Stuck in the Cis-tem: How Outdated Healthcare Systems Harm Trans People

Introduction

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For those trans people who seek to medically transition, access to gender-affirming healthcare is vital. Sadly, trans people are all too often shut out from the very systems of healthcare supposedly designed to help us. 

 

The reality of trans healthcare is typically characterised by long waiting lists, segregation, gatekeeping, and lack of provision, and in many countries it is entirely absent. Trans people are pathologised and stigmatised, and, in some cases, outright criminalised. 

 

However, there is a shining light at the end of the tunnel. We can overcome these barriers and labyrinthine structures: trans healthcare can and must be desegregated, and the needs and experiences of patients must be heard and put first. We deserve to be treated with dignity and respect, and access to gender-affirming healthcare is a crucial part of that.

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Brief History

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Although trans people have existed in every culture throughout human history, the roots of modern transition-related medical care can be found in its classification as a disease by sexologists in the late 19th Century. Richard Krafft-Ebing's 'Psychopathia Sexualis' is seen by some as the first work to (incorrectly) classify gender incongruence as a mental disorder, describing it as the final stage of homosexuality, which he also considered a disease (Mulder, 2019). Ideas like this have been highly pervasive in the development of transition-related healthcare, and pathologisation is still prevalent in most modern trans healthcare settings.

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Magnus Hirschfeld's Institute of Sexology in Berlin was an early attempt at providing gender-affirming care. Opened in 1919, the institute centred the experiences of trans patients, rejected pathologisation, and carried out the first recorded gender affirming genital surgeries in history (Mulder, 2019; Khan, 2016). However, in the early 1930s, it was attacked by the Nazis, its efforts tragically cut short (Holocaust Memorial Day Trust, no date). Books were burned and institute members were killed, sent to concentration camps, and forced into exile.

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In the following decades, many of those in need of gender-affirming care had to travel across continents to seek out specific individuals willing to help them (Khan, 2016). Others were able to access care more locally, despite patchy and limited availability/provision (Playdon, 2022). In the 1960s, several medical practitioners who had been disparately dealing with transition-related healthcare came together to form specialist institutions (Playdon, 2022). Thus, the Gender Identity Clinics (GICs) were born.

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However, this model was not one built with trans people's best interests in mind.

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In the UK, the Charing Cross GIC was founded by John Randell, a self-professed eugenicist who believed that trans people were delusional and mentally ill (Playdon, 2022). The GIC pathologised trans people and Randell presided over a medical regime of gatekeeping that withheld treatment from all but those who were seen as capable of passing as their true gender (Faye, 2021; Playdon, 2022). Some early patients were even subject to electroshock therapy (Faye, 2021).

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Transphobia and gatekeeping were, and still are, central components of the GIC model. In many countries, trans people are still forced to act out sexist gendered stereotypes in order to access affirming care. The World Professional Association for Transgender Health standards of care still require people to live 'in a gender role that is congruent with their gender identity' for a year before certain surgeries can be carried out (2012).

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In countries such as the US and Canada, centralised and specialised GICs have been phased out in favour of more adaptable systems that offer treatment on the basis of informed consent at local health centres (Faye, 2021). Elsewhere, particularly in the global south, access to gender-affirming care is extremely limited or even illegal (Transrespect versus Transphobia Worldwide (TvT), 2014 and 2018). It is often simply unavailable through normal medical channels (TvT, 2014 and 2018). Trans people are, therefore, frequently forced to seek out treatment without medical supervision, for example by DIYing hormones after buying them through alternative vendors, especially online or through black markets (TvT, 2014 and 2018). The health risks of such alternatives are obvious. Others travel to neighbouring countries for private medical care, however this is usually prohibitively expensive (TvT, 2018)).

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Where transition-related healthcare is offered, it is often through a process that is intrusive, dehumanising, and humiliating. Across the world, trans people face long waiting lists (Savage and Bauer, 2021), and GICs often remain as steadfast gatekeepers of medical transition. Gender-affirming care frequently remains locked behind mental health diagnoses. Of 54 countries in Europe and Central Asia surveyed in 2021 by Transgender Europe, an NGO, only Malta and some parts of Spain had depathologised transition-related healthcare (TGEU). We need to start doing better globally.

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Mapping the Gaze

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The UK is an excellent example of a broken system. It still relies on the GIC model, under which almost all transition-related care is accessed through a specialist clinic. To access gender-affirming healthcare through the NHS, you must be referred by your GP to a GIC, after which you are placed on a waiting list. Once you have reached the end of the list, you are psychologically assessed and may be deemed eligible for medical treatment such as hormone replacement therapy, hair removal, voice therapy, or gender affirming surgeries.

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This sounds simple enough, however the process is mired with ill-educated professionals, long waiting lists, bureaucracy, gatekeeping, and even outright transphobia.

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It is common for people to not even get past the first hurdle without any trouble. Although GPs are required to refer patients to a GIC, they often don't. This may be because they don't understand the process or because of their own bigotries. Reports of hostility are accompanied by stories of those GPs who insist on referring trans people to mental health services instead, or the referrals that are promised but never sent.

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There are 14 adult GICs in the UK. I'm currently on a waiting list for one of them and, for a first appointment, the anticipated waiting time is officially four years and four months long (GIC, 2022). However, this number is somewhat misleading. The listed wait times don't take into account the fact that the amount of people on the waiting list is growing whilst the speed at which the GIC is processing patients is actually declining. Some have estimated that the true waiting time, if referrals continue to be processed at their current rate, is actually in the range of 25 years or more (u/anti-babe, 2021).

