“Living as a woman” – MPs take on the Real Life Test

I’m currently writing up a section of my thesis that describes trans people’s experiences of navigating the public health system in the UK. A large part of this is related to the “real life test”, a stage of treatment which patients are required to live for a period of time in their “acquired gender” in order to demonstrate that they are suitable candidates for hormone therapy and/or surgery.

This requirement (which, incidentally was absent from the latest version of the international World Professional Association for Transgender Health Standards of Care) has a lot of issues. These include the prioritisation of cisnormative standards, little-to-no recognition of non-binary identities, white-centric cultural insensitivity, and the frequent demand that patients hold down “an occupation” as part of the test (particularly pernicious in a time of high unemployment).

It was therefore very interesting to see MPs questioning the idea of the real life test during the fourth and final session of the UK Parliament Women & Equalities Committee’s inquiry into transgender equality earlier this week. The conversation, in which MPs quizzed Ministers and NHS England representative Will Huxter, went as follows:

Jess Phillips MP:
“I think I’d like to go back again to this idea of living in one gender identity: I wonder if you can tell me – clinically – what ‘living like a woman’ – or alternatively, man – actually means?”

Will Huxter:
“I’m not a clinician I can’t tell you what that’s – ”

Jess Phillips MP:
“Do you think that there is a clinical way to live as a woman? Or a man?”

Will Huxter:
“The point I am making is that we are guided by specialists who work in this area, the clinical consensus among gender identity specialists about how services should operate. We are absolutely open to looking at how that might change, but I’m not in a position to make a change to the way in which those services are commissioned without having gone through a clinical process”.

Maria Miller MP:
“Mr Huxter, sorry, I think we’re going to have to press you on that. Is – this is just factual, we have read that people have to ‘live like a woman’ or ‘live like a man’, we as a committee have struggled to know what that looks like in a day and age where men and women live in very similar ways. What do you – factually – what does that mean?”

Will Huxter:
“Well in terms of what is required by the clinic I’d be very happy to provide some details from clinical colleagues after this because it’s not – I don’t deliver the services nor am I a clinician. I feel I could give a better representation to the committee if I provided that outside.”

Maria Miller MP:
“Is the Minister comfortable with the fact that the government requires this information to be available, or that individuals have to live ‘like a man’ or ‘live like a woman’ in order to be able to change their identity?”

Jane Ellison MP:
“Well, I mean, put as you put it to us, I mean obviously you know it gives cause for concern in a sense that, you know, who wouldn’t have sympathy for someone put in that situation etc , clearly the committee has heard I know some really difficult evidence and I quite understand why you wish to reflect that. I mean I think that as Will has said you know there is actually currently a review going on anyway about this very issue, which is essentially about looking at the current guidelines, about understanding that represents current better practice, about giving some challenge to that. There are a number of – compared to even five years ago – there wasn’t a mechanism for the NHS to receive that sort of, you know, feedback from critical friends or otherwise. Those now exist, the transgender network has been set up, the various stakeholder groups that are, you know, really locked into the process. So I think what I’m saying is I don’t think there is ever, you know, clinical understanding of situations is rarely completely frozen in time, I mean this one particularly isn’t, because for a lot of people this is a very new speciality, and therefore I would imagine over the next ten years for example, the next few years, you will see an evolution. And that process is underway, which is exactly why the NHS is consulting and is looking at, particularly at its clinical, you know, specification. That process is actually going on at the moment and, as Will has said, very open to the committee’s recommendations being fed into that. But I know I’m not a clinician too, and I know from other areas of my portfolio perhaps better than this one because I’ve been doing it longer, I do know that you do need to test. Because once you commission to a standard, once you’ve got that, you know you do, you need to make sure you’ve tested your views, and that you actually capture a clinical consensus, because that’s the only way you can move forward. But that consensus will evolve.”

Jess Phillips MP:
“Okay, I just – from the Minister – just, I suppose, what I’m looking to hear, is that you recognise that there is not a single list of attributes that represents what it is to be a woman and/or a man; and therefore, there cannot be a clinical list of things that a person can be told to do by a doctor in order to tick those boxes. Do you recognise that fact?”

Jane Ellison MP:
“Well I understand what you’re saying and I think that it would be very helpful if we – subsequent to this hearing – write to the committee with some – with an example from a clinician operating in the field as to what they would mean by that, because obviously you know people are sitting down with individual people and saying, you know, requiring them to do that and they must have an idea of what that requirement is, what that looks like. So I think we should ask the question of clinicians and supply the committee with some, perhaps some examples, obviously anonymised, of where that’s already happening in clinical practice, and what that looks like.”

