Trans healthcare in the UK: How things got so out of shape.
Disclaimer: This is written from my own 21-year trans perspective, and anything I write is framed through my own understanding. Nothing I write intentionally, or otherwise, seeks to over-ride the experiences of many trans folk going through the current NHS or private gender pathways.
I find it increasingly frustrating that the narrative around trans healthcare in the UK appears to have forgotten, or may not even be aware of, the state of trans related medicine prior to 2010. Indeed, many of the critical issues facing the NHS’ approach to trans medicine stem from the decisions made in the 2000s, in particular both the breaking down of barriers to entry and the increasing reluctance of GPs to prescribe hormones without a specialist referral.
Gatekeeping has always been a significant issue within the trans community, and I was one of the first generation of trans women to essentially enter the NHS gender pathway as those original gender essentialist gatekeepers were retiring or were being sued out of practice. There was an inflection point around 2003 to 2005 when senior gender clinicians who essentially saw male to female patients as needing to be ultra femme to pass and succeed as women slipped out of the system. In their place came clinicians who saw gender as less essentialist, but at the same time still saw gender as a more binary construct.
Alongside this, and a significant reason why there are major flaws in transgender related healthcare in the UK, were several major court cases and General Medical Council hearings that either stuck off or censored out of practice more liberal trans healthcare providers for being too liberal with their prescribing. In major echoes of the recent puberty blocker case, these clinicians were sued by patients who regretted their transitions, and it effectively put the kibosh on ease of access trans hormone treatments by informed consent.
I was extremely fortunate that in 2000 my GP prescribed hormones to me on an informed consent basis, and it was not until 2005 that things became formalised through the NHS gender pathway. I am one of the few people I am aware of from that period, or after, that effectively managed the system without any real issues. However, due to the lower volume of patients being seen by the NHS at the time, waiting times were low and I got regular three-monthly appointments after 2005 until my final surgery in 2008. What made me unusual was that because I went private with my surgery in Thailand, I avoided the worst of the NHS surgeons and the worst gatekeeping due to both my sexuality and gender.
Nothing I went through was hard. Aside from the stalled entry into the system after my suicide attempt and moving address in 2001 (which delayed me by around two years), I never once encountered a gender healthcare professional who actively sought to either block or gatekeep me. Nor did any of them simply had me a prescription and leave to my lonesome. It was almost too easy and relaxed, with enough safeguards to keep me from falling over the edge.
Around me, however, significant issues were being stored up. One was the slow replacement of senior clinicians and a ramping up of training for an expanded gender service across the UK. A second was the centralisation of trans medicine in several key node, one being the Tavistock Centre and Charing Cross. And a third being that trans awareness across the UK was still very much women’s magazines and TV talk shows. Many of my trans friends from this period lament the gatekeeping and delays, especially with the binary nature of gender being enforced, and these three issues played out slowly in their health care much to their chagrin. It was not easy, and I am sure they will tell a very different story to me, but many of them managed to work their way through the system in a timely fashion.
Then the true impact of the internet, easy of access to trans issues, and the media fascination with Laverne Cox and Caitlyn Jenner exploded. By this point I was nearly five years post-op, and for me it was more of a curiosity. However, all three critical issues, plus the legal complexities of GP prescribing hormones, came home to roost with a vengeance. If only one of them had been in place things would have been difficult, but with the added bonus of the UK government’s austerity drive, trans healthcare took a nosedive.
Waiting times skyrocketed because more people became aware that yes, in fact you could actually do something about the gender dysphoria you were feeling. People who generations passed would have suffered in silence, possibly with significant mental health issues, saw an opportunity to alleviate their dysphoria. Only that the NHS was not ready, and had no clear project management in place to be able to scale their resources to meet the needs of patients. Starved of money by central government, gender services collapsed into the blackhole they are in 2021.
On the side lines GPs who wished to cater for the needs of patients privately flourished, and they were burned down by General Medical Council action. At least three providers post-2010 have been shut down, with those who remain becoming increasingly reticent in their handling of patients.
