gender reassignment nhs england

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• Health and social care
• Public health
• Population screening programmes
• NHS abdominal aortic aneurysm (AAA) programme
• NHS population screening: information for transgender people
• NHS England

NHS population screening: information for trans and non-binary people

Updated 4 January 2023

Applies to England

© Crown copyright 2023

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

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This publication is available at https://www.gov.uk/government/publications/nhs-population-screening-information-for-transgender-people/nhs-population-screening-information-for-trans-people

This information is for trans (transgender) and non-binary people in England. It tells you about the adult NHS screening programmes that are available in England and explains who we invite for screening.

We use trans as an umbrella term to embrace the diverse range of identities outside the traditional male/female definitions. These include transgender, gender fluid and non-binary. Find more trans health information on NHS.UK .

Screening for trans people at a glance

Trans women and non-binary people assigned male at birth who are registered with a GP as female:

• are invited for breast screening
• are invited for bowel cancer screening
• do not need cervical screening as they do not have a cervix
• are not routinely invited for abdominal aortic aneurysm ( AAA ) screening but can request screening

Trans women and non-binary people assigned male at birth who are registered with a GP as male:

• are not routinely invited for breast screening but can request screening
• are invited for AAA screening

Trans men and non-binary people assigned female at birth who are registered with a GP as female:

• are invited for cervical screening
• are not invited for AAA screening

Trans men and non-binary people assigned female at birth who are registered with a GP as male:

• are not routinely invited for cervical screening but can request screening
• are invited for AAA screening but do not have a high risk of AAA

Trans men who are pregnant should be offered the same antenatal and newborn screening tests as all other pregnant individuals.

Breast screening

Breast screening is a free NHS test that is carried out at breast screening centres and at mobile breast screening units across England.

Breast screening can find cancers when they are too small to see or feel. Finding and treating cancer early gives you the best chance of survival. Screening will miss some cancers, and some cancers cannot be cured.

Taking part in breast screening is your choice. You can find out more information from your GP or by visiting NHS.UK .

Breast screening invitation process

All individuals from 50 up to their 71st birthday who are registered as female with their GP are automatically invited to breast screening. When you are due for screening, we will send you an invitation letter. It is not possible for individuals registered as male to have mammograms as part of the NHS Breast Screening Programme, but your GP can refer you for mammograms at a hospital near you (see the information for people registered as male below).

We invite you for breast screening every 3 years. Your first invitation will arrive sometime between the ages of 50 and 53. If you are trans it is important that your GP makes sure that your records are up to date so you are invited for screening correctly.

If you do not want to be invited for breast screening, you need to contact your local breast screening office. They will explain how you can opt out of breast screening.

It is important that you feel that you are treated with dignity and respect at all times.

Let your screening service know if you would:

• like your appointment at the beginning or end of a clinic
• prefer to be screened at your local breast screening centre rather than a mobile breast screening unit

Visit NHS.UK for your service’s contact details.

Trans men and non-binary people assigned female at birth

Registered with a gp as female.

If you are aged from 50 years up to your 71st birthday and registered with a GP as female, you will be routinely invited for breast screening. We recommend you consider having breast screening if you have not had chest reconstruction (top surgery) or still have breast tissue.

If you are worried about visiting a breast screening unit you can ring to arrange a more suitable appointment. For example, we can arrange for you to have an appointment at the beginning or end of a clinic.

Registered with a GP as male

If you are registered with a GP as male, you will not be invited for breast screening. If you have not had chest reconstruction (top surgery) and are aged 50 or over we suggest you talk to your GP . They can arrange a referral for you to have mammograms at a hospital near you.

You should keep aware of the symptoms of breast cancer , and contact your GP if you notice any unusual changes.

If you have had chest reconstruction (top surgery), we advise you have a conversation with your surgeon about the amount of breast tissue you have remaining. If they confirm you still have breast tissue, you can ask your GP to refer you for mammograms at a hospital near you.

Trans women and non-binary people assigned male at birth

Registered with a gp as a female.

If you are aged from 50 up to your 71st birthday and registered with a GP as female, you will be routinely invited for screening. Long-term hormone therapy can increase your risk of developing breast cancer so it is important that you consider going for breast screening when you are invited.

If you are registered with a GP as male, you will not be invited for breast screening.

If you have been on long-term hormone therapy you may be at increased risk of developing breast cancer. Your GP can arrange a referral for you to have mammograms at a hospital near you.

Breast screening test

A breast X-ray called a mammogram is used to look for signs of cancer. Each breast is pressed firmly between the plates of an X-ray machine for a few seconds. The pressure is needed to get good images and also reduce the radiation dose. Your test will be carried out by a specially trained female mammographer.

Some people say having a mammogram is uncomfortable and a few may find it painful, but the discomfort should pass quickly.

Breast screening usually involves 2 X-rays of each breast. People who have implants are offered the choice of additional X-rays so the mammographer can see as much breast tissue as possible.

Preparation

If you are a trans man or non-binary person assigned female at birth who is registered with a GP as female, has not had chest reconstruction (top surgery) and wears a binder, you will need to remove this before having your mammogram.

Private changing facilities will be available so that you can remove your binder just before having your mammogram. If you have any concerns about your appointment, you can contact your local breast screening service.

Breast screening results

For most people the mammograms will show no signs of cancer. If changes are seen on your X-rays, you will be recalled to an assessment clinic for more tests which will include:

• a breast examination
• more X-rays or ultrasound scans

You may also have a biopsy, where a small sample of tissue is taken from the breast with a needle.

Sometimes breast screening can pick up cancers that would never have caused harm, so people are treated for breast cancer that would never have been life-threatening.

Reducing your risk

Screening reduces the number of deaths from breast cancer by finding signs of disease at an early stage.

It is important to know what is normal for your body. If you notice any changes report them to your GP .

Cervical screening

Cervical screening (also known as a smear test) is a free NHS test that is carried out at your GP surgery or at some sexual health clinics. The test looks for early changes in the cells of the cervix.

Cervical screening aims to prevent cancer from developing in the cervix (neck of the womb).

It is important to go for screening as finding changes before they become cancer gives you the best chance of successful treatment.

Nearly all cervical cancers are caused by human papillomavirus ( HPV ). HPV is a very common virus – most people will be infected with it at some point in their life. It can be passed on through any type of sexual activity.

Screening will not prevent all cancers and not all cancers can be cured.

Taking part in cervical screening is your choice. You can find out more information from your GP or by visiting NHS.UK .

Cervical screening invitation process

We invite people registered as female for cervical screening every 3 years from the age of 25 to 49 and every 5 years from the ages of 50 to 64. We also invite people who are over 65 who have not been screened since age 50 or those who have recently had abnormal tests.

We send an invitation letter when the cervical screening test is due, asking you to make an appointment.

If you are trans it is important that your GP contacts the NHS Cervical Screening Programme so you are invited for screening correctly. If you do not want to be invited for screening you should contact your GP . They will be able to remove you from the cervical screening invitation list.

It is important that you feel that you are treated with dignity and respect at all times. If you are worried about having cervical screening, talk to your doctor or practice nurse.

If you are aged 25 to 64 and registered with a GP as female, you will be routinely invited for cervical screening. We recommend that you consider having cervical screening if you have not had a total hysterectomy and still have a cervix.

If you are aged 25 to 64 and registered with a GP as male, you will not be invited for cervical screening. However, if you have not had a total hysterectomy and still have a cervix, you should still consider having cervical screening. This is especially important if you have had any abnormal cervical screening results in the past. If this applies to you, let your GP or practice nurse know so you can talk to them about having the test.

