trans

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Imagining a trans-inclusive Stonewall

“The meeting actually went pretty well, didn’t it?”

I heard a number of variations upon this statement echo around the pub we gathered in yesterday evening, as some 40-odd trans activists digested the day’s work. There was an undertone of incredulity: most of us had managed our expectations carefully in advance of the day. This was due in part to the fractious nature of trans communities, but also stemmed from our difficult history with Stonewall.

Back in 2008, many of us had been present at a loud, colourful demonstration outside the Victoria and Albert Museum as it hosted the annual Stonewall awards. We were there to express our displeasure at an organisation that didn’t simply exclude trans people, but seemed to keep making mistakes that caused harm to us.

A lot can happen in six years. Change has come from two directions: from continued external pressure from trans people, but also from a genuine willingness to reconsider matters from Stonewall following a shift in management in February.

In this post, I outline the themes and outcomes of a meeting held on Saturday to discuss potential options for trans inclusion in Stonewall. I will repeat some of the points made by CN Lester and Zoe O’Connell in their accounts of the day, but recommend you also have a look at what they have to say. For an idea of what is at stake, I recommend posts by Natacha Kennedy and Kat Gupta, as well as my previous writing on the topic.


A meeting with trans activists

The meeting – held in central London – was attended by a large number of trans activists who had been directly invited to the event, as well as three cis attendees: new Stonewall CEO Ruth Hunt, Jan Gooding who is Chair of trustees for the group, and a facilitator (who, incidentally, did a very good job).

A number of us felt that a more open meeting or more transparent means of securing invitation would have been beneficial. I’ve made my own views about this clear (particularly on social media) but in this post I will focus upon what we actually achieved, and what will happen next.

The event was in some ways quite diverse, and in others ways very limited in terms of representation. There were a wide variety of experiences represented, and views from across the political spectrum. There were a great range of gender identities represented, although a particularly large part of the group were trans women. There were attendees from across England and Wales, with James Morton from the Scottish Transgender Alliance present to talk about the situation in Scotland (where Stonewall is an LGBT organisation). The group was overwhelmingly white. There were a number of disabled people present, but not many with experiences of physical impairment.

Several commentators have stated that Stonewall were responsible for the make-up of the meeting, and therefore could have made more effort in terms of inviting a diverse range of participants. This is true, but I feel that trans activists also need to step up and take some responsibility here. Most of our loudest voices are white trans women like myself. We need to keep our own house in order: by reaching out to communities of trans people from under-represented groups, by “boosting the signal” and talking about the work of trans people from under-represented groups, and by ensuring that it’s not just us with places at the table.

It’s worth noting that this event was framed by Ruth as one part of a far wider consultation on Stonewall’s future engagement with trans issues. If you’re trans please ensure that your voice is heard in this. You can do so by writing to Stonewall here, or by emailing: trans@stonewall.org.uk. There will be more about the next steps of consultation later in this post.

The meeting ultimately had two purposes: to move on from the problems of the past, and examine potential options for future collaboration between Stonewall and trans communities.


An apology from Ruth Hunt

The day began with a refreshingly honest admission of fault on the part of Stonewall from Ruth. She offered a point-by-point account of how Stonewall has let trans people down over the past few years, and offered both apology and explanation for these incidents, as well as an account of how these are now being addressed.

This was not the main focus of the day, instead clearing the air from the start to enable a productive discussion. However, I feel it is important to provide a public record of this session: if we are to collectively move on from the past, then we need to remember that Stonewall has demonstrated a commitment to change.

Some of the issues discussed by Ruth included:

  • Nominating transphobic individuals for awards. This was acknowledged as a mistake, and we were assured that nominees are now scrutinised more carefully (not just for transphobia).
  • Insensitive use of language in Fit, Stonewall’s video resource for schools. Ruth explained that the inappropriate section has been removed from the DVD.
  • Stonewall’s campaign with Paddy Power, who were severely rebuked by Advertising Standards Authority for a transphobic advert in 2012. Ruth noted that Stonewall is now using its relationship with Paddy Power feed back on advertising they consider to be offensive (interventions which are not just limited to addressing homophobia) which has resulted in a number of changes being made.
  • Stonewall representatives speaking out inappropriately and/or not speaking out on trans issues whilst lobbying Government and MPs. There’s a long and complex history here that I’m not going into in this post: suffice to say that one aim of Saturday’s meeting was to ensure that this is done better in the future.

There was also significant evidence that Stonewall is undergoing major institutional change in regards to trans issues. I was pleasantly surprised to hear that Ruth had emphasised seeking a solution to the organisation’s difficult relationship with trans people when applying for the position of CEO, and that this was viewed favourably by trustees who considered her job application. Trans employees of Stonewall are reportedly more likely to be “out” and feel comfortable speaking about trans issues and concerns.


