Sullivan Review

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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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It’s a long hard revolution

Lesbian conspiracies in Lausanne

On the evening of Tuesday 15th April 2025, I was widely perceived to be a British lesbian, both legally and socially. By 11am the following day, that was no longer the case, following a ruling by the UK’s Supreme Court.

I was not actually in the UK for this momentous occasion. I was instead in the Swiss city of Lausanne, for a workshop on standards of evidence in sex and gender policy. I was there to consider the very questions the UK’s highest court, in their supreme ignorance, had effectively dismissed. Their ruling determined that the term “sex” in the Equality Act referred to “biological sex”, which in turn should be understood as “the sex of a person at birth”. But what do we actually need to know about when we make policy around sex and gender, and what is the role of evidence in this?

The Tuesday evening found me hanging out in a second-rate Thai restaurant with Professor Sarah Lamble, an esteemed criminologist and fellow dyke. Lamble and I spent some time talking about how conspiracy theories around “disappearing lesbians” highlighted the strange ironies inherent in British anti-trans discourse. The anti-trans movement has been extremely successful in raising “reasonable concerns” around supposed problems that are completely ungrounded in reality, to the point where that reality itself begins to warp.

Mainstream political discourse in the UK increasingly reflects anti-trans claims that lesbians are somehow threatened by trans people, or are even being transed en-masse in gender clinics and youth groups. The true biological attraction between two adult human females is disrupted. Young people are tempted away from lesbianism with promises of luxurious facial hair and male privilege; meanwhile, horrifically manly and/or confusingly attractive trans dykes are introduced to the dating pool.

If these claims were true, we might expect to see some kind of reduction in the number of homosexual females. Instead, the evidence we have indicates quite the opposite. Surveys such as the Annual Population Study show a rising number of lesbians over recent years, part of a wider increase of 1.2 million in the recorded lesbian, gay, and bisexual (LGB) population of the UK. This is driven especially by young people coming out, with over 10% of people aged 16-24 identifying as LGB as of 2023.

But what about the lived reality of queer womanhood? Well, there’s great news here too: we are living in a truly historic time for sapphic culture in the UK. Proudly out lesbian and bisexual women can be found across the pop charts, on TV, and across social media. Queer bookshops are on the rise. Pop-up butch bars and new queer cafes can be found in major cities and small towns.  And, excitingly, even the much-maligned lesbian bar is making a comeback, with three permanent venues and numerous occasional nights now running in London alone. It’s all got so out of hand that in 2024 the Queer Brewing company sold a juicy pale ale named Dyke Renaissance, which conveniently listed an educational series of cultural milestones on the can.

If trans people are trying to disappear lesbians, we’re doing a really bad job of it.

Photo of a beer can. Text on the can reads as follows. The great Dyke Renaissance of Spring 24. The lesbian tapas riot of Broadway Market. Rapid increase in lesbian parties. Carabiner sales increase. Finally more than one lesbian bar in London. Leatherdyke night. Top shortage worsens. Bestie to lover pipeline shortens. Queer Brewing, pale ale, 4.4%.


Meanwhile, queer cis women tend to be pretty supportive of trans people. In fact they’re one of the single most supportive demographics in the UK – which is presumably why the Equality and Human Rights Commission is, right now, attempting to ban trans dykes such as myself from associating with any more than 25 biological lesbians at any one time.

On evidence

As lesbian conspiracy theories show, the very concept of evidence has had a bit of a hard time over the past decade.

In the UK, this was perhaps best encapsulated in 2016 by the Conservative politician Michael Gove. While campaigning for Brexit, he declared that the British people “have had enough of experts”. Gove’s claim is echoed in a growing anti-intellectualism across the globe. From the mass purge of universities in Türkiye, to the post-truth bizarro world of Donald Trump, to Israel’s scholasticide in Gaza, this trend manifests in blunt and brutal ways. Anti-expert authoritarianism doesn’t care about your facts or your feelings.

However, attacks on evidence can also be more subtle. Gove’s comments are widely quoted, but it’s less well-known that he singled out a particular kind of expert for criticism: “people from organisations with acronyms saying that they know what is best and getting it consistently wrong”. While this was gloriously vague in a way that allowed the listener to project all kinds of things onto Gove’s words, in context it was nevertheless evocative of the kind of group that tends to advocate for social justice. LGBTQQIAAP groups, perhaps.

From academic thinktanks, to charities, to campaigning organisations, the implicit problem was any kind of challenge to conservative common sense. The UK’s political mainstream has since doubled-down on this approach. In the run up to the 2024 general election, Tory home secretary Suella Braverman criticised “experts and elites”, while the secretary of state for science, innovation and technology, Michelle Donelan, promised to “kick woke ideology out of science”.

