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Recent NHS decisions have effectively removed gender-affirming care for trans young people in the UK. This long read explains what happened and what it means for trans+ young people and their families.
The past few months have brought news that will have been incredibly distressing for many trans+ young people, their families, and everyone who cares about our community. The NHS Pathways trial, the last remaining way for trans+ young people to access puberty blockers through the NHS, has been stopped with no end date in sight.
Now, in March 2026, NHS England has gone even further, stopping new referrals for hormone treatment for 16 and 17-year-olds, after a review decided there was not enough evidence to support continuing it. For those who were waiting, hoping, and holding on, the last doors are being shut in their faces, one after another.
At Anne, we work every day with trans+ people trying to get healthcare that too often treats them as a problem to be managed rather than a person to be cared for. What has happened to the Pathways trial, and what is now happening with hormone treatment, are not one-off events. They are the latest steps in a pattern our community knows all too well. Everyone affected deserves a clear, honest account of what has happened, why it matters, and what it means for trans+ young people in the UK right now.
In February 2026, the Medicines and Healthcare products Regulatory Agency (MHRA), the government body that oversees medical trials in the UK, stopped the NHS Pathways trial into puberty blockers for trans+ young people. The trial was being run by King’s College London, with £10 million of NHS funding, and had been just weeks away from taking on its first participants.
The MHRA said it had concerns about how the trial was being run, including a plan to raise the minimum age for participants from around 10 to 12, up to 14. Shortly afterwards, it came to light that Professor Jacob George, the MHRA’s newly appointed chief medical and scientific officer, and the person who had raised those concerns, had a history of anti-trans posts on social media. He had called trans+ people a “militant minority”, praised well-known anti-trans campaigners, and publicly questioned the gender of a cisgender female Olympic athlete. He was removed from any involvement in the trial. The pause he had triggered was not lifted.
Then, in March 2026, NHS England announced it was stopping new referrals for hormone treatment for 16 and 17-year-olds. This followed a review of all available medical evidence, carried out after the Cass Review, which found the evidence was not strong enough to show whether this treatment helped or harmed young people with gender dysphoria. A 90-day public consultation on removing the treatment as a standard NHS option has now begun. Young people already receiving hormones through the NHS can continue for now, but their treatment must be individually reviewed by their medical team.
The result is that gender-affirming care for trans+ young people through the NHS has been almost entirely removed. Puberty blockers are gone. Hormone treatment for 16 and 17-year-olds has been paused for anyone new. And with that, a two-tier system has been created that is not incidental but is the direct consequence of the decisions described in this piece.
If your family has the money to go private, you may still be able to get this care. If you do not, you cannot.
“Access to trans+ healthcare is now decided by how much money your family has, and it is trans+ young people from the least well-off families who will pay the highest price. Gender-affirming care should be available to everyone who needs it, not just those who can afford it.”
Puberty blockers are medicines that pause the physical process of puberty. They have been used for decades to support trans+ young people, and they are also routinely given to cisgender children who go through puberty unusually early. The exact same medicines, in the exact same developing bodies. For many trans+ young people, getting access to blockers at the right time can be life-changing, and sometimes life-saving. They create space to think, to grow, and to understand their identity, without the debilitating distress of watching their body change in ways that feel wrong.
In 2024, following the publication of the Cass Review into NHS gender services, the UK government banned new prescriptions of puberty blockers for trans+ young people. The Review said the evidence for blockers was “poor.” The Cass Review itself was never peer-reviewed before publication; an extraordinary omission for a document that would determine healthcare policy for an entire group of children. It has since been formally criticised by WPATH, EPATH, and several national health bodies for its methodology. Many doctors pointed out that the “poor evidence” conclusion reflected decades of failure to invest in trans+ healthcare research, not evidence that the treatment itself was harmful. Underfunded research is not the same as absent evidence.
“Underfunded research is not the same as absent evidence. The absence of research is itself a policy choice; one that successive governments have had decades to correct and have not.”
The same logic has since been applied to hormone treatment for 16 and 17-year-olds, with the conclusion again being that the evidence is too weak. This is not a finding that the treatment causes harm. It is the predictable result of a deliberate failure to fund research into trans+ healthcare, and the government now using that failure as justification for removing treatment.
The Pathways trial was supposed to fill that evidence gap. It would study the effects of puberty blockers on trans+ young people over three years, building the research needed to shape future NHS policy. In practice, it was also the only way trans+ young people could access blockers while the ban was in place. It was imperfect, but a lifeline nonetheless.
The MHRA said its decision was about keeping participants safe. But that explanation has some serious holes in it. The MHRA had already approved the trial’s design before Professor George was appointed. His role did not even exist until a month before he started. And yet within weeks of him joining, concerns that had never been raised before suddenly appeared, with no new scientific evidence to back them up.
When Professor George’s social media history came to light, the picture became very hard to explain. Dr Hilary Cass, who led the original review that called for the trial, said publicly that no new research findings had emerged and the MHRA had not presented any new evidence, and that it felt to her as though they were responding to political pressure rather than science. Dr Max Davie, a children’s doctor with direct experience of NHS gender services, said that there was no strong scientific reason to stop the trial, and the only explanation supported by the evidence was Professor George’s own personal views.
