Victoria Keilthy is a senior manager in an NHS trust and the author of “Incoherent and Unsafe“, a report on the dangers posed by the NHS’s current approach to recording sex and gender identity in patient records.
I met Victoria recently and heard her talk in succinct terms about the problems the NHS has created for itself in needlessly conflating the concepts of sex and gender. To be fair, everyone was doing it in the early 2000s when gender was being used to mean biological sex as distinct from the fruity act, but the Gender Recognition Act (which also confused concepts of sex and gender in its clauses) culturally re-separated the two.
At that point people who had to make crucial decisions based on someone’s sex should have clocked the situation and understood the need to make very clear the difference between identity and biology. That means doctors, research scientists and the NHS managers who set the rules for NHS data collection. But they didn’t. Because taboo, fashionable thinking and fear of denunciation. Et cetera.
Victoria has not bowed to the prevailing culture. She looked at the data standard and how it is being implemented, and was horrified. Here is a lightly edited version of her recent talk, published with kind permission:
“Healthcare professionals need to know a patient’s sex to deliver safe and effective care. Although knowing someone’s gender identity – if they have one – can help with personalising care, knowing someone’s sex is clinically essential.
There are four key things to understand about NHS patient records:
1) There is no unified electronic patient record across the NHS. I know of at least 10 electronic patient record systems in use in the NHS, and I’ve seen sex and gender recorded in at least five different ways:
- ‘gender’ only – the most common approach;
- sex and gender;
- sex only – less common;
- ‘legal sex’ – based on the marker in a patient’s passport/driving licence (which can be changed); and finally,
- a pair of questions about gender identity from which sex can supposedly but not always be inferred.
2) NHS data standards prioritise the recording of gender identity over sex. This is unsafe.
3) GP records only record ‘gender’—and the NHS defines ‘gender’ as self-declared gender identity. Adults can ask to change the ‘gender’ recorded in their GP record. The Health Secretary recently blocked children from doing this, but adults retain this right.
4) Many NHS data systems feed into each other. For example, the ‘gender’ field from a GP record is sometimes used to populate the ‘sex’ field which exists in some hospital data systems. If a patient has changed their ‘gender’ in their GP record, then their hospital record may show inaccurate information about their sex.
As a result, clinicians can no longer rely on NHS records to provide accurate information about patient sex. This partly explains why we’re seeing absurdities like radiographers asking men if they could be pregnant.
This shift was not accidental. It was a deliberate change – made, it would appear, without following the safety testing protocols that would usually apply to any major clinical change.
Dr Hilary Cass has described how gender-questioning children have been “exceptionalised” – that is, usual clinical approaches have not been followed for this patient group. The same has happened with patient data – rules and protocols which would usually be followed to ensure patient safety have been set aside, with no apparent justification, other than a vague appeal to the notion of inclusion.
This is dangerous. And NHS England and the Professional Record Standards Body, which sets NHS data standards, should never have allowed it.
Serious Medical Consequences
Ironically, the biggest direct risks fall on people with a trans identity. If a man identifies as a woman, his NHS record may say ‘female’ if he has asked to change his gender. Likewise, a woman identifying as a man may be recorded as ‘male’. These inaccuracies can have serious medical consequences.
There are documented cases where confusion about patient sex has led to harm:
In the US, a pregnant woman identifying as male, and recorded as male in her patient record attended an emergency department with abdominal pain. Staff failed to recognise her pregnancy in time, and her baby was stillborn due to a delayed response to cord prolapse.
In another US case, a trans-identified woman had her kidney function assessed using the male rather than the female diagnostic range. This led to months of delay in her being added to the transplant list.
These cases could happen here. The NHS’s current approach offers no safeguards.
Indeed, in the UK, radiation incidents have already occurred involving patients with a trans identity. These include a pregnant woman, presenting as male and whose NHS record showed her as male. She received an x-ray in error (see here, page 6) which exposed her foetus to potentially harmful ionising radiation.
My report includes another UK case: a man experiencing complications following private gender reassignment surgery. He suffered delay in diagnosis and care for these problems because he was recorded as female on his NHS record and his private surgery was not documented in his record.
These are not theoretical concerns—they are examples of real harm. And for every case of actual harm, there are many other ‘near misses’.
Clinicians are compromised
However, inaccurate sex data doesn’t just harm individuals. It affects everyone who uses or relies on the NHS in the following ways:
Research and statistics become unreliable. Without accurate sex data, we can’t reliably study sex-based differences in disease incidence, treatment outcomes, or the side effects of medication.
Service planning and policy implementation suffer. We need to know disease incidence by sex to plan services. And on the policy front, the NHS can’t implement its commitment to single-sex wards, if it doesn’t have an accurate record of patient sex.
Legal compliance is at risk. The current approach may breach data protection laws, hinder compliance with the Public Sector Equality Duty, and potentially discriminate against those who don’t believe in gender identity.
Clinicians are compromised. Doctors are exposed to negligence claims and forced into ethical dilemmas when safety and truth conflict with institutional policy.
Finally, public trust in the NHS is eroded. Patients can’t have confidence in an NHS that asks men if they might be pregnant. This is biologically illiterate and damages the NHS’s credibility.
So where do we go from here?
The NHS must return to science-based care which puts patient safety first. This means recognising the importance of sex and accurately recording it in patient records.
I have two specific requests for our political leaders:
Firstly, please press the Department of Health and Social Care and NHS England to revise health data standards. Sex must be accurately recorded, independent of any record of self-declared gender identity. Patient safety must return to being the top priority. The UK must also act to help shape international health data standards to protect patient safety globally.
Secondly, please press for broader reform to counter NHS institutional capture. Although the Supreme Court has clarified the legal meaning of sex under the Equality Act—and both the Prime Minister and Health Secretary have made encouraging statements—most NHS trusts still remain out of step with the law.
Very few trusts have acted to bring their policies and practice in line with the law.
Annex B of the national Same Sex Accommodation policy is being reviewed, but it remains in place.
And implementation of the findings of the Sullivan Review of data on sex and gender is proceeding far too slowly.
These delays embolden those seeking to undermine the recent Supreme Court ruling. They further entrench unsafe practice and contribute to the ongoing chilling effect which prevents NHS staff from challenging gender identity, even when they see it endangering patients or undermining their rights as employees.
The NHS must return to being a healthcare system which is grounded in science, and which prioritises the commitment to ‘do no harm’. Restoring accurate sex data in patient records is a key next step.”
My thanks to Victoria for allowing me to publish the above. I am amazed the NHS has allowed itself to create this kind of mess and equally delighted there are some brave people in the service putting patient safety before their careers.
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