None of this is acceptable for trans patients, especially as the binary notions of gender are breaking down and non-binary folk are lost in the conversation. Trans healthcare has become such a hot potato that for me to even write this article invites critique from all sides. I was extremely fortunate to be of the generation that came in after the major old school gatekeepers had retired and before the post-2010 shit show began, and for me the critical issue comes down to how much risk are we as a society willing to allow trans folk to take with their own healthcare.
The major trans medical court cases, including Kira Bell, have hinged on the willingness of healthcare professionals to take the word of patients with respect to their gender. Bell’s case stated clearly that more gate keeping was necessary, that the NHS has a duty of care to guard the sanctity of a person’s assigned gender at birth until proven otherwise. Conversely, the vast majority of trans folk view this as an outdated and outmoded way of thinking, and that we as individuals who intrinsically know our internal gender should be allowed to progress without heavy handed policing. Trans folks’ risk appetite is a lot higher than the law currently allows or wishes.
The hurdles to obtain medicine, hormones, surgery, and other necessary appliances has always been based around risk. Any medical intervention to alleviate symptoms is never 100%, always carries a risk to the patient. Every single medication and hormone has side effects. In the right dose they cure us, in the wrong quantities poison. The same goes for surgery. Trans medicine carries risks that have to quantified based on each patient, as no two people react the same way to hormones or the preferred surgery. HRT for menopausal women has a vast amount of research and evidence backing it us, hence a GP can prescribe it, whereas trans healthcare research is still in its infancy, and thus requires endocrinologists and qualified surgeons to make the judgement calls. Neither of these should be a hurdle, indeed, if anything this is an argument in favour of expanding the numbers of both. Every time a trans patients starts on the medical interventionist route to conforming their gender they are a walking experiment that needs close monitoring to ensure they stay fit and healthy for the rest of their lives. We all accept this risk, and all of us who undergo these treatments do so readily.
Kira Bell is a clear example of the complex knot at the heart of this issue. Go back 15 years and you see a slew of cases for adult transitioners. Regret is clearly a thing, but it should not be the deciding social factor for risk. Every single treatment has a regret rate, with trans healthcare being less than 1%. One person going through the UK courts has derailed the healthcare of those who overwhelmingly would have never regretted walking down the gender pathway with the NHS. This is the current state of trans healthcare in the UK, with the general populous unwilling to accept the risks that all trans folk willingly take. And this is not even getting into the philosophical debates about gender identity, gender conformity, and child gender awareness.
The UK is blessed with a free-at-the-point-of-use healthcare service in the shape of the NHS. By law every trans person in the country should be able to see a gender specialist within three months of referral, not over three years as is presently the case. No-one trans patient should have to pay privately for their treatment, nor should they pay above the odds for prescriptions (if they have to pay). The British system is based on patient needs regardless of background or personal intersection. That it has failed an incredibly vulnerable group within society is in part by government austerity, in part by a failure of imagination on the part of gender services and scaling those services up when they have the capacity to do so, and just as significantly by the cultural whiplash stirred up by those who are fixated on an outdated notion of gender.
Nothing will change unless there is a root and branch restructuring of NHS gender services and a legal willingness to allow patients to accept an appetite risk far above the current guidelines. This potentially could mean that patients have to sign indemnity forms for early access to hormones, preventing legal measures if they regret their decision. This could mean dedicated post-graduate trans medicine training for surgeons, mental health professionals, and other ancillary gender healthcare professionals. It could even, more radically, strip out the mental health side of the gender pathway entirely and treat gender like we do flue or the common cold. Some of this is risk, some of this is expanding healthcare in meaningful ways, and a lot of it is reshaping societal ideas of gender away from simple shock and awe.
Finally, while things are grim with waiting lists, the fact that the UK has a gender pathway despite all the legal and social travails, shows that the NHS does want free gender healthcare for those who needs it. Britain may becoming a dank land where gender is once again in the trenches, but it is a culture war that can be won without sacrificing more trans bodies on the alter of far right ideology. No system is ever perfect, and while my experiences were halcyon, I feel I have a responsibility to ensure that those who walk the path behind me do so in Elysia and not a miasma swamp of despair.