Sex, Gender Identity, Medicine, Lived Experience and the Changing Meaning of “Woman”
For most of the modern women’s-rights movement, nobody needed to ask what a woman was.
The political arguments were about what women should be permitted to do, whether they should receive equal pay, whether their sex should restrict their employment, how they should be protected from discrimination and violence, and whether being female should prevent them participating fully in society.
The category itself was not seriously disputed.
Women were female human beings.
Indeed, biological sex was fundamental to the argument because it was the characteristic upon which much of the historical discrimination had been imposed.
Then society encountered another legitimate equality question.
How should people whose gender identity differs from their biological sex be treated?
The humane answer should be straightforward:
With dignity.
Without harassment.
Without unjustified discrimination.
With appropriate healthcare.
And with the same fundamental human rights as everybody else.
But eventually a much more difficult question emerged.
What happens when recognition of gender identity conflicts with protections established specifically because women are female?
This is where two movements concerned with equality — women’s equality and transgender equality — have sometimes found themselves in an uncomfortable collision.
The question is not whether transgender people should have rights.
Of course they should.
Nor is it whether transgender people deserve respect.
They do.
The harder question is this:
When sex and gender identity point towards different outcomes, which characteristic should determine the decision?
And behind that lies an even more uncomfortable question:
Has the understandable desire to protect transgender people sometimes caused institutions to become reluctant to defend women’s sex-based rights?
Women’s Rights Were Built Around Sex
The rights British women possess today did not appear spontaneously.
They developed through generations of political, legal and social change.
Women fought for political representation, employment opportunities and financial independence.
The Equal Pay Act 1970 addressed sex-based inequalities in contractual pay.
The Sex Discrimination Act 1975 created much broader protections against discrimination because of sex.
Maternity protections developed.
Sexual harassment became increasingly recognised.
Domestic and sexual violence received greater legal and institutional attention.
Female sport developed protected categories.
Women-only refuges, changing facilities and other services arose in circumstances where privacy, dignity or protection from male violence could justify separation according to sex.
The Equality Act 2010 eventually consolidated much of Britain’s anti-discrimination legislation.
There is an important historical point here.
Women did not acquire these protections because they identified themselves as disadvantaged.
They acquired them because substantial disadvantages had historically been imposed upon them because they were female.
Sex was not incidental to women’s equality.
Sex was the reason much of the protection existed.
Then Came a Different Equality Movement
Transgender people also have a history of discrimination, exclusion and hostility.
Protecting them against unjust treatment is entirely compatible with a liberal society.
British law progressively recognised this.
Protection concerning gender reassignment entered sex-discrimination legislation in 1999.
The Gender Recognition Act 2004 created a mechanism through which qualifying transgender people could obtain legal recognition in an acquired gender.
The Equality Act 2010 subsequently protected both:
sex
and
gender reassignment
as protected characteristics.
That distinction is extremely important.
Parliament did not simply replace sex with gender identity.
It recognised different characteristics requiring protection.
For most ordinary interactions there is no conflict whatsoever.
Protecting a transgender employee from harassment does not diminish a woman’s right to equal pay.
Providing appropriate healthcare to a transgender patient does not undermine women’s employment rights.
Allowing somebody to dress, live and socially present according to their gender identity does not inherently disadvantage anybody else.
The collision occurs where access to something depends specifically upon sex.
Sport.
Prisons.
Changing facilities.
Some medical services.
Some refuges and trauma services.
Sexual-orientation provisions.
Statistical recording.
And certain single-sex associations.
At that point society cannot avoid asking what its categories mean.
“What Is a Woman?”
Few questions illustrate the transformation better than the media’s repeated challenge to politicians:
“What is a woman?”
On the surface it can appear absurd.
Why should senior politicians need to define one of humanity’s most familiar categories?
Yet the question became politically effective precisely because politicians sometimes struggled to answer it.
The conventional biological answer is straightforward:
An adult human female.
A gender-identity framework offers another conception:
A person who identifies as a woman.
The difficulty appears when the second statement is required to function as a definition.
If a woman is somebody who identifies as a woman, what is the thing with which the individual identifies?
The definition risks becoming circular.
Politicians consequently found themselves caught between constituencies.
Define woman exclusively by sex and risk accusations of excluding transgender women.
Define woman exclusively through self-identification and immediately encounter questions concerning sport, prisons, statistics, healthcare and single-sex services.
Refuse to answer and the refusal itself becomes the story.