You can watch the footage here.

women and equalities

All of this is relevant to the law – in addition to clinical practice – because of the current functioning of the Gender Recognition Act. In order to gain “full” legal recognition as female or male (non-binary options aren’t available) people who have transitioned are required to apply for a Gender Recognition Certificate (GRC). In addition to £140, a whole load of paperwork and scrutiny from the national Gender Recognition Panel (no, really), individuals wishing to acquire a GRC need clinical approval. It’s no wonder that many trans people simply refuse to play along, leading to consequences such as the Tara Hudson case.

As it turns out, there is an answer to be found in the clinical literature. Charing Cross GIC clinical lead James Barrett has the following to say on the subject of the real life test in his book, Transsexual and Other Disorders of Gender Identity: A Practical Guide to Management:

“The question immediately arises of what constitutes ‘success’ in a chosen gender role. In essence, ‘success’ amounts to occupation, sexual, relationship and psychological stability. Of these, the first can be measured by whether or not the patient can manage to hold down a full-time (or equivalent part-time occupation in the chosen role for a year, in the course of the real life experience […] ‘Success’ in an occupation is achieved if the patient is treated by most others as if they are of the assumed sex. It is not necessarily that those around the patient believe that they are that sex […] Rather than being believed to be the assumed sex, the goal should be taken as an treated as that sex.”

[…]

“Some patients fiercely maintain that they do not care what others think of them, and that their own conviction of their gender is what matters. This position is at odds with the philosophy of a real life experience and if followed seems not to be predictive of a good longer-term outcome.”

Barrett further qualifies that “success cannot occur within a “purely transvestite or transsexual environment”, because “others may be supranormally accepting”.

So there you have it: “living as a woman” or “living as a man” means being taken as such within a cis environment. A very postmodern basis for clinical excellence!

No, I will not help Sundog make a documentary on trans “regret”

This afternoon I received an unsolicited email in my work account from an employee of Sundog Pictures. An excerpt follows:

I’m currently working on an idea alongside Channel 4 following transgender individuals who have come to regret their sex changes and are keen to undergo further treatment / operations to reverse the change. The doc will be insightful and sensitive and will look at the way in which transgender individuals are treated in society and whether the process before someone is permitted an operation is robust enough.

I’m currently looking for real life cases to include in my pitch document and was wondering whether you might be able to recommend people I could speak to, or places I could contact to find individuals who are currently thinking about a reverse sex change. Any help would be really appreciated.

Given the email account used, I feel that I can safely assume that I was contacted because of my academic work, which looks at discourses of trans healthcare provision. Sundog seem to hope that I will (without compensation) draw upon my community contacts and research findings to recommend participants for their television programme.

I couldn’t think of anything more inappropriate.

There’s a lot to be said about research ethics and a duty of care towards participants, but plenty has been written about that elsewhere (the BSA Statement of Ethical Practice offers a decent broad overview). So in this post I focus on the huge problems that come with the proposed topic of the documentary: that of trans “regret”.


The numbers

The mainstream media take an undue interest in trans “regret”. It’s very easy to come across such stories on daytime television and in both tabloid and broadsheet newspapers. The popularity and frequency of such stories suggests that it’s not too unusual for people who have undertaken a physical transition from male to female, or from female to male, to consider or undertake a “reverse sex change”.

In reality, research has shown time and time again that the actual rate of regret is extremely low. For instance, only 2% of respondents in the Trans Mental Health Study (the second-largest trans study undertaken in the UK) reported “major regrets” about the physical changes experienced during transition. Reported regrets from participants included:

“…not having the body that they wanted from birth, not transitioning sooner/earlier, surgery complications (especially loss of sensitivity), choice of surgeon (if surgery required revisions and repairs), losing friends and family, and the impact of transition on others.”

It’s clear therefore that “regret”, when it occurs, is likely to stem from societal and surgical issues rather than the process of physical transition in and of itself. The Trans Mental Health Study also demonstrates a clear link between physical transition and wellbeing in terms of mental health, body confidence and general life satisfaction.

With so few trans people regretting physical transition – and even less considering some kind of “de-transition” – it’s no surprise that sometimes the same individuals are trotted out time and time again to re-affirm a discourse of regret.


What’s missing from this story?

It’s pretty clear from the email I received that that the author has not done their research. Given the existence of organisations such as Trans Media Watch and All About Trans who are entirely keen to offer advice, this does not exactly inspire confidence.

For a start, transition is conflated with “sex change”, a term that is not only most frequently associated with transphobic tabloid headlines, but is also broadly meaningless. At what point can we talk about a “sex change”? When an individual undertakes hormone therapy? Chest surgery? Genital surgery? What about individuals who transition socially, but only undergo some (or even none!) of these processes? It’s not the kind of language that suggest an “insightful and sensitive” documentary can be made.

There’s a couple of more fundamental mistakes in the proposal, however. The first is the question of “whether the process before someone is permitted an operation is robust enough”. My own initial research findings suggest that if anything, the process in question is too robust – in that patients requiring surgery are typically required to wait many years before treatment is available.

