This article is quite different from what you might usually find here on A News Education, however we are proud to be putting transgender people’s experiences at the forefront of discussion, and hope that mainstream outlets will one day do the same.
We thank James for being so open about his experience, and hope that this article sheds some light on the reality of transgender healthcare in the UK.
Trigger warning: There are mentions of suicide in this article. Please feel free to skip if you find this subject triggering.
What does “transgender healthcare” mean?
Transgender healthcare refers to the physical and mental treatment transgender people receive directly related to their gender transition. Many transgender people experience gender dysphoria, which is discomfort with their physical body due to it not aligning with their gender. Gender dysphoria can cause serious harm, leading to adverse mental health, self-harm, and suicide. Access to transgender healthcare is vital; it saves lives.
A transgender person's transition has two main stages: social transition and medical transition. Social transition can begin whenever the individual wishes to; however, medical transition is dictated by local availability to NHS Gender Identity Clinics (GICS), or whether an individual has the funds to access private gender clinics.
For most transgender people, the social transition includes changing their birthname to one more befitting of their new identity, changing their pronouns to the ones used by their new gender (for example, someone assigned female at birth may change their pronouns to he/him, to reflect their male gender), and changing or adapting their appearance. For transgender men, such as myself, this can include cutting their hair, wearing more masculine clothing, and training their voices to become lower.
"Access to transgender healthcare is vital; it saves lives."
Medical transition can be split into two categories: hormones and surgery. Taking hormones is identified under HRT (hormone replacement therapy). This is where the transgender person is prescribed hormones commonly found in the sex aligned with their gender. So, for transgender men, this would be testosterone. For transgender women, oestrogen. These hormones are vital in easing gender dysphoria, bringing the individual’s physical body more in line with their gender.
HRT can only be prescribed to transgender people over the age of sixteen; however, trans people under 16 can be offered hormone blockers to delay puberty. Hormone blockers can help ease gender dysphoria as they delay the onset of puberty, meaning the individual has more time to explore their gender identity without the burden of going through the puberty inappropriate to their gender. The person may then decide to start HRT at the age of 16, or they may conclude that they are not transgender and can come off the puberty blockers to resume puberty.
The most common surgeries for transgender people are commonly known as 'top' surgery and 'bottom' surgery. There are many different types of top and bottom surgery for both transmen and transwomen, but they all strive to create the primary sex characteristics of their gender.
Each stage of transgender healthcare is subject to its own prejudices and misinformation. From GPs and therapists spreading incorrect information, to puberty blockers being made extremely difficult to get hold of (this ruling has now been overturned), transgender people of all ages find themselves battling against a system designed to make their access to healthcare near impossible.
My experience with transgender healthcare
In 2016, I was told by my therapist it would be a 2 year wait before I could see anyone at my local GIC (Gender Identity Clinic) and that the clinic required me to have been living in my chosen gender for at least 2 years before they would begin to pursue HRT. For me, this was a problem. I still had another year at an all-girls school, and my family was firmly against me changing sixth forms. Even if I began my social transition after I had left the school, I would still be a year short by the time I reached my first GIC appointment. I was upset, confused, and highly stressed I would be turned away at the GIC's door for something I could not control.
The following timeline ensued:
I received a letter from my local GIC stating that they were looking into an 'opt-in' system for first appointments and that I needed to contact them within 4 weeks or I would be referred back to my GP.
At my first appointment, my clinician was confused when I expressed, very apologetically, that I had only been living in my new gender for a year. She then told me that the requirement to live for 2 years in your chosen gender was "old news" and was not applicable anymore.
Unfortunately, this "old news" was a direct impact of the lack of education GPs and other medical professionals receive regarding transgender healthcare. A simple update to my therapist about the changes would have saved me a year of stress and made my first GIC appointment a far more positive experience.
May 2019 (GIC appointment)
By this time, I had referred myself to the local hospital for fertility preservation. I had been told the waiting list was a few months’ long but afterwards the process would be very quick, and that a hormone prescription would be waiting for me as soon as I had finished.