The media undoubtedly discovered the question’s usefulness as political theatre.
But journalists did not invent the underlying contradiction.
They exposed it.
When Language Becomes Law
Definitions may matter relatively little during ordinary social courtesy.
They matter enormously when legislation attaches rights to words.
If government seeks to increase the number of women on public boards, who counts?
If statistics measure discrimination against women, which population is being measured?
If a hospital provides a single-sex medical service, what determines sex?
If a refuge is lawfully organised around the needs of one sex, who belongs to that category?
If sporting regulations protect a female category, what defines female?
Once government attaches protections, resources or restrictions to a category, the boundaries of that category cannot remain entirely subjective.
Eventually this disagreement reached the UK Supreme Court.
In For Women Scotland Ltd v The Scottish Ministers, decided unanimously on 16 April 2025, the Court held that the words “sex”, “woman” and “man” in the Equality Act 2010 refer to biological sex.
The judgment is important precisely because of what it did not decide.
It did not declare transgender identities illegitimate.
It did not remove protection from transgender people.
It did not determine how somebody must describe themselves socially.
Gender reassignment remains independently protected by the Equality Act, and the Court expressly emphasised the continuing protections available to transgender people.
What it did establish was that the sex-based provisions of the Equality Act require a coherent biological meaning of sex.
That distinction is fundamental.
Protecting transgender people does not require making biological sex legally meaningless.
Who Gets to Define Womanhood?
There is nevertheless another dimension to this debate.
Some strands of gender-identity activism advance a stronger proposition than:
“Trans women deserve equal treatment and dignity.”
The proposition becomes:
“Trans women are women in precisely the same sense as women who are biologically female, and rejecting that proposition is itself discriminatory.”
That creates a philosophical difficulty for women’s rights.
If womanhood is defined entirely through gender identity, what becomes of the historical category around which sex-based equality developed?
Women did not experience historical discrimination because they announced a female identity.
Society classified them according to sex.
Female puberty occurred irrespective of identity.
Menstruation occurred irrespective of identity.
Pregnancy and childbirth occurred irrespective of identity.
Restrictions imposed specifically upon women were imposed because society regarded them as female.
This raises a legitimate question:
Who has authority to define the class whose historical inequality created women’s rights in the first place?
There is no reason transgender experience should be dismissed.
But neither is there an obvious reason why transgender experience should acquire greater authority over the meaning of female experience than the experiences of women themselves.
The Paradox of Lived Experience
Contemporary social-justice thinking places considerable importance upon lived experience.
There is good reason for that.
Someone who has experienced racism may understand aspects of racism an outsider has never encountered.
Someone living with disability can identify barriers invisible to somebody who has never experienced them.
A transgender person understands gender dysphoria, transition and the social experience of being transgender in ways a person who has never experienced them cannot completely reproduce.
But the principle must operate consistently.
A transgender woman possesses the lived experience of being a transgender woman.
A woman born female possesses the lived experience of being female.
Those experiences can overlap socially while differing biologically and developmentally.
A transgender woman may experience gender dysphoria, transition, hormone treatment and hostility associated with transgender status.
A biological woman may experience female puberty, menstruation, pregnancy, childbirth, menopause and lifelong treatment arising from being recognised by others as female.
Neither experience invalidates the other.
The contradiction appears if society says:
“You cannot question a transgender person’s lived experience.”
while simultaneously allowing a biological woman’s description of her own sex to be dismissed as exclusionary.
If lived experience possesses moral significance, it must operate in both directions.
When Disagreement Becomes Discrimination
This connects with another contemporary phenomenon.
Political disagreement can become moral classification.
Instead of:
“I disagree with your definition of woman.”
the response can become:
“You are transphobic.”
The term TERF — trans-exclusionary radical feminist — has a specific political history, but it can also be deployed pejoratively against people expressing sex-based positions.
The principle must, however, work in reverse.
Transgender people are themselves subjected to derogatory and deliberately dehumanising terminology.
That is equally unacceptable.
There is an essential difference between challenging an idea and attacking a person.
Someone should be capable of arguing that biological sex matters without expressing hatred towards transgender people.
Someone should equally be capable of advocating greater recognition of gender identity without expressing contempt for women who disagree.
Tolerance cannot mean:
“You are entitled to your opinion provided it is the same as mine.”
That is not tolerance.
It is conformity.
“Cis” and Reciprocal Autonomy
The word cisgender provides an interesting example.
It is an established term generally used for somebody whose gender identity corresponds with their sex.
