In Babel

(This essay was originally written in February 2023 as part of an assignment to develop improved care services for transgender people.)

Introduction

Poorly implemented care policies, hostile rhetoric at the national political level, gaps in GP knowledge, and persistent structural barriers to healthcare access which predate the Covid-19 pandemic are harming the health of transgender and gender diverse (TGD) people in the UK (Bachman and Gooch, 2018; ILGA, 2023 p.153). Despite the hostile atmosphere, this paper discusses the healthcare challenges for TGD patients, and solutions which can be implemented at the local level within primary care partnerships.

Local and National Policy, Public Opinion and Context.

NHS England has committed to giving patients more control over their healthcare via the personalised care initiative (NHS England Online, 2019, p.24). To achieve this an emphasis has been placed on partnership with GPs services, and changes made to the GP Quality and Outcomes Framework to enable this (NHS England Online, 2019, p.15). However, this commitment stands in contrast with care for TGD patients as it is currently implemented by the NHS (Wright et al., 2021).

Since 2019 there has been a significant public debate about the rights of transgender people in the UK, Murray (2022) described the discussion as “frequently toxic” and McLean (2021) characterised it as a situation where it has become legitimate to question trans people’s right to participate fully in the social life of the country, with senior politicians becoming involved. In August 2022, the then Attorney General, Suella Braverman, stated that schools had no obligation to respect the gender identity preferences of transgender students (Whittaker, 2022). Other ministers expressed hostile views on transgender women’s participation in sport (Reuters, 2022) and, based on significantly flawed data (Bent Bars, 2020, pp 14-17) implemented policy changes to the housing of transgender prisoners (UK Govt, 2023). Current Prime Minister Rushi Sunak has also signalled his intention to remove transgender people’s workplace legal protections from the Equality Act, (Wakefield, 2022). This contrasts significantly with the situation before 2019.

In 2017 Theresa May’s government launched the National LGBT Survey which sought to understand the challenges faced by Sexuality and Gender Minority (SGM) people in the UK (UK Government, 2018a, p.3). Based on the results of this survey the government produced a report (UK Govt, 2018a) and a detailed action plan to address “the significant barriers to full participation in public life” faced by SGM people in the UK (Government Equalities Office, 2018, p.1). On coming to power, Boris Johnson scrapped these commitments for TGD people, also suspending plans to improve the Gender Recognition Act (UK Parliament, 2022; Milton, 2020) and stated his intention to remove transgender people from proposed legal protections banning conversion therapy for SGM people (Holton, 2022). Conversion therapy describes a range of activities aimed at changing SGM people’s sexuality and gender identity, often with elements of coercion (American Psychological Association 2021). It should be noted Johnson eventually reversed his position on the Gender Recognition Act. Local and international advocacy organisations expressed concern at the UK’s changing positions regarding TGD people (ILGA, 2023, p.153); the ILGA aslo reduced the UK’s ranking for SGM people’s rights (Brooks, 2022). Hate crime charity Galop have subsequently reported rising levels of hate crime in the UK against SGM people (Galop, 2021). Six months after the Attorney General’s statement about transgender school students, 16 year old transgender student Brianna Ghey was murdered (Galop, 2023). Her death served as a focal point for vigils in protest about transphobia, and the deteriorating situation for SGM people in the UK (Bugel and Vinter, 2023).

These events are of concern from the healthcare perspective because it’s known that transgender people already experience higher levels of suicidality and mental ill health than comparable non-transgender populations (Rothblum, 2020, p.37; Puckett, et al., 2020), higher rates of adverse childhood experiences (ACES) (Biedermann, et al., 2021), greater unemployment (LGBT Foundation, 2020, p.37), more workplace and school bullying (Jadva, et al., 2021), more barriers to healthcare access than the non-transgender population (Bachmann and Gooch, 2018, pp.11 – 14; Murray, 2022), poorer overall health outcomes (Arthur, et al., 2021) and persistent stigmatisation (UN Office of the High Commissioner for Human Rights, 2018). This is exacerbated by long standing problems with NHS gender identity services (GIDs) (Public Service Consultants, 2021).

In the past ten years, the number of patients being referred to GIDs has increased several-fold, with numbers of clinicians and appointments failing to keep up (NHS GIC, 2023) a situation which the Royal College of GP’s describes as placing immense pressure on clinicians (Royal College of General Practitioners, 2019). As a consequence, even before the Covid-19 pandemic waiting lists at the UK GIDs clinics were being measured in years, Zottola et al (2022) report an increase at one clinic from 6 months for the first appointment in 2016 to upwards of 3 years by 2020. Clinic waiting times since the beginning of the Covid-19 pandemic, in line with healthcare broadly, have continued to worsen, with the UK’s main gender identity clinic now reporting a waiting time of almost 5 years for a first appointment (NHS GIC, 2023).

