Transgender Awareness Week 2020 #3 - The State of Trans Healthcare in the UK.
Today we will be looking at the state of transgender specific healthcare in the UK - or rather the lack of it and the difficulty in accessing it.
This article provides a very high level overview of the current process and issues but is not particularly in depth.
There are currently seven Gender Identity Clinics (GIC) across the UK, and each is run as a separate entity. Earlier this year, as part of the whole Gender Recognition Act Reform debacle, the government announced three new clinics would be provided - however this was untrue. The “new clinics” are pilot programmes which had already been announced some time previously by the previous government.
While very welcome, access to these is very limited.
The average wait time for a first appointment at a GIC is now in excess of 3 1/2 years (180 weeks +), and four years ago it was already 2 years.
The NHS Target for wait times to see a specialist consultant is 18 weeks. Let that sink in - the current wait time is more than 10 times the target, and growing.
How is it supposed to work, and how does it all work in reality?
Lets look at the process for adults - its slightly different for young people, and in many ways worse.
Getting a referral from your GP.
The first step is to get a referral from your GP to the GIC of your choice. This should be a very simple, easy first step - but it isn’t. Simply obtaining a referral is a lottery which is very highly dependent on whether your GP is trans supportive or not.
Many GPs simply refuse to do the referral at all.
Others insist that the trans person must be referred to the mental health services in the first instance before being allowed to be referred - which can add several years to getting help. This step is not a requirement, and if the GP feels the person may benefit, or the person asks for it, then the referral to both services can and should be done simultaneously. Referring to mental health services is often a way that unsupportive GPs can “offload” the problem of dealing with a trans person onto someone else, without actually providing help.
If you’re really lucky, you may have a supportive GP and get your referral straight away.
Then you wait.
Gender Identity Clinic - How its supposed to work.
Lets ignore the wait time and look at what is supposed to happen once you manage to access the GIC.
Broadly speaking the steps are relatively simple :
Get assessed for the extent of your Gender Dysphoria
Explore underlying reasons why it exists via counselling
Work out what “transition” steps may be required
Guide person through transition step by step - social transition, Hormone Therapy, Surgical Intervention
Unfortunately, the detail in these processes is where it fails, completely.
Gender Identity Clinic - What Actually Happens.
The NHS operates on what is known as an “interim pathway” for transgender healthcare, and has done for many years. Its worth noting that this process is not in line with international standards, and is heavily reliant on an outdated, restrictive and largely disproved psychotherapy model which assumes that trans people are “broken” in some way.
The current process is also only designed to accommodate those who are “binary” transgender people - that is those who completely align with the sex opposite to that which they were noted as at birth - it isn’t designed to work for Non-Binary trans people.
So, what actually happens?
The Assessment / Counselling phase is inconsistent not only across GICs, but within GICs themselves. How you are assessed is largely depended on the therapist you are assigned, you rarely get the same therapist twice.
Some therapists take an “affirmative” approach, but most commonly a “gatekeeping” approach is used. Gatekeeping means proving to the therapist that you are “trans enough” to receive help.
The gatekeeping process means highly intrusive, asking deeply offensive questions which include describing your sexual habits, preferences and activities in deep detail, looking for evidence of “trauma” and then dissecting those to determine the underlying cause, and whether that is why you have Gender Dysphoria.
If the therapist deems you are “trans enough” for treatment, you may be encouraged to start socially transitioning without any medical help.
Once socially transitioned for a length of time, you may be offered and referred for Hormone Therapy.
When you have been socially transitioned for two years you become eligible for Gender Confirmation Surgery - where again before referral you will be questioned intrusively.
You then go on the wait list for surgery.
So in reality, the process from getting a referral to Gender Confirmation Surgery can take between 6 and 10 years, depending on where you are in the country.
Given the timescales now experienced, many trans people are now arriving at the GIC having already socially transitioned and started Hormone Therapy privately - which then throws the whole process into disarray.
In the Meantime, Back to the GP.
So, assuming youve managed to secure some actualt treatment in the form of hormone therapy, we are back to the GP postcode lottery.
Hormone Therapy requires blood tests and monitoring, under guidelines supplied by the GIC / Endocrinology.
Many GPs refuse to do both, citing that they are “untrained” and that it is “specialist care” - it isn’t, it simply involves checking hormone levels and adjusting dosage in accordance with what is expected for cisgender norms.
GPs also often look for excuses to remove hormone therapy completely, using it as an excuse for the cause of other ailments the trans person may experience, and refusing to treat those ailments in case “its being caused by the hormones”. This excuse is also used in specialist care settings as well.
Why is it such a mess?
The first thing to note is that the current process isn’t actually there to help trans people, but is designed to ensure that cisgender people don’t “make a mistake” and transition when they shouldn’t.
So rather than helping those in need, it does the opposite.
The second is underfunding. The current system is designed for a few hundred referrals a year, where the actual rate of referral is now running into the thousands. The rise in referrals was predicted more than 11 years ago by several trans organisations, however this was ignored by both government and the NHS.
The third is staffing. There are not enough “gender specialists” in the country (for everything from counselling to GCS), and few are being trained. Those that are being trained are generally being done so under the failing current model, making things worse.
Fourth is the model itself - as mentioned the current process does not conform to international standards, and relies on a “prove you’re transgender” model, rather than a “ok, you’re trans, what can we do to help” model. This is what’s known as Gatekeeping vs Affirmative Care. The model also reinforces the gender binary (the assumption that there are only two sexes & genders), and as such is largely incompatible with Non-Binary identities.
Lastly, the approach for running every aspect of care though a single provider (the GIC) as a centralised model created a massive bottleneck. Think of what happens when you’re on the motorway and three lanes are reduce to one due to roadworks and a lower speed limit.
Can it be fixed?
Yes, and relatively simply in most respects.
The first step would be to adopt the Affirmative Care, Informed Consent model - essentially believing the trans person when they seek help that they are transgender, they want help, and either know what they want to do or want help exploring things - and understand the risks and outcomes of doing so.
This would involve decoupling both gender related counselling and hormone treatment from the purview of the GIC, and moving them into the mental health service and GP provision respectively, effectively moving from centralised care to localised care.
This would leave only transition related surgeries as a specialist treatment under the purview of the GICs.
By doing this the “system” would be much better placed to provide care and treatments for all transgender people, rather than restricting it to a few hundred each year.
Will it be fixed?
Many trans people do not believe so.