Last week, Pills and Policies were at the first ever meeting held by the Women and Equalities Committee. Although the meeting was too short to initiate a deeper discussion, there was poor representation of the affected parties, and it is not certain if the government will act on the evidence, these were the key issues identified within the healthcare system that relate to trans people:
1. LACK OF TRAINING: ACCORDING TO STONEWALL, 1 IN 4 NHS STAFF ARE UNSURE ABOUT HOW TO TREAT PEOPLE WITH GENDER DYSPHORIA
Whether it is due to ignorance or transphobia, many NHS staff are not comfortable or confident when dealing with trans patients. This lack of understanding is not only a concern when it is within GPs and specialists, but also within admin staff who often use the wrong pronouns when referring to trans people. Such insensitive actions may seem small although they have a negative cumulative effect on the overall patient experience. Jess from Action for Trans Health spoke about this, noting the ‘lack of cultural competence’ that exists within the NHS.
During the select committee meeting, suggestions were made that the GMC should include trans peoples’ concerns as a ‘fundamental aspect of medical training’, and doctors who are already practicing should also be educated. It is true that trans cases are not a daily occurrence in GP centres, medical training is already quite extensive as it is, GPs are overworked, and there is a high rate of burnout, but health professionals need at least a basic level of education on trans issues. Currently, a doctor would have to learn under apprenticeship from a specialist, which means that only a minority have adequate training.
Training health professionals may not be the best solution if done in isolation however; The problems trans people face within the healthcare system stem from a whole society issue, whereby trans people are generally stigmatised. To fully address the problems in the NHS, we therefore need society-wide campaigns and increased awareness especially within schools. The culture within the NHS should also reflect changing attitudes within society, as more people feel like they can express their true identities.
Healthcare professionals are a part of society, so it is not surprising that their personal views tend to align with those of the general society. A shocking 84% of NHS staff view trans procedures as a lifestyle choice that should not be funded by public money. Whilst personal views should have no place within decision making in healthcare, the reality is that they do. This brings us to our next point:
2. PATIENTS RELY ON GP REFERRALS TO ACCESS SERVICES AND PROCEDURES THAT THEY NEED
When it comes to healthcare that is specific to trans people, all the power seems to lie in the hands of GPs. Patients have little control over decisions that ultimately affect their bodies, with GPs being able to deny them treatment (often on the basis of their own beliefs). GPs are able to override a specialist’s decision to prescribe hormones, and this leaves the patient with one of three choices: try to find a GP who will offer you a prescription, switch to expensive private care, or self-prescribe potentially lethal hormones online.
An added dimension that makes the need for referral so impractical is that the referral isn’t a one-off; you need to know that a GP will support you throughout your life, and this uncertainty can make patients anxious.
An informed consent model would be more practical and fair – patients would be able to take control over their care, understanding the consequences of the decisions they make, and knowing all the options that are available to them. This makes sense since most trans patients tend to be better informed about the issues affecting them than the GPs are. The decisions they make would therefore be more justified.
3. THE REAL LIFE TEST AND LONG WAITING TIMES
Waiting times for gender reconstruction surgeries are long. Besides all the consultations and decision-making processes, patients are required to undertake a ‘real life test’ that could last up to 2 years. This test involves living in a ‘congruent gender role’ for an arbitrary time setting, which basically means that a patient has to ‘provide a stereotypical ideal of the gender they are’. This may be achievable for people transitioning in the traditional sense from ‘male’ to ‘female’ or vice versa, but it presents a problem particularly for non-binary people, who are even less understood by health professionals.
There is no one way that a non-binary person is expected to present, so when the health system is built from stereotypes/ based on a hypothetical patient, it is set to fail. Gender dysphoria can manifest itself in many different ways, so it is unfair to ask a patient to change their identity or personality just so boxes can be ticked. A real life test is pointless since gender dysphoria is not something that someone wakes up one morning feeling – they’ve probably been experiencing it their whole lives, and to discredit that life experience only acts to diminish trust between patients and health workers. People enter the health system at different points, so instead on insisting on a one-size-fits-all standard pathway, they should be assessed as individuals. Some people may feel like they’d benefit from a real life test, but make it their choice, instead of having cis people making decisions for trans people.
Waiting times vary across the country, but with only 7 Gender Identity Clinics, its fair to say that the system is stretched. A lack of funding despite the growing demand for such services has created inefficiency, with more pressure being placed on third sector companies such as charities like Action for Trans Health.
The NHS needs to rely less on charities, and have a consistent high standard of healthcare across the country.
Surprisingly, a major factor contributing to failures within trans healthcare was administrational error, which also adds to waiting times. There have been too many instances of miscommunication and missed appointments due to lost letters, as GPs and Gender Identity Clinics have to forward information to each other. The patient is often left acting as a middleman and taking on admin responsibilities, when it shouldn’t be their duty. Increased use of innovative technology within the NHS should mean that this will not be a problem for much longer.
4. TRANS PEOPLE ARE ALWAYS DEFINED BY THEIR GENDER, EVEN WHEN IT IS IRRELEVANT
‘When you have a cold, it’s a trans cold’
Being trans isn’t the only thing that a trans person is, and so it shouldn’t be the only thing that a health professional focuses on. The fixation on the medical histories of trans people only serves to objectify and alienate them, and is also very intrusive. You shouldn’t have to be given unnecessary genital examinations and be interrogated about your gender when you’ve only gone to a GP because you have a cold. Trans people are entitled to the same healthcare experience as cisgendered people, and that should go without saying.
5. GENDER DYSPHORIA IS OFTEN PATHOLOGISED, WITH THE LINK BETWEEN IT AND MENTAL HEALTH BEING WIDELY MISUNDERSTOOD
In the UK, gender dysphoria is not classed as a mental health disorder, so staff should stop thinking of it as one. Pathologising gender dysphoria not only increases stigma, but also leads to trans people being wrongfully referred by GPs to psychiatric services. Being trans doesn’t equal being mentally unstable, although trans people do have an above average incidence of mental illnesses because of transphobia. It is important to have a clear distinction between mental illness and gender identity, so that the two can be addressed appropriately – this leads back to the initial point of increasing awareness and education about trans people.