If you are a trans woman or non-binary person assigned male at birth, you will not need to be screened as you do not have a cervix.

If you are registered with a GP as female, you will be routinely invited for cervical screening unless your GP has already told us you’re not eligible. We can update our records so you are not invited unnecessarily.

If you are registered with a GP as male, you will not be invited for cervical screening.

Cervical screening test

The nurse or doctor will put an instrument called a speculum into the vagina to help them see the cervix. They will then take a sample of cells with a soft brush.

If you are a trans man who has taken long-term testosterone, you may find screening uncomfortable or painful. You may want to talk to your doctor or nurse about using a different size speculum and some extra lubrication.

Cervical screening results

For most people their test results are normal. If cell changes are found you may need another cervical screening test, or an appointment at a colposcopy clinic where the cervix is looked at in detail.

Nearly all cervical cancers are caused by a virus called human papillomavirus ( HPV ) which is passed on through any type of sexual activity. If you are worried about your risk of developing cervical cancer you may want to speak to your GP or practice nurse.

We recommend you consider going for cervical screening every time you are invited, even if you have had a previous normal result.

Let your GP or practice nurse know if you think you should be invited for screening.

Even if you have had the HPV vaccine we still recommend you consider going for cervical screening when invited.

Consider stopping smoking, as smoking increases your risk of cervical cancer.

If you have symptoms such as unusual vaginal discharge or bleeding, or pain during or after sex, please speak to your doctor even if you have had a normal cervical screening result.

AAA screening

AAA screening is a free NHS test that is carried out in the community, including hospitals, health clinics and GP practices.

AAA screening involves a simple ultrasound scan to measure the abdominal aorta.

The aorta is the main blood vessel that supplies blood to the body. Sometimes the wall of the aorta in the abdomen can become weak and stretch to form an abdominal aortic aneurysm ( AAA ). There is a risk that an AAA may split or tear (rupture).

There is a high risk of dying from a ruptured AAA . Finding an aneurysm early gives you the best chance of treatment and survival. AAA screening reduces your risk of dying from a ruptured AAA .

Taking part in AAA screening is your choice. You can find out more information about AAA screening from your GP or by visiting NHS.UK .

AAA screening invitation process

AAAs are far more common in men aged over 65 than in women and younger men. That’s why the NHS AAA Screening Programme only invites for screening individuals registered as male. However, any trans woman will have the same risk as a man and should consider accessing screening.

Individuals registered as male are invited for an ultrasound scan to check the size of their abdominal aorta when they are 65.

Individuals over 65 can request a scan by contacting their local AAA screening service directly. Visit NHS.UK for contact details.

If you are trans it is important that your GP contacts the NHS AAA Screening Programme so you are invited for screening correctly. If you do not want to be invited for AAA screening, you will need to let us know.

If you are not sure if you should be screened or not, contact your local screening office. You will find your local screening office number and more information about clinic locations on NHS.UK .

Trans men and non-binary people assigned female at birth do not have the same risk of AAA as people assigned male at birth.

If you are registered with a GP as female, you will not be invited for AAA screening.

If you are a trans man aged 65 who is registered with a GP as male, you will be sent an appointment to attend for AAA screening. You can have AAA screening if you wish even though your risk is lower. If the clinic location or appointment time is not suitable, you can contact your local screening office to change this. You will find your local screening office phone number on your invitation letter.

If you are registered with a GP as female, you will not be invited for screening. However, if you are 65, you will have the same risk as a man aged 65 and should consider accessing screening. You can contact us to arrange a suitable appointment. Visit NHS.UK for contact details.

If you are aged 65 and registered with a GP as male, you will be invited for AAA screening.

Any trans woman or non-binary person assigned male at birth will have the same AAA risk as a man and should consider accessing screening.

AAA screening test

The test is a simple ultrasound scan of your abdomen to measure the size of the aorta. Your screening appointment usually takes about 10 to 15 minutes.

The screener will check your personal details and ask for your consent (permission) to do the ultrasound scan.

You will be asked to lie on your back and lift up your top. You will not need to undress completely. If you are wearing a binder, you may be asked to remove it.

The ultrasound scan is usually painless. It can be slightly uncomfortable as the screener may need to apply some pressure.

AAA screening results

The screener will give you your results following your scan.

It is not always possible to see your aorta at your screening test so you may be referred to hospital.

If your aorta is found to be bigger than normal, you will need regular scans to check if it is growing. Some people never need surgery for their AAA .

If your AAA is large you will be referred to a specialist team to discuss planned surgery. Large AAAs can be treated successfully with surgery.

Consider taking part in AAA screening and follow-up when you are invited.

You should also consider:

• stopping smoking
• drinking less alcohol

It is also important to maintain a healthy weight through a healthy diet and physical activity.

Bowel cancer screening

Bowel cancer screening starts with a test kit that is offered for use at home. If the result shows further tests are needed, you are offered a colonoscopy (an examination of the bowel).

Bowel cancer screening reduces your risk of dying from bowel cancer.

Finding cancer early gives you the best chance of survival.

Screening will miss some cancers, and some cancers cannot be cured.

Taking part in bowel cancer screening is your choice. You can find out more information from your GP or by visiting NHS.UK .

Bowel cancer screening invitation process

Both men and women are routinely invited for screening.

Bowel cancer screening is offered every 2 years from the ages of 60 to 74. This age range is gradually being extended down to age 50. People aged 75 and over can request a test kit every 2 years by calling the free programme helpline on 0800 707 60 60.

The home test kit

A bowel screening test kit and information pack will be sent to you when you are due for screening. You are asked to collect one or more samples of your poo using the test kit provided.

You will need to complete the test kit within the timeframe on the instructions and return it using the freepost packaging provided.

The test looks for tiny amounts of blood in the sample which you may not be able to see and which could be a sign of bowel cancer. You can contact the free NHS Bowel Cancer Screening Programme helpline for advice on 0800 707 60 60.

Results from the test kit

If blood is found, you will be referred for further tests. This may involve you having a colonoscopy, which looks at the lining of the bowel using a flexible camera. You may find this more uncomfortable if you have had gender reassignment surgery.

To reduce your risk of bowel cancer you should:

• consider taking part in screening, even if you have had a previous normal result
• try to eat a high-fibre diet with plenty of fruit and vegetables, take regular physical exercise and stop smoking
• visit your GP if you notice blood in your poo, a change in your bowel habit over a number of weeks or unexplained weight loss

Bowel cancer can run in families. If you are worried about your risk please speak to your GP .

Your personal information

It is your decision whether or not to have any of these tests.

The NHS Screening Programmes use personally identifiable information about you to ensure you are invited for screening at the right time. NHS England also uses your information to ensure you receive high quality care.

Find out more about how your information is used and protected, and your options . Find out how to opt out of screening .

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Part of Data quality of protected characteristics and other vulnerable groups

• Gender identity

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• Sexual orientation

Gender identity and why it is important to ask about

Gender identity is a way to describe a person’s innate sense of their own gender, whether male, female, or non-binary, which may not correspond to the sex registered at birth. Gender identity should not be confused with registered sex at birth, or with sexuality or who someone is attracted to .

Guidance on the differences between sex and gender have been published by the World Health Organisation and the Office of National Statistics:

• Definition of Gender - WHO
• What is the difference between sex and gender? - ONS

For many, but not all people, the sex they were registered at birth is the same as their current gender.

Anyone can change their legal gender, through the Gender Recognition Act, and ‘gender reassignment’ is a protected characteristic under the Equality Act (2010). 

