Is Transgender People’s Right To Health At Risk?

Last month, the Equality and Human Rights Commission wrote to the Scottish government asking it to pause plans to reform the gender recognition process north of the border. We explore how this intervention and other recent developments relate to transgender people’s right to health in the UK.

The Equality and Human Rights Commission (EHRC), which is the UK’s equalities watchdog, wrote to the Scottish government saying that “more detailed consideration” was required before introducing a new, simplified system which would enable transgender people to change the sex recorded on their birth certificate.

The EHRC’s letter was widely critiqued by lesbian, gay, bisexual, trans and queer (LGBTQ+) equality campaigners as an unnecessary and worrying move. LGBTQ+ rights charity Stonewall said: “We are deeply troubled by the approach that the EHRC is taking to trans people’s human rights. Their approach appears to focus on pleasing a noisy minority of anti-trans activists, rather than promoting human rights for all LGBTQ+ people.”

Updating the Gender Recognition Act (GRA) to enable smoother transitions for transgender people has been the subject of debate for some time. Lack of progress in this regard, campaigners argue, poses a threat to transgender people’s right to health, as outlined by the UN and the International Covenant on Econmic, Social and Cultural Rights. The EHRC’s intervention has also been criticised as interfering with transgender people’s right to freedom from discrimination, protected under Article 14 of the Human Rights Act.

What Does Transgender Healthcare Encompass?

There is no robust data on the exact number, but estimates indicate that there are between 200,000 and 500,000 trans people living in the UK.

Typically, trans healthcare discussions focus on the medical care provided during transition, which encompasses everything from puberty blockers and gender reassignment surgery to managing gender dysphoria and facial feminisation surgery. However, healthcare for trans people is not limited to these areas.

Trans people require access to healthcare for their general wellbeing, not just their transition. However, one in seven LGBTQ+ people stated that they have avoided seeking treatment for fear of discrimination, according to a Stonewall survey. Another 2021 survey by the campaigning group TransActual UK (TAUK) showed that 57% of trans people avoided going to the doctor when unwell.

Although the available treatment is extensive, there are significant gaps and limited availability

Providing mental healthcare is another key component of trans healthcare that regularly gets overlooked, which is particularly dangerous considering the increased prevalence of mental health issues amongst LGBTQ+ people. In a Stonewall study, almost half of trans people had considered taking their own life. Another 2017 study by the UK Health Security Agency reported that 52% of young LGBTQ+ people reported self-harm recently or in the past compared to 25% of heterosexual cisgender young people. 

Despite the number of trans people living in the UK and their legal right to be treated fairly under the Equality Act, one in eight LGBTQ+ people report having experienced unequal treatment from healthcare staff due to their LGBTQ+ identity.

What Care Does The NHS Provide For Trans People?

Under the NHS, there is a variety of help available for transgender people. The NHS website states that children and young people will typically be referred to the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust. 

A multi-disciplinary team, which includes a clinical psychologist, child psychotherapist, child and adolescent psychiatrist, family therapist and social worker, assesses patients over a period of several months. Following the assessment, options may include family therapy, counselling, group work, child psychotherapy or a referral to a specialist hormone clinic for hormone blockers for children who meet strict criteria. 

Adults reporting gender dysphoria are generally referred to a gender dysphoria clinic where a multidisciplinary team of medical professionals can offer assessments, treatments, support and advice. Treatments could include psychological support, hormone therapy, speech and language therapy and, later, surgeries. 

Common surgical procedures for trans masculine people include bilateral mastectomy, construction of a penis (phalloplasty or metoidioplasty) and the construct of a scrotum or testicular implants. For trans feminine people, common surgeries include the removal of the testes and penis and vaginoplasty.

Credit: Raphael Renter / Unsplash

Although the available treatment is extensive, there are significant gaps and limited availability. Breast implants for trans feminine people, facial feminisation surgery and hair transplants are not routinely available on the NHS. The availability of clinics is also limited, with just two main GIDS clinics in the UK – one in London and the other in Leeds. 

Waiting times for treatments are also extremely long, according to an October 2021 survey by TAUK. The group’s research showed that 38% of people waiting for a phalloplasty (a multi-staged procedure for the creation of a penis) and metoidioplasty (a procedure that uses tissue from the clitoris to create a neophallus) have been waiting for two to three years for treatment. 

Delays relating to phalloplasty and similar operations are longstanding but were lengthened when, in March 2020, NHS Central Commissioning withdrew its contract with the only surgical team commissioned to provide NHS-funded phalloplasty and metoidioplasty. It took 17 months for the group to announce a new contract with New Victoria Hospital. 

