A damning official investigation into clinics has found that doctors treating vulnerable patients with gender dysphoria have no way of assessing whether NHS treatment has worked, because results are not systematically recorded.
Waiting times for a first appointment at NHS adult gender dysphoria clinics in England are expected to reach 15 years unless there are improvements, the review found. The number of people seeking treatment is increasing significantly, and on average patients are already waiting five years and seven months for their first assessment.
The review was commissioned by Dr David Levy, NHS medical director and cancer specialist, following last year’s CAS report into gender care for children and young people.
Levy, an NHS medical director and cancer specialist, took a team to nine NHS clinics in England to assess the effectiveness and safety of each service, interviewing staff and patients.
His report found that clinics’ failure to study outcomes for their patients made it impossible to judge the safety of these services.
The review said: “It is unacceptable that there are no outcomes data to support or guide patients, clinicians and commissioners in understanding which treatments and interventions may achieve the best outcomes for patients.”
Long waiting lists also create safety issues, prompting people to self-source hormonal medications from high-risk online providers abroad. The report noted that by the time doctors saw patients, staff said it was often difficult to provide appropriate support because patients were now requesting information and support online, some of which could be inaccurate.
Aside from detailed information about wait times, there was “virtually no other data” available from adult clinics, Levy wrote, making it impossible to analyze how patients responded to a range of treatments, from prescribing sex hormones to psychological support. Adult clinics can refer patients for surgical interventions, but this is provided through a separate NHS service, which is not reviewed by the team.
The review heard that some patients expressed remorse and dissatisfaction after treatment, and a smaller number later chose to reverse their gender transition, but it was impossible to estimate what proportion subsequently changed due to the absence of outcome data.
“These services need robust, high-quality research. While the review noted that some government data centers were involved in national or international research projects, little evidence was shared before or during the review visits.” Doctors told the review team that it was difficult to conduct clinical audits on residents “who may feel vulnerable and uncertain about how the data is held and used”.
In her report last year, Dr Hilary Cass noted that she had been contacted by a number of staff working in adult clinics who were concerned about “out of control” waiting lists and inconsistent standards in services.
The profile of people seeking help has changed dramatically, shifting from a predominantly older age group to a younger age group of patients; The majority of referrals (57%) are now for those aged 18-25. The report noted that the population had also shifted from males registered at birth to a more balanced proportion of registered females, but obtaining accurate data was difficult because not all clinics recorded sex at birth, using patient-reported sex instead.
The review was told that the younger group of patients had a higher incidence of additional neurodevelopmental conditions, such as autism spectrum disorder, and a wide range of other issues, such as mental health conditions, trauma or abuse during childhood, than patients referred in the past.
The review team found that only 31.5% of patients were discharged after completing their treatment, raising questions about why patients were not continuing to attend or could not be contacted. “This should be an early priority for national scrutiny,” the report said.
“The provision of gender-related services is an area where there are strong views about how care should be delivered and by whom. These services must navigate this challenging landscape, where debate is often hostile and polarized, while continuing to deliver care to patients,” the report noted.
The review team heard from some staff that they were not encouraged to raise concerns at team meetings, “felt that clinical curiosity or constructive challenge was not encouraged” and that “issues raised were dismissed as transphobia or bias”. The review found that this atmosphere was not felt in all clinics, with some workplaces encouraging staff contributions.
Professor James Palmer, National Medical Director for Specialist Services, said: “Many people are waiting too long for care, care experiences are variable, and we need to ensure care is equitable wherever patients live. We have already started taking action to improve gender services for adults by increasing investment and opening more clinics to help reduce long waiting times, but we will use the recommendations in this report to continue to improve services across the NHS.” Funding available for non-surgical gender care has doubled from £16 million in 2020-21 to £36 million in 2024-25.
Levy made 20 recommendations, including a requirement that clinics nationwide begin reporting outcomes data that includes patients’ sex recorded at birth. From January, he will head a new national program to improve gender services for adults.
Campaign group TransActual welcomed the recommendations “for a simpler, patient-centred care pathway”, but raised concerns about the proposed end to self-referrals and said requiring an initial assessment by a senior doctor risked “unnecessarily hampering efforts to reduce waiting times”.