Trans joy in hateful times

“We’re living in the future!”

I bounced up to an old friend to share this important insight. All around, queer bodies danced and swayed to furiously enthusiastic music. We have always sought refuge in one another, in our in our art, in utopic dancefloors and community care. But something felt different.

The collective energy of the crowd was wild, strong, cohesive. The entire room was dancing – and among us, so so many out, happy trans women and transfeminine people. On stage, a non-binary person sang explicitly about their experiences of gender to an assertive ska beat. It was a joyful moment – but the true wonder of it for me was that it was far from unique.

This was the last in a string of winter tour dates for my band wormboys, at the brilliant Queer As Punk event in Edinburgh. But I’d experienced similar in Dundee, in Glasgow, in Newcastle, in Hull, in Leeds. At every gig, trans women and non-binary people were scattered throughout the audience; at most, there were also several of us on stage through the night. It’s a world of difference from when I encountered just the occasional trans man playing gigs in the mid-2010s; let alone from when wrote a blog post titled Trans/queer rock music back in 2010, in which I desperately sought validation in questionable gender-bending tunes written by (largely) cis musicians.

While trans women (and trans people more broadly) have always been involved in DIY music, there’s a clear change taking place. We have taken our inheritance and run with it. There are more of us making our own art, telling our own stories, and celebrating one another more than ever before. We are more visible, we are more assertive, we are more respected within our scenes, and – collectively – we are having more fun.

Photo of three people from a band, rocking out in front of an audience in a darkened room
wormboys play Queer As Punk. Photo by Blanka Bandi.

The very night we enacted a better future on that dancefloor in Edinburgh, 16 year-old trans girl Brianna Ghey was stabbed to death in Warrington. Two other teenagers, a girl and a boy, have been charged with her murder.

For trans people across the UK – especially trans women and girls – this lethal attack was not unexpected. It feels like the culmination of a vicious hate campaign that permeates our media and politics. It’s also the tip of a vast iceberg of intentional violence and untimely death.

Suicide is endemic among trans youth driven to despair by the socially-sanctioned antagonism directed at them every hour of every day. I am tired of citing statistics. I have lost so many of my friends and peers. Words and numbers are insufficient for the raw anguish of my grief.

This is only compounded by the failures of bystanders who refuse to intervene, schools and employers who try to make us disappear, a National Health Service that inflicts harm upon us. England’s only child and adolescent gender clinic is due to close in a matter of weeks, with nothing ready to replace it. In an extraordinary open letter, the majority of clinical, research, and administrative staff at the clinic note an “increase in deaths related to the service” since the suspension of endocrine treatments in 2020.

Many of my friends have been threated or assaulted in broad daylight. One, for instance, had rocks thrown at her. Another was assaulted in front of the school gates. Another was raped by boys in the school playground. I frequently struggle with feelings of survivor’s guilt, having merely been publicly assaulted, stalked, harassed, and subject to threats of legal action and murder. Relatively minor matters, in the scheme of things.

Photograph of a large crowd in a narrow street in London, with occasional placards and a trans flag.
Vigil for Brianna Ghey outside the Department of Education, London. Photo by David Griffiths.

How to understand joy in the face of so much hate and despair?

This is a question I struggled with throughout our tour. The night before Brianna’s murder, 400 people rioted in Knowsley outside a hotel that houses asylum seekers, spurred on by the fascist group Patriotic Alternative. This horrific event, too, did not occur in a vacuum. Racist and anti-migrant sentiment has similarly been stirred up by cynical politicians and journalists, as asylum seekers, economic migrants, British Black and Asian people, Gypsies and Travellers are repeatedly failed or directly targeted by our authorities and institutions. Patriotic Alternative have also repeatedly targeted LGBTIQ+ communities, through their campaign against Drag Queen Story Hour.

The Sunday prior, a large rally was held in Glasgow by anti-trans group “Let Women Speak”, who have a long history of collaboration with white supremacists and antisemites. This event, supposedly organised in support of “women’s rights”, featured numerous flags in the suffragette colours of green, white, and purple, alongside massive black banners emblazoned with the slogan: “Woman (noun): Adult Human Female”. It was attended by Holocaust deniers, anti-migrant, and anti-abortion campaigners, and was described by supporters as an “undisputed Aryan victory”.