Since the publication of the LGBT Action Plan (Government Equality Office, 2018), the nature of the crisis in GIDS services has been recognised, with many NHS stakeholders issuing guidance and implementing initiatives to improve transgender patients healthcare access. The Royal College of Nurses (RCN) produced Fair Care for Trans and Non Binary People (RCN, 2020); the Care Quality Commision created digital resources for transgender patients seeking care (CQC, 2022a) and advice for G.Ps supporting them (CQC, 2022b). The General Medical Council (GMC) updated prescribing guidance (GMC, 2022) in an effort to assist GPs dealing with distressed TGD patients. In London, the healthcare challenges faced by TGD people were recognised by the London Assembly in their policy document “Trans Health Matters” which laid out several commitments to improve TGD people’s healthcare access and experiences, including the need for improved clinician training around TGD patient needs (London Assembly, 2022, p.8).

Gender Affirming Healthcare

The CQC pathway for NHS gender affirming healthcare (CQC, 2022a) follows international guidance issued by the World Professional Association for Transgender Health and consists of three main domains, mental health assessment, endocrine support via hormones (WPATH, 2022, p.S31); and, for a significant percentage of people, surgery (Jha, et al., 2022). It is known that prompt and early access to gender affirming hormone treatment, the first line treatment, leads to significantly improved mental health outcomes for TGD people (Turban, et al., 2022) with delays inevitably prolonging the distress for patients (Zottola, et al., 2020). However, to access hormones TGD people in the UK require a diagnosis of gender dysphoria (NHS England Online, No Date) by a clinician with recognised experience in the field. This requirement is a contentious subject (Schultz, 2018), and has substantially contributed to the growth in GIDS waiting lists (NHS GIC, 2023). The expansion of waiting times has led to a situation where, according to Metastasio, et al (2018) approximately 23% of transgender patients on gender identity service waiting lists resort to self-medication via grey markets sources; without any kind of blood monitoring, presenting potentially serious health risks to the individual.

As mentioned previously, to mitigate the risk of worsening self-harm and suicidal behavior the General Medical Council (GMC) and the Royal College of General Practitioners issued guidance for G.P.s, outlining the circumstances in which they may provide ‘bridging’ prescriptions without the need for a diagnosis of gender dysphoria first, replacing it with the requirement to consult directly with specialist gender identity specialists before prescribing (GMC, 2023). However, this has made little difference, in practise G.P.s remain reluctant to intervene due to a lack of knowledge, uncertainty about dosing, difficulties in communicating with specialists, and uncertainty about follow-up blood testing (Boyd et al 2021). It can be argued that the experience of gender dysphoria is a crisis that in and of itself warrants such a harm reduction intervention. In addition to creating risks for patients, the requirement for a diagnosis before beginning hormone treatment also creates ethical considerations around TGD patients’ right to consent to treatment.

Models of Consent

The Mental Capacity Act (2005), states the principle that just because someone makes an unwise decision, does not mean they lack the capacity to make decisions about their healthcare. In the case of TGD people seeking help, this principle is reversed. Requiring prior approval for treatment from a gender identity specialist is done as a safety measure, to ensure a hypothetical non-TGD person, importantly a person who the therapist believes is not TGD, but who is articulating a TGD identity for reasons related to trauma or mental illness, mistakenly gets gender affirming treatment (WPATH, 2022, p.S36). In practise this places the well-being of TGD people secondary, effectively forcing them to bear the burden in extended waiting times, because of potentially poor healthcare decisions of non-TGD people. The result is unnecessary distress among patients forced to wait for years for specialist appointments (Zottola, et al., 2020). It is also the case that when they finally see a specialist, TGD people are then required to prove that they are “transgender enough” to obtain the care they seek, a process which Ashley (2019) calls “mistrusting trans patients.” Additionally, this creates a situation of double victimisation for TGD survivors of abuse, or those with poor mental health resulting from stigma or discrimination, people who are in every way confident in their TGD identity are forced to prove they are not just “confused” by negative experiences, a variation on Wall et al’s (2023) “gender related medical misattribution and invasive questioning.” Schultz (2018) proposes a less harmful model of consent where prescribing is carried out after an assessment of the patient’s capacity to consent, rather than the assessment of whether a patient is transgender enough to merit help.

Conclusion

Holistic Primary care for Trans and gender diverse people is an issue of cultural competence and transgender patients are being failed by current healthcare policy. With very modest investment and training at the local level, it is possible to transform this situation, and deliver the NHS’s commitment to giving patients personalised care, whilst also allowing clinicians supporting them to develop confidence in informed clinical decision making under current prescribing guidance. There is good evidence that better training leads to more confidence in supporting SGM and TGD patients among clinicians (Salkind, et al., 2019). In instances where individual NHS GP services have created TGD specific clinics, the results have been improved patient satisfaction (Boyd et al; 2021). To properly achieve personalised care however, the current requirement for every patient to be assessed for gender dysphoria in a specialist clinic will need to be reconsidered. The advantage of training primary care clinicians to become familiar with the needs of TGD patients also provides opportunities to carry out research towards developing more effective, humane, and sustainable care delivery for TGD people.

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