It is not inherently derogatory.
Nevertheless, some women reject “cis woman” as a description of themselves.
They simply describe themselves as:
women.
This creates an interesting philosophical question.
If self-identification is fundamental to interpersonal respect, should that principle not operate reciprocally?
A transgender person can reasonably ask others not to use terminology they consider disrespectful.
A non-transgender woman should equally be able to say:
“I do not describe myself as cis. I describe myself as a woman.”
This does not mean individual preference determines every legal, scientific or medical classification.
It means interpersonal courtesy cannot coherently operate in only one direction.
Autonomy must be reciprocal.
When Biology Still Matters: The Medical Reality
Medicine introduces an unavoidable reality into this discussion.
Gender-affirming medicine can profoundly alter the body.
Hormonal treatment can alter secondary sexual characteristics.
Surgery can reconstruct external genital anatomy to a remarkable degree.
These interventions can be extremely significant to the individual undergoing them.
But transition does not exchange one complete reproductive system for another.
A transgender woman undergoing vaginoplasty will ordinarily retain the prostate.
Vaginoplasty does not create functioning ovaries or ovarian physiology, nor does standard gender-affirming surgery provide a functioning female reproductive system.
Conversely, phalloplasty can construct a penis for a transgender man and scrotoplasty can create a scrotum. Testicular prostheses can provide external form, but prostheses are not functioning testes: they do not produce sperm or perform normal testicular reproductive function.
A transgender man may retain a cervix, uterus or ovaries depending upon which procedures have been undertaken.
This has direct clinical consequences. Current NHS guidance states that everyone with a cervix should undergo appropriate cervical screening and specifically addresses transgender men and non-binary people who retain a cervix.
This is not political philosophy.
It is anatomy.
Gender-affirming treatment can alter anatomy and physiology substantially, but it does not replace the entire reproductive biology of one sex with that of the other.
Medicine Cannot Treat Identity Alone
This matters because healthcare cannot safely treat a demographic label instead of the individual patient.
A transgender woman retaining a prostate can still develop prostate disease.
A transgender man retaining a cervix may require cervical screening.
Someone retaining ovaries can develop ovarian pathology.
Someone retaining a uterus can develop uterine pathology.
Hormonal treatment itself may create additional clinical considerations.
A clinician therefore sometimes needs to ask a question more precise than:
“What is your gender?”
They may need to know:
“What anatomy does this particular patient have, and what is clinically relevant to the problem in front of us?”
That question is not an attack upon identity.
It is necessary for safe medicine.
And it provides perhaps the clearest example of the difference between respecting somebody’s identity and being required to disregard biological reality.
A clinician can respect a transgender patient’s identity completely while recognising biological characteristics relevant to diagnosis and treatment.
Indeed, beneficence and non-maleficence may require exactly that.
Ignoring clinically relevant anatomy simply because discussing it may be uncomfortable would not necessarily be compassionate.
It could cause harm.
Sport: Why Does the Female Category Exist?
Competitive sport provides another particularly difficult example because the female category was not created simply as a social identity.
It exists because sex can produce physiologically relevant differences in athletic performance.
Exactly how those differences should affect eligibility varies between sports and continues to be scientifically and ethically contested.
But governing bodies increasingly have to answer a fundamental question:
What is the purpose of the female category?
Whatever eligibility system an individual sport ultimately adopts, there are competing interests.
A transgender athlete has an understandable desire to participate consistently with their gender identity.
Female athletes have an equally understandable expectation that the category created for female competition continues to serve its intended purpose.
Neither side of that disagreement should simply be declared morally illegitimate.
Evidence, proportionality and the purpose of the category must determine the answer.
Prisons: When Vulnerabilities Collide
Prisons make the ethical problem even clearer.
A transgender woman may be genuinely vulnerable within a male prison.
That deserves serious consideration.
But women in prison are themselves a vulnerable population.
Some have histories of sexual abuse, exploitation or domestic violence. HMPPS policy for the women’s estate expressly adopts gender-specific, trauma-informed principles.
A responsible policy therefore cannot ask only:
“How do we protect the transgender prisoner?”
It must ask:
“How do we protect everybody affected?”
Sex, anatomy where relevant, offending history, behaviour, vulnerability and individual risk may all matter.
Current HMPPS policy explicitly describes its approach as balancing the safety and needs of transgender prisoners with the wellbeing and safety of others, particularly within women’s prisons.