One of Donelan’s targets was the “denial of biology” in research by feminists, social scientists… and biologists. The problem here is that supposedly common sense notions of sex and gender, which assume clean and tidy biological divisions between male and female, collide violently with the beautiful messy reality of the material world. At this point in history, it is well-established that sexual diversity exists throughout nature, that men are not biologically superior to women, that social advantage is not conferred or denied by chromosomes, and that queer, trans, and intersex people exist in the world. The evidence for this is gloriously multifaceted. We find it in laboratories, in systematic reviews, in surveys and questionnaires, in the way that men shout abuse at us in the streets, in how our sexed bodies shift and change under hormonal influence, in the way we feel when we finally have a language that describes our experiences.

Michelle Donelan decided to tackle the thorny problems of feminist science, intersex bodies, and trans existence by commissioning a research project by Alice Sullivan, a supposed sociologist who doesn’t care one jot for any of the evidence outlined above. Published in March 2025, the Sullivan Review insisted that data collection relating to sex and gender should rely on a very narrow definition of biological sex: one that ignores trans and intersex women’s real lives, bodies, and experiences of misogyny, while promoting a sexist model of essentialised womanhood. Her findings were echoed in those of the Supreme Court judges a month later, whose pronouncements on biological sex were made without any reference to relevant social, scientific, or philosophical research on how this might actually be understood or defined in practice. 

To position this as a wholly new trend would, of course, would be inaccurate. Western jurisdictions have long used and abused pseudoscience to oppress minoritised groups, especially in colonial contexts. This can be seen for example in the British state’s shameful embrace of “race science” and eugenics in the 19th and 20th centuries. What we are now witnessing is an example of the imperial boomerang, in which the logics of colonialism are turned inwards, resulting in increasingly fascist domestic politics.


But did you have a nice time in Switzerland, Ruth?

On that fateful week in April, I joined a group of feminist, trans, and lesbian researchers and activists for the workshop at the University of Lausanne. In the face of increasingly ill-informed policymaking across multiple contexts, it provided us a space to think together about the lessons we might learn collectively from our very different work on healthcare, sports, and prisons.

One overarching theme was the importance of evidence in understanding human experience, in terms of rigorous data collection, careful analysis – and accounting for the lived reality of actual people’s actual lives. A powerful account of the latter point was provided by Dinah Bons, a veteran campaigner for HIV prevention. She pointed out that if a sex worker repeatedly attends a community clinic for her STI tests, this provides evidence that the clinic feels safe enough for her to return regularly, which is far from a given. Such matters are often highly evident to service users and providers on the ground, without any need for a survey or interview.

Another key theme at the workshop was the extent to which various principles of evidence are increasingly abused by politicians, journalists, and institutions.

The concept of evidence has not been rejected wholescale by sexist, transphobic, and lesbophobic policymakers. Rather, “evidence” is increasingly a buzzword to justify particular approaches or points of view, rather than something grounded in a commitment to scholarly standards or an acknowledgement of lived experience. At the workshop, we explored how flawed notions of evidence have been used to support misleading statements or outright lies about human bodies or human experiences. We heard about the use and abuse of evidence in justifying invasive sex-testing for woman athletes, misrepresenting research on young people’s ability to engage in informed decision-making, and defending conversion practices. Notably, while most of these abuses arose from a specifically transphobic politics, they have far wider consequences: especially for women, intersex, and queer people, but also for scientific processes, community consultations, and informed advocacy more broadly.

You can see an example of this in the Cass Review. Through successfully performing the aesthetics of acceptable expertise and science to the satisfaction of the British public, the Review has become what one workshop participant described as a black box. By this they meant that it has become an abstracted justification for policy and practice, handily replacing any ongoing discussion of evidence regarding young trans people’s health and wellbeing. You don’t need to know what the Cass Review actually says or how rigorous it actually is, only that it exists. Well-documented criticisms of the review from healthcare practitioners, academic experts, trans community groups, and (most importantly) young trans people themselves are been rendered irrelevant. The Cass Review is the evidence, and no other systematic review, original research, or personal testimony can henceforth count against it. Not, at least, until 2031 at the earliest: the official end-date of a single £10 million study, based on the Cass recommendations and featuring precisely zero trans researchers.

The British establishment is now attempting to repeat this trick with the Sullivan Review – never mind that projects such as MESSAGE have conducted more extensive and nuanced work on the same topic with a far wider group of experts – and, of course, with the Supreme Court judgement.

Beyond doom

As with Cass, as with Sullivan, it is difficult to capture the sheer enormity of harm caused by the Supreme Court’s pronouncement on biological sex. The consequences are still playing out, and will no doubt continue to do so for many awful months and years.

At the time of writing, the Equality and Human Rights Commission have proposed a programme of mass segregation, designed to discriminate against trans people in the workplace, in public services, and in social groups. The guidance they have written is just that: guidance, not law. Nevertheless, major organisations such as the Football Association, the British Transport Police, and Barclays Bank, all of whom shamelessly paraded rainbows through their social media profiles last Pride season, are falling over themselves to comply. We are witnessing the attempted complete exclusion of trans people from public life, in the latest culmination of a transparent attempt to eliminate us altogether.

In such moments, it can be easy to despair. This is in part because it is easy to forget the strength, resources, power held within trans communities and by our allies. That includes the knowledge and evidence we have access to.