The World Professional Association for Transgender Health Standards of Care require patients to undergo at least 12 months of hormone therapy prior to genital surgery. In reality, patients in England and Wales face a substantial waiting list (sometimes lasting years) before they are able to attend an NHS Gender Clinic, where two separate clinicians are required to approve a regime of hormone therapy before it can be undertaken. An additional two opinions are needed at a later date before a referral for genital surgery can take place. There are many, many opportunities and a great deal of time for patients to consider and re-consider their option – and that’s even before we take into account the horrific scale of the current crisis in surgery provision for trans women.

The current system is not constructed to facilitate transition so much as prevent the very possibility of regret. The result is increased suffering – in terms of the mental and physical health impact upon individuals who are forced to wait many years for hormones and surgery, whilst fearing (sometimes with good reason) that they will be denied treatment on spurious grounds. It’s no surprise that the Trans Mental Health Study found that “not transitioning sooner/earlier” is a major cause of “regret”, as individuals who have waited until breaking point to transition soon discover that there is still a long, long road ahead of them.

The second fundamental problem with Sundog’s proposal is their idea that trans people who aren’t too happy with their transition might be “keen to undergo further treatment / operations to reverse the change”. This is a very binaristic notion that both stems from and reinforces the notion that transition is a one-way process, from one (binary) gender to the other. In reality, there are many people for whom transition is a complex, ongoing process. For instance,  an individual who initially transitions from male to female might later feel that their identity is better understood as genderqueer, and may allow or pursue further physical changes to reflect this.


The wider political context

Given the tiny proportion of trans people who “regret” transition and the realities of service provision, the choice of a documentary about the subject appears at best to be somewhat misguided. However, the impact of insensitive coverage on this topic is such that I believe that I believe this documentary could be actively harmful, particularly as Sundog’s email asks “whether the process before someone is permitted an operation is robust enough”.

This is in part because the way in which discourses of regret are handled makes it harder for trans people to get treatment. Gender clinics in the UK require urgent intervention to make life easier for individuals who transition, not harder. Media hysteria over the possibility of regret reinforces the current system’s approach, which is to require people to demonstrate over and over again that they are trans before there is any hope of treatment.

But it’s also because discourses of regret are employed by those who campaign against trans liberation, including conservative commentators and anti-trans radical feminists who would deny funding for transition on the NHS altogether. Writers such as Julie Bindel are all too keen to use any example of individual regret to argue that transition is unnecessary mutilation, undertaken by sad, sick individuals who might have done otherwise if only they’d been given the option of, say, some form of reparative therapy.

The focus on the medical process is therefore politically loaded. Yes, some people do de-transition, and their stories are important and of worth. But these stories have yet to be told by the mainstream media in a non-sensationalised manner, in a way that doesn’t reinforce (intentionally or otherwise) a pernicious anti-trans agenda. Sundog’s proposal appears to feed right into this agenda.

This proposed documentary should not be regarded as a curiosity piece taking place in a cultural vacuum. It draws upon and will contribute to damaging and inaccurate tropes about transition. Ill-informed media accounts ultimately play a part in creating and maintaining a situation where “regret” frequently stems from the responses of friends and family, delays to transition and other negative experiences that come with transitioning in a transphobic society.

I hope therefore that any future attempts to examine trans health issues in this way will involve better research into the topic at the initial stages, and a greater sensitivity to both the personal and political consequences of exposing trans lives to media scrutiny.

Provisional English Protocol for Gender Reassignment, 2013-2014

NHS England Interim Gender Protocol CPAG Approved 12-7-13 (released 15th July 2013)

Key changes to current treatment, and other points of interest:

