outcome.”

Barrett further qualifies that “success cannot occur within a “purely transvestite or transsexual environment”, because “others may be supranormally accepting”.

So there you have it: “living as a woman” or “living as a man” means being taken as such within a cis environment. A very postmodern basis for clinical excellence!

by

No, I will not help Sundog make a documentary on trans “regret”

This afternoon I received an unsolicited email in my work account from an employee of Sundog Pictures. An excerpt follows:

I’m currently working on an idea alongside Channel 4 following transgender individuals who have come to regret their sex changes and are keen to undergo further treatment / operations to reverse the change. The doc will be insightful and sensitive and will look at the way in which transgender individuals are treated in society and whether the process before someone is permitted an operation is robust enough.

I’m currently looking for real life cases to include in my pitch document and was wondering whether you might be able to recommend people I could speak to, or places I could contact to find individuals who are currently thinking about a reverse sex change. Any help would be really appreciated.

Given the email account used, I feel that I can safely assume that I was contacted because of my academic work, which looks at discourses of trans healthcare provision. Sundog seem to hope that I will (without compensation) draw upon my community contacts and research findings to recommend participants for their television programme.

I couldn’t think of anything more inappropriate.

There’s a lot to be said about research ethics and a duty of care towards participants, but plenty has been written about that elsewhere (the BSA Statement of Ethical Practice offers a decent broad overview). So in this post I focus on the huge problems that come with the proposed topic of the documentary: that of trans “regret”.


The numbers

The mainstream media take an undue interest in trans “regret”. It’s very easy to come across such stories on daytime television and in both tabloid and broadsheet newspapers. The popularity and frequency of such stories suggests that it’s not too unusual for people who have undertaken a physical transition from male to female, or from female to male, to consider or undertake a “reverse sex change”.

In reality, research has shown time and time again that the actual rate of regret is extremely low. For instance, only 2% of respondents in the Trans Mental Health Study (the second-largest trans study undertaken in the UK) reported “major regrets” about the physical changes experienced during transition. Reported regrets from participants included:

“…not having the body that they wanted from birth, not transitioning sooner/earlier, surgery complications (especially loss of sensitivity), choice of surgeon (if surgery required revisions and repairs), losing friends and family, and the impact of transition on others.”

It’s clear therefore that “regret”, when it occurs, is likely to stem from societal and surgical issues rather than the process of physical transition in and of itself. The Trans Mental Health Study also demonstrates a clear link between physical transition and wellbeing in terms of mental health, body confidence and general life satisfaction.

With so few trans people regretting physical transition – and even less considering some kind of “de-transition” – it’s no surprise that sometimes the same individuals are trotted out time and time again to re-affirm a discourse of regret.


What’s missing from this story?

It’s pretty clear from the email I received that that the author has not done their research. Given the existence of organisations such as Trans Media Watch and All About Trans who are entirely keen to offer advice, this does not exactly inspire confidence.

For a start, transition is conflated with “sex change”, a term that is not only most frequently associated with transphobic tabloid headlines, but is also broadly meaningless. At what point can we talk about a “sex change”? When an individual undertakes hormone therapy? Chest surgery? Genital surgery? What about individuals who transition socially, but only undergo some (or even none!) of these processes? It’s not the kind of language that suggest an “insightful and sensitive” documentary can be made.

There’s a couple of more fundamental mistakes in the proposal, however. The first is the question of “whether the process before someone is permitted an operation is robust enough”. My own initial research findings suggest that if anything, the process in question is too robust – in that patients requiring surgery are typically required to wait many years before treatment is available.

The World Professional Association for Transgender Health Standards of Care require patients to undergo at least 12 months of hormone therapy prior to genital surgery. In reality, patients in England and Wales face a substantial waiting list (sometimes lasting years) before they are able to attend an NHS Gender Clinic, where two separate clinicians are required to approve a regime of hormone therapy before it can be undertaken. An additional two opinions are needed at a later date before a referral for genital surgery can take place. There are many, many opportunities and a great deal of time for patients to consider and re-consider their option – and that’s even before we take into account the horrific scale of the current crisis in surgery provision for trans women.

The current system is not constructed to facilitate transition so much as prevent the very possibility of regret. The result is increased suffering – in terms of the mental and physical health impact upon individuals who are forced to wait many years for hormones and surgery, whilst fearing (sometimes with good reason) that they will be denied treatment on spurious grounds. It’s no surprise that the Trans Mental Health Study found that “not transitioning sooner/earlier” is a major cause of “regret”, as individuals who have waited until breaking point to transition soon discover that there is still a long, long road ahead of them.

The second fundamental problem with Sundog’s proposal is their idea that trans people who aren’t too happy with their transition might be “keen to undergo further treatment / operations to reverse the change”. This is a very binaristic notion that both stems from and reinforces the notion that transition is a one-way process, from one (binary) gender to the other. In reality, there are many people for whom transition is a complex, ongoing process. For instance,  an individual who initially transitions from male to female might later feel that their identity is better understood as genderqueer, and may allow or pursue further physical changes to reflect this.


The wider political context

Given the tiny proportion of trans people who “regret” transition and the realities of service provision, the choice of a documentary about the subject appears at best to be somewhat misguided. However, the impact of insensitive coverage on this topic is such that I believe that I believe this documentary could be actively harmful, particularly as Sundog’s email asks “whether the process before someone is permitted an operation is robust enough”.

This is in part because the way in which discourses of regret are handled makes it harder for trans people to get treatment. Gender clinics in the UK require urgent intervention to make life easier for individuals who transition, not harder. Media hysteria over the possibility of regret reinforces the current system’s approach, which is to require people to demonstrate over and over again that they are trans before there is any hope of treatment.

But it’s also because discourses of regret are employed by those who campaign against trans liberation, including conservative commentators and anti-trans radical feminists who would deny funding for transition on the NHS altogether. Writers such as Julie Bindel are all too keen to use any example of individual regret to argue that transition is unnecessary mutilation, undertaken by sad, sick individuals who might have done otherwise if only they’d been given the option of, say, some form of reparative therapy.

The focus on the medical process is therefore politically loaded. Yes, some people do de-transition, and their stories are important and of worth. But these stories have yet to be told by the mainstream media in a non-sensationalised manner, in a way that doesn’t reinforce (intentionally or otherwise) a pernicious anti-trans agenda. Sundog’s proposal appears to feed right into this agenda.

This proposed documentary should not be regarded as a curiosity piece taking place in a cultural vacuum. It draws upon and will contribute to damaging and inaccurate tropes about transition. Ill-informed media accounts ultimately play a part in creating and maintaining a situation where “regret” frequently stems from the responses of friends and family, delays to transition and other negative experiences that come with transitioning in a transphobic society.

I hope therefore that any future attempts to examine trans health issues in this way will involve better research into the topic at the initial stages, and a greater sensitivity to both the personal and political consequences of exposing trans lives to media scrutiny.