Rt Hon Sajid Javid MP
House of Commons,
4th March 2022
Dear Secretary of State,
I am writing to you, the Secretary of State for Health and Social Care, to express an immense dissatisfaction with the NHS’ provision of healthcare for transgender individuals in the United Kingdom. My intent is to convey to you the urgency of a drastic, and radical, reformation of the current model of healthcare for transgender individuals, and to propose to you recommendations for how to engender this vital reformation.
As of this calendar month, there are 10,648 individuals awaiting an initial assessment at the Gender Identity Clinic (GIC) in London (GIC 2022). The period between a referral and an initial assessment at this GIC is over 33 months, according to data from February of 2021 (Trans Health UK 2021). This severely contravenes the requirement, as outlined by the NHS Constitution, that an individual should not have to wait more than 18 weeks to receive treatment after their referral (NHS 2022). The reasons underpinning these excessive, and unnecessary, waiting times are multiple; I intend to explicate these shortly, and to argue for a potential solution to this problem. However, before I do this, I wish to delineate my recommendations — in the discussion that follows, I will elaborate upon why these reformations are necessary. I urge you to:
- Implement an informed consent model of care for transgender individuals, and ensure the equity of treatment in all aspects of healthcare.
- Include transgender healthcare in the medical school curriculum.
Informed Consent Model of Care
In 2012, the World Professional Association for Transgender Health Standards of Care, in its 7th version, recommended that transgender individuals — this includes gender diverse and non-binary individuals, as well — undergo a psychosocial assessment by a gender-specific psychiatrist or psychologist as a prerequisite to the prescription of feminising or virilising hormones (i.e., oestrogen or testosterone) (Spanos 2021). In addition, it specifies that ‘persistent, well-documented gender dysphoria’ (Coleman 2012) is a criterion for the receipt of this prescription. The requirement for assessment, and approval, by a mental health practitioner has received criticism for being paternalistic, and a ‘form of gatekeeping that actually limits access to gender-affirming care’ (Ashley 2019). Identifying as non-binary transmasculine, and currently experiencing the extent of this gatekeeping within the GIC, I unequivocally concur. The reliance on a psychosocial assessment, and on a clinical diagnosis of gender dysphoria, is unnecessary. The prolonged waiting times for an assessment at a GIC engendered by this reliance on a psychosocial assessment, and on a clinical diagnosis of gender dysphoria, threaten to kill. Transgender individuals who are suffering from debilitating gender dysphoria — which is, perhaps, compounded by other psychological diagnoses, such as depression or anxiety — are oftentimes in need of feminising or virilising hormones to alleviate suicidality. Withholding immediate access to these essential prescriptions, by means of an unnecessary practice of gatekeeping by the GIC, and ‘hoop jumping’ by the transgender individuals, is equivalent to enabling a suicide.
Those who are at risk of suicide, or are deeply unhappy due to a sense of incongruence between their gender identity and their biological sex, are confronted with either: 1) paying for an assessment with a gender-specific psychiatrist or psychologist; or 2) acquiring feminising or virilising hormones illicitly, by means of a black or grey market, or purchasing somebody else’s prescription. Most importantly, the costliness of privately provisioned healthcare, or of an illicit prescription medication, can render the individual extremely vulnerable if they are on a low income or struggling financially. This is, by no means, a decision made lightly; instead, it a decision reflective of desperation, and an inadequacy of the healthcare provisioned by the GIC. It is a lack of sufficient funding for the NHS, and an encroachment of neo-liberalisation, that are to blame. In the case of the former, the financial cuts to the government’s funding of the NHS — these may be referred to as ‘austerity measures’ — underpin the excessive waiting times for the GIC (Carlile 2020). In the case of the latter, the inadequacy of the publicly funded GIC is, perhaps, underpinned by a growing trend towards neoliberalism; there is, subsequently, a reliance on privately funded healthcare providers to meet the needs of transgender individuals in the United Kingdom. The tenets of neoliberalism — ‘a strongly market-based approach, which emphasises deregulation, minimalisation of the State, privatisation, and the emergence of individual responsibility’ (Sakellariou & Rotarou 2017: 2) — are ostensibly incompatible with the ethos of justice espoused by the NHS Constitution, or healthcare systems more generally (Rylko-Bauer & Farmer 2002). This can, and should, be understood as a form of structural violence, a term that features heavily in the writings of Paul Farmer (Farmer 2006). ‘Structural violence’ refers to the ‘avoidable impairment of fundamental human needs or … the impairment of human life, which lowers the actual degree to which someone is able to meet their needs below that which would otherwise be possible’ (Farmer 2006: 1686; Galtung 1993). This is embedded in ‘ubiquitous social structures’ (Gilligan 1997: 306), such as the policymaking of the NHS, for example. In this way, transgender individuals, who are vulnerable and oftentimes desperate, are disproportionately denied access to an essential form of healthcare; this remains unaffordable for most. In this way, pre-existing inequity is exacerbated, and suffering perpetuated.