February 2020 (GIC appointment)
I had heard nothing from the fertility team. I decided to ask the clinical nurse at the GIC to contact my GP to find out where I was on the fertility waiting list.
The following year was a constant battle. I moved, which meant I lost my place on the waiting list and had to be referred by my new GP to a new fertility service.
I had my first appointment with the fertility service.
After months of miscommunication between my GP, the fertility service, and GIC, I was finally in regular contact with the fertility clinic and was looking at imminent treatment.
Late September - early October 2021
I have my fertility treatment. During this time, I contact the GIC to let them know I'll be ready to start testosterone as soon as the treatment is finished. As it's been so long, I'm told I need another appointment.
Mid-October 2021 (GIC appointment)
I'm told there's a 4 to 6-week delay in letters being sent out and that I would need more blood tests before starting testosterone.
In the same appointment, I reminded them I was also interested in pursuing top surgery. I was told that, after an initial wait time for an appointment with the clinic's doctor, the waiting list to be seen by a surgeon was roughly 18 months.
"What this means for me is a daily battle"
At the time of writing this article, I'm waiting for these letters and the blood tests. From my initial referral to the GIC to today, I have waited 5 and a half years. I'm still weeks away from starting my medical transition, and years away from any surgery. What this means for me is a daily battle. A daily battle with misgendering due to my voice and feminine features, where one 'Miss' or 'She' can make the dysphoria too strong to push down. A daily battle with assuring well-meaning people that yes, I am still transgender. Yes, I am still pursuing hormones and surgery. Yes, it is taking a very long time. A daily battle with myself, where I have to wear my rib-crushing, breath-taking binder, or I can't leave my bedroom, or where I'm inevitably late to things because I'm trying to find an outfit that doesn't accentuate my curves. To non-transgender people, these battles may not seem significant, but imagine if you spent every second of every day trying to not only accept yourself in your current situation but ensure that other people accepted you. For transgender people, acceptance isn't just a warm, fuzzy feeling. Acceptance is the difference between living to see another day or dying from your own hand or that of another.
Unfortunately, my case is not an anomaly. It's the norm. Transgender people all over the country are facing increasingly longer waiting times, as well as unsympathetic, sometimes transphobic therapists or GPs, who often have very little knowledge of trans healthcare. And during these times and after, there is little to no mental health support. Most are told to be glad they're even being seen, while at the same time, mainstream media has convinced the world that transgender people are being given hormones and surgery from their first appointment. This is not true.
The state of transgender healthcare in the UK
While it is impossible to know precisely how many people currently identify as transgender in the UK, in 2018 it was estimated to be between 200,000 and 500,000 people, roughly 0.3-0.7% of the UK's population. Due to the small population of transgender people in the UK, it would be logical to assume that there are enough resources to go around. However, transgender people still experience complicated access to healthcare due to ill-informed professionals, an inherently transphobic-designed system, and vast underfunding of gender-related healthcare across the UK.
One transgender person may decide to pursue all treatment options available, whereas another may choose certain aspects which they know will help minimise their gender dysphoria. There is still a huge expectation for transgender people to behave in a way that’s stereotypical of their gender, and this expectation can lead to treatment being refused or massively delayed. One person I interviewed spoke of the 'inhumane and degrading requirements [which force them] to come out, change legal identity and start presenting in public to prove they deserve hormone medication.'
"Wait times of 4 years are commonplace"
While my 2 year wait time in 2016 seemed dire, the average wait time in 2021 for an initial GIC consultation is inconceivable. An NHS London-based GIC is only now seeing patients referred to them in October 2017: wait times of 4 years are commonplace across the UK. From my experience, I know that even after your initial appointment, you can be waiting years for HRT and surgery. This would not be deemed acceptable in any other health department, yet transgender people have no other choice.
One transgender individual told me of the complete suspension of lower surgery, i.e., surgery on the genitals, for transgender men since March 2020. 'About 2,000 men have been left completely in the dark for almost 2 years... We're now told surgeries will resume in December , but even so, the waiting list is likely to be 2+ years for many of us.'
