Ideological capture at the heart of the NHS

When our collective, With Woman, heard there was research project underway called Improving Trans Experiences of Maternity Services (ITEMS) we welcomed the news. As a group of midwives, doulas and others with an interest in pregnancy, birth and breastfeeding, we want all who use maternity services to have the best experience they can possibly have. But in May last year, when the ITEMS report was published, it quickly became clear it was little more than gender ideology dressed up as research. Moreover, the report authors were so focused on driving their agenda they missed crucial opportunities to actually address the unique medical needs of this group.

The ITEMS study was commissioned by the VCSE Health and Wellbeing Alliance, a body run jointly by NHS England and the Department of Health and Social Care. In other words, this venture was paid for by UK taxpayers. But it seems neither DHSC nor NHS England noticed quite how poor the research was, and now they are poised to double down on implementing the report’s apparently ideologically inspired recommendations. NHS England have announced £100,000 in funds for a “training programme”, which went out to tender just before Christmas. (The deadline for applications is 11 January and work is meant to be completed by 31 March – an extremely tight turnaround. On studying the Invitation to Quote for this tender, it appears NHS England already have specific contractors in mind.)


The most significant finding of the ITEMS study, as set out in the report published by the LGBT Foundation, was a shocking 30% of trans and non-binary birth parents “freebirthed”, rising to an even more disturbing 46% of trans and non-binary birth parents of colour. Happily, these statistics appear to be no more than a deliberate attempt to fearmonger as they certainly do not stand up to scrutiny. 

Let’s look at what freebirthing actually is. The Association for Improvements in the Maternity Services (AIMS) says “broadly speaking, a woman freebirths when she intentionally gives birth to her baby without a midwife or doctor present.” Professional organisations of midwives and others discourage freebirthing because of the possibility of emergencies arising during birth.

However, the ITEMS report uses its own definition of freebirthing, which includes only those who have given birth “without ever accessing perinatal care”. This makes it doubly surprising such apparently high proportions of trans and non-binary birth parents meet this definition. There are no statistics available for the overall number of freebirths in the UK, but it is surely a very small fraction of the 2.4% of births at home, the vast majority of which were planned with the support of a midwife or were simply cases of a BBA – baby born before arrival – when rapid progress in labour means a woman gives birth before medical assistance has arrived.

Where does this statistic come from? Delving into the report, it appears this was the proportion of respondents who answered the question “Did you get support from NHS or private midwives during your pregnancy/pregnancies?” Of the 117 responses, 35 appear to have answered no. Did they really mean they received no maternity care whatsoever during their whole pregnancy and birth? Or might the respondents have been trying to convey they did not feel supported by their midwives? Common sense, and the poor phrasing of the question, would suggest the latter.

Midwives, obstetricians and researchers who have seen the report say it raises more questions than answers, and that there significant flaws in its methodology and analysis. They are calling for a halt to NHS England’s proposed training programme that is based on the study.

Missed opportunities to support trans people

The report also included four case studies, who were interviewed in more depth. It’s a shame the researchers didn’t focus more on this rather than wasting time manufacturing dubious and overblown statistics. There were clear examples where individuals were not treated with respect, and where important lessons could be learnt that could ultimately lead to better experiences for this particular group of maternity service users.

But perhaps the most striking omission in the report is a complete lack of discussion about the additional medical needs of trans individuals. They may have undergone a double mastectomy. They may have been using the hormone testosterone for some time. These would have important effects on the experience and outcomes of pregnancy, birth and breastfeeding. Yet while there are a couple of references to ‘specialist support’, this support is seen as a ‘marker of inclusion’ only  – on a par with being greeted by a receptionist wearing a pronoun badge) – with no information on what extra medical or midwifery input might be needed.

Evidence or ideology?

The report includes eight “key recommendations” aimed at health professionals, commissioners and policymakers. Most of the eight are already NHS maternity policy (such as personalised care, continuity of carer, upgrading IT systems) or are sensible suggestions (collecting data on trans status), yet the authors don’t make clear how any of them “emerge from the findings”, as is claimed. It would appear the ITEMS steering group paid little attention to the findings and simply restated previous demands for inclusive language.

Nowhere in their questionnaire were study participants asked what sort of language was important to them. While it was clear using preferred pronouns was important on a personal level, none of the case studies expressed a need for the sorts of inclusive language the report goes on to recommend.

In fact, one of the case studies explicitly said evidence an environment was inclusive did not mean “a rainbow poster or something”. Yet the ITEMS report recommends “visible markers of inclusion such as posters, badges, including name badges with pronouns, and lanyards” – practically the reverse of what the case study said they needed! This continued focus on posters is reiterated in the tender document for the £100,000 contract now available to a training provider who can deliver on the ITEMS recommendations. One of the “key principles” in the training package is to produce downloadable inclusive posters.

Two of the 8 recommendations cover “inclusion” – one titled Inclusive Language and the other Pro-Active Inclusion. It’s unclear what the difference might be, and these are in addition to a recommendation for Targeted Information”. On first reading the recommendation on Inclusive Language appears to be about providing personalised care. It begins by saying: “Another key element of providing individualised care includes prioritising the use of inclusive language for every service user.” But in an imaginary example they talk about a non-binary individual named Cam who becomes “worried” about how inclusive the service might be after receiving a letter addressed only to “pregnant women”.

