Hi all
I don't think this has been posted. It's remarkable for such a critical piece to be published in the journal associated with the highly-captured British Medical Association. UK medical culture is clearly changing.
I think some of it is visible to members only. I'll cut and paste it here.
"Adult gender dysphoria services after the Levy review
Inadequate data and weak evidence continue to limit safe, effective clinical care
The Levy review1 was carried out in response to a recommendation in the Cass review of services for children and young people,2 and to rapid rises in referrals, prolonged waits, and concerns about unsafe self-medication.3 Published in December 2025, it focuses on the work of adult gender dysphoria services, which provide care for people aged 18 and over who want to consider medical treatment for gender dysphoria, and makes recommendations about wider services. Like Cass, Levy highlighted a demographic shift in referrals of younger female adults with high levels of psychiatric and neurodevelopmental comorbidity, often transferring from children’s services.
The review also identified serious concerns about internal governance, clinical leadership, workforce capability, and the poor quality and use of routine data. Unlike Cass,2 Levy’s remit did not include an assessment of evidence to determine clinical interventions, and focused on organisation of services rather than the medical interventions offered, which are covered in the adult service specification.4 Although Levy’s review recognised that long term treatment outcomes are uncertain, it did not describe the paucity of evidence.
Development of research evidence and monitoring of care and outcomes are basic standards in other areas of medicine, and their lack in this field hinders evidence based solutions. Without rigorous randomised trials considerable uncertainty remains about the effects of medical and surgical interventions on physical, psychological, and quality-of-life outcomes for adults and children with gender dysphoria.35 The evidence from cohort and case-control studies is not reassuring. Both medical and surgical harms of gender treatments have been documented, such as increased risk of venous thromboembolism6 and cardiovascular harms.7 A 2022 systematic review and meta-analysis of 39 studies evaluating phalloplasty outcomes reported a 76.5% rate of urogenital complications, including fistulas and strictures.8 A 2026 registry study of 2083 young people in Finland showed significantly increased need (61.3% v 14.2%, P<0.001) for psychiatric services two years or more after receiving gender reassignment interventions, compared with two control groups—those who did not receive interventions and those without gender dysphoria. 9
In the absence of formal evaluation by the National Institute for Health and Care Excellence or similar independent body, an exceptional response is required to mitigate harms, improve understanding of outcomes, and strengthen oversight of practice. Levy’s proposed national quality improvement programme and the planned review of the adult service specification could together provide important mechanisms for change.
The review also gives limited attention to the contested aetiology of gender dysphoria, including the potential roles of culture and sexual trauma.210 This omission, alongside sparse evidence, makes it doubly important that clinical care does not favour unproved medical intervention. Any review of service specification should explicitly require a shift in clinical culture from the current “affirmative” approach (favouring medical intervention for identity purposes) to one of “neutral support” (supporting the individual to make decisions based on evidence). Given the vulnerability of the population and uncertainty of outcomes, strong senior clinical leadership will be needed to maintain neutrality and clinical equipoise.
The interpretation of limited and contested evidence can also be a challenge. Levy recognises detransition as an important clinical harm.1 People who have detransitioned have described a range of experiences, commonly including an initial overwhelming desire for medical treatment, often in the context of profound emotional distress, followed by regret at irreversible bodily changes, loss of fertility and sexual function,1112 and the need for multiple revision surgeries to deal with complications.9 The review also acknowledges that robust estimates of regret, detransition, or other unwanted effects and complications are lacking.
Studies reporting a low regret rate (eg, 1%13) often involve selected populations, such as those receiving specific interventions, and exclude those lost to follow-up, risking significant bias.14 In contrast, the three population audits of NHS care reported rates of patients experiencing regret or detransition ranging from 5% to 20%.151617 It is unclear what proportion of the roughly 70% of patients who disengage from adult services in England do so because of desistance or regret.1 Care pathways for people who detransition therefore need to be developed. Some may want support independent of the services that caused them harm, but integration within reformed services may be possible, and even beneficial, if a new clinical culture recognises harms and uncertainty of outcome.
Planning to improve care
In response to the rapid rise in referrals, Levy emphasised demand management and capacity planning to reduce waiting times and increase service throughput. Levy reported substantial increases in referrals, reaching 10 000 in 2024-25,1 alongside increased NHS funding from around £16m in 2020-21 to over £36m in 2024-25.1 Proposals include standardisation of pathways of care and a single national waiting list (rather than service based) to improve productivity.1 The proposed creation of primary care led services for ongoing prescribing, outside of both specialist adult services and general practice, is intended to increase throughput. However, funding is unclear, and while a test and learn approach is envisaged, this proposal risks further siloing of care and reducing the oversight of quality and safety.
To support patients with gender dysphoria access the best available care, clinical reform and oversight are required and should be welcomed. The proposed national improvement plan could become a substantive learning health system, essential for improving both data collection and generating evidence to direct further improvement in services’ culture, processes, and outcomes.18 Funding for this new activity should be ringfenced. Given reported underspends because of recruitment and retention challenges in services,1 this seems feasible. All referrals should be included in routine cohort based data collection with robust linkage and follow-up to assess short, medium, and long term benefits and harms.6 Research, including randomised trials and qualitative studies, should be embedded within this framework.
The plan will also need to oversee the development of strong, collaborative leadership and clinical supervision,19 enabling continuous learning and facilitating the cultural shift towards reflective and neutrally framed care.20 With such an approach, the Levy review could mark the beginning of much needed and potentially world leading improvements in the care of adults with gender dysphoria."