  • GPs may refer patients directly to Gender Identity Clinics (GICs). It is not necessary for GPs to first refer patients to another specialist service (e.g. a psychiatrist). This is important because until now most GICs in England have required patients to be referred by a mental health specialist.
  • Facial hair removal will be available on the NHS. The Interim Protocol describes facial hair removal as “essential treatment for MtF patients” (p.10). It is funded by NHS England, rather than CCGs (Clinical Commissioning Groups: these replace Primary Care Trusts). Patients are (in theory) guaranteed nine facial hair removal treatments: one test patch, and nine sessions. Funding can be sought for further treatments but is not guaranteed.
  • Hair removal prior to genital surgery will be available on the NHS. Funding for this service is provided through NHS England in a similar manner to facial hair removal for MtF patients.
  • Adult treatment is available to trans people from the age of 17. The Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust will continue to provide services in London, Exeter and Leeds for trans people under the age of 18, according to its own guidelines. This means that trans people aged 17 may choose between “adult” and “young people’s” services.
  • Breast augementation, facial feminisation surgery, lipoplasty and sperm/egg storage may be funded. Breast augementation will only be funded if “there is a clear failure of breast growth in response to adequate hormone treatment”. All of these procedures are funded by CCGs rather than centrally through NHS England, which means that GICs must apply to CCGs for funding. They will be funded (or not) according to CCG policy, which may vary.
  • Patients require only one assessment from a GIC team member in order to be referred for psychotherapy or speech therapy. This is important as it has the potential to speed up access to speech therapy and additional psychotherapeutic support.
  • Patients must recieve assessment from two GIC team members in order to recieve hormone therapy. This is important because until now, some GICs in England have required assessment from more than two team members. Conversely, it reinforces the position of those clinicians who argue that two opinions is necessary before treatment can begin.
  • 12-24 months of “real life experience” is required prior to the provision of genital reassignment surgery. This is important because it means that patients can (in theory) access genital surgery within a year, in line with WPATH guidance. However, it is likely that clinics will continue to demand at least 2 years of “real life experience” prior to surgery.
  • A wait of at least 6 months is necessary prior to the provision of chest surgery for FtM patients. The guidance on this is somewhat vague, which should allow flexibility but may be exploited by more conservative GICs. The Interim Protocol states that patients who qualify for chest surgeries “may have engaged in a social role transition” (emphasis mine), and that a referral will “typically” be offered “around 9-12 months, but no less than 6 months, after the patient’s first consultation”.
  • Surgical providers are supposed to inform primary care staff (i.e. GPs and nurses) of procedural details and post-operative needs. We’ll see how this one pans out in practice!

Overall, this Protocol should result in a broad improvement in transition-related services for trans people living in England and Wales. If all goes to plan, more services will be available to more people, who will have to do less waiting for them! I offer a more in-depth discussion of these changes – and comparisons to the Scottish Protocol – here (please note that there have been changes since I wrote that post – e.g. GPs should now be able to directly refer to GICs, and facial hair removal should be provided on the NHS in England and Wales, just like Scotland) .

However, GICs may yet resist some of the measures in this document. The protocol was meant to come into force for all trans patients access transition-related services from 1 October 2013, so now is the time to hold medical providers to account.

Scottish protocol for Gender Services (largely) adopted in England

It appears that much of the widely-lauded NHS Scotland Gender Reassignment Protocol will be adopted in England from 1st June 2013.

This will be a temporary measure, taken as the result of “inconclusive feedback through the consultation exercise on specifications and policies” for the English Protocol. Last year, the draft English Protocol was criticised by many trans people for failing to live up to the progressive standard set by the Scottish Protocol. I wrote about this here.

This information comes from a letter written to stakeholders in the Gender Identity Services Clinical Reference Group.


What will this mean for English patients in the short term?

As the Scottish Transgender Alliance noted in July 2012, the Scottish Protocol “is not perfect but it is an important step forward for trans people in Scotland“. It incorporates a number of clauses that ensure relatively swift access to services (including hormone therapy and surgeries) for those already “in the system” and on the books of a Gender Identity Clinic (GIC).

Key features of the temporary Protocol for England would therefore include:

  • that psychotherapy/counselling, support and information should be made available to people seeking gender reassignment and their families where needed.
  • that two gender specialist assessments and 12-months experience living in accordance with desired gender role are needed for referral for NHS funded genital surgeries
  • only one gender specialist assessment is needed for referral for speech therapy, hormone treatment and FtM chest reconstruction surgery and that these can take place in an individualised patient-centred order either prior to starting the 12-month experience or concurrently to the 12-month experience.

(Bullet points from the Scottish Transgender Alliance. Emphasis mine.)

All of these provisions should (in theory!) entail a more rapid, efficient access to services for patients at many English GICs.


Exceptions

Unfortunately, several particularly progressive aspects of the Scottish Protocol will not be adopted in England. According to the letter sent out to stakeholders, these include:

  • Referral to Gender Identity Clinics (access)
  • Facial hair removal
  • Breast augmentation

Discussion on these areas” is being “deferred” because “it is recognised these need further discussion and also because England’s health service is structured differently and therefore a slightly different approach will be necessary

The first point (“referral to Gender Identity Clinics”) is somewhat ambiguous, but appears to mean that provisions made in Scotland for self-referral and referral by GP to GICs will not be implemented in England, at least in the short term. Most English GICs currently only accept referrals from mental health specialist such as psychiatrists, so this looks set to continue.

The letter further states that:

“[…] decisions relating to direct access, facial hair removal and breast augmentation being deferred by all NHS England Area Teams until after the June meeting when further work can be undertaken to reach the interim NHS England Policy and Specification for adoption. Where an individual has already had agreement for any of these procedures then these would go ahead, the deferment relates to decisions not yet made.”

This would appear to imply that no new referrals will be provided for facial hair removal and breast augmentation on the NHS in England, at least for the time being. In most parts of the country this is the norm, but in some areas this will effectively be a step backward.


What about young people?