The decision on hormone treatment is dressed up as a neutral, evidence-based process rather than one official’s actions, yet the conclusion is identical. And the same questions apply: who designed the review, who sat on it, and whose voices were absent from it? Treatment is removed. The NHS does not routinely pause treatment for other conditions simply because research has been underfunded.
Antidepressants are prescribed to adolescents on a limited evidence base. Treatments for rare conditions proceed with far less data than is now being demanded here. The standard of proof is applied to trans+ young people in a way that simply is not applied to any other group. And the voices of trans+ young people, their families, and the clinicians who work with them stay absent from the decisions that shape their lives.
A close examination of the ten evidence reviews NHS England published alongside its announcement reveals just how that conclusion was manufactured. Rather than conducting a comprehensive review of all evidence for hormone therapy in trans+ young people, NHS England split the question into ten separate, artificially narrow reviews; divided first by exact hormone type, and then again by whether the patient identified as binary or non-binary.
This kind of unjustified fragmentation is known in research methodology as “salami slicing,” a practice the Cochrane Handbook, the gold standard for systematic review methodology, explicitly warns against, noting that splitting comparisons into too many pieces results in each being “too small to yield a useful synthesis.” The result was exactly that: 547 full-text studies were screened, and just 17 were included. A 97% exclusion rate, not because the evidence does not exist, but because the reviews were designed to exclude it.
The studies that were excluded include some of the most significant research on trans+ young people’s healthcare published in the last decade. The largest prospective study of trans+ young people ever funded by the US National Institutes of Health, Chen et al., published in the New England Journal of Medicine in 2023, with 315 participants, was excluded from all ten reviews. So was Tordoff et al., published in JAMA Network Open in 2022, which found that trans+ young people receiving hormone therapy had 60% lower odds of depression and 73% lower odds of suicidality.
The Dutch Protocol studies, the research that forms the basis of the modern standard of care for trans+ adolescents used worldwide, were systematically excluded too. The exclusion logic was circular: the combination therapy reviews excluded any study where puberty blockers had been started for suppression purposes; the monotherapy reviews also excluded them. NHS England’s own data, cited within the reviews themselves, confirms that 98% of its patients had followed precisely the pathway every review was designed to exclude.
Even among the 17 studies that survived this process, several showed statistically significant benefits, including reductions in depression and anxiety. To dismiss these, the reviewers applied the GRADE system, a framework for rating the certainty of evidence. Every study was rated “very low certainty.” But this too is a distortion of the tool being used. Gordon Guyatt, the researcher who coined the term “evidence-based medicine” and helped develop GRADE, has described using systematic reviews in this way to justify banning gender-affirming care as “egregious and unconscionable.” A low GRADE rating is not a finding that a treatment does not work. It is a technical classification reflecting the type of study available, not the direction or strength of the results. Observational studies, which form the foundation of almost all paediatric medicine, automatically receive low GRADE scores regardless of what they find. By that standard, over 90% of all medicine in use today would fail the test being applied to trans+ young people.
It is also necessary to ask who is politically accountable for this pattern. Professor George did not appoint himself. The MHRA’s leadership structure was created and approved by government ministers. The Cass Review was commissioned by NHS England. The hormone treatment review that followed it was sanctioned at ministerial level. These are not bureaucratic accidents or the eccentric decisions of individual officials. They are the cumulative result of deliberate government policy choices, and the people who made those choices should be named and held to account.
This is not the first time our community has watched a process that was supposed to help trans+ people be shaped by people with openly anti-trans views. The Cass Review itself faced widespread criticism on exactly these grounds. The same pattern keeps repeating. The reviews, trials, panels, and policy decisions that determine whether trans+ people can access healthcare are designed, led, and carried out by people who do not include trans+ voices in any meaningful way, and who in some cases are actively hostile to the reality of trans+ lives. When that happens, the outcomes are predictable, and it is our young people who bear the cost.
“When a child must justify their existence through fifty assessments and thirteen hours of questioning, the process itself is the harm.”
It’s important to be honest here, because our community deserves the full picture. The Pathways trial had many serious, deep-rooted problems even before it was paused. These problems go far beyond politics and into the day-to-day reality of what trans+ young people were actually being asked to go through.
When the trial’s plans were published, what they revealed was alarming. To access treatment through the Pathways trial, a trans+ young person would have needed to complete over fifty separate assessments, repeated examinations, and more than thirteen and a half hours of testing. Over thirteen hours of intrusive, exhausting evaluation, just to access a safe, reversible medicine that other children receive without any of this.
More than seven of those hours consisted of thinking and memory tests, the kind normally used to assess brain injuries or neurological conditions, repeated three times during the two-year trial. Children were asked to complete intelligence tests, memory tests, and even tests designed to check whether they were trying hard enough in other tests. Many of the psychological questionnaires were repeated six, eight, or more times over two years, regardless of whether anything in the young person’s life had changed.
The physical examinations were also distressing in their own right. Children were required to have their chest and genitals examined as part of puberty assessments, an intrusive experience for any child, and particularly harmful for a young person already experiencing distress about their body. They were also asked to repeatedly pick images from a chart that matched their own physical development.