I could say so much more: about assaults on disabled people’s rights and livelihoods, about the demonisation of the poor, about attacks on pay, pensions, and the unions that attempt to defend them (I am writing this post while on strike). About how fascist violence is excused by sexist men in the name of “defending women and girls”. About how oppressed groups are played off against one another, while the effects of all this hateful discourse and action are felt most keenly at the intersection of multiple forms of persecution, such as by migrant trans women of colour.

Ultimately though, my point is this: what we are seeing is both a consequence of historic prejudices in our society, and of rising fascism.

Minority groups, women, migrants, and working class people in the UK have always faced a shared struggle against systemic discrimination and violence. Following a period of mild reform in the 1990s and 2000s, we are now experiencing a significant upswing in bold, blatant hate speech and violence,  effectively condoned by every major political party and the majority of mainstream media publications.

This is the context of trans joy in the 2020s – and the reason why that joy is so necessary and vital.

Our tour reminded me that art is resistance, and resistance is collective. In recent days I have felt myself marinading in my own fear, a recipe for passive inaction. If we cannot experience joy, we cannot dream; if we cannot dream, we cannot hope; if we cannot hope, we cannot fight back. In the face of a world that wants so many of us dead, it is vital that we create reasons to live, and to thrive.

In Leeds, wormboys played to a rammed room in Wharf Chambers, a triumphant hometown crowd. We invited the brilliant Punjabi-Celtic-indie fusion trio Kinaara and gorgeous queer folk duo Serin to support us, building new friendships and cementing old ones. In Hull we debuted at the New Adelphi, where now-legendary acts such as Lizzo, Manic Street Preachers, Pulp, Skunk Anansie, and PJ Harvey played before they were famous. We shared the stage with Sandbox Mode – a solo hip-hop artist making deeply honest and funny songs about mundanity and despair – and Baby Flowers, an exciting young grunge group playing their second ever gig. This was the least well-attended, most male-dominated, and least obviously queer gig on our tour. And yet: the mood was vibrant, I noted at least one other trans woman in the audience, and Baby Flowers’ bassist was showing off a well-placed trans rights sticker.

In Newcastle, we found ourselves in the Little Buildings, a venue which has miraculously survived Covid-19 despite being founded just the pandemic began. The event was hosted by new dance party Queer Love. We played alongside the incredible hardcore group Disciplinary with their two bass guitars, and also the feminist dance-punk phenomenon of Fashion Tips. The whole night was amazing, but Fashion Tips were particularly exciting for me. Frontwoman (and Queer Love organiser) Esmé Louise Newman has a long history of involvement in groundbreaking queer feminist punk, metal and no-wave groups, including Penance Stare and Etai Keshiki. The new band were just as brilliant, with aggressive guitars and vocals underpinned by a powerful rhythm section, heralding a new era of revolutionary dancefloor divination.

Next to Glasgow, where I organised a well-attended gig at The 13th Note in less than a week, after our original promoter pulled out at the last minute. We booked the astoundingly powerful riot grrrl group Brat Coven to play with us, along with HAVR, purveyors of gorgeous post-punk soundscapes. The latter band are fronted by Carrie Marshall, author of Carrie Kills A Man, who noted to cheers that she was a different gender the last time she played the venue. This was an event with plenty of trans women present, beaten only by brilliant gig in the same venue the very next night, which I went to see my soulful dyke folk pal Pictureskew play inbetween our own shows. That event might well be the first of its kind I’ve been to where there were at least as many trans women in attendance as anyone else. It was beautiful.

Then to Dundee, where Rad Apples and Make That A Take put anarchist theory into practice by actively working to provide a safer punk venue and events for women, queer people, and migrants, through simultaneously building a welcoming space and promoting a zero-tolerance attitude towards discrimination and abuse. There I had two totally new life experiences. First, I witnessed somebody crowdsurfing in a shopping trolley during a storming set from banjo punks Alldeepends. Then, we were subject to the well-organised chaos of the “crowd surfing machine” by jubilant anarcho-folk headliners Boom Boom Racoon (a variant on the sat-on-the-floor rowing boat dance associated with songs such as “Oops Upside Your Head” and “Rock The Boat”, but with audience members encouraged to take turns in crowdsurfing along the boat).