Private healthcare isn't much better. Between the thousands of pounds needed for both hormones and surgery, and the loose regulation of hormone prescriptions, many people who opt for the private route find themselves treading a dangerous path. Gender dysphoria can push people into debt or crowdfunding in order to afford trans healthcare.
An anonymous source told me that they ‘[knew] numerous trans people who have resorted to escorting, porn or selling drugs to pay for surgeries that the NHS doesn't cover often flying to other countries for more affordable surgery. Most people cannot just pull tens of thousands [of pounds] out of a bank account to pay for the reality of transition.'
"Gender dysphoria can push people into debt in order to afford trans healthcare"
Even more concerning is that some transgender people choose to pursue DIY transitions. This is when the individual decides to buy hormones off the internet and facilitate surgeries overseas. While these medical transitions are faster than NHS or private transitions, they are unregulated and can lead to serious medical problems in the future.
An anonymous source spoke of their choice to pursue a DIY transition and how it required them to do ‘research … to know the appropriate amount of medication to take and required me to have blood tests done privately since my GP didn't want to co-operate...with no options left I started taking unregulated homebrewed oestrogen compounded by a trans lady in Europe. I had no idea on the safety profile, the purity and how sanitary the vial was, but I used it regardless as I felt I would end my life if I hadn't.'
I also spoke with Luna, a trans woman who told me she pursued DIY transitioning as she 'couldn't deal with the wait as it's known that age reduces the effectiveness of [HRT].' Speaking of her experience with DIY transitioning, she said it 'exceeded her expectations’, and that she's 'heard from other trans people on the NHS services that they're often under-dosed and [aren't provided with] progesterone.'
Why is it important for transgender people to have access to healthcare?
While inaccessible healthcare can negatively affect physical health, the more common problem is the drain it causes on transgender peoples' mental health.
In 2018, a Stonewall survey of 5,000 LGBTQ+ people revealed that 67% of transgender respondents had experienced depression in the last year, and 12% of transgender respondents had attempted suicide in the previous year. 32% of transgender people said they had experienced unequal treatment from medical staff because they were transgender. Due to waiting years for an initial GIC appointment, with no way of knowing when it will be, coupled with an intolerant society, transgender people have a unique strain on their mental health which isn't being addressed.
67% of transgender people experienced depression in the last year - Stonewall
Medical transitioning is vital to many transgender people's happiness. Everyone I know who has accessed transgender healthcare feels more in tune with themselves overall and have new confidence they didn't even know existed.
I spoke with Ingrid, who told me of the positive effect transgender healthcare has had on her life: "I had very much withdrawn and become a hermit … [had been] single for nearly the entirety of my 20s, lacked confidence, self-worth, or desire to be with everyone … I have a lot more confidence now, I'm starting to go on dates again and really love aspects of my life I long forgot I could. I [have] been on hormones for just less than a year too and seeing the changes happen over time is the most bizarrely exciting time and affirming thing."
Wider access to transgender healthcare is also essential for accepting transgender people in wider society. Trans healthcare is currently seen as a taboo or inappropriate subject, only spoken about behind closed doors with medical professionals. This creates a huge stigma and helps spread misinformation. People claim that children as young as two are being offered surgery and that most transgender individuals end up de-transitioning, both of which are false. In fact, only 1% of 3,398 trans patients who accessed NHS support between 2016-2017 chose to detransition, If transgender healthcare was more readily available, transgender people could feel less anxiety about the processes and look beyond their medical transition to the rest of their lives.
What can be done to help?
If the Government put more funding into transgender-based education for GPs and other medical staff, more transgender people would feel confident about seeking medical help and advice. It would also mean that GPs and medical staff would be ready with the correct language and tools to assist that person. If more funding was allocated to NHS GICs, more clinicians would be trained, and more GICs opened, meaning wait times would decrease.
Having access to healthcare is probably the most essential thing for a transgender person. Gender dysphoria is severe but easy to manage when a transgender person is listened to and offered the right medical interventions.
Transgender people should not spend countless years of their lives feeling so at odds with themselves and the world. Transgender healthcare means freedom and is lifesaving.
For more information, as well as help and advice, please explore the websites below:
Edited by Christophe Locatelli