trans healthcare

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New article: Pathologising Legacy Measures and over-assessment

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

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

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

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

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

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

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

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

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

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

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Crowdfunder: help a Black trans kid afford care

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

Share or donate:
Help a Black trans kid afford care


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

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

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

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

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

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

Isaac’s story

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

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

They therefore need your help to afford care for Isaac.

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

NHS failings

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

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

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

How much money does Isaac’s family need?

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

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

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

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

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



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

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

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

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

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


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

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New book chapter: By Us and For Us: Bringing Ethics into Transgender Health Research

I’ve co-authored a short chapter for a new book that’s due out in February. The book, titled A History of Transgender Medicine in the United States: From Margins to Mainstream, traces the development of trans medicine across three centuries, with writing from more than 40 contributors.

The book is currently on offer from the publisher, SUNY Press. If you order by 6th December you can buy the book for 50% off with the code HOLIDAY24. That means the paperback edition will come to $22.47 for those in the USA, or £24.12 with postage for buyers in the UK.

I should clarify also that, as usual with academic books, I won’t personally be seeing a penny from its sale. So if you’d like to read this publication, please do get it at a bargain price if you can!

Book cover for A History of Transgender Medicine in the United States: From Margins to Mainstream, by Carolyn Wolf-Gould, Dallas Denny, Jamison Green, and Kyan Lynch. The cover features an anatomical drawing of a heart in the trans flag colours of white, pink, and blue, against a white background.


Our chapter is titled “By Us and For Us: Bringing Ethics into Transgender Health Research“, and I wrote it collaboratively with Noah Adams, Jaimie Veale, Asa Radix, Amrita Sarkar, and Danielle Castro.

In this chapter we explore the context and subsequent impact of an earlier work, our co-authored journal article (with additional author Kai Cheng Thom) Guidance and Ethical Considerations for Undertaking Transgender Health Research and Institutional Review Boards Adjudicating this Research. That article is now one of the most highly-cited works I’ve contributed to. Since its publication in 2017, it’s been used to inform the design and implementation of hundreds of studies, becoming more influential than I ever could have imagined.

I’m really grateful especially to Noah Adams for leading on the process of both our 2017 article and new book chapter. I first met Noah, along with Jaimie and Asa , at the 2016 WPATH Symposium in Amsterdam, which saw the presentation of numerous extremely unethical studies on trans and intersex people. I learned a great deal very fast at that symposium, and through the subsequent writing process with Amrita, Danielle, and Kai.

Most importantly, I learned that it is possible to change research and practice for the better through interventions that centre community perspectives, mutual learning, and our collective responsibilities to one another. This is an important thing to bear in mind in our current age of disinformation and the abuse of scientific discourse: while abusive practices have a long history in trans medicine and medical research, another world is possible.

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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.