Trans patients should be cared for on single-sex hospital wards or bays that align with their biological sex rather than their gender identity, according to new NHS England (NHSE) guidance.
It says when this is not "clinically appropriate" then alternative arrangements should be made.
But the guidance also says decisions may have to be made on a case-by-case basis and must ensure clinical needs are met, and that the dignity and safety of the trans patient and of other patients are maintained.
Previous NHSE guidance suggested patients and staff could be accommodated on wards or use facilities based on their gender identity.
That meant that a trans woman – a biological male who identifies as a woman – could have chosen to be on a women's ward, or a trans man – a biological female who identifies as a man – could have opted for a men's ward.
That guidance was withdrawn following the Supreme Court ruling in April 2025 that under equality law the term "sex" means biological sex and "woman" refers to a biological woman.
The judgment said for a space or service to be single sex it should only allow those of the same biological sex to use it.
Also under the new guidance issued on Thursday, NHSE emphasised that in order to avoid discriminating against trans people they should be offered gender neutral spaces.
It also makes clear that there are circumstances where clinical need is the overriding priority, including on emergency units and urgent care settings.
In addition to the patient document of the guidance, NHSE has published advice for trusts on how to organise changing rooms, toilets and other single-sex facilities for staff.
Again, it says they should be used by people based on their biological sex, not their gender identity.
The document encourages NHS trusts in England to carry out an audit to ensure they are offering enough alternatives to single-sex facilities, for instance, gender neutral or single occupancy toilets.
Pressures on hospitals mean many have already struggled to keep wards single sex.
NHSE data shows that the number of breaches of the previous mixed-sex accommodation guidance has been growing every year since 2021- where members of the opposite sex were placed on a single-sex ward.
The most recent figure for August 2026 shows there were 5,520 breaches, compared to 3,853 in June 2025.
Sex-based rights charity Sex Matters has welcomed the guidance as a "momentus shift back to reality", but is concerned about how it will be applied.
"NHS patient data is a mess, with potentially thousands of trans-identifying people recorded as the opposite sex," CEO Maya Forstater said.
Trans rights organisations TransActual and Trans+ Solidarity Alliance have said they are concerned NHS staff will be unclear on how to safely look after trans patients.
"This guidance will not survive contact with reality in resource-strapped hospitals and will create unworkable operational challenges," they said.
The NHS has been at the centre of a number of high-profile arguments over the interpretation of equality law and workplace regulations.
In January 2026, Darlington Memorial Hospital was found to have violated the dignity of a group of nurses who complained about a transgender colleague - a biological male who identified as a woman - being allowed to use the female changing rooms. The nurses were told they should change somewhere else if they objected.
The tribunal concluded that the trust had indirectly discriminated against them.
The nurses are currently seeking £400,000 from the NHS to cover their legal costs.
One of the nurses who brought the action, Bethany Hutchison, who is now president of the Darlington Nurses Union, says they welcome the "clear and necessary guidance" from NHSE, but the test will be whether trusts follow it.
"The Darlington nurses should never have had to take their own employer to court to secure privacy, dignity and lawful single-sex facilities," she said.
"Enforcement cannot continue to depend on the courage and personal sacrifice of individual nurses."
In Scotland, another employment tribunal found, in December 2025, that a nurse, Sandie Peggie, had been harassed by NHS Fife over its interpretation of rules on single sex spaces.
Peggie had complained about a doctor, who was a trans woman, using the female changing rooms.
She was suspended after raising concerns. The tribunal dismissed her other claims of discrimination and victimisation.
An appeal is under way and expected to reach the courts next year.