In an email shared with EachOther, director of TAUK, Chay Brown, revealed correspondence with the new provider indicating that it will take around two years for all patients on the waiting list to have their operations. Brown, who has already begun his surgery journey and has been waiting for two years for the next stage, could be waiting a further two years before being operated on again. 

What Is The Current State Of Trans Healthcare?

For many people beginning a medical transition in the UK, the healthcare system is failing. Eva Echo, an activist, blogger and public speaker, thought that coming out would be the hardest part of her journey but she was quickly proven wrong. 

“It took two months for my gender identity clinic (GIC) to acknowledge the referral and to confirm that I was on their waiting list,” she explained. “No support was offered during my time on the waiting list. Over four years later, I’m still on the waiting list. It’s so incredibly frustrating.”

Later, Echo discovered that her GIC had stopped seeing new patients because of the high demand for their services. No one notified her of the change. Echo eventually sought private healthcare to start her medical transition sooner, “enabling me to get my diagnosis and to start hormone replacement therapy.” 

“Having to go private means I’m having to use my own savings, which, as a self-employed person, means taking a huge risk just to do what the NHS should have done a long time ago,” she said. “We’re expected to just wait in limbo and to be grateful for them offering us less than bare minimum throughout.”

Credit: Ehimetalor Akhere Unuabona / Unsplash

The inaccessibility of treatment appears systemic. jane fae, director of TAUK and chair of Trans Media Watch, said: “On trans-specific healthcare, there is a crisis. There is a healthcare crisis for a lot of people across the country, and waiting lists for everything are going through the roof. The problem is that trans healthcare entered the pandemic in a crisis.”

The coronavirus pandemic has been blamed for causing delays in various NHS departments. However, some barriers were present long before Covid-19 came to the UK. 

“When it comes to trans healthcare, the NHS has forgotten about one of its founding principles: that it meets the needs of everyone,” said Echo. “The issues with waiting times is not because of the global pandemic, although that hasn’t helped. For the past five years, it was obvious that it was only going to get worse. Rather than address the issue, it carried on, hoping that trans people wouldn’t mind waiting or that the situation would somehow fix itself.”

Even once trans people are able to start the process of transitioning, obstacles continue to arise. The current system for gender recognition has been widely criticised by LGBTQ+ activists who argue that it prohibits smooth transition and further traumatises marginalised groups. 

“By the time I transitioned, I had been married with children and I had been a company director,” said fae. “But when it came to deciding whether to take hormones, unlike a middle-aged woman, I needed two psychiatrists to say I was up to it, which is ridiculous. If you put your hand up today to say ‘I’m 30 and I want to transition’ you will be 40 before you get there. We don’t want special treatment but it would be nice if our waiting lists were looking a bit more like waiting lists for other things.”

Another significant issue is the discrepancies in treatments offered by different medical professionals and providers. While one trans person may encounter well-informed GPs with whom to consult, others could face transphobia and medical discrimination.

Brown explained: “Every time you move house and move to a different GP surgery, you are wondering, ‘Am I going to have issues with my prescription? Are they going to do treat me properly?’”

Credit: Ehimetalor Akhere Unuabona / Unsplash

Appropriate cover may also be absent for patients who need medication at specific times. Brown once had to delay his hormone blocker injection because there was no cover for a nurse who went on holiday.

He continued: “I had a tail-off, so I could physically and emotionally feel when my period was due. The one time I did have to have [the period], I was getting abdominal cramps and it really affected my mental health.”

Trans patients may also slip through the cracks in other ways, such as cervical and breast screenings. The NHS website states that patients should ask a GP to notify them if such screenings are required but some may be unaware that it is their responsibility to do so. 

“Up until a month ago, I had a cervix,” said Brown. “My GP was quite good and they asked me if I wanted to be invited to cancer screenings when I joined them. Obviously, I wasn’t getting reminders in the post because only people with an ‘F’ next to their name are on the automatic system. The only reason I ended up going to a cancer screening is because someone did outreach and that’s when I had some pre-cancerous cells.”

The gaps in trans healthcare services are widespread and activists are campaigning for significant changes to ensure all transgender people in the UK are afforded equal treatment. 

A Royal College of General Practitioners spokesperson said: “New presentations of gender dysphoria in general practice are infrequent, and therefore initiating treatment sits outside of a generalist’s role. Nevertheless, it goes without saying that GPs and our teams should treat our transgender and gender-questioning patients on the basis of need and without bias, as we would any patient. This includes being mindful of the terminology and language we use when talking to our trans patients, based on each patient’s individual preference.”

How Have The Courts Impacted Access To Healthcare?

Sometimes, the courts have ruled on questions relating to healthcare inequalities for the transgender community. A significant example occurred when the High Court ruled that children under the age of 16 considering gender reassignment were unlikely to be mature enough to give informed consent to be prescribed puberty-blocking drugs. 

