A couple of days ago I joined Katy Montgomerie’s livestream to work through the current NHS England consultation on child and adolescent gender services. We discussed the background to the consultation, what the questions mean, and what some of the major issues are.
You can take part in the consultation here. It is open until 4th December 2022. Filling it in is a bit of an intense experience, but if you fancy some friendly company and catty cameos, I hope our video will help.
LGB rights charity Stonewall has a difficult history of engagement with trans issues. For 25 years the charity has been a powerful voice in the struggle for LGB equality, but ‘trans’ is not included in its remit within England and Wales. Stonewall has been criticised on one hand for this omission at a time when a majority of ‘LGB’ organisations have become ‘LGBT’, and accused on the other of undue interference in trans matters.
After years of misunderstandings and disagreement, Stonewall announced in June that it would be addressing these problems:
“At Stonewall we’re determined to do more to support trans communities (including those who identify as LGB) to help eradicate prejudice and achieve equality. There are lots of different views about the role Stonewall should play in achieving that. We’re holding roundtable meetings and having lots of conversations. Throughout this process we will be guided by trans people.”
I have been invited to a closed meeting that will take place as part of this process at the end of August.
I really welcome the proposal from Stonewall. In this post I’m going to explore why this dialogue is important, outline some of the proposed approaches to working with Stonewall (or not), and outline my priorities in discussing this issue with both Stonewall and other trans activists.
I also encourage readers to leave their own thoughts and feedback in the comments.
The current situation for trans people in England and Wales
I don’t feel it is an exaggeration to describe the current social and political climate as an emergency. Whilst it is true that trans people in the UK currently benefit from unprecedented civil rights, and there is talk of a “transgender tipping point” in terms of public discourse in the English-speaking world, many trans people still face very serious challenges in everyday life.
For instance, trans people are still likely to face discrimination, harassment and abuse in accessing medical services, as demonstrated in horrific detail by #transdocfail. Trans people are particularly likely to suffer from mental health problems, and this is often made worse by members of the medical profession.
For many years now there has been an exponential rise in the number of trans people accessing transition-related services; with cuts and freezes to healthcare spending from 2010, this has meant that many individuals now have to wait years for an initial appointment at at gender clinic. This problem has been compounded for trans women seeking genital surgery by the additional backlogs accompanying the recent resignation of surgeon James Bellringer.
Meanwhile, the impact of the Coalition government’s austerity agenda is being felt particularly keenly by less privileged trans people. With many continuing to face aforementioned mental health problem and discrimination from employers, benefit cuts and the increasing precariousness of employment and public demonisation of the unemployed are hitting hard amongst my contacts (some discussion of this in a wider LGBT context can be found here). Cuts to public services are also felt strongly by groups such as the disproportionate number of trans people who face domestic abuse.
Then there’s what we don’t know. For instance, research in the United States shows that young trans people are particularly likely to be homeless, and that trans women are considerably more liable to contract HIV than the general population. Both anecdotal evidence and extrapolation from international statistics and small local studies pointing to similar problems existing in the UK, but this is not enough evidence to properly address these serious issues.
Activism
I believe that trans people need a campaigning organisation that is up to the task of tackling the above problems. A campaigning organisation with the funding, resources and knowledge to lobby government, conduct research and push for social change.
Currently we rely on the energies of unpaid activists and ad-hoc organisations that are lucky to attract any kind of funding. The importance and achievements of organisations such as Press For Change and Trans Media Watch should not be underestimated, but this is not enough. Whilst Stonewall attracts millions of pounds in funding and wields an impressive range of resources, trans groups staffed largely by enthusiastic volunteers are lucky to land a few hundred pounds in donations, or a temporary project grant. You can probably count the number of trans activists employed to push for change in this country on your fingers.
Under such circumstances, stress and burnout are common amongst trans activists, even expected. Personality clashes are capable of sinking an organisation. The individuals most able to work long hours for free are typically the most privileged, meaning that there is poor representation in terms of race, disability and class.
We have to do better. We need to do better.
Solution 1: a new trans organisation
There will be those who wish to pursue the creation of a new trans organisation entirely separate from Stonewall. From this perspective, a dialogue with Stonewall offers the opportunity to discuss instances where the charity might have overstepped the mark in speaking out in relation to trans issues without this being within their remit. Beyond that, there will probably be a desire to ‘go it alone’.
For some, this will be because of Stonewall’s non-democratic structure (it is not intended to be a membership organisation), corporate links, and past disappointments such as the organisation’s initial refusal to campaign for same-sex marriage.
For others, this will be because of the view that the ‘T’ should remain independent of ‘LGB’. This position can be based upon the argument that the interests and needs of trans people differ to those of lesbian, gay and bisexual people, and/or a recognition that the trans liberation project is significantly less advanced than the LGB equivalent. From this also comes the idea that cis gay activists might not be able to properly campaign on trans issues.