This is not merely theoretical. HMPPS statistics for 31 March 2025 recorded 275 transgender prisoners in the men’s estate and 64 in the women’s estate, excluding GRC holders from that part of the analysis.
This illustrates something fundamental about competing rights.
Recognising that one person is vulnerable does not make everybody else’s vulnerability disappear.
Ethics: Do Good and Do No Harm — But To Whom?
The familiar four principles of biomedical ethics provide an exceptionally useful framework for these questions.
Autonomy requires us to respect the individual.
Beneficence asks us to do good.
Non-maleficence asks us to avoid unnecessary harm.
Justice requires fairness between competing interests.
The difficulty is that these principles do not belong exclusively to one side.
Autonomy matters to the transgender person.
It also matters to the woman who rejects terminology imposed upon her.
Beneficence requires society to protect transgender people from genuine discrimination.
It also requires institutions to protect women from genuine disadvantage.
Non-maleficence requires consideration of harms experienced by transgender people.
It also requires consideration of harms that policies intended to protect transgender people might inadvertently create for somebody else.
And justice prevents us simply identifying whichever group appears most vulnerable and automatically giving that group’s interests priority.
Justice requires everybody to remain visible.
Equality Does Not Mean Identical Treatment
There is another distinction worth making.
Equality does not necessarily require treating everybody identically.
Sometimes fairness requires different treatment because circumstances genuinely differ.
A wheelchair user requiring a ramp is not receiving preferential treatment.
A person requiring an appropriate disability adjustment is not necessarily receiving an unfair advantage.
Likewise, protecting a transgender person from harassment is not preferential treatment.
The problem occurs when the concept of equality becomes confused with an entitlement to a preferred outcome.
Nobody possesses an automatic right to win every conflict involving their protected characteristic.
Women do not.
Transgender people do not.
Religious groups do not.
People with disabilities do not.
Men do not.
Equality legislation exists to prevent unlawful discrimination — not to create a hierarchy in which membership of one protected group automatically defeats the interests of another.
That is precisely why competing-rights cases are difficult.
Have Trans Rights Eclipsed Women’s Rights?
The evidence does not support the simplistic conclusion that transgender people have legally acquired greater rights than women.
British equality legislation protects both sex and gender reassignment.
The Supreme Court has now clarified that “sex”, “woman” and “man” in the Equality Act refer to biological sex while stressing that transgender people continue to possess statutory protection against discrimination.
But something more subtle has occurred.
For a period, institutional interpretations of gender identity generated genuine uncertainty about the boundaries of sex-based rights.
Politicians sometimes struggled to define the word “woman”.
Organisations attempted to reconcile conflicting interpretations of sex and gender.
Women expressing sex-based beliefs sometimes reported professional or social consequences.
Transgender people simultaneously experienced genuine hostility and discrimination and sometimes saw ordinary requests for dignity characterised as threats to women’s rights.
These realities are not mutually exclusive.
That is precisely why this subject requires more thought rather than less.
Equality Is Not a Competition
Perhaps the greatest mistake is imagining equality as a league table.
Women should not have to lose rights for transgender people to acquire protection.
Transgender people should not have to surrender dignity for women’s sex-based protections to remain meaningful.
The challenge is identifying circumstances in which sex genuinely matters.
For much of ordinary human interaction, it does not.
The chromosomes or reproductive anatomy of the person serving us in a shop, sitting beside us on a train or working at the neighbouring desk are generally irrelevant.
But sometimes sex matters considerably.
Medicine.
Reproduction.
Some sporting categories.
Some safeguarding environments.
Some statistical questions.
Some intimate services.
Recognising that does not require hostility towards transgender people.
It requires accepting that equality does not mean pretending every human difference is irrelevant.
Limitations of This Analysis
This article deliberately concentrates upon situations in which sex-based rights and protections associated with gender reassignment can come into genuine conflict. Those disputed cases should not be treated as representative of the everyday experiences, beliefs or behaviour of transgender people generally.
Transgender people are not a homogeneous political movement. The opinions of prominent activists, campaign organisations or highly visible participants in social-media disputes cannot automatically be attributed to a much larger and diverse population.
Equally, examples of hostility towards women expressing sex-based views should not be used to dismiss the genuine discrimination and harassment that transgender people can experience.
The medical issues discussed here also vary substantially between individuals. Not every transgender person undergoes hormone treatment or surgery; the procedures undertaken differ; and anatomy following transition therefore differs from patient to patient. Biological sex, gender identity, current anatomy and medical history can each be relevant depending upon the clinical question.