Data collection about gender identity also covers if a patient’s gender identity is the same as their sex registered at birth and can also be referred to as ‘trans status’, ‘trans history’ or ‘trans identity’. Trans is an umbrella term used to refer  to people whose gender is different from the sex they were registered at birth. In the context of the Equality Act 2010, trans people are referred to as having undergone, currently undergoing, or proposing to undergo gender reassignment, a process for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex. It is also important to distinguish between gender identity (which everyone has as per definitions above) and being trans (or having the protected characteristic of gender reassignment) which is a relationship to gender but is not a gender in itself.

To be protected from gender reassignment discrimination, an individual does not need to have undergone any specific treatment or surgery to change from their sex assigned at birth. This is because changing physiological or other gender attributes is a personal process rather than a medical one. A person can be at any stage in the transition process – from proposing to reassign their gender, to undergoing a process to reassign their gender, or having completed it. This can additionally include a change of name, pronouns and/or appearance.

Gathering information on gender identity and trans identity is important to allow us to better understand health inequalities. By collecting this data, services can provide more personalised care to patients, as well as better understand trans and non-binary people’s experiences, outcomes, and inequalities at a local system level. https://www.lgbtqiahealtheducation.org/wp-content/uploads/Collecting-Sexual-Orientation-and-Gender-Identity-Data-in-EHRs-2016.pdf');" onkeyup="return vjsu.onKeyUp(event)" class="nhsd-a-link">The opportunity to share information about patient’s gender identity in a welcoming environment can facilitate important conversations with clinicians who are in a position to be extremely helpful  (Opens in PDF).

How to ask patients about their gender identity

Staff and patients have to understand why this information is being collected, how it will be analysed and what the information will be used for.

It is important to find the right time to ask these questions, as patients may not feel comfortable disclosing at first but may feel comfortable enough to do so later on. It is also important to allow trans and non-binary identities to signal that trans and non-binary identities should be recognised and valued by services, to avoid cisnormativity and to promote LGBT+ inclusive practice. The consequences of not including and using options for trans and non-binary individuals to record and use their gender identity, could result in disengagement from care and feelings of stigmatisation.

A patient may ask why this data is being collected or choose not to share their gender identity and/or trans status. Staff should make it clear they are under no obligation to share anything they are uncomfortable with and reassure them that if they choose to share this information, it will be kept strictly confidential.

If a patient wishes to know why you are asking for this data, you can inform them that the service collects this information so that they can enhance services and to ensure that it continues to remain inclusive of people of all identities.

If a patient declines to respond to a gender identity data item as they do not agree with the question or how it is asked, then that is their choice and they can leave the field blank.

There is an increasing range of guidance and support to help people working in health services to consider how they can provide trans inclusive healthcare and how to appropriately ask for information on gender, including “Recommendations for Trans*- Inclusive Healthcare” from  Kings College London.

How to collect and record gender identity data

In MHSDS v5.0 and IAPT Data Set v2.1 (from April 2022), two new data items, which relate to gender identify and gender at birth (shown in in Table 3) together aim to better capture how patients would like their gender and sex to be recorded. They will also support services on how to better care for their patient.

These data items should be completed using information provided by the patient as part of registrations and/or care contacts. They should not be completed by linkage to the NHS Spine or assumed/inferred by the service. This is important because gender data recorded by other NHS services could relate to sex registered at birth or their gender identity, and also because it’s possible that a patient’s gender identity may have been recorded differently by services at an earlier time in their journey in understanding their identity.

In line with this, the gender identity selected by a patient within a service should never be overwritten by information recorded by other services or via the NHS Spine.

Further information on the gender data items present in MHSDS v5.0 and IAPT Data Set v2.1 is set out below:

Gender Identity Code (new code for MHSDS v5.0 and IAPT Data Set v2.1)

This is now the priority data item on gender identity. This data item captures how patients tell providers how they would like their gender recorded by the service. Providers should collect/verify this information from/with patients and not extracted or assumed from NHS Spine data.

Gender Identity Same at Birth Indicator (new code for MHSDS v5.0 and IAPT Data Set v2.1)

This is also now a priority data item to provide a complete understanding of the patient’s gender. Providers should proactively ask for this information as part of the demographic information discussed with and requested from patients. This should be done by asking the patient the question, not by making assumptions from other data provided.

Person Stated Gender Code (existing code)

This is no longer a priority data item. It records the gender information that the GP holds from the NHS Spine and providers do not need to request this data from patients. If no GP data is available to complete this, it can be left blank on provider systems. This data item is now low priority to complete as it does not reflect best practice in recording gender identity. It has been retained as it matches the gender data item in the NHS Spine and so retaining it avoids any potential issues with data linkage and matching.

Why prioritise the new data items Gender Identify and Gender Identity Same at Birth?

The NHS has a public sector duty to ensure equality for all our patients under the equality act, including sex and trans status. 

The move from requesting completion of the Person Stated Gender Code (version 4.1) to prioritising the Gender Identity Code and the Gender Identity Same at Birth Indicator Code (version 5) is to enable patients to more accurately and inclusively record their gender identity, sex and trans status, and thus more effectively gather information about how to treat someone. What is the benefit of these changes?

• align with the changes made to the 2021 census.
• support Advancing Equalities Mental Health Strategy and understand inequalities and risk factors surrounding different population groups accessing mental health services
• close the gap in the evidence available on trans and non-binary patients' service access and care experience
• develop more inclusive and trauma-informed care services.
• remove the mixing of gender and sex registered at birth that exists in data held within person stated gender

The new data items GENDER IDENTITY CODE and GENDER IDENTITY SAME AT BIRTH INDICATOR allow patients and datasets to better distinguish gender and sex by recognising they are separate concepts.

What does the Person Stated Gender data item record?

The NHS data dictionary definition of person stated gender is “self-declared or inferred by observation for those unable to declare their PERSON STATED GENDER”.

It is sometimes incorrectly assumed that in practice the PERSON STATED GENDER CODE is capturing the sex assigned at birth of patients.

This data captures the gender someone states to an NHS service and so does not capture sex assigned at birth. However, for many people these two things will be the same. Patients can also request the gender recorded for them in NHS systems to be changed to reflect their gender identity - Process for registering a patient gender re-assignment (england.nhs.uk).

It is therefore important for patient safety and care to ask gender inclusive questions of patients regardless of what gender has been recorded for the patient.

How and why are the new gender data items included in the Data Quality Maturity Index (DQMI) score?

Currently only Person Stated Gender is included in the performance scoring for the DQMI.

The Gender Identity code and Gender Same at Birth Indicator code have been included as experimental data items in the DQMI. This means they do not have an impact on the DQMI score. 

As the priority is to record the Gender Identity code, it is important that providers are not penalised for recording that data rather than Person Stated Gender. The methodology for the DQMI is therefore being updated so that where data is submitted in the Gender Identity field, it is used to determine the scoring for Gender Identity data instead of Person Stated Gender. 

When this change is implemented, the DQMI score will only be impacted negatively for the Gender Identity code if providers submit:

• Invalid codes
• “X (not known)” code 

Person Stated Gender will be used for DQMI scoring where no data is recorded against the Gender Identity code, in which case that would have no impact on the DQMI score.

This approach to scoring gender data will be implemented from February’s 2023 data reporting.

How are the new gender data items used in mental health metrics, including perinatal mental health service access?

Gender based metrics, such as the perinatal mental health services access metric, are currently only based on contacts with patients recorded as “Female”. 