A final significant aspect of the Scottish Protocol is that it provided for the provision of better services young trans people:

  • that young people aged 16 are entitled to be assessed and treated in the same manner as adults in terms of access to hormones and surgeries.
  • that children and young people under age 16 are entitled to child and adolescent specialist assessment and treatment as per the relevant section of the WPATH Standards of Care.

(Bullet points from the Scottish Transgender Alliance. Emphasis mine.)

It’s not clear whether or not this part of the Protocol will come into play in England, but I suspect that this counts as “access to Gender Identity Clinics”, meaning that nothing will change – in the short term at least.


Analysis

I would suggest that this development is, on the whole, a positive one for the majority of trans patients in England. It will hopefully ensure a number of improvements in access to treatment, particularly for individuals seeking hormone therapy and individuals on the transmasculine spectrum seeking chest surgery (including for individuals seeking chest surgery prior to hormone therapy, or chest surgery without any accompanying hormone therapy). It should encourage GICs to acknowledge trans diversity and provide treatment more adequately tailored to individual circumstance.

Moreover, the implementation of this Protocol means that some of the more regressive elements of the draft English Protocol (such as the requirement for GPs to undertake a “physical examination” ) will hopefully not see the light of day.

Of course, there will continue to be resistance from some of the more conservative GICs. However, the existence of the temporary protocol should empower patients who wish to make the case for better services from these bodies.

It is important to note once again that this is a temporary measure, and that the new English Protocol that is eventually implemented may not necessarily reflect the Scottish Protocol to such a great extent. A meeting will be held in June for members of the Clinical Reference Group to discuss what might happen next. We can only hope that the outcome will be a positive one for trans patients.

However, this move sets an important precedent. A set of relatively progressive new rules are being put in place, meaning that it should be harder for GICs to justify inadequate service provision. This is a new benchmark which health campaigners can use as a starting point for future campaigns.

Finally, the “inconclusive feedback” from “consultation” suggests that pressure from trans health advocates is actually having an effect, particularly as many GICs will no doubt have been pushing for a continuation of the status quo. Credit is due to all those individuals and organisations that responded to the consultation on the draft English protocol a year ago, and members of the Clinical Reference Group who are pushing for positive change.

NHS scraps “Equality and Diversity”

File under: “you couldn’t make it up”.

NHS bureaucrats have crawled deep into their own backsides in what looks like an attempt to appease the Conservatives. The NHS Equality and Diversity Council is out – the NHS Personal, Fair and Diverse Council is in.

The important thing to take away from this is, of course, that “equality” is an outdated concept: inappropriate for our streamlined modern age. With “equality” comes the idea that we might want to put some effort into ensuring that everyone has an equal chance of gaining that job, receiving respect in the workplace and feeding themselves and/or their family. This kind of woolly thinking fails to recognise the hard-earned nature of personal gain.

“Equality” should therefore be regarded as socialistic nonsense that has no place within the choice agenda. Instead, we need to celebrate the negative freedoms that allow hard-working white men to rise to the top whilst paying lip-service to the beautiful diversity of those at the bottom.

That’s why we should focus on fairness. It isn’t “fair” that the rich should be taxed more than the poor. It isn’t “fair” that money should be spent on subsidising health care for lazy and poor people. It isn’t “fair” that there’s a black history month but not a white history month.

If in doubt, just ask Nick Clegg, a man who has handed out “fairness” in spades to the disabled, to the poor and to students over the past couple of years.

And remember – if it’s not immediately obvious what a given body is for, then why should you bother to critique its work?

Personal, Fair and Diverse Council to launch as part of the NHS Commissioning Board

5 November, 2012

The NHS Equality and Diversity Council (EDC), chaired by Sir David Nicholson, Chief Executive of the NHS Commissioning Board (NHS CB), has announced that it is to change its name to the Personal, Fair and Diverse (PFD) Council.

The name change has been agreed in response to the Council’s new responsibilities for health inequalities and human rights as part of the Health and Social Care Act 2012 and supports its wider role to act on behalf of the whole health and social care system.

The choice of name mirrors the vision at the heart of the work carried out by the EDC, including its successful Personal, Fair and Diverse Champions campaign, which is run on behalf of the Council by NHS Employers. The name also promotes the values of the NHS Constitution and the creation of fairer, more inclusive workplaces and health and care services for everyone.

(Guest Post) Draft Protocol Review

A review of England’s draft protocol for gender dysphoria services by CL. You can read a copy of the draft protocol here, respond to the survey here, and read my own analysis here.

Following the lead of an information note published by the department of health, the draft protocol confirms and compounds the problems of treating gender dysphoria on the NHS. It would at least mostly standardise treatment protocols across England, burdening everyone with the same problems: We’re all in this together, right?