However, there is an alternative: an informed consent model of care. This emerged, for the prescription of gender-affirming hormone therapy (GAHT), in the early 2000’s (Spanos 2021). This enables shared decision-making between a patient and their treating clinician (Schulz 2018), as opposed to necessitating a formal, psychiatric assessment prior to the prescription of GAHT. This achieves a de-pathologisation of gender diversity in transgender individuals, and eliminates obstacles to their receipt of healthcare (Schulz 2018). Furthermore, it ‘seeks to emphasize partnership [between the clinician and the patient], and self-determination’ (Spanos 2021: 202) for the patient, or transgender individual. It, I believe, dismantles the imbalance of power that is inherent in the current model of care for transgender individuals; it firmly, and correctively, grants an agency that is oftentimes displaced within the ‘clinical encounter’ — it enables transgender individuals to regain autonomy over their bodies, as opposed to pleading with, or appeasing, the gender-specific psychiatrist or psychologist to prescribe. In the diagnostic model, the patient is perceived as a ‘passive recipient of care, and the practitioner is in the role of determining the [patient’s] eligibility’ (Schulz 2018: 85) for care; this may manifest as the clinician instructing the patient on how to transition, or determining the patient’s eligibility on the basis of their ‘appearance o gender presentation’ (Schulz 2018: 85). This is not so for the informed consent model of care, whereby the patient and the clinician are partners.
The informed consent model of care is, already, acknowledged ‘within the World Professional Association for Transgender Health Standards of Care as an accepted alternative pathway in the provision of GAHT’ (Spanos 2021: 202), and is recognised by the European Society for Sexual Medicine (T’Sjoen 2020). The initiation of GAHT can be conducted in a primary care setting by a General Practitioner (GP), using the informed consent model of care; this presents an immediately actionable solution to reduce the amount of time spent waiting for an initial assessment at a GIC. Furthermore, the extant literature pertaining to this model demonstrates an association with improved patient satisfaction (Spanos 2021).
Transgender Healthcare in the Medical School Curriculum
The informed consent model of care, if it is to be conducted in a primary care setting, will rely on the GP being 1) better informed on transgender individuals, and their healthcare needs; and 2) more respectful towards transgender individuals. For this reason, I encourage you to drastically improve the medical school curriculum, by ensuring the inclusion of transgender healthcare. Transgender individuals are frequently asked invasive, disrespectful questions upon a disclosure of their transgender identity to a GP; these may include topics relating to their sexual activity, or traumatic events that they have experienced (Ellis, Bailey & McNeil 2015). In this way, a clinical consultation becomes a disempowering, and dehumanising, experience. This is especially true for an individual with gender dysphoria; this patient may be excessively pathologized by the GP, or reduced to a mere diagnosis, as opposed to being perceived as a nuanced, complex individual (Carlile 2020). This is equivalent to ‘the clinical gaze’, as theorised by Michel Foucault (Foucault 1975). Foucault’s notion of ‘the clinical gaze’ refers to the way in which the patient is perceived as an object; the patient is ‘the bearer of the disease’ (Ristić, Zaharijević & Miličić 2020: 103), whereby the person is abstracted from the body — the subject of the gaze is ‘not an afflicted person, but an affliction’ (Ristić, Zaharijević & Miličić 2020: 101). In this way, the patient, or the transgender individual, is perceived by the clinician as an amalgam of symptoms — or, a ‘system of signs, readily accessible to’ (Ristić, Zaharijević & Miličić 2020: 101) the gaze — that constitute the diagnosis of gender dysphoria.
Misgendering, and ‘deadnaming’, by a GP are commonplace occurrences for a transgender individual. These micro-aggressions have the potential to be extremely harmful, and to become a deterrent for an individual seeking healthcare in the future. Extant literature demonstrates that misgendering, which is to associate a transgender individual by their biological sex, or the gender they were given at birth, can cause immense distress, as well as damage the relationship between a doctor and their transgender patient (Malpas 2011; Pullen Sansfaçon 2019). Given that a transgender individual may, already, hesitate to attend appointments with a GP due to ‘expectations of hostility, lack of understanding, or invasive questioning’ (Ellis, Bailey & McNeil 2015), this must cease immediately.
The lack of exposure to transgender healthcare amongst both undergraduate and postgraduate medical students is troubling (Dubin 2018). According to James and Colling Sylvester, final-year medical students do not receive any education pertaining to transgender healthcare beyond ‘equality and diversity’ sessions (James & Colling Sylvester 2018). The medical school curriculum in the United Kingdom must, urgently, become more representative of transgender healthcare. This must not be strictly biomedical; it should extend to communication skills training, or role-play scenarios (James & Colling Sylvester 2018). This may improve medical students’ awareness of the importance of using the correct, and respectful, terminology in an encounter with a transgender individual.
