NHS England tells hospitals to place trans patients by biological sex, with clinical exceptions

NHS England published new guidance on Thursday, Oct. 15, telling hospitals that trans patients should be cared for on single-sex wards and bays that match their biological sex, not their gender identity.

It replaces earlier NHS England guidance that let patients choose accommodation by gender identity. That guidance was withdrawn after the Supreme Court ruled in April 2025 that "sex" in the Equality Act 2010 means biological sex and "woman" means a biological woman.

The new document says "trans people and others with the protected characteristic of gender reassignment should be accommodated in line with their biological sex." In practice, hospitals can lawfully keep trans women off female wards and trans men off male wards.

What the guidance requires

The guidance covers acute, mental health and community trusts, plus NHS-funded patients in private settings. It says all patients "should be treated with respect, dignity, compassion and care."

Where placing a trans patient on a ward of their biological sex "would not be clinically appropriate," hospitals "should identify alternative arrangements." It also says: "where clinical needs and same-sex accommodation requirements cannot both be met, clinical needs are the priority."

The single-sex requirement does not apply in A&E, urgent treatment centres, critical care, cancer and dialysis treatment areas, children's wards, or end-of-life care.

Any case where a trans patient is placed on a ward matching their gender identity is expected to be "rare." The reasons must be "clearly recorded and reported nationally as breaches of this guidance."

NHS England also says trans patients should be offered gender-neutral spaces, and that decisions may need to be made case by case.

Staff facilities and audits

A separate document covers staff in hospitals and GP surgeries. Changing rooms and toilets should be used according to biological sex.

Trusts with mainly single-sex facilities are told to consider whether alternatives such as single-occupancy rooms or mixed-sex facilities with individual lockable rooms can be provided. Trusts have been asked to audit their current provision. All NHS providers have also been asked to appoint an executive board lead for compliance.

The Darlington case

The guidance lands after an employment tribunal in January found that County Durham and Darlington NHS Foundation Trust had harassed and discriminated against a group of nurses. The trust had allowed a colleague who is biologically male to use the female changing room.

Bethany Hutchison, who led the claim, welcomed the guidance as "clear and necessary." She said: "Biological sex is not an optional belief. It is a material reality."

She also put the pressure on enforcement. "The test now is whether NHS trusts will actually follow it," she said, adding that "the Darlington nurses should never have had to take their own employer to court to secure privacy, dignity and lawful single-sex facilities."

Where the guidance meets the data

Hospitals were already struggling to keep wards single-sex. NHS England figures show breaches of the mixed-sex accommodation rules, where a patient of the opposite sex is placed on a single-sex ward, have risen every year since 2021. The most recent figure, for August 2026, is 5,520. In June 2025 it was 3,853.

Sex Matters, a sex-based rights charity, welcomed the guidance as a shift "back to reality." Its chief executive, Maya Forstater, raised a practical concern about enforcement. "NHS patient data is a mess," she said, "with potentially thousands of trans-identifying people recorded as the opposite sex."

Wards can only be sorted by biological sex if the records are right.

The objections

Trans rights groups TransActual and Trans+ Solidarity Alliance acknowledged that the guidance puts clinical judgment ahead of blanket exclusion. They argue it still leaves individual clinicians unclear on how to look after trans patients safely.

In their words: "Forcing trans people into spaces based on our sex assigned at birth will never be the most clinically appropriate decision, and will push trans people away from accessing care."

They also argue that doctors and nurses should be able to focus on "the person in front of them, not juggling scarce side rooms and writing breach reports." The guidance, they say, "will not survive contact with reality in resource-strapped hospitals." They accuse the government of "putting politics over patient care" by failing to resolve the legal position.

The guidance itself concedes the pressure point. It acknowledges that "due to high demands on NHS services, there may be occasions when both meeting clinical needs and delivering same-sex accommodation is not possible," and tells staff to put care first.

What comes next

The Equality and Human Rights Commission's code on single-sex spaces came into force just over two months ago. It states that a trans woman "will be excluded from the women-only service because her sex is male," and that single-sex hospital wards can lawfully exclude trans patients.

NHS England's guidance now brings the health service in line with that code. Two things will show whether it holds. One is the national breach reporting that trusts must now do. The other is the audits of single-occupancy and alternative facilities. With mixed-sex breaches already at 5,520 a month, the number of side rooms trusts can find will decide how often the rule can be kept.