The Gender Services Clinical Reference Group is aiming to implement standardised service provision by April 2013 and has given interested groups until September 30 to respond. GIRES has responded, as has Terrence Higgins Trust’s Trans* Women’s Sexual Health and Wellbeing Group, whose submission I contributed to. Our issues with the Department of Health’s Information Note are seen again here, and I’d like to focus on those in particular: the framing, tailoring and requirements of treatment.

Framing Gender Services Treatment

A problem in the protocol that has carried over from the information note and current practice, is the framing of gender dysphoria treatment as the property of psychiatric specialists. Even in updating the condition being treated to ‘gender dysphoria’ from Gender Identity Disorder, which explicitly frames the problem as one with our gender identities rather than our physical characteristics and the dysphoria resulting from them, the protocol places gender dysphoric people under the care of “a mental health professional (eg. psychiatrist or psychologist) who specialises in transsexualism/gender dysphoria and has general clinical competence in diagnosis and treatment of mental or emotional disorders.”

The logic behind this in the current protocol is not forthcoming. Perhaps it is because there’s a likelihood of additional mental health issues due to the stress of dysphoria. Realistically, it’s because dysphoric people have always been treated as mentally ill, and tradition has kept us under the exclusive care of psychiatrists.

Assessment is a large part of the GICs role: confirming that we have Gender Dysphoria and are not merely deluded about our gender identities. Gender Dysphoria strong enough to necessitate transition is rare, certainly, and doctors are warned to be warey of ‘Zebra diagnoses’ (as House of God, the inspiration for ‘Scrubs’ described them). That is, when you hear hooves, think horse, not zebra. That’s sensible advice, but if you’re in southern African plains, thinking Zebra first might not be so unreasonable. In this case, if someone is distressed by their assigned gender and sexed body, identifies strongly as another gender and feels relief when living as that gender, a diagnosis of ‘trans*’ is the most likely answer. Trusting this principle would rob the GICs of hours of questions about your childhood hobbies and masturbatory habits, but it would free up a lot of unnecessary appointments.

Scotland has already moved away from the complete ownership of Gender Services by mental health teams, allowing patients to self refer to a GIC. This saves an appointment with a GP, one with a community mental health team and allows direct access. For those who need a diagnosis, removing these two stages of waiting, where ignorance or prejudice can delay or waylay a patient, can get them that diagnosis quicker. Given the burden on admin staff and funding, a time, appointment and money saving move like that is far better than the protocol’s recommendations.

Tailoring Service

The introduction to the protocol claims that it is ‘informed by the 7th edition of the WPATH Standards of Care’ – sadly, it isn’t based on them. Some key recommendations from the 7th SOC were: HRT could be prescribed without RLE and one assessment, Lower Surgery required only one year of RLE (rather, one year of HRT). None of those recommendations are followed here, so the role of the 7th SOC’s ‘informing’ is not apparent. As Ruth points out, this is essentially just the existing Charing Cross treatment.

The protocol makes references to giving patients time to consider other options, other approaches, time to reflect and, of course, the RLE’s time to consolidate. There can be great value in this and many people seek the GIC to explore and understand their gender identity. Chances to really assess their history, feelings and situation can be very valuable. A friend in this situation said that her diagnosis brought her great relief and confirmation of her feelings.

For others though, this is unnecessary. Many others will have thought, reflected and considered extensively, almost exclusively at times, before seeking a GIC: they know who they are and what they need. For them, the numerous stages to access a GIC, double assessments and arbitrary RLE periods merely delay them, take up clinic time and appointments and cause additonal frustration as they wait for their treatment.

Clinics shouldn’t be forcing surgery on everyone at the first appointment, but the slowest common denominator approach is hardly ideal either, and unnecessary, arbitrary waiting is positively detrimental in many cases.

Requirements

Despite the 7th SOC’s ‘informing’ of the protocol (perhaps they were low on coasters?), RLE remains a key feature of the proposed gender services. The protocol is unclear about RLE requirements for HRT, but indicates that full HRT can be prescribed ‘Dependent on whether an individual has socially transitioned in the sense of living full time’ or is likely to ‘do so immanently’. Top surgery needs a year of RLE, lower surgery needs 2 years.

The problems with this are numerous:

  • It’s arbitrary. There are medical reasons for a year of HRT for lower surgery, but not for living full time in role.
  • Requirements of being employed have nothing to do with a stable, well founded gender identity.
  • Whilst individuals vary greatly, some people have considerably more difficulty being read as their gender prior to HRT, and AMAB people are more likely to recieve certain forms of harassment if people read them incorrectly. Forcing people into public facing roles to get the treatment they need puts them at direct risk of violence, harassment and discrimination.
  • What ‘real life’ is being experienced? From my own and others’ experience, I know that living full time as a woman pre HRT is vastly different to being full-time after a year on HRT. The near daily abuse and marginalisation, with incumbent stress, is not the real life I’m  experiencing now, but was a feature of living as a woman who was visibly trans*. The RLE required is entirely unrepresentative.
  • For all the regional variation and obfustication, the 2 years of RLE for surgery is well known, and patients work to it. The lengthy requirement can prompt patients to ‘start the clock’ running on RLE long before they are ready. Who knows how much suffering has come from that, or from knowing that no help will come before an arbitrary deadline?
  • Patients remain on the GIC’s book during this period: the aforementioned zebras get called in for appointments to needlessly check that they’re still serious, then sent away to wait another 5 months. This takes up appointments that could help patients who are less certain of their needs.