Through the tour, I’d been carrying a trans flag to drape over my bass amp, and have often said something about trans liberation from stage inbetween songs. wormboys are a political band, but not in the same way as more in-your-face punk groups I’ve previously fronted. I’ve reveled in the ability to just be a musician and make that – rather than my status as a trans woman – the focal point of my involvement, leaving most of the talking to dual vocalists duo Sop and Harry. In the current political environment, that has increasingly felt untenable. It seems important to speak out, make myself visible, be obviously a trans woman making music.

But at Rad Apples I didn’t need to. There was already a trans flag up. There were plenty of other trans people there. There were placards in the bar opposing Section 35. I could just be.

And so to Edinburgh, where I found myself living in the future during a joyous set from opening act Bufandas. A future in which we experience the true paradox of trans visibility, in that we are both uniquely vulnerable, and uniquely strong. No longer hiding in the shadows, we are easier targets for those who hate us, but also have so much more potential to build power together.

Brianna Ghey’s killers may be convicted and jailed, but that will do nothing to stop the violence we face across these islands, and across the wider world. We have learned that we cannot trust the police to save us, or the courts, or politicians, or journalists, or managers, or human resources departments. But we don’t need any of these people or organisations. We owe it to Brianna to continue the grassroots work she did to improve other people’s lives, because another world is possible.

The headliners at Queer as Punk in Edinburgh were the fiercely feminist disco punk group The Red Stains. Their set included several explicit statements of support for trans people and especially trans women and girls, reflecting the attitude of most women active within actual feminist movements. This was an important reminder that anti-trans movements do not speak for all women, and never will.

My experience of sharing a stage with so many amazing musicians, from so many backgrounds, featured many such reminders. I was reminded of the sheer depth and range of human creativity. I was reminded of how much we can be inspired by our differences as well as shared experience. I was reminded of how far we have come, as well as how far we have to go. 

There are so many of us. Today, we mourn. Tomorrow, we fight. Soon, we will win.

Let’s respond to the NHS consultation together!

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.

NHS England proposals put young people in danger

NHS England logo

Three weeks ago, I wrote to the NHS England Gender Programme Board (of which I am a former “patient public voice” member) to raise urgent concerns about their consultation on a new interim service specification for children and adolescents.

The proposed service specification is deeply transphobic on numerous levels – from the dearth of relevant treatment pathways, to the assertion that being trans is likely a “phase”.

It is also probable that if implemented, this service specification will impact other young people more widely – especially girls and LGBTIQ+ youth – by undermining principles of autonomy and respect.

You can read more about the service specification here.

The proposals have been condemned by UK and international experts including Dr Natacha Kennedy, Cal Horton, and the Australian Professional Association for Transgender Health. Their well-evidenced critiques are well worth a read, especially if you might consider participating in the consultation. Edit 26/11: the proposals have now also been condemned in a strongly-worded and well-evidenced statement from world professional bodies WPATH, ASIAPATH, EPATH, PATHA, and USPATH.

The consultation is open to anyone. If you have the time and energy, there is a guide to participating in the consultation here, prepared jointly by Gendered Intelligence, Stonewall, Mermaids, and the Trans Learning Partnership. If you are a community member, a healthcare practitioner, a researcher, or work with a relevant charity, it would be particularly useful for NHS England to hear from you.

Other things you could do to oppose the proposals include: organising a demonstration, raising awareness of this issue on social media, and/or writing to your MP or trade union and asking them to place pressure on NHS England to reconsider.

To date, I have not received a reply from NHS England. Given the danger the proposed service specification poses to the safety of young people, I have now decided to make my letter to them public.

~

Dear all,

I am emailing to share my great alarm at the proposed service specifications for child and adolescent gender dysphoria services. It is my expert opinion that, if implemented, these proposals will cause great harm to young people. Moreover, in opening such poorly designed and unevidenced specifications to consultation and media commentary, NHS England has already caused harm.

The fact that this consultation is happening at all represents an enormous failure on the part of every professional involved.

I stepped down from the Gender Programme Board earlier this month due to clashes with my teaching schedule. However, given the severity of this situation, I would be remiss in my ethical duties if I did not also email you directly to share my concerns.

My three main areas of concern are:

  1. Social transition should not be subject to medical oversight. This would represent a gross abuse of power on the part of commissioners and practitioners. Choosing to wear different clothes, and possibly use a different name and/or pronouns – is a personal, non-medical decision related to a person exploring their identity and/or coming out. Preventing a young person from choosing a social transition amounts to an attempted conversion practice.

