The NHS is in crisis – but trans healthcare in the UK has been in a terrible state for a long time, especially when it comes to accessing gender-affirming hormones.
Hormone replacement therapy (HRT) is a lifeline for many trans people, and can play a key role in medical transitioning. In a 2018 survey by the advocacy group Action for Trans Health, 84% of people who had previously experienced suicidal thoughts reported a decrease after starting hormone treatment. There was also a decrease in acting on such feelings.
But many trans people find themselves on years-long waiting lists, have to endure humiliating and invasive questioning at gender identity clinics (GICs), and – as openDemocracy revealed today – can be refused prescriptions on seemingly arbitrary grounds.
The system for obtaining hormones through the NHS is “not fit for purpose”, according to many of the trans people we spoke to for our investigation. As a result, many are potentially risking their health by choosing to self-medicate by purchasing hormones from unregulated online sources. The other alternative is to go private, which for most trans people is simply not affordable.
So how could the NHS improve the process of accessing gender-affirming hormones? Here are nine things that could make a difference – and improve the lives of trans people in the UK.
1. Believe people are who they say they are
Much of the stress involved in trying to get HRT would be avoided if healthcare professionals believed people are who they say they are. This applies to both the NHS and private providers.
Typically, after surviving a waiting list that can now be almost six years long, trans people have to endure hours of exhausting and invasive questioning to ‘prove’ that they are trans. This is undignified, as well as a waste of time, energy and resources.
The outdated attitudes of the health service are also a problem, especially for non-binary people, who are often expected to have the same experiences, needs or desires as trans women or trans men. Trans medical student Caleb Howard warned: “There’s a risk of that whole portion of society not being able to access hormones because they don’t fit into that nice little neat box that they want them to.”
2. Stop demanding that people have no regrets
It’s absurd to expect that no one will have any regrets post-treatment – but this seems to be a requirement before a trans person will be prescribed hormones.
Eli Jaeger from Trans Safety Network, a research collective that documents anti-trans campaigns, told openDemocracy: “Demanding that no one ever regrets treatment is just transphobia, because you can't possibly have a treatment that absolutely everyone will never regret. [It’s an] impossible standard that we don’t demand of any other kind of treatment.”
By way of illustration, it has been estimated that almost a third of women diagnosed with breast cancer in the UK undergo a mastectomy – almost 15,000 a year. Yet, according to one study of 123 people who had undergone breast reconstruction, 47% regretted the treatment. That’s a high regret rate, but it would be absurd to deny the option of treatment on these grounds.
If anything, such a high regret rate suggests that patients need to be better informed before they decide to undergo breast reconstruction and/or the quality of treatment (including support and aftercare) needs to be improved. The same could be said of gender-affirming hormones.
The regret rate for trans people taking HRT, especially trans young people, is wildly exaggerated by reactionary trolls, who often cite studies with flawed methodology, if they cite any at all. A review of more than 3,000 patients who attended a UK GIC in 2016 and 2017 found that fewer than 0.5% had expressed regret or detransitioned.
The reality is that when healthcare professionals refuse to believe trans people or expect them to prove there is a 0% chance they will regret treatment, they will likely just start self-medicating anyway, as openDemocracy has revealed.
3. Provide bridging prescriptions for DIYers
A bridging prescription is a temporary prescription of hormones while the patient is awaiting specialist treatment.
The General Medical Council’s (GMC) ethical advice is that GPs should provide bridging prescriptions to trans patients who are self-medicating or highly likely to, as a form of “harm reduction”. This is a straightforward way to minimise health risks, as it will deter people from getting hormones from unregulated, possibly dangerous sources.
Yet a survey of users of private health provider GenderGP found that 80% of NHS GPs had refused, despite having no real grounds to do so.
4. Provide monitoring for DIYers and private patients
The Royal College of Psychiatrists’ good practice guidelines for treating adults with gender dysphoria state that patients who are self-medicating or using private healthcare services should receive health monitoring from clinicians, with blood tests and other checks, to look out for any complications or concerns.
Many GPs refuse to do this, as noted by Trans Harm Reduction, an organisation that aims to reduce the risks of self-medicating for trans people in Scotland and Ireland. Some even refuse for patients who are considering going private. Some GPs claim this is due to lack of expertise (which could be true, but could also be remedied). Some tell patients that they aren’t allowed to monitor their health, although this is not the case. Again, this refusal just increases the health risks to the patient.
Proposed changes to youth gender identity services would deny monitoring to young trans people who access private trans healthcare or self-medicate using unregulated sources. As people tend to pursue these options because of unbearable NHS wait times, this is very worrying. Even more worrying is that GPs are encouraged to “initiate local safeguarding protocols” – to report parents and carers to their local councils – if their children use unregulated sources.
