University College London
FAO: Cass Review Team
PO Box 16738
Dear Dr. Cass,
I came across the “Independent review of gender identity services for children and young people”[i] while following the appeal of the 2020 ruling that prevented under-16’s consenting to hormone blockers[ii]. As a member of the LGBTQ+ community, I was overjoyed to hear about the decision to overturn this ruling and acknowledge the ability of youths, regardless of their gender identity, to consent to and make decisions regarding their own medical care. I write to you as I believe my perspective as an anthropology student may offer additional insights into further structural changes that are imperative to improving healthcare access for trans youths, and hope that you will consider them in your review.
The September 2021ii appeal brought transition-related medical decisions more in-line with those that youths may make regarding giving consent to any other medical treatments, if considered sufficiently competent[iii]. With the legal basis for care assured, the focus must shift to a healthcare system that takes ‘being trans’ seriously. Only when ‘being trans’ is formulated positively can the system be reformed to provide the best care.
With the phrase “taking ‘being trans’ seriously” I refer to trans identities, assumed by around 1% of the UK population[iv], whose legitimacy as an identity should not be questioned. Anthropological concepts of identity have moved from focusing on sameness to identity as expressing difference and being tied to political projects[v]. Considering identity is important because it is voiced in contexts where the protection or allocation of specific rights is at stake. The framing of trans identities in public discourses questions the very fact of trans identities being real. However, ethnographies reveal that transgender people define gender according to individual subjective experience[vi]. For example, a study conducted in a US paediatric clinic revealed that trans individuals view their identity as originating from within the self, corresponding with US neoliberal political views[vii]. Considering the similar historical and social context of the UK, when taking trans identities seriously, we must support the identity claimed by an individual which is crucial to make changes to the structures that currently limit and restrict their right to healthcare.
The current system of trans-related healthcare is inadequate, underfunded, and outdated, making structural changes indispensable. But most problematically, it is built off assumptions that do not positively value trans as a legitimate identity and which prioritise worries of de-transitioning over treating gender dysphoria through transition-related care. These assumptions are perpetuated and reinforced by public discourses that focus on transition narratives of regret[viii]. The idea that the increasing number of trans youths can be explained by ‘social hype’ is dangerous because it dismisses trans as a legitimate identity and gender dysphoria as a distressing condition requiring treatment. If trans identities are adopted by people only because it is a popular fad, it is not unthinkable that these same people may later come to regret bodily choices made in pursuing this ‘trend’. Focusing public discourses on regret and framing trans as a social trend dismisses trans identities as something real that people associate with. And by dismissing trans identities one also dismisses the rights to healthcare and gender-affirming interventions that can be imperative to treating the anxiety and distress some people feel in relation to their sex characteristics.
Despite these assumptions, studies have shown that the number of trans people who experience regret in relation to any part of their transition is incredibly low. Some studies even place this number at less than 1%[ix]. Focusing on these untrue narratives of regret and de-transitioning dismisses trans identities and the political rights they are entitled to. They only succeed in supporting a crusade to delay, limit and deny transition-related healthcare to trans youths.
The current availability and forms of trans healthcare are synonymous with deferring and restricting care. The UK’s approach to transgender healthcare is focused on numerous psychological evaluations and assessments conducted by a plethora of therapists and psychologists[x]. Although the 2021 appeal has reintroduced considering medical treatment for gender dysphoria for trans youths, this is still not the primary modus operandi of trans healthcare and medication is still viewed as the last resort. The system relies predominantly on mental health professionals, despite national[xi] and global[xii] recognition that gender dysphoria is not a mental health disorder. Trans youths must still perform their gender identity and bodily discomfort to appear ‘trans enough’ for cis doctors and justify their right to hormonal treatments. As Franklin puts it, “gender identity – and the problematic “right diagnosis” – is the basis for access to biomedical technology and social inclusion”[xiii]. But why must the healthcare system and access to it be determined by an external perception and diagnosis of identity rather than taking a stated identity at face value? Why must access to healthcare be justified to others?
These approaches only highlight that the focus of transition-related healthcare is preventing de-transitioning. This reliance, despite classification changes, continues to pathologize gender dysphoria and transgender people, increasing stigma and discrimination, the stress of which causes detrimental health outcomes[xiv]. For example, trans people facing stigma and discrimination have increased risk of depression, suicide and HIV[xv]. Stigma has been defined as “the social process of ‘othering, blaming and shaming’ that leads to status loss and discrimination”xii. The rigorous and repeated psychological evaluations required to access transition-related healthcare is othering and distressing because individuals are asked to perform and justify their identity to others time and time again. A stigmatising focus leaves systems inadequately equipped to provide for the diverse needs of trans youths and can also compound and worsen the health issues they suffer from. Only by accepting ‘trans’ as a legitimate, unquestionable identity, can healthcare move away from determining how trans someone is to refocusing on the project of trans identity: accessing healthcare that takes seriously, and cures, gender dysphoria.
Stigma also indirectly worsens health by limiting healthcare accessxi. The limited number of UK clinics providing care to trans youths are the legacy of stigmatising and dismissing trans identities. When there are only two clinics across the country providing services to an increasing number of trans youths, is this really a sufficient provision of access to care? Particularly when the lack of options leads to waitlists of untenable lengths. Currently UK gender identity clinics are only offering first appointments to those referred in December 2017[xvi]. When only 38 first appointments can be offered each month compared to the 293 received referrals, it is not surprising that clinics are playing catch-up. It is crucial to recognise how public narratives scorning trans identities leads to social discrimination, political exclusion, and reduced access to healthcare. Just as a lack of national identity limited healthcare access for Bedouins in Lebanon[xvii], and increased the discrimination they faced in healthcare settings when they could access care, the lack of a validated trans identity restricts access in the UK. Trans youths are discriminated against due to their healthcare only being available in specific clinics or privately. Provision for trans healthcare across all GP’s and hospitals will only be available when we refocus on and legitimise trans identities.
