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National Health Service (UK) and transgender people

by Andrea James Reviewed October 28, 2026 8 min read

The United Kingdom has nationalized healthcare through the NHS (National Health Service). While some trans and gender diverse people have found the care to be adequate, many have experienced long wait times, sometimes a decade or more, for a referral to a specialty gender clinic. For that reason, many choose to make a gender transition outside the NHS system through private providers, through foreign providers, or through do-it-yourself options like ordering hormones online.

Background

The National Health Service (NHS) was established in 1948, founded on the principle of providing free healthcare at the point of use for all UK residents. Initially, the NHS focused on universal access to general and specialist medical care, but it did not formally address the needs of transgender people.

In the 1960s and 1970s, pioneering clinicians began offering support and medical interventions for transgender patients. The Charing Cross Gender Identity Clinic in London, established in the 1960s, became one of the first centers in the world to provide specialist gender care, including hormones and surgery. Charing Cross clinicians included John Bulmer Randell, Harold Delf Gillies, J.O. Dalrymple, Ashley Robin, Peter Philip. and Richard Green.

Throughout the late 20th century, transgender healthcare remained limited and inconsistently provided across the UK. Legal and social reforms, such as the Gender Recognition Act 2004 and the Equality Act 2010, helped secure rights and protection for transgender individuals, prompting the NHS to expand gender identity services.

In the 21st century, demand for gender-affirming care has grown rapidly, highlighting long waiting times and regional disparities. One clinic was reported to have a wait list with delays of over 200 years.

Healthcare for young people

Trans and gender diverse minors have faced special challenges under the NHS.

The Tavistock Gender Identity Development Service (GIDS), founded in 1989 within London’s Tavistock and Portman NHS Foundation Trust, became the UK’s only NHS clinic for children and young people questioning their gender. Initially small and research-oriented, it expanded rapidly in the 2010s amid rising referrals. Concerns grew over long waiting lists and the use of psychological assessment before medical intervention. Clinicians like Marcus and Sue Evans began openly criticizing the clinic, and anti-trans journalists like Hannah Barnes began writing pieces and books critical of clinical practices around the use of puberty blockers. In 2020, the Bell v Tavistock case challenged consent procedures for puberty blockers. Soon after, several anti-trans groups began actively campaigning to restrict or even ban all healthcare for minors.

Following a 2022 interim report of an independent review by pediatrician Hilary Cass, the NHS announced GIDS would close in 2023, replaced by regional centers. In 2025, NHS announced tightly controlled clinical trials for puberty blockers, to be managed by the Children and Young People’s Gender Dysphoria Research Oversight Board.

Timeline of reviews, policies and trials

October 2020: NICE reviews commissioned

NHS England asked NICE to carry out an evidence review of puberty blockers and of feminizing and masculinizing hormones for children and young people with gender incongruence. NICE produced two separate reviews, one on blockers and one on hormones. They were commissioned as part of the wider review of gender dysphoria care led by Hilary Cass.

March 2021: NICE reviews published

The published NICE reviews used a modified GRADE system. The puberty blocker review rated the evidence “very low.” It found no statistically significant effect of blockers on gender dysphoria, mental health, body image or psychosocial functioning, judged the evidence for all of these as low quality, and noted possible effects on bone density during puberty. The hormone review also rated the evidence on effectiveness and safety as “very low” quality. In addition, NICE said any benefits of hormones had to be weighed against their largely unknown long-term safety in young people. Both reviews were then used to inform the Cass Review.

February 2022: Cass interim report and Tavistock closure

The Cass Review published an interim report, which was used as a pretext to close the Gender Identity Service for young people at Tavistock and Portman NHS Trust. Cass concluded that having one specialist provider for all of England was not a safe or viable long-term option, and it recommended setting up regional services. The closure was officially announced on July 8, 2022.

April 2023: NICE puberty blocker review update

NHS England updated the 2020 NICE puberty blocker review with 9 more studies and reached a similar conclusion.

March 2024: Puberty blocker policy

NHS England published its final policy on puberty blockers, which made them no longer routinely available outside research.

March 2024: Under-18 hormone policy updated

NHS England updated its under-18 hormone commissioning policy in response to Cass’s Recommendation 8. It also commissioned a “living” evidence review of under-18 hormones, run by the Evidence for Policy & Practice Information Centre (EPPI Centre).

April 2024: Cass Review and York reviews

The Cass Review final final report included the gender identity service series published by University of York published on April 9, 2024.

May 2024: Cass letter on adult services

Hilary Cass wrote a letter to John Stewart and James Palmer at NHS England raising concerns about adult services. In response, NHS England decided to develop a new hormone policy covering everyone over 16. This work sat outside the separate Levy Review of adult services.