To identify female patients, the analysis now prioritises using any valid codes recorded against the Gender Identity code. This means that if providers are not collecting accurate data against this data item and simply put “Z” (not stated) or “X” (not known) against all records, then it will lower the access count for that provider.

If the provider does not have accurate gender identity codes collection for patients, the solution is simply to leave the Gender Identity code empty until meaningful data is collected against it.

The perinatal team plan to implement changes to that approach in 2023/24 to also include patients identified through the two new gender data items as trans men or non-binary.

Why is it not possible to record a specific gender at birth for non-binary patients?

The new data items to record GENDER IDENTITY CODE and GENDER IDENTITY SAME AT BIRTH INDICATOR enable more inclusive recording of gender identity while also more clearly identifying gender at birth for cisgender and transgender patients.

However, it is not possible to identify gender at birth for patients whose gender identity is non-binary. That is because the gender at birth data item only records Y/N whether current gender is the same as at birth.

The consultation process through which the new gender data items developed established that non-binary individuals actively do not wish to be considered within the binary protected characteristic sex and may decide not to answer any questions that cover this area. It was through engagement that it was established that non-binary people were likely to reject a direct sex question and including one could mean that cohort disengaging and rejecting to answer any of the questions on gender.

For more information on how to ensure your services are providing inclusive healthcare for non-binary people, please visit the LGBT Foundation website .

Complying with the Gender Recognition Act 2004

Organisations will not be in breach of the Gender Recognition Act 2004 by asking for and, where the patient consents, sharing and recording the trans status of patients with a Gender Recognition Certificate (in line with other medical data). Organisations will also not be in breach for reporting this to the MHSDS via the gender at birth data item.

It is not an offence under this act to disclose protected information relating to a person with a Gender Recognition Certificate if that person has agreed to the disclosure of the information.

Delivering clinically safe care to patients where sex-based characteristics are relevant

All services should be asking all patients inclusive questions to identify relevant care information. It is not safe to make assumptions about an individual using the Person Stated Gender code. 

The MHSDS data items are not meant to replace clinical information about the patient’s anatomy, hormone levels, medical and/or surgical treatment to alter the body. This information should be documented properly in the clinical notes, not relied upon from this data field. The fields are for data monitoring, not clinical information.

To understand the sex assigned at birth for non-binary people, this should be done through the patient’s assessment process, as with any person with a male/female gender recorded, not based from the Gender Identity or Gender Same at Birth data items.

This briefing on monitoring Trans Status provides further information on why is important to capture this information from patients. In addition, there are videos available on the Trans Health Inequality YouTube channel that support healthcare professionals understanding of the needs of trans patients not only as an equality issue, but also as a patient safety issue.

Good practice examples of gender inclusive service support are set out in the same sex accommodation guidance published in 2019.

The British Medical Association (BMA) has also published guidance on Inclusive care of trans and non-binary patients to support services.

What about services that rely on sex assigned at birth information? 

Some services do in part use the Person Stated Gender item to identify patients in scope of their services, such as cervical and prostate screening services. 

Sex based services already need to take additional steps to use the person stated gender data items to identify trans men and women that should be referred to those services. The screening programmes that are linked through primary care settings, such as their GP clinic, use the gender code recorded in the GP system to pull people onto screening lists. 

The National LGBT Advisor team is working with screening programmes to enable manual removal/addition to screening lists, which will be assisted by better inclusive questions. The Person Stated Gender is already not adequate to be used in isolation for this purpose. Therefore, services must have inclusive processes and conversations with their patients for important healthcare issues like screening.

The two new gender identity codes, and the more inclusive conversations with patients that clinicians aim to promote, will therefore improve services’ ability to identify people that need screening and other support.

Table 3 identifies the data items required to record and flow this data to the MHSDS and IAPT Data Set.

Last edited: 25 January 2024 3:53 pm

• Data quality of protected characteristics and other vulnerable groups
• Changes to these data items in the national data set
• Inequalities in mental health and why this data is a priority
• How to collect this data
• Accommodation status (homelessness and rough sleeping)
• Explaining why and how we collect this data to patients
• Reporting on mental health equality
• How to contact us

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Chelsea Centre for Gender Surgery (CCGS)

Our Trust has been commissioned by NHS England to provide lower masculinising gender affirmation surgery. The Chelsea Centre for Gender Surgery is passionate about helping patients alleviate their gender dysphoria. We work with service specialists and the transgender community to deliver a high quality, patient centred service, supporting patients through their surgical journey. 

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What the trans care recommendations from the NHS England report mean

The report calls for more research on puberty blockers and hormone therapies.

A new report commissioned by the National Health Service England advocates for further research on gender-affirming care for transgender youth and young adults.

Dr. Hillary Cass, a former president of the Royal College of Paediatrics and Child Health, was appointed by NHS England and NHS Improvement to chair the Independent Review of Gender Identity Services in 2020 amid a rise in referrals to NHS' gender services. Upon review, she advises "extreme caution" for the use of hormone therapies.

"It is absolutely right that children and young people, who may be dealing with a complex range of issues around their gender identity, get the best possible support and expertise throughout their care," Cass states in the report.

Around 2022, about 5,000 adolescents and children were referred to the NHS' gender services. The report estimated that roughly 20% of children and young people seen by the Gender Identity Development Service (GIDS) enter a hormone pathway -- roughly 1,000 people under 18 in England.

Following four years of data analysis, Cass concluded that "while a considerable amount of research has been published in this field, systematic evidence reviews demonstrated the poor quality of the published studies, meaning there is not a reliable evidence base upon which to make clinical decisions, or for children and their families to make informed choices."

Cass continued: "The strengths and weaknesses of the evidence base on the care of children and young people are often misrepresented and overstated, both in scientific publications and social debate," read the report.

Among her recommendations, she urged the NHS to increase the available workforce in this field, to work on setting up more regional outlets for care, increase investment in research on this care, and improve the quality of care to meet international guidelines.

Cass' review comes as the NHS continues to expand its children and young people's gender identity services across the country. The NHS has recently opened new children and young people's gender services based in London and the Northwest.

NHS England, the country's universal healthcare system, said the report is expected to guide and shape its use of gender affirming care in children and potentially impact youth patients in England accessing gender-affirming care.

MORE: Lawsuit filed by families against Ohio trans care ban legislation

The debate over transgender youth care.

In an interview with The Guardian , Cass stated that her findings are not intended to undermine the validity of trans identities or challenge young people's right to transition but to improve the care they are receiving.

"We've let them down because the research isn't good enough and we haven't got good data," Cass told the news outlet. "The toxicity of the debate is perpetuated by adults, and that itself is unfair to the children who are caught in the middle of it. The children are being used as a football and this is a group that we should be showing more compassion to."

In the report, Cass argued that the knowledge and expertise of "experienced clinicians who have reached different conclusions about the best approach to care" has been "dismissed and invalidated" amid arguments concerning transgender care in youth.

Cass did not immediately respond to ABC News' request for comment.

Recommendations for trans youth care

Cass is calling for more thorough research that looks at the "characteristics, interventions and outcomes" of NHS gender service patients concerning puberty blockers and hormone therapy, particularly among children and adolescents.

The report's recommendations also urge caregivers to take an approach to care that considers young patients "holistically and not solely in terms of their gender-related distress."

The report notes that identity exploration is "a completely natural process during childhood and adolescence."

Cass recommends that pre-pubertal children and their families have early discussions about how parents can best support their child "in a balanced and non-judgemental way," which may include "psychological and psychopharmacological treatments" to manage distress associated with gender incongruence and co-occurring conditions.