Overall, this protocol standardises existing Charing Cross treatment, which is already behind the times in not adjusting to WPATH’s SOC 7, and seems particularly inadequate when compared to the updated Scottish protocol. Most worryingly, its requirements standardise the appointments that add to the waiting times, administrative burden (which currently means Charing Cross are taking 2-3 months to send appointment summaries) and sense of disempowerment that service users experience. With multiple screenings, assessment and ‘time for reflection’, it is particularly unsuited to those who have a clear understanding of their identity and wish to proceed, and who have thought over their option extensively prior to seeking a referral. If this protocol is to last for any significant time, it will hold service users to standards that are already inadequate – If the next update will last, we need to fight for a protocol that truly moves treatment forward, so make sure to give your views in the protocol’s survey.

Business as usual? A look at the draft English protocol for gender dysphoria

The main achievement of England’s new draft protocol for transition-related services is not to offer progress, but to codify certain elements of existing practice.

In this sense, it somewhat resembles Scotland’s new protocol, which was published a couple of weeks ago.

The Scottish protocol appears to have been based largely upon the services offered by Sandyford, the nation’s largest gender identity clinic. The English protocol seems rooted in current practice at Charing Cross, which plays a similar role within England and Wales. The differences between the documents hinge largely on the differences between the progressive policies instituted at Sandyford, and the more conservative attitude of Charing Cross.

In this article I’m going to examine some aspects of the draft English protocol that have really struck me, before discussing political elements of difference between the English and Scottish protocols. I also briefly talk about the survey that is being distributed alongside the draft guidance.

The Good

LanguageThe language used within the draft English protocol largely acknowledges the complexity and diversity of trans experience. It encourages a respect for patient identities in terms of correct name, pronoun usage etc. (regardless of legal status). There’s even an explicit acknowledgement of non-binary identities, although this is somewhat undermined by binary assumptions elsewhere in the document, and a focus upon transitions that follow the typical “female to male” or “male to female” routes.

Referrals – The document provides some important clarifications for referral to a gender clinic: that individuals do not have to have lived in their preferred gender role prior to referral, that neuro-diversity and mental/physical health issues should not be a barrier to referral, and that psychotherapy is not a necessary precursor to referral. However, these points are not made as strongly as they could be, leaving some room for (mis)interpretation.

Treatment process The document states that two appointments should be sufficient for a diagnosis of gender dysphoria (to be diagnosed according to the ICD-10 criteria, as opposed to DSM-IV). The prescription of hormones should (if appropriate and desired) follow this diagnosis, and surgery should follow within approximately two years. This might all sound very familiar to Charing Cross patients, but may work to reign in some of the more eccentric practices of smaller gender clinics such as Nottingham.

Overall – It will be beneficial to have this protocol at hand to bring local referral practices and the actions of smaller GICs in line with national standards.

The Bad

Referrals – Referrals must come from a GP or specialist (psychiatrist or psychologist), with clinics able to insist upon referral from a specialist. This means that long-winded battles for referral look set to continue as normal. In contrast, the new Scottish system appears allows individuals or GPs to refer to any clinic.

Treatment process – The protocol states that it is informed by the most recent edition of the WPATH Standards of Care. However, it seems (again, contrary to the Scottish protocol) to ignore large parts of the Standards of Care in favour of current Charing Cross practice.

For instance, FtM spectrum individuals must have been on hormones for at least six months and full-time for at least a year before top surgery is considered, and patients must wait at least two years before being offered genital surgery (although a referral appointment for surgery may take place after 18 months under some circumstances). This last point in particular is justified with reference to ICD-10. Interesting here that guidance for diagnosis from 1992 is given precedence over guidance for care from 2011.

Trans youth– There is an acknowledgement of the benefits of hormone blockers for under-18s, but (unlike the Scottish protocol) no real engagement with the possibility of hormones and surgery for trans people aged between 16 and 18. The protocol continues to relegate all young people to specialised – and limited! – youth services.

Overall – The document pays lip service to the WPATH Standards of Care but does not really live up to the spirit of those guidelines. This is particularly evident when the draft document is compared to the Scottish protocol. Patients are expected to put up with a long-winded, complex system in which treatment is spread out over many years.

The Ugly

Get a job – Patients are still expected to be in education or employment in order to gain a referral for genital surgery. If you don’t have a job or you’re not on a course, you’re expected to be involved in some volunteering role. It’s all about demonstrating your ability to move through the world in your “new” gender prior to irreversible surgery.