Don’t get me wrong. The people who want to eliminate us are better-funded, better-connected, and now have the Labour government on-side as well as the UK’s traditional right-wing parties. We are not going to win trans liberation overnight.

But then, again, we never were.

Everything I said about lesbian culture earlier is true of trans people too. There are more of us publicly creating art and culture, more of us creating events and running nightclubs and playing in bands and writing essays (hi). There are more community groups providing mutual aid and support when charities and state bodies fail us. And, importantly, we are not alone.

Trans women and non-binary people are a part of the dyke renaissance. We are at the butch bars, and bemoaning the top shortage. We are dancing to Le Tigre and to Chappelle Roan. We are reading Gideon the Ninth and watching We Are Lady Parts and having all the feelings. My partner of the last decade was probably the most surprised of all to learn from the Supreme Court that I am not, in fact, a lesbian, as every bit of evidence from our shared personal lives points to quite the contrary.

I will concede that some trans people are not in fact lesbians, or even queer. Nevertheless, there are so many other places to find us in community with others. Trans people are in trade unions. Trans people are in workplaces. Trans people are in schools and colleges and universities. Trans people are in the streets. Trans people are on the bus. Trans people are in families. Trans people are making families. Trans people are playing football (suck it, Football Association). Trans people are eating pizza. Trans people are restoring the countryside. Trans people are hanging out beside Lake Geneva in the glorious sunshine, enjoying a much-needed break.


There are more of us than ever, and it is too damn late to put us back in a box.

Resistance is fertile

I was honoured to present the keynote presentation at the Swiss workshop. I spoke about the findings of the Trans Pregnancy Project, a study that produced enormous amounts of evidence on the experiences, needs, and perspectives of men and non-binary people who conceive, carry, and give birth.

No matter how much our findings are slammed by the media and billionaire children’s authors and washed-up comedy writers, our peer-reviewed work has demonstrated the lived reality of male and non-binary pregnancy over and over again. Most importantly, it has helped people. We are part of a far wider movement of parent groups, midwives, and researchers who are collectively building knowledge. I am constantly hearing from people who describe how much this knowledge has resulted in better care for them and their child. This kind of story drives everything I do.

Towards the end of my talk, I discussed the anti-trans moral panic, and the Supreme Court judgement. I then showed the below table of findings from the National Maternity Survey. This annual survey involves those who have recently given birth every year in many (but not all!) English hospitals, over the course of a few weeks. Since 2021, they have started asking whether the person giving birth has a different gender to the sex they were assigned at birth – i.e. are they trans?

Table showing data in response to the question, is your gender different from the sex you were assigned at birth. It shows a statistically significant increase in the proportion of people answering "yes", which rises from 0.56% in 2021, to 0.65% in 2022, to 0.77% in 2023, to 1.58% in 2024.


Two things leap out from this table for me. Firstly, the 2021 data shows a very similar proportion of people indicating they are trans when compared to the 2021 censuses in Scotland, England, and Wales. This suggests that, contrary to assumptions around trans infertility or undesirability, trans men and non-binary people may well be just as likely to give birth as cis women are to become birth mothers.

Secondly, the number of trans people giving birth has risen dramatically over four years. Even as the anti-trans moral panic has deepened. Even as attacks on even recognising the existence of trans people in perinatal services have increased. As Del La Grace Volcano once it put it: “resistance is fertile!”

In the face of growing oppression, trans people are simply refusing to disappear. In fact, we are doing the opposite.

This, then, is the power that the anti-trans movement, the Labour party, and the Supreme Court cannot possibly take away from us. The more trans people are out and visible to one another, the more trans people come out and become visible to one another. Sure, we will unfortunately need to think more carefully about where and when we are out, and where and when we are visible, if this is something we even have any power over in our specific lives. I am sure that more trans people will be going stealth in future years, if they can. But regardless – there are more of us in community, more of us organising protests, and more of us than ever in the lives of our friends, families, colleagues, and allies, showing that it possible to have a good life while being trans.

In this context, it is important to know that people from many parts of the world gathered in Lausanne this April to pool our knowledge and skills and experiences. It is important to know that we have each returned to our home countries to share what we gained. It is important for people to know that similar meetings are happening across the world, in community centres and on university campuses, in board rooms and in bedrooms, involving trans people, and feminists, and yes, lesbians. We are constantly building a movement for positive change, and you do not have to be an academic or veteran activist to be a part of it. Trans power is for everyone.

There is much to say what needs doing in the current moment. We need allies to continue fighting alongside trans people for our collective liberation. We need to be demonstrating in the streets, funding mutual aid and legal action, actively resisting complicity in Labour’s eliminationist agenda, and encouraging every public body under the sun to do the same.

Evidence will be helpful for this. Evidence from academic research, sure, but also – as Dinah Bons pointed out – testimony from the everyday reality of trans people’s lives. And oh boy, do we have that evidence.

More of us than ever are producing evidence of trans existence, and trans persistence.

And this is how we win.