In past interviews, U.S. physicians told ABC News , that patients, their physicians and their families often engage in a lengthy process of building a customized and individualized approach to care, meaning not every patient will receive any or every type of gender-affirming medical care option.

Cass' report states that evidence particularly for puberty blockers in children and adolescents is "weak" regarding the impact on "gender dysphoria, mental or psychosocial health. The effect on cognitive and psychosexual development remains unknown."

The NHS has said it will halt routine use of puberty blockers as it prepares for a study into the practice later this year.

MORE: Amid anti-LGBTQ efforts, transgender community finds joy in 'chosen families'

According to the Endocrine Society puberty blockers, as opposed to hormone therapy, temporarily pause puberty so patients have more time to explore their gender identity.

The report also recommends "extreme caution" for transgender youth from age 16 who take more permanent hormone therapies.

"There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18," the report's recommendations state.

Hormone therapy, according to the Endocrine Society , triggers physical changes like hair growth, muscle development, body fat and more, that can help better align the body with a person's gender identity. It's not unusual for patients to stop hormone therapy and decide that they have transitioned as far as they wish, physicians have told ABC News.

Cass' report asserts that there are many unknowns about the use of both puberty blockers and hormones for minors, "despite their longstanding use in the adult transgender population."

"The lack of long-term follow-up data on those commencing treatment at an earlier age means we have inadequate information about the range of outcomes for this group," the report states.

Cass recommends that NHS England facilities have procedures in place to follow up with 17 to 25-year-old patients "to ensure continuity of care and support at a potentially vulnerable stage in their journey," as well as allow for further data and research on transgender minors through the years.

Several British medical organizations, including British Psychological Society and the Royal College of Paediatrics and Child Health, commended the report's recommendations to expand the workforce and invest in further research to allow young people to make better informed decisions.

“Dr Cass and her team have produced a thought-provoking, detailed and wide-ranging list of recommendations, which will have implications for all professionals working with gender-questioning children and young people," said Dr Roman Raczka, of the British Psychological Society. "It will take time to carefully review and respond to the whole report, but I am sure that psychology, as a profession, will reflect and learn lessons from the review, its findings and recommendations."

Some groups expressed fears that the report will be misused by anti-transgender groups.

"All children have the right to access specialist effective care on time and must be afforded the privacy to make decisions that are appropriate for them in consultation with a specialist," said human rights group Amnesty International. "This review is being weaponised by people who revel in spreading disinformation and myths about healthcare for trans young people."

Transgender care for people under 18 has been a source of contention in both the United States and the United Kingdom. Legislation is being pushed across the U.S. by many Republican legislators focused on banning all medical care options like puberty blockers and hormone therapies for minors. Some argue that gender-affirming care is unsafe for youth, or that they should wait until they're older.

Gender-affirming medical does come with risks, according to the Endocrine Society , including impacts to bone mineral density, cholesterol levels, and blood clot risks. However, physicians have told ABC News that all medications, surgeries or vaccines come with some kind of risk.

Major national medical associations in the U.S., including the American Academy of Pediatrics, the American Medical Association, the American Academy of Child and Adolescent Psychiatry, and more than 20 others have argued that gender-affirming care is safe, effective, beneficial, and medically necessary.

The first-of-its-kind gender care clinic at Johns Hopkins Hospital in Maryland opened in the 1960s, using similar procedures still used today.

Some studies have shown that some gender-affirming options can have positive impacts on the mental health of transgender patients, who may experience gender-related stress.

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The NHS Ends the "Gender-Affirmative Care Model" for Youth in England

Following extensive stakeholder engagement and a systematic review of evidence , England’s National Health Service (NHS) has issued new draft guidance for the treatment of gender dysphoria in minors, which sharply deviates from the “gender-affirming” approach. The previous presumption that gender dysphoric youth <18 need specialty “transgender healthcare” has been supplanted by the developmentally-informed position that most need psychoeducation and psychotherapy. Eligibility determination for medical interventions will be made by a centralized Service and puberty blockers will be delivered only in research protocol settings. The abandonment of the "gender-affirming" model by England had been foreshadowed by The Cass Review's interim report , which defined "affirmative model" as a "model of gender healthcare that originated in the USA."

The reasons for the restructuring of gender services for minors in England are 4-fold. They include (1) a significant and sharp rise in referrals; (2) poorly-understood marked changes in the types of patients referred; (3) scarce and inconclusive evidence to support clinical decision-making, and (4) operational failures of the single gender clinic model, as evidenced by long wait times for initial assessment, and overall concern with the clinical approach.

The new NHS guidance recognizes social transition as a form of psychosocial intervention and not a neutral act, as it may have significant effects on psychological functioning. The NHS strongly discourages social transition in children, and clarifies that social transition in adolescents should only be pursued in order to alleviate or prevent clinically-significant distress or significant impairment in social functioning , and following an explicit informed consent process . The NHS states that puberty blockers can only be administered in formal research settings, due to the unknown effects of these interventions and the potential for harm. The NHS has not made an explicit statement about cross-sex hormones , but signaled that they too will likely only be available in research settings. The guidelines do not mention surgery , as surgery has never been a covered benefit under England’s NHS for minors.  

The new NHS guidelines represent a repudiation of the past decade’s approach to management of gender dysphoric minors.  The “gender-affirming” approach, endorsed by WPATH and characterized by the conceptualization of gender-dysphoric minors as “transgender children” has been replaced with a holistic view of identity development in children and adolescents. In addition, there is a new recognition that many gender-dysphoric adolescents suffer from mental illness and neurocognitive difficulties, which make it hard to predict the course of their gender identity development.

The key highlights of the NHS new guidance are provided below.* 

1. Eliminates the “gender clinic” model of care and does away with “affirmation”

• The NHS has eliminated the “gender clinic” model of care where children are seen solely by a specialist gender dysphoria practitioner, replacing it with standard care in children’s hospital settings.
• Rather than “affirming” a transgender identity of young person, staff are encouraged to maintain a broad clinical perspective and to “embed the care of children and young people with gender uncertainty within a broader child and adolescent health context.”
• “Affirmation” has been largely eliminated from the language and the approach. What remains is the guidance to ensure that “assessments should be respectful of the experience of the child or young person and be developmentally informed.”
• Medical transition services will only be available through a centralized specialty Service, established for higher-risk cases. However, not all referred cases to the Service will be accepted, and not all accepted cases will be cleared for medical transition.
• Treatment pathway will be shaped, among other things, by the “clarity, persistence and consistency of gender incongruence, the presence and impact of other clinical needs, and family and social context.”
• The care plan articulated by the Service will be tailored to the specific needs of the individual following careful therapeutic exploration and “may require a focus on supporting other clinical needs and risks with networked local services.”

2. Classifies social gender transition as an active intervention eligible for informed consent

• The NHS is strongly discouraging social gender transition in prepubertal children.
• diagnosis of persistent and consistent gender dysphoria
• consideration and mitigation of risks associated with social transition
• clear and full understanding of the implications of social transition
• a determination of medical necessity of social transition to alleviate or prevent clinically significant distress or impairment in social functioning
• All adolescents will need to provide informed consent to social gender transition.

3. Establishes psychotherapy and psychoeducation as the first and primary line of treatment

• All gender dysphoric youth will first be treated with developmentally-informed psychotherapy and psychoeducation by their local treatment teams.
• Extensive focus has been placed on careful therapeutic exploration, and addressing the broader range of medical conditions in addition to gender dysphoria.
• For those wishing to pursue medical transition, eligibility for hormones will be determined by a centralized Service, upon referral from a GP (general practitioner) or another NHS provider.