July 2024: Levy review

NHS England’s Specialised Commissioning team selected David Levy, Medical Director of Lancashire and South Cumbria ICB, to complete a review of adult services. The Levy report was published on December 18, 2025 and made 20 recommendations, grouped under access, quality, productivity and culture.

August 2024: Proposed changes on puberty blockers

On August 20, 2024, NHS published proposed changes to restrict the availability of puberty blockers.

December 2024: Puberty blocker restrictions made permanent

The government published the consultation outcome on puberty blocker availability. The resulting law criminalized access to puberty blockers in England.

January 2025: Policy working group

According to a 2026 letter by TransActual to Yvette Cooper, in January, the working group was told that policy could still be evidence-based where evidence was lacking. In March, members objected to reviewing hormones without puberty blockers, and the signatories say these objections were overruled. In April, the group split the work into separate under-18 and adult reviews.

2025: New under-18 evidence reviews

A Policy Working Group formed by January 2025. NHS England commissioned Arden and Greater East Midlands Commissioning Support Unit (Arden & GEM CSU), via their public health consultancy Solutions for Public Health to do updated pevidence reviews, which were completed that year. The reviews split into 10 narrow sub-questions (PICOs), and six of them found no studies at all. Any study whose participants had previously taken puberty blockers was excluded. That removed dozens of studies the York reviews had included. The reviews were used in the March 2026 published consultation on a proposal to stop routinely providing masculinising and feminising hormones to under-18s.

November 2025: PATHWAYS trial

The PATHWAYS puberty blocker trial recommended by the Cass Review faced many obstacles in being launched, including a Protecting Puberty petition by Genspect and legal threats by Bayswater Support Group.

  • Trial registration: ISRCTN12491684
  • Health Research Authority (HRA) updates page
  • HRA publication of ethics committee minutes and decision letters
  • Medicines regulator (MHRA) February 11 letter to the sponsor raising safety concerns
  • MHRA February 20 statement on its concerns
  • Streeting’s February 23 written statement to Parliament confirming the pause
  • MHRA February 27 statement that Jacob George had stepped back from the trial
  • MHRA June 19 update on the modified protocol
  • Petition to cancel the trial, with government’s response
  • Westminster Hall March 23 debate on the petition

March 2026: forthcoming adult reviews

NHS England mentioned it will complete evidence reviews of adult hormone treatment.

May 2026: First letter of concern

TransActual sent an open letter to NHS England’s James Palmer on behalf of 85 experts. They argued that the 2025 evidence reviews of gender-affirming hormones for under-18s were unnecessary, given the existing York review and the ongoing living review run by EPPI-Centre and others, and had not been peer reviewed. They argued the reviews were methodologically flawed: splitting the question into 10 narrow sub-questions and excluding patients previously given puberty blockers left 11 eligible studies against York’s 53. They urged NHS England to pause and reverse the resulting policy, and noted it had no plan to monitor the impact of withdrawing treatment.

August 2026: Palmer’s reply

Palmer’s reply defended excluding studies of patients who had taken blockers, because England no longer routinely provides them.

October 2026: Second letter of concern

The signatories escalated their concerns in a second open letter to Health Secretary Yvette Cooper. They argued the reviews had no clear rationale, since they were probably triggered by Cass’s out-of-scope concerns about adult services; their methods were flawed as described previously; they treated a lack of evidence as grounds for withdrawing treatment rather than providing it with safeguards; there was no plan to monitor harm; and withdrawal would have unaddressed effects on the PATHWAYS trial. They asked Cooper to meet Palmer urgently before the policy is finalized, and to meet trans healthcare clinicians and researchers so that the forthcoming adult hormone reviews respect clinical expertise, patient autonomy and the risks of denying care.

References

Sugg, Aaron (October 13, 2025). NHS conducting review as suicide of 17-year-old trans girl is deemed ‘preventable’ by coroner. Attitude https://www.attitude.co.uk/news/nhs-adult-gender-dysphoria-services-review-trans-suicide-499716/

Hansford, Amelia (October 6, 2025). Trans adults in the UK are waiting a third of their life for an NHS gender-clinic appointment. PinkNews https://www.thepinknews.com/2025/10/06/gender-clinic-wait-times-scotland-glasgow/

Collington, Faefyx (October 8, 2025,). Trans people have to wait an average of 25 years for care in the UK, new report finds. LGBTQ Nation https://www.lgbtqnation.com/2025/10/trans-people-have-to-wait-an-average-of-25-years-for-care-in-the-uk-new-report-finds/

Resources

NHS (nhs.uk)

The Cass Review (cass.independent-review.uk) [archive]

TransActual (transactual.org.uk)

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