  2. Punishing young people and their families by subjecting them to investigation if they access private services will not help them access healthcare. Young trans people who access private healthcare in the UK or abroad generally due so due to the severity of NHS failures.  It will increase the likelihood of young people hiding the fact they are accessing external treatment from NHS clinicians, and of people turning to black-market hormone providers rather than private doctors. I am not sure that members of the Gender Programme Board are fully aware of how prevalent and dangerous the home-made substances already in circulation can be.

  3. Requiring that young people become research subjects as a condition of accessing treatment is completely unethical. This is a well-established principle in the trans health literature. There is no way in which you can truly obtain informed consent for research participation from individuals who will be denied healthcare if they refuse to participate. I fully support the expansion of NHS-funded research into trans healthcare, but participants must not be recruited through coercion.

I will end by inviting all recipients of this email to reflect on what they do not experience, and what they do not know.

Most members of the Gender Programme Board have not experienced gender incongruence or gender dysphoria.

Most members of the Gender Programme Board are not members of a trans community. It is likely therefore that you – even if you are a clinician – have never found yourself in a position where you are confronted with the true impact of NHS failings on young trans people who rely on community support. You do not know what it is like to be trying to look after many extremely damaged members of your community dealing with complex trauma and self-harm from people who have been repeatedly abused by NHS clinicians and processes. We, in the community, are the ones left picking up the pieces of your failings, finding ourselves on constant suicide watch and scrabbling to keep people alive. Invitations onto bodies such as the Gender Programme Board, where we are expected to be polite while fighting for scraps – only to be ignored – do not right these overwhelming wrongs.

It is now on you to rebuild trust.

Sincerely,

Ruth

Understanding Trans Health on Philosophy Tube

My book Understanding Trans Health is cited prominently in the new Philosophy Tube video on complaint, systematic inflexibility, and England’s NHS trans health crisis.

It’s a great video, which manages to capture the sheer horror of NHS failings while still delivering silly jokes, ridiculous costumes, and a strong analysis. In addition to drawing on my work, Philosophy Tube’s Abigail Thorne consulted me on the script for this episode, and I appreciated the opportunity to use my research in this way.

I am personally more optimistic than Abigail about the opportunities offered by the four NHS England ‘pilot’ clinics. These are beginning to slash waiting times, and several are now effectively run by trans people, for trans people. However, I do think it’s important to still critique the very logic that underpins many trans healthcare systems, especially the highly questionable ways in which the medical diagnosis of ‘gender dysphoria’ is constructed, and used to try and control us.

You can buy Understanding Trans Health directly from Policy Press here. It’s also available from all major booksellers, plus many independent queer book stores (e.g. Leeds’ brilliant The Bookish Type). I have also written to my publisher for permission to put a chapter of the book online for free – watch this space! In the meantime, free links to much of my other academic writing can be found here.

Resources for trans pregnancy a cause for optimism

Cover of the Trans and Non-Binary Experiences of Maternity Services report. Cover art depicts two Black transmasculine people - one standing and smiling with a visibly pregnant belly, and the other is kneeling next to them and has their face pressed against the belly, with their eyes closed and a peaceful expression on their face. The title text and clothing for the people on the cover uses the colours of the non-binary flag - yellow, black, white, and purple.

There have been some really exciting developments in England over the last couple of months for trans birth parents (that is: men and non-binary people who conceive, carry, and give birth to their own children).

In April, a groundbreaking report on Trans and Non-Binary Experiences of Maternity Services was published by the LGBT Foundation. I am really proud to have co-authored parts of this report with colleagues in NHS England and the LGBT Foundation, and to have supported the research which informs it.

The report, which was funded by NHS England, offers a sobering account of healthcare inequalities for trans birth parents. However, it also includes important examples of good practice and recommendations for professionals.

  • Trans people’s experiences of perinatal care are consistently worse across the board compared with cis women.
  • 30% of trans birth parents didn’t access perinatal healthcare at all during pregnancy – this compares to less than 2.1% of the general population.
  • Transphobia and racism in perinatal care intersect to produce particularly poor outcomes for trans parents of colour.
  • Recommendations include: supporting the delivery of personalised and trauma-informed perinatal care; proactively adopting inclusive language and targeting outreach to trans birth parents; and implementing IT and demographic monitoring systems to enable the sensitive collection of data about gender identity and trans status in perinatal services.