4. Sharply curbs medical interventions and confines puberty blockers to research-only settings

• The NHS guidance states that the risks of puberty blockers are unknown and that they can only be administered in formal research settings. The eligibility for research settings is yet to be articulated.
• The NHS guidance leaves open that similar limitations will be imposed on cross-sex hormones due to uncertainty surrounding their use, but makes no immediate statements about restriction in cross-sex hormones use outside of formal research protocols.
• Surgery is not addressed in the guidance as the NHS has never considered surgery appropriate for minors.

5. Establishes new research protocols

• All children and young people being considered for hormone treatment will be prospectively enrolled into a research study.
• The goal of the research study to learn more about the effects of hormonal interventions, and to make a major international contribution of the evidence based in this area of medicine.
• The research will track the children into adulthood.

6. Reinstates the importance of “biological sex”

• The NHS guidance defines “gender incongruence” as a misalignment between the individual’s experience of their gender identity and their biological sex.
• The NHS guidance refers to the need to track biological sex for research purposes and outcome measures.
• Of note, biological sex has not been tracked by GIDS for a significant proportion of referrals in 2020-2021.

7. Reaffirms the preeminence of the DSM-5 diagnosis of “gender dysphoria” for treatment decisions

• The NHS guidance differentiates between the ICD-11 diagnosis of “gender incongruence,” which is not necessarily associated with distress, and the DSM-5 diagnosis of “gender dysphoria,” which is characterized by significant distress and/or functional impairments related to “gender incongruence."
•  The NHS guidance states that treatments should be based on the DSM-5 diagnosis of “gender dysphoria.” 
• Of note, WPATH SOC8 has made the opposite recommendation, instructing to treat based on the provision of the ICD-11 diagnosis of “gender incongruence.” “Gender incongruence” lacks clinical targets for treatment, beyond an individual’s own desire to bring their body into alignment with their internally-held view of their gender identity.

8. Clarifies the meaning of “multidisciplinary teams” as consisting of a wide range of clinicians with relevant expertise, rather than only “gender dysphoria” specialists

• The NHS guidance clarifies that a true multidisciplinary team is comprised not only of “gender dysphoria specialists,” but also of experts in pediatrics, autism, neurodisability and mental health, to enable holistic support and appropriate care for gender dysphoric youth.
• neurodevelopmental disorders such as autistic spectrum conditions
• mental health disorders including depressive conditions, anxiety and trauma
• endocrine conditions including disorders of sexual development pharmacology in the context of gender dysphoria
• risky behaviors such as deliberate self-harm and substance use
• complex family contexts including adoptions and guardianships
• a number of additional requirements for the multidisciplinary team composition and scope of activity have been articulated by the NHS.

9. Establishes primary outcome measures of “distress” and “social functioning”

• The rationale for medical interventions for gender-dysphoric minors has been a moving target, ranging from resolution of gender dysphoria to treatment satisfaction.  The NHS has articulated two main outcome measures of treatment: clinically significant distress and social functioning .
• This is an important development, as it establishes primary outcome measures that can be used by researchers to assess comparative effectiveness of various clinical interventions. 

10. Asserts that those who choose to bypass the newly-established protocol will not be supported by the NHS

• Families and youth planning to obtain hormones directly from online or another external non-NHS source will be strongly advised about the risks.
• Those choosing to take hormones outside the newly established NHS protocol will not be supported in their treatment pathway by NHS providers.
• Child safeguarding investigations may also be initiated if children and young people have obtained hormones outside the established protocols.

With the new NHS guidance, England joins Finland and Sweden as the three European countries who have explicitly deviated from WPATH guidelines and devised treatment approaches that sharply curb gender transition of minors. Psychotherapy will be provided as the first and usually only line of treatment for gender dysphoric youth.

The full text of the NHS guidance can be accessed here .

 * This is a transitional protocol as the NHS works to establish a more mature network of children’s hospitals capable of caring for special needs of gender dysphoric youth. A fuller service specification will be published in 2023-4 following the publication of the Cass Review’s final report .

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1st May 2024

Sex and the NHS constitution

Sex Matters welcomes the announcement by the Department for Health and Social Care that it is updating the NHS Constitution for England to reflect the Equality Act 2010 and protect single-sex care. 

Secretary of State Victoria Atkins said:  

“We have always been clear that sex matters and our services should respect that.” 

When the NHS constitution was first adopted in 2009, its first principle, to provide a universal service, did not mention the protected characteristic of sex but instead included “gender”. This sloppy language allowed confusion, which was exploited by activists inside and outside the NHS . 

The NHS constitution guarantees “separate-sex” sleeping accommodation, but in practice the policy has operated on the basis of gender self-identification as set out in the “Annex B” policy . 

The NHS also messed up its data, despite being told by its own experts in 2009 that the term “gender” was “too ambiguous to be desirable or safe”. It failed to make sure that sex was accurately and clearly recorded , allowing both patients and healthcare professionals to identify themselves on the basis of their personal preference. Most recently it adopted a system developed by a US company that records patients’ “legal sex” and whether a person is “cisgender” or “transgender”, and asks clinicians to fill in a mix-and-match checklist of organs. This is confusing, dangerous and exclusionary. 

The proposals 

The government proposes to update the first principle of the NHS constitution to reflect the Equality Act 2010 and state that healthcare “is available to all irrespective of sex, race, disability, age, sexual orientation, religion or belief, gender reassignment, pregnancy and maternity or marriage and civil partnership status.”

It then makes three specific proposals:

A new pledge on single-sex intimate care 

The new pledge will state: 

“Patients can request intimate care be provided, where reasonably possible, by someone of the same biological sex.” 

Intimate care is defined as an examination of breasts, genitalia or rectum, and care tasks of an intimate nature such as helping someone use the toilet or changing incontinence pads.

Clarification on single-sex accommodation

Additional wording to be added to the existing pledge: 

“If you are admitted to hospital, you will not have to share sleeping accommodation with patients of the opposite biological sex, except where appropriate. The Equality Act 2010 allows for the provision of single-sex or separate-sex services. It also allows for transgender persons with the protected characteristic of gender reassignment to be provided a different service – for example, a single room in a hospital – if it is a proportionate means of achieving a legitimate aim.”

This is in line with our recommendations (published in 2021) to revise “Annex B”, the NHS policy on how to accommodate transgender patients and maintain single-sex accommodation. 

While there have been some media reports that this means that transgender males will still be placed in “female-only” areas and then be provided with a single room if someone complains, we do not think this is the correct interpretation. We will be giving input to the consultation on this, asking for more clarity in the revised operational policy.  

Clarification on single-sex and separate-sex services and sex-based language

The final proposal is to add wording that states: 

“You have the right to expect that NHS services will reflect your preferences and meet your needs, including the differing biological needs of the sexes, providing single and separate-sex services where it is a proportionate means of achieving a legitimate aim.”

The introduction to this states: 

“Patients may be unclear about whether a specific condition applies to them and may not come forward for treatment if language is ambiguous. Clear terms that everyone can understand should always be used.”

The response from healthcare organisations

These proposed changes to the NHS constitution are a welcome and overdue return to common sense, and have come about because thousands of ordinary women and men have raised it in conversations and with their MPs, and because journalists have covered the issue .

But the response from organisations representing healthcare professionals and NHS managers reveals the problem of engrained institutional capture by gender ideology. 

The British Medical Association (BMA), the trade union for doctors, entirely misses the point of the change, and does not consider female patients at all in its response. Dr Emma Runswick says:

“If these proposed changes come into effect, transgender and non-binary patients will potentially find their access to vital NHS services limited.”