And then there are the questionnaires themselves. Children were asked about trauma. About suicide. About eating disorders. About sexual attraction. Questions with no direct medical relevance to gender identity, repeated four times over two years. Young people were asked to revisit the most painful and private parts of their lives over and over again, not because anything had changed, but because the protocol required it.
No other group of children in the NHS faces anything close to this level of scrutiny for a safe, reversible treatment. This goes beyond what is required to access puberty blockers anywhere else in the world. And none of this accounts for the four-plus year waiting list just to get a first appointment, which itself can only be reached after going through Child and Mental Health Services (CAMHS), where waits are often years long too.
Experts who study conversion practices, including the United Nations, the American Psychological Association, and the UK’s Memorandum of Understanding on conversion therapy, describe them as systems that treat a person’s identity as a problem, put up barriers to supportive care, and rely on repeated scrutiny, intrusive questions, and psychological pressure. They look for “underlying causes”, treat identity as something to be corrected rather than supported, and subject people to assessments that imply something is wrong with who they are.
The Pathways trial met that description. It told trans+ young people, in the language of its own design, that their identity was a problem requiring investigation rather than a reality requiring support. When a child must justify their existence through fifty assessments and thirteen hours of questioning, screened for neurological conditions, trauma, suicidal ideation, and sexual attraction before they can access a safe, reversible medicine, the process itself is the harm.
“The trial did not need to say ‘change who you are.’ It communicated that message systematically, at every step.”
Three of the world’s leading transgender health organisations, WPATH, EPATH, and USPATH, raised formal concerns that the trial’s design may have violated the rights of participants around informed consent. And that concern is even more serious when you consider that this trial was the only option left. Families were not choosing to take part in research out of a desire to advance medical knowledge. They were signing up because there was no viable alternative.
There were also serious concerns about who was running the trial. TransActual highlighted that several of the senior figures involved had publicly expressed gender-critical views. The questions research asks, and the starting assumptions it makes, shape what it finds. A trial designed by people who begin from the position that being trans+ is something to question or resolve, rather than something to support and affirm, will reflect that, and it will cause real harm to the young people it claims to be helping.
When NHS gender services were dramatically cut back after the Cass Review, there was a documented rise in suicides among trans+ young people. The government denied it. Families who had spent years on waiting lists watched their children’s distress grow worse as puberty continued. They were told that caution was needed, that evidence had to be gathered, that all of this was being done for the right reasons.
Today, a trans+ young person in the UK has no NHS route to puberty blockers at all. Hormone treatment for 16 and 17-year-olds has now been paused for new patients too, following a review that many advocates say reflects decades of failure to fund research rather than any evidence of harm. TransActual has described the hormone treatment pause as “a serious attack on young people’s right to make decisions about their own bodies, with trans+ people once again being singled out”. NHS England says the evidence is not strong enough to show whether the treatment helps or harms, but as this piece has set out, that is the result of a deliberate failure to fund research, and it is being weaponised to justify removing care that has helped young people for decades.
For those whose families cannot afford private care, this is final. This is what a two-tier system looks like. Wealthier families can still access gender-affirming care, but everyone else cannot. Healthcare is being separated by wealth, and it is the most vulnerable trans+ young people who are paying the price on top of everything else they are already carrying.
And this may not stop with young people. Buried in NHS England’s own equalities impact assessment, published alongside the evidence reviews, is a statement that NHS England is separately reviewing the evidence for hormone treatment for trans+ adults, with a consultation expected later in 2026. If that review follows the same methodology as the ten reviews described above, the same manufactured scarcity of evidence could be used to restrict or remove gender-affirming care for trans+ adults across the NHS too.
The consequences of these decisions will also reach beyond the United Kingdom. The Cass Review, with its methodological flaws, was cited by Republican legislators in the United States, referenced in briefs before the Supreme Court, and used to justify state-level bans on gender-affirming care across the country, despite being criticised by major international medical organisations. These ten evidence reviews, built on the same foundation, are likely to be used in the same way. The UK continues to export anti-trans pseudoscience to governments around the world that are looking for academic cover for decisions they have already made. What happens here does not stay here.
What this piece describes is not the result of insufficient evidence, bureaucratic caution, or good-faith disagreement about medical science. It is the outcome of a healthcare system that has, step by step, decision by decision, been shaped to deny trans+ young people the care they need. The young people and families we work with at Anne understand this, even when the institutions responsible will not say it plainly. We will.
We see the impact of these failures every day, in the trans+ young people and families who come to us exhausted, frightened, and let down by a system that should have been there for them. We will keep providing affirming, compassionate care, advocating loudly for our trans+ community, and calling out institutional failures clearly and without apology. Trans+ young people are not a policy problem and they do not need to be cured. They are our community. They are not asking for special treatment, just healthcare with dignity and compassion. They are asking for the same standard of care that every other child in the UK routinely receives.
At Anne, we will keep fighting to make gender-affirming care more accessible to trans+ people who need it. We will continue fundraising to provide more free, funded care for trans+ people of all ages.
Take the first step with Anne.
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