The R22 Project: Questions Every Parent Should Be Asking
A concerned parent wrote to me about her seven-year-old trans daughter and the NHS R22 project. Her questions are exactly the right ones, and they deserve honest answers.
A message arrived in my inbox recently. A parent wrote to tell me about the R22 project, running out of Bristol Children’s Hospital, which offers NHS support to families of gender-questioning children aged nine and under. She has a seven-year-old trans daughter, and she has decided to take part. She is eloquent and thoughtful, she is careful, and she has real concerns, because the project is linked to the Cass Review. She wanted to know if I had heard about it, and what I thought.
Here are my questions:
Who will be conducting the interviews with children and families?
What training have they received, and who provided it?
What experience do they have working with young transgender children?
What questions will be asked, and how have they been developed?
Who specifically will be asked questions, the child, the parents, teachers?
What will be done with the answers, and who will have access to them?
What outcome is the project designed to produce for the children referred to it?
Has the assessment methodology been reviewed by anyone with lived experience of raising a trans child?
Will the findings inform national policy, and how will the voices of trans families be represented in that process?
What happens if a family disagrees with the conclusions drawn about their child?
What is the R22 project?
R22 is described as a fixed-term service-development feasibility project, running across the South West of England in 2025 and 2026. It is hosted by University Hospitals Bristol and Weston NHS Foundation Trust, and it accepts referrals from NHS GPs for children aged nine and under who have what the referral form describes as ‘gender related concerns.’ It is positioned as something families can access when they first ask for help, providing NHS support at an early stage.
That sounds, on the surface, like a positive thing. Access to NHS support for young trans children and their families has always been desperately inadequate, and any service that offers to fill that gap deserves serious attention. The questions I want to raise here are not about the existence of early support, which I wholeheartedly welcome, but about what that support actually looks like, who is delivering it, and what assumptions underpin it.
Why does the language matter so much?
The first thing I noticed when I looked at the referral form is the language used throughout. The children being referred are described as ‘gender questioning.’ The project is framed around ‘gender related concerns.’ The form asks about ‘natal sex.’ Nowhere in the document is the word ‘transgender’ used in relation to the children themselves.
This matters enormously. The language we use around children shapes how they are perceived, how they are spoken to, and how services are designed around them. A child like the seven-year-old daughter of the parent who wrote to me is not, in her mother’s eyes or in her own, simply gender questioning. She is a trans girl. She knows who she is. When services deliberately avoid that language, it is worth asking why, and what assumptions about these children’s identities are baked into the design of the service from the outset.
The Cass Review, to which this project is linked, took a position that children’s gender identities should be treated with what it called ‘watchful waiting,’ that identity should not be affirmed too readily, and that the aim of clinical work should be exploration rather than support. If the language choices in R22 reflect those assumptions, that is something families need to understand before they sign up.
The referral form flags social transition as a risk
One section of the referral form stopped me in my tracks. Under a heading about other risks identified, one of the items that a GP must tick yes or no to is:
‘Risk due to social transition (current or future).’
Social transition, to be clear, means a child living in the gender that matches who they are. It might mean using a different name, wearing different clothes, using different pronouns. It is not a medical intervention. It is something families choose to do because their child is distressed, and because allowing the child to live authentically brings relief and happiness.
The research evidence that social transition causes harm is not robust. The claim has been contested repeatedly by researchers, clinicians, and families with lived experience. Placing social transition on a referral form as a risk sends a clear signal about how the project views a family’s decision to let their child live as who they are. That is not a neutral clinical stance; it is a value-laden one, and families deserve to know it is there.
Who will be asking the questions?
The parent who wrote to me asked a question I cannot fully answer, because R22 has not published the information she would need. She wondered who will be doing the interviews, whether they have experience and skills in working with young trans children and their families, what questions they will be asking, and who has validated those questions.
These are not unreasonable requests. They are the minimum any family should expect to know before they consent to their child being assessed. In any other area of paediatric care, a referral to a new service would come with clear information about the qualifications of the people running it, the methodology being used, and the theoretical basis on which assessments are conducted.
If the staff conducting interviews have no experience in gender care, or have been trained in a model that treats gender diversity as something to be questioned or managed rather than supported, that will shape every interaction they have with the child and family. If the questions they ask are drawn from frameworks that assume most children will ‘grow out of’ a trans identity, that will shape the conclusions they draw. Families have a right to that information, and services have an obligation to provide it.
The Cass Review connection
The Cass Review has been subjected to substantial academic and clinical criticism since its publication. Concerns have been raised about its methodology, about the way it assessed existing evidence, and about the conclusions it drew about both puberty blockers and social transition.
The review recommended a model of care that is cautious about affirmation, sceptical about early social transition, and focused on exploring whether a child’s gender identity will persist. Many clinicians, researchers, and trans healthcare advocates, myself included, believe those recommendations are not grounded in the best available evidence, and that implementing them causes harm to children and families.
If R22 is built on those foundations, families need to know that. A project that presents itself as neutral NHS support may in practice be delivering an assessment model that is not aligned with the values of affirmation and dignity that trans children deserve.
Dr Webberley Responds: Why the Cass Review Still Matters, And Why We Must Look Again
What harm can negative questioning cause?
Children under ten are not abstract subjects for academic research. They are children. They go to school, they have friends, they have fears and joys and a growing understanding of who they are. When they are brought into a clinical setting and asked questions that subtly, or not so subtly, question the validity of their identity, the effects can be lasting.
Research on the psychological wellbeing of trans children consistently shows that family support and affirmation are among the strongest predictors of good outcomes. The opposite is also true. Children who encounter professionals who express doubt about their identity, who use language that suggests they might be wrong about who they are, or who link their choices to risk, can carry that experience with them for years.
I am not saying that R22 will do these things. I am saying that without clear, published information about methodology, training, and theoretical grounding, families cannot know whether those risks are present, and they deserve to know.
What do I say to families who are asking whether to take part?
This is the part of the message that weighs on me most. The parent who wrote to me said she has decided to take part, and she has thought carefully about it. I respect that entirely. She is a thoughtful, loving parent making the best decision she can for her daughter with the information she has.
Other families are writing to me asking for my view, and I want to be honest with them while being careful not to presume I know what is right for each individual child and family. What I will say is this: go in with your eyes open. Before your first appointment, ask for clear written information about who will be conducting the assessment, what their training and experience is, what model of care the project uses, and whether the project considers social transition to be a risk factor. Ask how the assessment questions were developed and validated, and by whom. Ask what happens to the information gathered and how it will be used.
You have every right to ask those questions. If the answers do not satisfy you, you have every right to decline or to withdraw at any point. Your consent is not a formality; it is a genuine choice, and it belongs to you.
To the parent who wrote to me so kindly: your daughter is lucky to have a mother who thinks this carefully, who asks these questions, and who takes such gentle, considered care of her. Whatever you decide, please know that you are doing a remarkable job.
If this has been helpful, please share it with other families who might be navigating similar decisions. The more information parents have, the better equipped they are to protect their children.
Resources
R22 Project GP Information Sheet: https://remedy.bnssg.icb.nhs.uk/media/in3pcqme/gp-information-10112025-final.pdf
Growing Up Transgender: Trans kids under 10 - The NHS Project R22: https://growinguptransgender.com/2026/03/02/trans-kids-under-10-the-nhs-project-r22/
BNSSG ICB Gender Incongruence page: https://remedy.bnssg.icb.nhs.uk/children-young-people/gender-identity/gender-incongruence-in-children-and-young-people/
Dr Webberley Responds: Why the Cass Review Still Matters, And Why We Must Look Again