Keira Bell, who was prescribed puberty blockers aged 16 and later detransitioned, brought the case against the Tavistock clinic, arguing that they should have questioned her decision more. The Court of Appeal overturned the original ruling, saying that clinicians can judge whether under-16s are capable of giving informed consent for puberty blockers.

In response to the ruling, Bell said: “I am obviously disappointed with the ruling of the court today, and especially that it did not grapple with the significant risk of harm that children are exposed to by being given powerful experimental drugs”.

Following the rulings, NHS England announced that it would set up a review group to assess the prescription of puberty blockers for under-16s. Currently, puberty blockers, which pause the physical changes of puberty, are only prescribed to those who meet strict criteria. 

How Could An Updated Gender Recognition Act Protect Trans Health?

The GRA 2004 gives people who have gender dysphoria the ability legally to change their gender. The act lays out how the Gender Recognition Certificate (GRC) operates. The GRC is a document issued to prove that a person has met all the criteria for legal recognition of their gender. 

To acquire a certificate, applicants must show a documented diagnosis of gender dysphoria to be considered by a Gender Recognition Panel (GRP) and go through a series of medical assessments and interviews with a psychiatrist to ‘prove’ their gender identity. In 2016, the Women and Equalities Committee (WEC) of the UK parliament published a review of the GRA, highlighting deficiencies in the “unfair and overly medicalised” process. 

The government ran a consultation on reforming the GRA in 2018, but little has changed since its publication. In December 2021, the WEC called for urgent reform, including the removal of the requirement of a gender dysphoria diagnosis, which would allow a shift to a system of self-declaration. It also advocated for removing the requirement for trans people to have lived as their gender for two years, doing away with the need for spousal consent and also for the government to develop a “specific healthcare strategy for transgender and non-binary people”. 

Credit: Sharon McCutcheon / Unsplash

“The government took nearly two years to respond to the consultation on an act that was written at the turn of the millennium,” said Caroline Nokes MP, chair of the WEC. “The GRA is crying out for modernisation, and the Government has spectacularly missed its opportunity. The current response to the 2018 consultation has amounted to little more than administrative changes. We are now calling on the Government to enact real, meaningful change.” 

Updating the GRA and introducing a demedicalised system for transition could benefit the overall health of trans people in the UK. The changes would remove unnecessary stress and ensure that more people can update their legal gender. 

Last year, a power-sharing government between the Scottish National Party and the Scottish Greens said that a bill to reform the GRA would be introduced in the first year of the parliamentary session. Scotland’s proposed changes mean that applicants would no longer need to produce a medical diagnosis of gender dysphoria or go before the GRP. Applicants would make a statutory declaration confirming that they have been living as their gender for three months and intend to do so permanently. The process would take a minimum of six months. 

The EHRC’s written intervention indicates that changes to the GRA  continue to create controversy, with consequent delays threatening trans people’s right to health. 

What Needs To Be Done To Protect Trans People’s Right To Health?

To ensure the protection of trans people’s right to health, significant changes to the current system are needed, including putting the funding in the right places. 

“Ultimately, what the government needs to be doing is listening to the trans community when we’re saying the transition related care system is broken,” said Brown. “The whole pathway is broken from start to finish.

He continued: “We’re asking healthcare professionals to be trans-inclusive. There’s no point funnelling money into a broken system. We don’t need more gender identity clinics, we need to reform the system so the money needs to go into reforming that system, it needs to go into training and spreading out services.”

For fae, she believes that improving trans healthcare needs to come down to GPs, who are often the first to meet trans patients on their journey. 

“Eventually, a lot of trans healthcare is going to have to come down to GPs, because most of it is not difficult,” she said. “It just needs some fairly basic training in monitoring hormones. A lot of improvements can be done by moving the services down to GPs. Quite frankly, it makes financial sense. Maintaining an expensive bunch of psychiatrists to see people and filter people at the rate they’re currently doing makes no financial sense.”

Great care also needs to be taken to address the intersectional dimensions of these inequalities. Ethnic minority groups are nearly twice as likely to experience transphobia from trans-specific healthcare providers, according to TAUK’s 2021 survey. Additionally, 60% of disabled respondents reported experiencing ableism when accessing trans-specific healthcare and transgender disabled people are more likely to experience delays in treatment. 

“It is clear that, following the pandemic, healthcare for everyone in the UK is in trouble,” added fae. “However, problems for the trans community were there long before the pandemic set in, and they go far deeper than capacity. They go to attitudes towards trans people and the willingness of the NHS to resource and train in this field. We don’t want to be queue jumping but we do want to at least be considered with other patients.”