What’s on the table?

We then moved onto the main point of the event: to discuss proposals for a new relationship between Stonewall and trans people. There were four options for us to consider in group conversations, with attendees also encouraged to suggest any additional solutions that might not have been considered.

The options were:

  1. A fully inclusive LGBT Stonewall, which considers campaigning on trans issues to be a full part of its remit.
  2. Stonewall becomes nominally LGBT, but also funds and provides resources and guidance for the creation of a new, effectively autonomous trans organisation to work on trans campaigns. This organisation will eventually become independent, but can work closely with Stonewall.
  3. Stonewall remains LGB, and provides grants for a number of trans organisations so they can do their own campaigning work.
  4. Stonewall remains LGB, and works to be better ally.

Ruth explained that option (4) was not really favoured by Stonewall, particularly given the appetite for a closer relationship amongst many trans activists. The general feeling of the room reflected this, and we focussed our discussion upon the first three options.

Option (3) was largely rejected also. Criticisms raised included concerns about who would get the money, the impact of competition between smaller trans organisations, about what the conditions might be for such grants, and the amount of money and energy that would be spent by both Stonewall and trans groups on managing the system and applying for grants – money and energy that could be better spent on actual campaigning. Ruth further pointed out that Stonewall doesn’t actually have a lot of money to spare, outlining how money is currently spent on Stonewall’s employees and existing campaigns.  If the grant scheme was to go ahead, then there would likely be a knock-on effect on (for instance) campaigning in schools, and Stonewall might need to apply for extra money from funding pots that are already used by trans groups.

Options (1) and (2) both had great deal of support from within the room. Several groups suggested variations upon an “option 1.5” that sat between the two – proposals included the creation of a “trans department” within Stonewall, and semi-autonomous “sibling” organisation linked permanently to Stonewall.


Outcomes

There was a pretty clear consensus on the following points at the end of the day:

  • Barring the unexpected (e.g. widespread opposition from trans people contributing to the public consultation) Stonewall will become an LGBT organisation, in one form or another.
  • Any eventual solution should provide for joint ‘LGBT’ campaigning on shared issues, such as homophobia and transphobia in schools.
  • Any eventual solution should provide for campaigning on trans-specific issues, such as on relevant legislation (e.g. the Gender Recognition Act and amendments to the recent Marriage Act) and on addressing issues with health care.
  • Future campaigning work must be intersectional, recognising the diversity of trans experience in areas such as gender identity, race, disability and age.

 

What happens next?

  • The public consultation will continue for several months. If you’re trans, please make sure your voice is heard!
  • There will be further meetings held with people from under-represented groups. This is a vital opportunity to address the problem of diversity at Saturday’s meeting. Stonewall are planning meetings with people from a number of groups, including intersex people as well as trans people of colour, disabled trans people and young trans people. If you want to attend one of these meetings, please contact Stonewall: trans@stonewall.org.uk
  • There will be a formal proposal for trans inclusion in Stonewall made in January 2015 in the shape of a report. This will then be consulted upon internally (i.e. within Stonewall) and externally (i.e. amongst trans people).
  • A final decision on the future of Stonewall should be made in April 2015. If this involves full trans inclusion and/or the creation of a new trans group, this will take several months to implement.

It’s important to note that this is not a process that can take place overnight! The process of consultation is lengthy in order to take on board the views of as many trans people as possible. We have such a range of perspectives that there is no chance that everyone will be happy, but the aim is for change to be trans-led, and to reflect the desires and interests of as many people as possible.

Once the consultation ends, its results cannot be implement immediately either. Stonewall may need to revise its priorities and work plans, and Ruth noted that a full-scale programme of training on trans issues and awareness will be necessary for the organisation’s staff.


Personal reflections

I feel positive about the future. There is so much unnecessary suffering amongst the trans population that allies are vital, and Stonewall could be a particularly large and powerful ally.

I believe in diversity of tactics to bring about change, and Stonewall takes a particularly centrist, “insider” approach to this. It is vitally important that Stonewall is never the only voice in LGBT activism, and that other groups continue to take more radical approaches to trans campaigning. It is also important that we remain capable of critiquing Stonewall, and holding it to account. Ultimately though, I’d rather be a critical friend than an entrenched foe.

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DSM-II

On Monday we released the second Dispute Settlement Mechanism EP, DSM-II. You can listen to it below. I perform on lead vocals, and also play clean bass guitar on our cover of Seven Nation Army.

NHS Vulva may be of particular interest to readers of this blog. It deals with issues of medical malpractice, transphobia in the legal system, and cultures of transition.

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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.

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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.