Nor does the existence of a legitimate sex-based distinction mean that sex must determine every social, medical or legal interaction. Context matters.
This article does not attempt to determine the legitimacy of anybody’s personal identity, nor does it argue that women’s interests should automatically prevail whenever rights conflict.
Its purpose is narrower:
to examine whether biological sex remains a materially, medically and legally relevant characteristic in some circumstances; whether recognition of gender identity can coexist with that reality; and how competing rights can be reconciled without denying either women or transgender people dignity and protection from discrimination.
Because this analysis deliberately examines sport, prisons, medicine, safeguarding and other areas in which conflicts are particularly visible, those examples should not be mistaken for evidence that such conflicts dominate ordinary interactions between transgender and non-transgender people.
They do not.
But where genuine conflicts occur, avoiding them because the discussion is uncomfortable does not resolve them.
Conclusion: Protect the Person Without Abolishing the Category
Seventy years of modern women’s equality were built upon recognition of a historical fact.
Women suffered substantial discrimination because they were female.
Transgender equality developed from another legitimate recognition.
People whose gender identity differs from their biological sex should not therefore be subjected to humiliation, harassment or unjustified discrimination.
Neither principle needs to destroy the other.
The mistake occurs when respecting one requires denying the reality underlying the other.
A transgender woman should be treated with dignity.
A biological woman should be able to describe herself as female without that statement automatically being interpreted as hostility.
A transgender patient deserves compassionate healthcare.
A clinician must nevertheless be able to discuss clinically relevant anatomy.
A transgender prisoner deserves protection from violence.
Female prisoners deserve safeguarding too.
A transgender athlete deserves dignity and respect.
Female athletes are entitled to ask whether a protected female category continues to fulfil the purpose for which it exists.
And everybody should be capable of discussing these questions without disagreement automatically becoming hatred.
Perhaps the answer to “What is a woman?” therefore depends partly upon why the question is being asked.
Socially, people may understand womanhood through identity, culture and personal experience.
Medically, anatomy and physiology may determine what information is relevant.
Legally, the UK Supreme Court has clarified the meaning of “woman” and “sex” for the purposes of the Equality Act 2010.
Historically, women’s rights cannot be understood without recognising the female sex upon which much of that discrimination was imposed.
So perhaps the most important question is not:
Whose rights matter more?
It is:
How do we protect transgender people from discrimination without making the sex-based protections women spent generations achieving meaningless?
That returns us to first principles.
Autonomy: respect the individual.
Beneficence: do good.
Non-maleficence: avoid unnecessary harm.
Justice: when legitimate interests collide, consider everybody affected.
Equality should never require one group to disappear so that another can be seen.
And tolerance cannot mean that difficult biological, legal or ethical questions become questions we are no longer permitted to ask.
A mature society should be capable of something considerably harder:
recognising biological reality, respecting individual identity, protecting both groups from discrimination and accepting that disagreement is not necessarily hatred.
That is not an abandonment of equality.
It is the test of whether we genuinely believe in it.
Sources and Further Reading
UK Supreme Court — For Women Scotland Ltd v The Scottish Ministers [2025] UKSC 16 — The judgment establishing the interpretation of “sex”, “woman” and “man” under the Equality Act 2010.
Equality Act 2010 — The principal UK statutory framework protecting characteristics including sex and gender reassignment and governing discrimination and particular exceptions involving single-sex and separate-sex provision.
Gender Recognition Act 2004 — The statutory framework governing legal recognition of acquired gender in the United Kingdom.
NHS — Cervical screening guidance — Current guidance includes specific advice for transgender men and non-binary people who retain a cervix.
HMPPS — The care and management of individuals who are transgender — Policy framework addressing the treatment, allocation and risk management of transgender prisoners while explicitly considering the safety and wellbeing of other prisoners.
HMPPS — Women’s Policy Framework — Guidance establishing gender-specific and trauma-informed principles for the women’s custodial estate.
Beauchamp TL & Childress JF — Principles of Biomedical Ethics — The influential framework of autonomy, beneficence, non-maleficence and justice used throughout this analysis.
The Supreme Court did not establish a hierarchy in which women’s rights automatically defeat transgender rights.
Instead, it clarified something arguably more useful: sex and gender reassignment are distinct protected characteristics, and recognising the legal reality of one does not abolish protection for the other.
That distinction may provide the most sustainable foundation for protecting both.