They also go on to say that for a “comprehensive explanation of inclusive language in perinatal services”, we should look no further than the Brighton and Sussex University Hospital Trust policy (developed with the help of the Trust’s Stonewall manager). It was widely reported in the press when it was introduced in 2020 because it tells staff to replace “women” with “women and people”, “mothers” with “mothers and birthing parents”, “breastfeeding” with “breast/chestfeeding”, “breastmilk” with “breast/chestmilk”, and “maternity care” with “perinatal care”.

While some have tried to defend the Brighton policy, arguing it only suggests using these new terms on an individual basis, reading the document it is clear this “inclusive language” is intended to be used in all communications materials.

“We are taking a gender-additive approach to the language used to describe our services. For us, a gender-additive approach means using gender-neutral language alongside the language of womanhood, in order to ensure that everyone is represented and included.”

In the preceding section the policy writers acknowledge “migrant women also face access issues due to language and cultural barriers, which contribute to health inequalities” and say they “are committed to working on addressing health inequalities for all those who use our services”. But there is no acknowledgement this obfuscating and complex language is a barrier to such women, and there has been no evaluation of the policy’s impact since it was introduced in 2020.

This article by Dr Karleen Gribble and other internationally respected academics describes in detail the potential unintended consequences on public health communication of these well-intentioned attempts at inclusion. Last year, when he was Health Secretary, Sajid Javid committed the NHS to using sex-specific language, referencing Gribble’s article. And Prime Minister Rishi Sunak has made similar commitments, saying he would reverse “recent trends to erase women via the use of clumsy, gender neutral language” and “we must be able to call a mother a mother and talk about breastfeeding”. Yet somehow gender ideology activists within the NHS are managing to push ahead regardless.

Activists play musical chairs with the NHS

Something that becomes apparent when you begin to delve into all this is how the same names crop up over and again. The ITEMS steering group responsible for the report includes many of all the same names that appear Brighton’s gender inclusion policy, cited as best practice in the report. One of the report’s recommendations is for investment in training “as a priority, designed and delivered by trans and non-binary led organisations, or individuals”.

Who might provide such training? The very same list of activists who took part in the ITEMS steering group and the Brighton policy, perhaps? Looking at the new tender for NHS England’s Maternity Gender Inclusion training programme, this certainly seems the intention. This particular recommendation is quoted word for word in the tender document. Some of those involved in the Brighton policy are now paid good money to run training programmes for other NHS Trusts. In addition to the recommendation that training be run by trans and non-binary organisations or individuals, the document includes in its “essential deliverables” section a “track record in developing and delivering trans and non-binary awareness training, preferably within NHS maternity services” as well as an “assigned senior manager for the project (Band 8a NHS Agenda for Change or equivalent)”. Might Brighton’s Gender Inclusion Midwives – who wrote the Brighton policy, were on the ITEMS steering group and whose work was quoted as best practice – be just the ones for the job? Heck, they even have a poster already made!

Just following government policy

Is NHS England delivering government policy or exercising its independence? It’s hard to tell from the tender document. On the one hand, it seems to disregard all the recent pronouncements of Prime Ministers and Health Secretaries on the subject of language. Yet the tender asks those applying to have an “understanding of current strategy and key policies within LGBT health and care”, an “understanding of the political and policy environment that the NHS operates within and partnership working” and an “awareness of the Government’s LGBT Action Plan”.

This last reference is very interesting. The strategy was produced in 2018 by the previous government, and there has been a clear change of direction on trans issues in the government Equalities Office since then. What the tender doesn’t seem to require knowledge of is the government’s more recent Women’s Health Strategy, which includes the following paragraph:

“Language matters. Concern has been raised about removing language around biological sex and women – for example, referring to ‘pregnant people’. Such an approach has the potential for unintended adverse health consequences. The government has been clear that we must not countenance the erasure of women from our public discourse or our legislation. We will work with NHS bodies to ensure that women are properly represented in communications and guidance, and that there is appropriate use of sex-specific language to communicate matters that relate to women’s and men’s individual health issues, and their different biological needs.”

Why might NHS England ignore the government’s most recent policies and statements while referencing the previous government’s strategy? Might it be that Lizzie Streeter, its National LGBT Programme Manager and named lead on the contract, doesn’t like the government’s new policy and much prefers the old one?

If what’s most important to you in a Women’s Health Strategy is it should include transwomen, then perhaps it’s not surprising you would overlook the potential impact on women of wholesale changes to language within maternity services. While the Brighton policy does at least acknowledge language might be important to women too, the ITEMS report glosses over this possibility. “While many [sic] service users are cis women, and there is already language in place that they may be comfortable with, there are also many ways to use language that is more inclusive to trans and non-binary pregnant people.”

The tender for the NHS England Maternity Gender Inclusion project doesn’t mention women service users at all. The contract asks the provider to mark their own homework through “monitoring and evaluation in relation to impact on staff and patient experience”. They don’t say which patients will be asked about their experiences, but presumably they just mean the trans and non-binary ones. They are, after all, the most marginalised of all, what with one-third of them freebirthing… Everyone else – migrant women, refugee women, women with learning disabilities – just need to keep quiet, lie back and above all don’t make a fuss, dears.

Related blog:

Open letter: Pause £100k midwifery training based on flawed research into trans maternity experiences

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