Excitingly, it appears that work is already underway on many of these points. For example, last year a fabulous series of resources for practitioners were published by Brighton and Sussex Gender Inclusion Midwives, and I have heard good things about progress on trans-inclusive data collection.

Best of all, NHS England now provide a range of tailored, accessible advice to trans parents as part of their new guide to having a baby if you’re LGBT+. This includes ways to become a parent, advice on testosterone and pregnancy, and chestfeeding/breastfeeding for men and transmasculine non-binary people.

These resources should really be seen as a starting point (for example, there is no advice for trans women who breastfeed). But equally, it is brilliant to see progress being made on the provision of practical advice that will help prospective and new parents. I am especially grateful to an NHS whistleblower who ensured their dissemination through revealing to The i that their publication had been blocked by some senior figures at NHS England for nearly a year.

This all serves as an important reminder that NHS England is not a monolith, and that concerted pressure from community groups and allies can have real long-term benefits.

It’s very easy to be cynical about our NHS given the poor overall state of trans healthcare, as well as opposition to equitable provision by some within the health service. However, all the positive moves I have reported in this post are also the result of hard work by numerous NHS midwives and members of the NHS digital team. Alongside community members who generously offered their time and knowledge, they have collectively fought to ensure that trans birth parents and the practitioners who work with them have access to resources and information.

All of this makes me feel hugely optimistic. These are difficult times, in which prejudice and disinformation are rife. Yet ordinary people are still fighting – successfully! – for positive change. This new research and guidance should be of great help to new parents and their children, and for that we can be grateful.

Trans inequalities in English perinatal care

About a month ago I participated in the TPATH conference. This groundbreaking online event centred trans healthcare practice, research, and activism by and for trans people.

I was very impressed with the measures taken by TPATH organisers to ensure the conference was accessible to as many people as possible from around the world. They organised live translation to and from English, French, and Spanish, provided live captioning, encouraged presenters to speak slowly and clearly to enable lipreading, and ensured that generous scholarships were available for those who would not otherwise afford to attend. Most of the event was recorded, and videos are gradually being uploaded to the TPATH Youtube channel.

At the conference I joined Tash Oakes-Monger from NHS England to present initial findings from the ITEMS project (Improving Trans Experiences of Maternity Services). The ITEMS team, led by Michael Petch from the LGBT Foundation, ran a survey in early 2021 to explore the experiences of trans people (including non-binary people) who give birth in England. I supported the design and dissemination of the survey through my former role with the Trans Learning Partnership.

Bar chart indicating that increasing numbers of trans and non-binary people are giving birth in England every year.
Bar chart indicating growth in number of trans people giving birth in England each year.


There is some really exciting information emerging from the ITEMS data. For example, it appears that more trans people are giving birth than ever before (see above). However, it was also apparent that trans people face substantial inequalities.

Many of the questions in the ITEMS survey used comparable wording to the CQC Maternity Survey – from this we can see that trans people appear more likely to have negative experiences in NHS maternity services than cis women across the board. Even more disturbing is that 30% of trans respondents gave birth without the support of an NHS or private midwife (rising to 46% among trans people of colour). This indicates a lack of trust in midwifery services among prospective trans birth parents, with potentially lethal consequences for both parent and baby.

To learn more, you can watch our presentation on the TPATH Youtube channel.

A formal report of ITEMS findings should be published in the coming months.

NHS Gender Identity Services consultation: it’s really important, and you can take part

 

For the past few months, NHS England have been running a consultation on Gender Identity Services for Adults (i.e. services typically provided through a Gender Identity Clinic, or GIC).

There’s still just over a week to respond: the consultation is open until Monday 16th October, and you can respond here.

Unfortunately, NHS England have not made the consultation process particularly clear. The documents are quite long and the whole thing can appear unnecessarily complex. So in this blog post, I explain what the consultation is about, why it matters, and how you can participate. I also outline some key issues within the consultation.

 

What is this all about?

NHS England have prepared two draft service specification documents: one for surgical services (including genital and chest surgeries), and one for non-surgical services (basically everything else, including assessment and diagnosis, hormones, counselling, voice therapy etc.

These draft documents are currently under consultation, with stakeholders (i.e. trans people, medical professionals and other interested parties) invited to comment on them.

 

Who is affected?

Basically everyone who is accessing (or intends to access) a GIC or surgery through the NHS in England, and every medical professional and NHS worker involved in delivering these services. This includes all patients based at England GICs. It will also indirectly affect patients in Wales who access treatment through Charing Cross, and patients across the whole of the UK who access surgical services in England. In time, Wales should get its own GIC, but this isn’t due to happen yet for some time.