This requirement is patronising, stupid, and fetishises trans genitals. What other surgery requires that those who undergo it are in work? Why is it that genital reconstruction is seen such a massive step, but the permanent changes that come with long-term hormone therapy is not? Yes, surgery is a big deal, but it’s clear that clinicians regard this surgery as something else entirely.

I can’t understand how this can possibly be acceptable at the best of times, but at a time of recession and mass unemployment it strikes me as particularly cruel and unreasonable. How to account for individuals who cannot find a volunteering role in their local area? Individuals with anxiety issues? Individuals who are told by the Job Centre not to volunteer, with the threat of benefit withdrawal hanging over this order? And how can this possibly be acceptable when trans people face considerable inequalities in the job market (with trans unemployment estimated at 50% in some European countries).

Physical examination – GPs are apparently “expected” to perform a physical examination of trans patients. Why? No reason is given. The document simply states that: “The GP will be required to carry out a basic physical examination and investigations, as a precursor to those physical treatments which may later be recommended.

I simply cannot comprehend where this idea comes from. For many trans people – particularly those contemplating physical transition – the very idea of a physical examination is extremely unpleasant and can cause severe distress. There are times when pre-operative trans people might require a physical examination: such as immediately prior to surgery, or during a sexual health check-up. These experiences can be deeply unpleasant, but at least they’re necessary.

GPs are not trained to understand the complexities of trans people’s relationships with their bodies. In fact, most GPs don’t receive any training on trans issues whatsoever. What are they meant to be looking out for during such an examination, and how are they supposed to know? An invasive examination such as this should only be performed when necessary, by someone who knows exactly what they’re doing.

Discussion: England vs Scotland

The headlines from the Scottish protocol included a number of moves to bring treatment more in line with the most recent edition of the WPATH Standards of Care. These included provisions for self-referral and referral by GP, less waiting time for surgeries, access to a wider range of treatments (e.g. hair removal) and full access to treatment for individuals aged between 16 and 18.

Whilst representatives from groups such as the Scottish Transgender Network played a vital role in putting provisions such as these on the national agenda, it’s important to recognise that many of them had already been implemented by Sandyford GIC.

The message seems to be that the English clinics – who are almost entirely responsible for the development of this draft protocol – are not interested in developing new practice, let alone conforming with the seventh edition of the WPATH Standards of Care. Instead, they seem keen to maintain a tight control over the processing of patients, an approach that renders the draft protocol even more strict than a new national commissioning policy that is being simultaneously developed.

Survey

The survey that accompanies the draft protocol is extremely short. This makes it quick and easy to fill in, but the form also seems to have been designed to shut down unwanted criticism. The Department of Health appears interested only in how current experiences match up to the proposed protocol, and seems keen to avoid any kind of critical feedback on the document.

It is, however, possible to offer you opinion on the nature of the protocol itself. Here are some tips for doing so:

  • Where your experiences differ from the protocol in a positive manner (e.g. you didn’t receive a physical examination from your GP), emphasise how your experience was more positive than would be the case should the protocol be implemented as-is.
  • Where your experiences differ from the protocol in a negative way, emphasise any manner in which you think the protocol could go further to ensure better treatment.
  • If you have sought care outside of the NHS for necessary treatments (e.g. hair removal for trans women) explain why this treatment should be a necessary part of the protocol

Final thoughts

The introductory text to the survey suggests that current political and financial pressures on the NHS prohibit the introduction of any real changes within the draft protocol:

DH wants the final document to outline the current position for transgender people seeking gender reassignment services through the NHS. The document should outline what support and services a transgender person can expect to receive in the tight financial constraints currently placed on the NHS.

This doesn’t really make a huge amount of sense. Yes, if more trans people have access to services (e.g. laser hair removal), this will cost money. But surely there is a lot more money to be saved through progressive reform?

Insisting on longer real-life tests, longer waits for surgery and so on won’t save a lot of money in the long term. A similar amount of trans people will be accessing services: they’ll just have to wait longer as individuals in order to access the a services. The money will still be spent. So why have such long waiting times?

Insisting on referral through a specialist (i.e. psychiatrist or psychologist) won’t save money. How does the NHS possibly benefit financially from insisting that trans people see more specialists rather than having them directly referred to a gender clinic by their GP? This is particularly the case when specialists decide that they need to assess people over multiple appointments before referring them to a gender clinic. The individuals concerned experience a frustrating delay, and it costs more money because the NHS is paying for all these extra appointments.

This isn’t really about the money. It’s about gatekeepers maintaining a certain level of control over patients, and putting certain ideologies into practice. It’s about picking and choosing which parts of ICD-10 and WPATH SOC 7 fit best with their pre-existing ideas, and using those elements to justify existing practice. It’s about conservativism over progression: a wasted opportunity.