5. Educate healthcare professionals on trans healthcare
There is a common assumption that a doctor is a neutral, impartial person who doesn’t bring any prejudices into the workplace. The truth is, a medical workplace is the same as any other workplace: you don’t leave everything behind. Some people are transphobic. And that doesn’t change because they’re wearing scrubs.
Howard, who has completed his first year as a medical student, said that, consciously or subconsciously, medical transphobia does occur. He believes these problems stem from the medical curriculum as transgender healthcare or identity is not touched on at all in the first year. This, Howard said, is a problem as first-year students go into hospitals and will interact with patients, some of whom will be trans. “The curriculum that the future doctors are being taught isn’t reflective of society,” he said, “and it’s only really if they have someone that they know or if the university is particularly good or someone has a special interest in that that they will be given that knowledge.”
Louise Wade, a trans person from Wales who was self-medicating and was denied a bridging prescription by her GP, suggested that GP surgeries should be more aware of the waiting times and what they can prescribe. “I know some people who have been able to just go to the GP and access a bridging prescription instantly… some GP surgeries do know what they’re doing. Some aren’t aware.”
Alex Woolhouse, who opted to go private to avoid being on an NHS waiting list for years, compared the situation to how things once were with diabetes patients. As with HRT for trans people, she said, GPs felt out of their depth – but with improved training, access to diabetes treatment has improved.
6. Compel GPs with ‘moral objections’ to pass patients onto another GP who will prescribe
Whilst it’s pretty cruel to refuse to prescribe hormones due to your own transphobic beliefs, it shouldn’t be the end for the patient trying to access treatment.
After points 1 to 4 are implemented and GPs have received the training and information they need, if a doctor still refuses to prescribe hormones, they should be required to pass the patient on to another GP.
Jaeger said that if a doctor morally objects to an abortion, they have to provide the details of someone who will perform the procedure, and that it should be the same for gender-affirming hormone prescriptions.
7. Stop treating transness as a mental illness or disorder
While it’s not the official position and is contrary to the World Health Organisation's understanding, transness is still often treated as a mental illness or disorder. In a 2012 Trans Mental Health Study, out of 411 people, 29% felt that their gender identity was being viewed as a symptom of a mental health problem rather than a genuine aspect of who they were. This view, even if not explicitly voiced by medical professionals, practices or institutions, would at least partially explain the unwillingness to prescribe hormones. Under the aforementioned proposed changes to gender identity services for young trans people, this looks likely to get worse.
Being trans and not having your gender recognised and affirmed can cause gender dysphoria, which leads to mental health problems. But treating transness itself as a disorder and refusing to prescribe treatment on that basis just exacerbates those mental health problems, trapping trans people in an endless cycle.
If we stopped pathologising trans people and started respecting their autonomy instead, they would be a lot less likely to be denied treatment for so long and have to jump through so many hoops to access it.
8. Create an independent complaints procedure
There is currently no real accountability when it comes to gender-affirming healthcare. This means a GP who ignores guidelines or ethical advice or a GIC that imposes impossible requirements for accessing treatment are not rogues but unfortunately a very normal part of the system.
The seven recommendations above are meaningless without ensuring there is a process to rectify the situation when things do go wrong for a trans patient.
There should be an independent, trans-led body that investigates these kinds of abuses – because that is what they are. This body should be authorised to introduce consequences for healthcare professionals who don’t follow guidelines, refuse to prescribe treatment or provide monitoring services without reasonable grounds to patients who are self-medicating or using private healthcare services, or violate a patient’s right to privacy. The consequences faced by healthcare professionals should be geared towards ensuring that trans people are protected and not discouraged from seeking treatment through the NHS. This could be through a combination of intensive mandatory training, greater supervision, and where necessary, disciplinary action.
9. End and reverse the privatisation of healthcare
An ill-informed healthcare system that is systematically being starved of resources is a deadly combination for already neglected, marginalised and stigmatised people.
Both the Tories and Labour have been sabotaging the NHS since the Thatcher era, while simultaneously privatising more and more services. The ineffectiveness of NHS services as a result of these cuts makes privatisation seem like a necessary option which it is not.
Basil Barron, who became disillusioned and opted to go private, told openDemocracy: “I think the entire NHS system is so starved by the Tory government. Unfortunately, even critical emergency surgeries are being messed with. So I think the NHS needs more funding, but also that more needs to be done specifically for transgender patients. I feel like the hormones and surgeries that we require are considered almost elective, rather than something that a person needs to be able to cope and live comfortably and have a normal life.”
A system that prioritises wellbeing over profitability is much more likely to provide trans people with adequate healthcare than an already squeezed health service in a systemically transphobic country.
The more the NHS is sabotaged and privatised, the worse its services will become for trans people (as well as everyone else), both in terms of quality and, as openDemocracy has shown, accessibility. The worse these services become, the more expensive private healthcare will become, as the demand for these services will increase, and it becomes an increasingly captive market. And the more this happens, the more it will be that trans people’s level of access to gender-affirming care will be determined by how rich they are.
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