There have been numerous attempts to create such an organisation over the last decade (one of which I was involved in, through Gender Spectrum UK) but none have been successful. I propose that one of the most serious barriers here is that of funding: there is so much work to be done and so many problems that individual activists are likely to face in their personal lives, that it has been extremely difficult for unpaid activists to put in the work necessary to launch such a body.
Solution 2: adding the ‘T’ to Stonewall
It has long been suggested that Stonewall should follow other LGBT organisations in becoming trans-inclusive. The arguments frequently centre upon an appeal to history, and the similarities of LGBT experiences.
The Pride movement emerged out of alliances forged between sexual minorities and gender variant people; this happened in part because homophobic and transphobic attitudes tend to stem from the same bigotry. Trans people have always been present in the struggle for gay and bisexual rights. Pretty much all LGBT people can talk about ‘coming out’, usually to family as well as friends, peers and/or colleagues. LGBT people often have to tackle internalised shame at some point in their lives, an inevitable outcome of growing up in a homophobic/transphobic world.
Moreover, with a great deal of organisations turning to Stonewall for LGBT equality advice and training, it has been argued that it only makes sense to explicitly incorporate trans issues, lest trans people get left behind. For instance, Stonewall does a lot of work on homophobic bullying in schools – surely it would make sense to also address transphobic bullying, particularly as the two tend to have a similar root cause?
Solution 3: a hybrid organisation
An idea I’ve heard bounced around a little ahead of August’s meeting is a kind of compromise between the two above positions. A trans charity that is linked to Stonewall in terms of sharing resources, information and funding, but remains semi-autonomous with its own leadership and trustees.
This is currently my favoured option. I feel that trans people would benefit greatly from effectively sharing some of Stonewall’s power. We’d certainly benefit from working more consistently together, instead of occasionally against one another. But we have different needs, different priorities. We might want to run our own organisation in a different way, and make somewhat different political decisions.
My priorities in the dialogue with Stonewall
1) Representation
I was actually a little bit uncomfortable to be invited to the meeting in August. Sure, I’ve been involved in plenty of both high-profile, national campaigns, as well bits of activism in my local area and place of work. Plus, a lot of people read this blog. But ultimately, I received an invitation because I have the right connections. So many didn’t get that chance. I also strongly suspect that the majority of people present at the meeting will be white and middle-class, and that there will not be many genderqueer people present (I’m less sure about disability, because there are a lot of disabled trans people).
I’m hoping that any future meetings will be more open. If it turns out that my suspicions are correct regarding the overrepresentation of privileged groups, I hope that we can take steps to ensure that any future meetings are more representative. It’s the only way we’re going to find a way to create consensus and work on the behalf of all trans people in the long term.
If you’re not going to be at the meeting, I strongly encourage you to respond to Stonewall’s survey so your voice is heard. Also, since I’ll be there in person, I’d really like to know what you think.
2) The creation of a new trans organisation
I’ve pretty much made the argument for this already. We need national representation that can genuinely address the many problems faced by trans people today. A democratically accountable body that reflects diversity of trans lives and experiences.
I hope this is something we can work towards by working with Stonewall. Yes, there will be political differences – certainly I have ideological objections to some of the approaches taken by Stonewall – but I feel the situation is too severe and the opportunity too important to reject an offer of help.
That isn’t to say that a new organisation should overrule the work of existing organisations. I would hope that any new body works alongside existing campaign groups such as Trans Media Watch, Gendered Intelligence and Action For Trans Health without seeking to duplicate their work.
3) Starting with the essentials
I believe that the initial basis for any new trans organisation – or trans campaigns within Stonewall – should be addressing the absolute, basic needs that are not currently being met for many trans people. Housing. Health. Employment. We should be looking out for the most vulnerable, as well as addressing universal needs. This is pretty much a moral duty.
What do you think? Please share your thoughts and ideas in the comments!
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.
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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:
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.
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
Language – The 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:
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.
Following hot on the heels of the new Scottish protocol for transition-related services, the Department of Health has published a draft guide for England.
They’re not holding a formal consultation on the document (meaning that it’s not available on the Department of Health website), but are “seeking the views of stakeholders […] to find out if the ‘journey’ outlined in the document reflects the experience transgender people actually have and, where there are differences, what they are.”
This is a really important opportunity for you to offer feedback on the proposed guide to English services.
A copy of the document is available below:
Gender Dysphoria Services – An English Protocol
When you’ve read the document, you can share your views through the following link:
I’m planning to post my own analysis of the draft protocol when I’ve had time to read through it properly.
Dr Ruth Pearce 