These structures limiting access and the availability of adequate forms of care are interlinked so changing these must tackle the whole. The 2021 appeal only addressed one problem related to access, and thus is incapable of bringing about sufficient structural changes to reform the trans healthcare system. Plemon’s ethnography[xviii] investigating transgender healthcare in the US shows that simply making surgical care more widely available through insurance coverage is insufficient to combat the effects of long-term discrimination. Even when insurance meant that surgical care became economically viable, the healthcare system could not cope with the higher demand due to lacking qualified surgeons. Similarly, the UK’s changes allowing trans youths to access medical care do not adequately compensate for a failing system. This small change cannot correct the injustices done by inadequate healthcare. Only a restructured healthcare system, which starts by taking trans seriously, can provide adequate care and address discrimination faced in care settings. Otherwise, as the ethnography from the US has shown, reactive changes will be made only to reveal greater failings in other areas.
These methods limiting healthcare availability and determining who may access which forms of care and when, are systems of medical gatekeeping. Gatekeepers to healthcare make critical decisions about whether and when to accommodate a patient’s request, and who they will see during their treatment[xix]. By denying the legitimacy of trans identities gatekeeping methods are justified and continually reproduced. The gatekeeping system will only be combatted when we take trans identities seriously, as the basis of healthcare structures, so that treatment is not based upon whether a limited number of others think it is deserved.
Clear problems of access and the provision of types of care are characteristic of the current trans healthcare system. The problematic areas of trans healthcare are not restricted to those I have highlighted, but I hope that they may act as examples showing how the current system fails to provide adequate trans healthcare. These have been introduced through discrimination and exclusion, underpinned by public narratives that dismiss the legitimacy of trans identities. That these narratives have been proven false demonstrates that it is high time to refocus our attention to providing equal access to sufficient healthcare, as the project of trans identity demands. There is a very real need to transform trans healthcare structures in the UK and accepting trans identities is the basis for the reformation to take place. I hope that when devising your recommendations, they will all start from a view that legitimises trans identities and does not provide care only after justification.
[ii] NHS England 2021, Update following recent court rulings on hormone blockers, NHS England, viewed 21/02/2022, https://www.england.nhs.uk/commissioning/spec-services/npc-crg/gender-dysphoria-clinical-programme/update-following-recent-court-rulings-on-hormone-blockers/
[iii] NHS England 2019, Children and young people. Consent to treatment, NHS England, viewed 21/02/2022, https://www.nhs.uk/conditions/consent-to-treatment/children/
[iv] Stonewall 2022, The truth about trans, Stonewall, viewed 12/05/2022, https://www.stonewall.org.uk/truth-about-trans#trans-people-britain
[v] Sökefeld, M., 2001. Reconsidering Identity. Anthropos 96, 527–544. – pp. 534
[vii] Sadjadi, S., 2019. Deep in the brain: identity and authenticity in pediatric gender transition. Cultural Anthropology 34(1), 103-129.
[viii] White Hughto, J.M., Reisner, S.L., Pachankis, J.E., 2015. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Soc. Sci. Med. 147, 222–231. https://doi.org/10.1016/j.socscimed.2015.11.010
[ix] Davies, S., McIntyre, S., Rypma, C., 2019. Detransition rates in a national UK Gender Identity Clinic. 3rd iennal EPATH Conderence Inside Matters. On Law, Ethics and Religion. 118.
[x] NHS England 2020, Treatment. Gender Dysphoria, NHS England, viewed 21/02/2022, https://www.nhs.uk/conditions/gender-dysphoria/treatment/
[xii] World Health Organisation 2019, WHO/Europe brief – transgender health in the context of ICD-11, World Health Organisation, viewed 21/02/2022, https://www.euro.who.int/en/health-topics/health-determinants/gender/gender-definitions/whoeurope-brief-transgender-health-in-the-context-of-icd-11
[xiv] White Hughto, Jaclyn M., Sari L. Reisner, and John E. Pachankis. ‘Transgender Stigma and Health: A Critical Review of Stigma Determinants, Mechanisms, and Interventions’. Social Science & Medicine 147 (December 2015): 222–31. https://doi.org/10.1016/j.socscimed.2015.11.010.
[xv] Poteat, T., German, D., Kerrigan, D., 2013. Managing uncertainty: A grounded theory of stigma in transgender health care encounters. Soc. Sci. Med. 84, 22–29. https://doi.org/10.1016/j.socscimed.2013.02.019 – pp. 22, referencing Deacon, 2006
[xvii] Chatty, D., Mansour, N., Yassin, N., 2013. Bedouin in Lebanon: Social discrimination, political exclusion, and compromised health care. Soc. Sci. Med. 82, 43–50. https://doi.org/10.1016/j.socscimed.2013.01.003
[xviii] Plemons, E., 2019. A Capable Surgeon and a Willing Electrologist: Challenges to the Expansion of Transgender Surgical Care in the United States. Med. Anthropol. Q. 33, 282–301. https://doi.org/10.1111/maq.12484
[xix] Solimeo, S.L., Ono, S.S., Stewart, K.R., Lampman, M.A., Rosenthal, G.E., Stewart, G.L., 2017. Gatekeepers as Care Providers: The Care Work of Patient-centered Medical Home Clerical Staff: Clerical Workers as Care Providers. Med. Anthropol. Q. 31, 97–114. https://doi.org/10.1111/maq.12281 – pp.98