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When I asked my GP for a referral to a GIC in October 2020, they were seeing patients who had been referred in September 2017 (u/anti-babe, 2021). As of April 2022, they are seeing patients who were referred in December 2017 (GIC, 2022). In this time, the amount of people waiting for a first appointment has grown by around 3,000 (Tavistock and Portman NHS Foundation Trust, 2022). What makes this worse is that this isn't even close to the longest waiting list for a GIC in the UK—The Laurels in South West England holds that title (DPT, 2022)!

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Imagine being asked to wait for any other life-saving treatment for that long – and it often is life-saving. Trans people are especially at risk of death by suicide. A 2014 survey found that 27% of trans young people in England had attempted to take their own lives and that 89% had considered doing so (Youth Chances, 2014). Research by Stonewall in 2017 had those numbers at 45% and 92% respectively. Although more research is needed, studies have shown that gender-affirming care can improve quality of life and reduce the likelihood of suicide (Nobili, Glazebrook, and Arcelus, 2018; Turban et al., 2020). Numerous professional bodies, including the Endocrine Society, have repeatedly emphasised the life-saving nature of this care and condemned those attempting to restrict access (Endocrine Society, 2020 and 2021; @lgbt, 2022).

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Even once people finally get an appointment at a GIC, things aren't much better. The first appointment (and second too, in most cases) is a psychiatric assessment intended to determine whether you are “trans enough.” This often involves intrusive and frankly irrelevant questions about, for instance, peoples' sex lives or childhoods (Healthtalk, 2022a). I've read accounts of trans women having their care delayed because they weren't wearing a dress or makeup (Healthtalk, 2022a). Others tell of psychiatrists refusing to diagnose them because they didn't want to come out to their abusive and transphobic family members or because they had not changed their name (Healthtalk, 2022a). Those who are disabled, fat, neurodiverse, or from ethnic minorities are subject to even more gatekeeping on the basis of their intersecting identities (Faye, 2021; King, 2021; Zhang, 2021; TransActual, 2022). The process is especially difficult for non-binary people, who often fail to meet psychiatrists’ expectations of what it is to be trans. It’s gatekeeping, pure and simple.

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Once past the diagnostic assessments, trans folks are met with further waits to access actual treatments, such as hormone replacement therapy (HRT) or surgeries. A recent freedom of information request reveals that, at the London GIC in 2021, the average wait between first and second appointments was about 17 months, while those who were discharged after completing their treatment had waited an average of almost four years since their first appointment (Tavistock and Portman NHS Foundation Trust, 2022).

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It is no wonder that many British trans people choose to save up to pay for private treatment or take the risks of DIYing HRT. The former can be expensive, and, with growing demand, there are now several month long waiting lists for many private providers. Plus, private gender specialists are often the same people who work in the GICs, which means that there's no guarantee that you’ll be free from problems such as gatekeeping.

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Actress and YouTuber Abigail Thorn perfectly summed up the way that accessing gender-affirming care makes people feel in her speech to London Trans Pride in June 2021. She said: 'When my doctor refuses to treat me, and makes me use a segregated healthcare system, I am humiliated.'

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Solutions

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The solutions to the trans healthcare labyrinth are strikingly simple in principle, although entrenched beliefs and institutionalised transphobia may make them difficult to implement.

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Gender-affirming healthcare must be desegregated and integrated into general practice. Trans people shouldn't be forced to wait years for treatments that cis people can access from their GP. We need an informed consent model in which a trans person can be directly referred by their GP to local specialists, such as endocrinologists or speech and language therapists, rather than psychiatrists. Being trans is not a mental illness and should not be treated as such. Psychiatrists have no place in transition-related healthcare. We must end the systems that pathologise and gatekeep trans people and replace them with systems of accessible, inclusive, and adaptive healthcare.

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We need to recentre transition-related healthcare away from diagnostic assessments to the choice of patients. Decisions about our care should be made with our input and participation. We deserve a say in how we are treated and how that treatment is delivered, and we deserve to be listened to.

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We need to train more specialists and ramp up education for healthcare professionals and support staff so that they understand trans issues and healthcare pathways. Trans specific counselling also needs to be made available, to facilitate discussions and to allow people to explore their identity and the options available to them. This could help provide some of the support that is crucially missing from current systems.

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Of course, there is also a desperate need for more funding for transition-related healthcare systems, however, we also need to strengthen and increase funding for healthcare systems more generally. Good quality healthcare needs to be readily available and free at the point of use for all, trans people included.

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In the UK, some of these solutions are already being implemented by NHS pilot clinics, however these schemes are relatively small and their impact is likely to be limited in the short term. They need to be radically and rapidly expanded and developed. There is no need for centralised gender identity clinics or the psychiatrists who populate them. We need to desegregate, decentralise, fund, and educate for trans healthcare.

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Transition-specific healthcare systems are labyrinthine and difficult to navigate but they don’t have to be. Their current chaotic, yet oppressive, design gatekeeps, delays, and denies healthcare for trans people—withholding a basic human right. We need to break free and demand better.

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If you're in a position to do so, please consider donating to a relevant cause supporting trans people's access to gender affirming healthcare. For example, in the UK, the Good Law Project's Transgender Legal Fund or their crowdfunder for a judicial review into GIC waiting times.

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You can also show support by signing this petition to ensure trans people are fully protected under any conversion therapy ban in UK.

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