Thirteen percent of the LGBT population in the United Kingdom may identify as transgender (GOV.UK 2019). Transgender individuals may be marginalised, but we are not, by any stretch of the imagination, marginal. Radical reformation of healthcare for transgender individuals is needed immediately. I urge you to consider, carefully, the arguments I have made, and most importantly, to act.
Ashley, F. (2019). Gatekeeping hormone replacement therapy for transgender patients is dehumanising. Journal of Medical Ethics, 45(7), 480-482.
Carlile, A. (2020). The experiences of transgender and non-binary children and young people and their parents in healthcare settings in England, UK: Interviews with members of a family support group. International Journal of Transgender Health (Print), 21(1), 16-32.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . Zucker, K. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. The International Journal of Transgenderism, 13(4), 165-232.
Dubin, S., Nolan, I., Streed, Jr, Carl G, Greene, R., Radix, A., & Morrison, S. (2018). Transgender health care: Improving medical students’ and residents’ training and awareness. Advances in Medical Education and Practice, 9, 377-391.
Ellis, S., Bailey, L., & McNeil, J. (2015). Trans People’s Experiences of Mental Health and Gender Identity Services: A UK Study. Journal of Gay & Lesbian Mental Health, 19(1), 4-20.
Farmer, P., Nizeye, B., Stulac, S., & Keshavjee, S. (2006). Structural violence and clinical medicine. PLoS Medicine, 3(10), E449.
Foucault, M. (1975). The birth of the clinic : An archaeology of medical perception / Translated from the French by A.M. Sheridan Smith. New York: Vintage Books.
Galtung, J. (1993). Kultuerlle Gewalt. Der Burger im Staat 43: 106.
GIC. (2022) ‘Waiting Times’, Gender Identity Clinic. Available at: https://gic.nhs.uk/appointments/waiting-times/ (Accessed: 4 March 2022).
Gilligan, J. (1997). Violence: Reflections on a national epidemic. New York: Vintage Books.
GOV.UK. (2019) ‘National LGBT Survey: Summary Report’. Available at: https://www.gov.uk/government/publications/national-lgbt-survey-summary-report/national-lgbt-survey-summary-report (Accessed: 6 March 2022).
James, S., & Colling Sylvester, H. (2018). Transgender health and its current omission from medical school curriculum: Medical students’ perspective. Advances in Medical Education and Practice, 9, 607-609.
Malpas, J. (2011). Between Pink and Blue: A Multi-Dimensional Family Approach to Gender Nonconforming Children and their Families. Family Process, 50(4), 453-470.
NHS. (2022) ‘Referral to Treatment’, NHS England. Available at: https://www.england.nhs.uk/rtt/ (Accessed: 4 March 2022).
Pullen Sansfaçon, A., Temple-Newhook, J., Suerich-Gulick, F., Feder, S., Lawson, M., Ducharme, J., . . . Holmes, C. (2019). The experiences of gender diverse and trans children and youth considering and initiating medical interventions in Canadian gender-affirming speciality clinics. The International Journal of Transgenderism, 20(4), 371-387.
Ristic, A., Zaharijevic, A., & Milicic, N. (2020). Foucault’s Concept of Clinical Gaze Today. Health Care Analysis, 29(2), 99–112. https://doi.org/10.1007/s10728-020-00402-0
Rylko-Bauer, B., & Farmer, P. (2002). Managed Care or Managed Inequality? A Call for Critiques of Market-Based Medicine. Medical Anthropology Quarterly, 16(4), 476-502.
Sakellariou, D., & Rotarou, E. (2017). The effects of neoliberal policies on access to healthcare for people with disabilities. International Journal for Equity in Health, 16(1), 199.
Schulz, S. (2018). The Informed Consent Model of Transgender Care: An Alternative to the Diagnosis of Gender Dysphoria. The Journal of Humanistic Psychology, 58(1), 72-92.
Spanos, C., Grace, J., Leemaqz, S., Brownhill, A., Cundill, P., Locke, P., . . . Cheung, A. (2021). The Informed Consent Model of Care for Accessing Gender-Affirming Hormone Therapy Is Associated With High Patient Satisfaction. Journal of Sexual Medicine, 18(1), 201-208.
Trans Health UK. (2021) ‘UK Trans Healthcare Information for the Coronavirus/COVID-19 Period’, Trans Health UK. Available at: https://transhealthuk.noblogs.org/covid-19-gender-identity-clinics/#tavistock (Accessed: 4 March 2022).
T’Sjoen, G., Arcelus, J., De Vries, A., Fisher, A., Nieder, T., Özer, M., & Motmans, J. (2020). European Society for Sexual Medicine Position Statement “Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction”. Journal of Sexual Medicine, 17(4), 570-584.
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