The new policy on intimate care and single-sex care would impact on trans and non-binary healthcare professionals who want to examine patients of the opposite sex without their consent . It would not not impact on trans and non-binary patients. 

The BMA has previously called for trans healthcare workers to be “able to access facilities appropriate to the gender they identify as” and “ensure trans people are able to access gendered space”. It is simply not possible to protect the privacy and dignity of single-sex accommodation while also including members of the opposite sex. 

Professor Nicola Ranger, chief nursing officer and deputy chief executive of the Royal College of Nursing (RCN), also failed to consider patients other than those with trans identities when she said : 

“Trans and non-binary patients are deserving of high-quality care like any other patient and changes to health policy should be done with them, not unto them.”

Matthew Taylor of the NHS Confederation , which represents the top management of NHS trusts, said:

“Whatever changes are eventually introduced following the consultation need to be clear and workable for NHS staff, who should not expect to have to interpret ambiguous guidance at a local level.”

Last year the NHS Confederation released guidance which told hospitals not to record patients’ sex but to ask them the ambiguous question of how they think of themselves, giving the options “female”, “male”, “non-binary” and “in another way”. It advised that “trans and non-binary people should be supported to use the bathrooms they feel most comfortable using”, disregarding the need for clear workable policies to protect the comfort and privacy of other patients. The guidance went on to say that patients have no right to know the sex of a healthcare worker, and that a patient cannot request same-sex care where there is no clear clinical benefit. 

The proposed changes to the NHS constitution will now be open for an eight-week consultation .

Sex Matters will be responding to it (and will publish some guidance), and will write to these professional bodies to call on them to consider the needs, concerns and welfare of all patients in their response.

Filed under Healthcare    Updates   

Tags: Consultation , NHS England

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• NHS gender identity...

NHS gender identity service to close and be replaced by regional centres

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The sole service in England treating children and adolescents for gender dysphoria will be shut down and a network of regional centres established, after a review concluded that a single specialist provider model was “not safe.”

The Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Trust in London will be discontinued after recommendations in the interim report from Hilary Cass, former president of the Royal College of Paediatrics and Child Health. 1

A multiprofessional review group set up by NHS England found that the service operated a predominantly “affirmative, non-exploratory approach, often driven by child and parent expectations” and that there was “limited evidence of . . . a discipline of formal diagnostic or psychological formulation.”

Cass’s review called for children and adolescents with gender incongruence or dysphoria to receive the “same standards of clinical care, assessment, and treatment as every other child or young person accessing health services.”

In a further letter of advice this month to NHS England, Cass has recommended that regional centres should generally be specialist children’s hospitals with established academic and education functions to ensure ongoing research and training, an integrated model of care to manage the holistic needs of patients, and staff with a broad clinical perspective. 2

NHS England said that it was taking immediate steps to establish two early adopter services. One in London will be led by a partnership between Great Ormond Street Hospital and Evelina London Children’s Hospital, with South London and Maudsley NHS Foundation Trust providing specialist mental health support.

The second, in the north west, will be led by a partnership between Alder Hey Children’s NHS Foundation Trust and the Royal Manchester Children’s Hospital, with both trusts also providing mental health services.

NHS England said that this was just the first step in commissioning a national network of regional centres over the coming years, with full consultation on the service specification. The initial view was that the optimal number of services might be seven or eight, but this would be confirmed in due course. The services might take the form of provider collaboratives, with each regional service led by an experienced provider of specialist paediatric care.

Children under the age of 16 with gender dysphoria may be given puberty blockers to stop them entering puberty, but Cass found that there was insufficient evidence to support their routine use. “To date, there has been very limited research on the short, medium, or longer term impact of puberty blockers on neurocognitive development,” she noted in her latest letter of advice.

NHS England has accepted her recommendation that young people being considered for hormone treatment should be enrolled into a formal research protocol, with follow-up continuing into adulthood, and “with a more immediate focus on the questions regarding puberty blockers.” It said it would collaborate with the National Institute for Health and Care Research to design and commission the research infrastructure and would “do everything possible to accelerate usual timeframes, learning the lessons from covid.”

The Royal College of Paediatrics and Child Health said it agreed that a new model was needed to increase capacity and reduce long waiting times. “The implementation of a regional model that focuses on reducing waiting time and providing tailored support to the individual needs of children and young people is welcomed. We also agree that more research is needed to understand the best treatment options for children and young people with gender dysphoria.”

• ↵ Cass H. Independent review into gender identity services for children and young people: interim report. 2022. https://cass.independent-review.uk/publications .
• ↵ Cass H. Independent review of gender identity services for children and young people: further advice [letter to NHS England national director for specialised commissioning]. Jul 2022. https://cass.independent-review.uk/wp-content/uploads/2022/07/Cass-Review-Letter-to-NHSE_19-July-2022.pdf .

What Tory gender laws changes would mean in hospitals, prisons and women’s sport

The Conservative Party has announced that it would change the Equality Act to protect “biological sex” and tighten up rules around access to single-sex spaces if it wins the general election.

Announcing the changes, the party said the Equality Act had “not kept pace with evolving interpretations and is not sufficiently clear on when it means sex and when it means gender”.

Equalities Minister Kemi Badenoch said the current definitions had caused “confusion”, adding: “Whether it is rapists being housed in women’s prisons, or instances of men playing in women’s sports where they have an unfair advantage, it is clear that public authorities and regulatory bodies are confused about what the law says on sex and gender and when to act – often for fear of being accused of transphobia, or not being inclusive.”

Under the current Equality Act, brought in by the Labour government in 2010, protections covering single-sex spaces do not differentiate between someone born female and someone who is transgender.

But the Conservative Party has promised to change existing laws to ensure the protections apply specifically to biological sex.

Here are what the changes proposed by the Conservative Party would mean in practice:

Under current regulations, someone who is transgender is usually housed in the prison population that is in line with their acquired gender , provided they have a gender recognition certificate and are living as their declared gender.

Exceptions are made on a case-by-case basis, for example if they are found to pose a serious risk or be at risk from a particular prison population.

This is because, under the Equality Act, it is illegal to discriminate against someone based on their gender identity, including if they are transgender.

The changes proposed by the Conservatives would see transgender individuals housed with others of the same biological sex, and ministers have argued this would protect women-only prisons from being populated with male-born prisons convicted of sexual offences.

Statistics published by the Ministry of Justice showed that there were 268 transgender prisoners recorded in 2023, up from 230 the previous year.

Of these, 203 identified as a transgender female, 41 as a transgender male and 14 as non-binary, while 10 self-identified differently or did not provide a response.

The majority of those identifying as transgender were in prisons that aligned with their biological gender, with five transgender females in women’s prisons and zero transgender males in men’s prisons.

Women’s sports

Currently, the Equality Act does allow for the separation of men and women when it comes to sporting activities and for those convening sporting events to exclude transgender people from participating in “gender-affected activity” to ensure fairness and safety for other competitors.

When it comes to sport, the main concern is that male athletes have some advantages over female athletes in terms of their size, testosterone levels and other factors. As a result, many sports bar transgender women from competing if they have high testosterone levels or have experienced male puberty.

The Government has claimed its changes would make it easier to prevent transgender females from participating in women’s sports, but it is unclear how this would operate in practice.

The current guidance from Sports England is that individual sports should develop their own rules regarding participation for transgender athletes in line with the Equalities Act.

It proposed that sporting bodies could either include transgender athletes with restrictions on testosterone, restrict the female category to only those who were registered female at birth, or create an additional universal category not dependent on sex or gender.