 

What will this consultation do?

Following the consultation, the service specification documents will be used to commission services. That means: a GIC will need to meet the requirements of the service specification in order for NHS England to commission them.

If the GIC does not meet the requirements of the service specification, they may lose their right to provide services through the NHS.

So, in the future the service specification documents can (in theory) be used to hold GICs to account. If certain inappropriate or discriminatory practices at a GIC are seen to contravene the service specification, then they might effectively have their funding pulled.

There are a lot of clauses in the new service specification documents that would effectively ban a range of potentially harmful practices that currently exist in some GICs. For example, some GICs require that patients undergo unnecessary genital examinations prior to hormone therapy, while others insist that family members attend assessment meetings in order to corroborate patients’ accounts of gender dysphoria. Both of these practices are explicitly prohibited in the draft guidelines.

At the same time, there are some really questionable elements that remain in the service specification, such as the requirement for GIC patients to be registered with a GP. This can discriminate against people of no fixed abode, such as asylum seekers, homeless people, Travellers and many sex workers.

In responding to the consultation, you get a say on what the new guidelines should look like – the bits you think are good, and the bits you think need re-thinking.

 

What will this consultation not do?

An issue I have with this consultation is that it doesn’t address the fundamental power imbalance that currently exists between GIC gatekeepers and trans patients.

The consultation also doesn’t directly address the commissioning of new services; instead, it focuses on existing services. So, interventions that aren’t already currently funded as standard by NHS England (such as breast augmentation and facial feminisation surgeries) are not included.

These are things you may wish to comment on in your response (I have done so). However, you should bear in mind that this consultation is primarily about improving existing practice, rather than undertaking fundamental reform. So, by responding you should definitely be able to help improve people’s lives in the short term, but we also need to continue being proactive with trans health activism in order to bring about bigger changes in the long term.


But wait, haven’t we been here before?

Yes. NHS England previously consulted on draft commissioning documents in 2013 and 2015. On both occasions, a considerable number of trans stakeholders indicated that the documents weren’t fit for purpose: they were too strict, too binary, and pathologised trans people too much. Each time, NHS England went back to the drawing board.

I studied these documents for my PhD. One of the really interesting things about them, is that each time they’re revised and come back to consultation, they’re more progressive, reflecting interventions from trans health advocates. For example, non-binary and genderqueer identities and experiences were barely mentioned in the 2013 document. There was some level of inclusion in 2015, and then the current non-surgical specification makes a real effort to avoid binary language altogether.

From the lessons I’ve learned in my work, I also think that this time around, the service specification will be implemented. This is a bigger and more wide-ranging consultation from before, and at events NHS England representatives have given a strong indication that they’re very keen to re-commission services during 2017-18. So, this is our major chance to bring about change in some areas.

 

Okay, so how do I take part?

There are three documents to read. There are the two service specification documents:

Surgical specification.

Non-surgical specification.

There is also a third document: the consultation guide. This one’s a bit of a mess.

The consultation guide provides information on the background to the consultation (pages 5-8), and includes some questions for respondents to consider (pages 9-12).

Four options are outlines for how hormone prescriptions might be managed in the future (pages 13-20).

Finally, there’s an equality impact assessment, which summarises the impact (both positive and negative) that NHS England thinks the document will have upon particular marginalised groups, including older and younger trans people, disabled trans people, trans people of different genders and sexualities, married trans people, trans people of colour, and trans people of faith (pages 21-32).

Once you’ve read the documents, you can email your thoughts about what you think is good and what needs changing to NHS England: england.scengagement@nhs.net.

You can also take part in an online survey: https://www.engage.england.nhs.uk/survey/gender-identity-services-for-adults/consultation/.

The survey refers to the three main consultation documents at various points, so have these handy when you take it.

Altogether, reading the documents and responding to the survey took me about four hours. If that feels like a really long time, bear in mind that you don’t have to respond to everything in the documents in order to take part in the consultation. You can choose to respond just to particular key issues (see below for two examples), or do it a bit at a time.

In particular, it’s worth bearing in mind that the online survey allows you to save your response and come back to it later.


Key issues

Since this is such a big consultation, there’s a lot to talk about. I’m trying to keep this post relatively concise, so I can’t cover it all (although I do link to some further reading at the end if you want look into this further).

So, here’s a couple of things that I feel are particularly worth focusing on.

  1. Prescribing arrangementsUnder the current system, patients are referred by their GP to a GIC. At the GIC they are assessed for gender dysphoria. Upon receiving a diagnosis, the GIC instructs the patient’s GP to prescribe hormones, if this is something the patient wants.The consultation proposes that this approach potentially be changed. It offers four options for different systems, which are outlined in the consultation guide, on pages 13-20. Option A is the status quo, as described above.

    Options B and C offer variations on this: in Option B, the GIC provides the first prescription and then the GP provides prescriptions thereafter. This would mean that patients can pick up their first prescription pretty much immediately. Option C requires prescriptions to be provided by the GIC for the first year. This would mean that patients would approach the GIC for a repeat prescription during this time.

    Option D proposes a major change: the appointment of a local specialist by each Clinical Commissioning Group, which means (in theory) there is a GP specialising in trans hormones in each local area. It is not entirely clear whether or not these GPs would continue to rely on GICs for assessments, nor if other GPs will be able to prescribe hormones still as they do at present.

    Option D is the most interesting option here in part because it offers the most radical change. There are some serious potential benefits and drawbacks. For example, this approach might lead to a decentralisation of care, whereby patients might access hormones (and potentially other services) from a specialist GP working in collaboration with an endocrinologist. On the other hand, it might lead to less GPs providing basic services as they do at present, which might be a problem particularly in rural areas.

    Ultimately, none of these options are perfect. Personally, I feel some combination of A and D could be beneficial: but I recommend reading through the options yourself and having a think.

  2. Referral to GICs
    At present, English patients are generally referred to GICs by their GP, although they can also be referred by a local mental health provider. This contrasts with Wales, where at present patients are referred first to a local mental health provider who then refers on to the GIC, and Scotland, where some providers accept self-referral.The draft service specification for non-surgical services currently insists that all patients be registered with a GP, who provides the referral to a GIC. The rationale for this is that – under the existing system – patients require a co-operative GP in order to provide hormone prescriptions.However, not all NHS patients are registered with a GP. This is acknowledged in the equality impact assessment included in the consultation guide, which states that people of no fixed abode might not have access to gender identity services as a result. Moreover, trans patients sometimes have to search for a long time for a GP who will provide them with a referral.

    I propose that NHS England follow the existing NHS Scotland guidelines in allowing for self-referral. This means that patients have the opportunity to find a supportive GP while they are on a waiting list and/or undergoing assessment. Moreover, it would be beneficial if some arrangement can be made to support patients who are still without a GP following diagnosis (perhaps some variant on Option C for hormone prescriptions).

 

Further reading

The above two issues are by no means the only pressing matters in the consultation: just two that I feel are particularly important. You may feel otherwise!

For more information, thoughts, reflections and ideas for responding to the consultation, here is a range of further reading.

My response to the consultation (Twitter thread)

My summary of a consultation event in Leeds (Twitter thread)

Response from UK Trans Info

Response from the National LGB&T Partnership

Thoughts from Michael Toze (general)

Response from Michael Toze (hysterectomies)

Response from Edinburgh Action for Trans Health (Trans Health Manifesto)

 

WPATH 2016 poster: “A time of anticipation”

Here’s the poster I presented at this year’s WPATH Symposium:

Anticipation poster.png

You can also download a PDF version here.

The magnet is a metaphor for anticipation, which is both a product of and shapes feelings, emotions and experiences of time. This process is mediated by both trans community discourses and medical systems.

It’s very important to note that the majority of research participants had good things to say about the health professionals who helped with their transition. However, there is also a high prevelance of transphobia and cisgenderism within medical systems and clinical pathways. Anxiety and mistrust of practitioners within the trans patient population is endemic, and this is compounded by long waiting times.

My wider research looks critically at how discourses of trans health are differently understood within and between community/support spaces, activist groups and the professional sphere; however, the purpose of this particular poster was communicate some of the difficult experiences that current patients have with waiting. It sparked some productive conversations and I hope that further work will follow from this.

Sources:

Transitional Demands (Jess Bradley and Francis Myerscough)

Experiences of people from , and working with, transgender communities within the NHS – summary of findings, 2013/14 (NHS England)

Current Waiting Times & Patient Population for Gender Identity Services in the UK (UK Trans Info)