Toilets and changing rooms

Under the Equality Act, service providers can operate single-sex and separate-sex services – such as toilets and changing rooms – when they have a good reason.

They must not discriminate against someone because of the protected characteristics of sex or gender reassignment. There are, however, certain circumstances where transgender people can be excluded if the service provider can prove they have a legitimate reason.

Dead bodies 'showing signs of decomposition' in NHS hospitals across England

One example would be if a leisure centre chooses not to allow a transgender woman into a family changing room, citing privacy concerns. They would be required to justify why this was deemed necessary.

These rules currently only apply to people who have not legally changed their gender, but the new regulations proposed by the party could see these disapplied in certain circumstances in favour of their assigned gender at birth.

The changes would also make it easier for service providers to justify policies which exclude transgender people based on their gender at birth.

Hospitals 

Current official NHS guidance states that transgender people should be “accommodated according to their presentation: the way they dress, and the name and pronouns they currently use” regardless of whether they have legally changed their gender.

It also recommends that they be afforded more privacy through curtains or by placing them in a side room if it makes them more comfortable.

However, Health Secretary Steve Barclay announced in April that the Conservatives planned to make changes to the NHS constitution requiring hospitals to protect single-sex wards and recommending that transgender people should be put in single rooms.

Under the latest changes announced by the party, hospitals would be likely to face a new requirement to consider only biological sex when deciding in which ward to accommodate a patient.

Election 2024 Rishi Sunak and Sir Keir Starmer have been out on the campaign trail since the Prime Minister announced a surprise snap election on 22 May. i ‘s general election live blog follows all the twists and turns of the election period from all the major parties. The Tories have been busy announcing policies which include a new national service policy , a “triple lock plus” for pensioners and a crackdown on fly-tipping . Labour have spent most of the first full week of campaigning battling headlines over their candidates, including Diane Abbott and Faiza Shaheen who claimed to have been blocked from standing. Abbott has since been given the go-ahead to run for the party in her seat. Keep up to date with the 2024 general election in our extensive coverage, on everything from the main parties’ environment pledges and who is odds on to become the next prime minister , to the seats still without a candidate and what Labour and the Tories’ tax pledges mean for your money.

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Tories to amend Equality Act to make ‘biological sex’ protected characteristic

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“Changing your clothes does not change who you are”, a Cabinet Minister said on Monday as the Conservative ’s laid out plans to amend the Equality Act to define the protected characteristic of sex as “biological sex”.

Kemi Badenoch claimed the changes will make it simpler for service providers, such as those running domestic abuse and women’s shelters, to prevent biological males from entering.

It could result in transgender women being barred from female-only spaces or taking part in women’s sports.

The Government said it believes that Labour ’s Equality Act has not kept pace with evolving interpretations and is not sufficiently clear on matters of sex and gender.

The Women and Equalities Minister told LBC: “This is about protecting those who are vulnerable, it is not about stopping trans people from having privacy and dignity.

“That’s why we have said you should have unisex toilets, a disabled toilet is an example of that, or where there are shared spaces, they should be on the basis of biological sex.”

Ms Badenoch added: “Changing your clothes doesn’t change who you are.

“We want people who are trans to be protected as well, people who want to change their clothes should not be able to exploit the laws we have put in place to protect those people who are genuine transgender people, those who suffer gender dysphoria.

“Just putting on a different set of clothes does not make you transgender.”

Ahead of the General Election on July 4, the Tory party has proposed a change to the law will not remove the existing and continuing protections against discrimination on the basis of gender reassignment provided by the Equality Act.

The sex of those with a Gender Recognition Certificate will still align with their acquired gender in law outside the Equality Act, for example marriage law.

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Under the new scheme the Conservatives will also establish that gender recognition is a reserved matter, with Ms Badenoch saying, “it is impracticable for gender recognition regimes to vary in different parts of the country”.

Prime Minister Rishi Sunak said: “The safety of women and girls is too important to allow the current confusion around definitions of sex and gender to persist.

“The Conservatives believe that making this change in law will enhance protections in a way that respects the privacy and dignity of everyone in society.

“We are taking an evidence-led approach to this issue so we can continue to build a secure future for everyone across the whole country.”

Last year Ms Badenoch wrote to the Equality and Human Rights Commission (EHRC) seeking further guidance on gender recognition.

She said public bodies are acting out of “fear of being accused of transphobia”.

It comes after the Gender Recognition Bill was passed in the Scottish Parliament in 2022 and would have made it easier for transgender people in Scotland to get gender recognition certificates.

The Bill was prevented from proceeding to royal assent by an order under Section 35 of the Scotland Act 1998, made by the then Secretary of State for Scotland, Alister Jack.

In December, the Court of Session ruled the action was lawful, despite a Scottish Government challenge.

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Workforce equality and inclusion

The NHS Equality and Diversity Council announced on 31 July 2014 that it had agreed action to ensure employees from black and ethnic minority (BME) backgrounds have equal access to career opportunities and receive fair treatment in the workplace. The move followed a number of reports, which highlighted disparities in the number of BME people in senior leadership positions across the NHS, as well as lower levels of wellbeing amongst the BME population.

The Five Year Forward View sets out a clear direction for the NHS which depends upon it being innovative, engaging and respecting staff, and draws on the talent in our workforce. The link between the experience of staff and patient care is clear for BME staff in the NHS, so this is an issue for patient care, not just for staff. Yet it is clear that the NHS still has a lot to do to act on this.

As an individual NHS organisation, NHS England has committed itself to work to achieve the NHS Workforce Race Equality Standard (WRES). To be successful and demonstrate leadership we need to collect, analyse and publish relevant workforce data. Our current staff barometer does not match the NHS national staff survey and therefore there will need to be some interpretation, certainly in the first year, as to how our own survey indicators are applied. These will need to be aligned much more closely and enable the measurement of the WRES metrics in a relevant way.

NHS England has been working to deliver on its Workplace Equality, Diversity and Inclusion strategy 2013 – 2015. This strategy described how we would aim to achieve our ambitions through a clear focus on five strategic themes:

• Leadership and culture
• Recruitment
• Talent management and performance

We are currently carrying out a detailed examination of progress against the original strategy and, where progress has not matched the pace we desire, we are escalating both risks and mitigating actions. We are highlighting the importance of understanding data and social science techniques to acknowledge and effectively address inequalities in all that we do. Recognising the culture of employment shapes not only how the organisation looks, but also how it performs in the delivery of both strategy and commissioning of services, consequently affecting the population we serve.

Metrics and programmes that were not originally contained within the 2013 – 2015 strategy have since been embedded in the NHS Standard Contract such as the Workforce Race Equality Standard (WRES) and the Equality Delivery System EDS2.

2015 is the year we will make strides to progress employment equality for people with a learning disability and for those from a black and minority background in recognition that if one of us is not equal, then none of us are equal.

The  NHS England WRES reporting data offers where possible our response to the metrics.

NHS England will publish its Workforce Equality and Inclusion data across all protected characteristics annually on 1 July and we aim to present the data in a user friendly and transparent way. This helps us to use the data to make improvements and also assists applicants or health and social care partners to develop their understanding of our workforce and leadership.

This report provides details of NHS England’s gender pay for 2018 under the requirements of the Equality Act 2010 Act (Gender Pay Gap Regulations) 2017 and details the six specific measures and the work that is being undertaken to address the gap. The Gender Pay Gap Report for 2017 is also available.

The Facility Time Publication report provides details of NHS England’s facility time reporting, under the requirements of the Trade Union (Facility Time Publication Requirements) Regulations 2017.