What is the Problem with Trans Healthcare?

Today I went to the annual Scottish Trans Pride march, which this year took place in Kilmarnock. After the march, there were the usual stalls, but in a new departure, there were workshops, including a panel discussion with political and NGO figures. The panel were discussing some preselected questions, the last of which was on trans healthcare. What really struck me about the discussion was that, contrary to my assumption that everyone knows the issue with trans healthcare, no-one seemed able or willing to say it out loud.

What do we Know?

So let's recap. The main issue with adult services is the shocking waiting list (two of the panellists, for example, had been waiting five years, and counting, for a first appointment). And after that, there are the further waiting lists, delays and bureaucratic muddle which means that those of us who are lucky enough to have had a first appointment face many years working through the system (in my case, eight years from the first appointment, and I'm still not done).

That's not all, of course. In many respects the services are notional rather than actual. In theory, the modern Scottish Gender Identity Clinic offers a suite of services, except that some have no identifiable practitioner associated with them (the Sandyford waiting list for tracheal surgery is entirely mythical, for example). And of course all top and bottom surgery happens outside Scotland, even where (as with mastectomies for trans men) the service is available for cis people. (Thanks to the facilitator for pointing that last one out.) The situation is even worse for children's services, even if in Scotland we haven't had the NHS rig a research study to provide a pretext for removing puberty blockers as even a theoretical option.

So why is this happening, and how can we fix it?

It's not about the Money

Speaker after speaker asserted: we need more money. As a response, this has the benefit of being true, given certain assumptions, but it has the added benefit of allowing everyone to wring their hands and not face the real issue. The partnership agreement between the Scottish Government and the Scottish Green Party was supposed to address both of these, the financial and non-financial issues: more money was to go into trans healthcare, some in the short term to tackle the appalling waiting lists, and an increase over the medium term to sustain any changes; the money was to be accompanied by a review of trans healthcare provision.

Because this is the issue: the current model is completely and irrevocably broken. More money would be helpful, of course, but we could slash waiting lists at a stroke if we just faced up to the failure of the Gender Identity Clinic model. It is ridiculously expensive, time-consuming, inefficient, frustrating, and serves very little practical purpose at all. Add to that the difficulties of recruiting staff, it is no surprise that NHS England (yes, them) are running trials of GP-led services.

The Gender Identity Clinic model as we know and loathe it is still fundamentally that set up at Charing Cross Hospital in 1966, slightly generalised. True, these days, the mood music in the system is rather different, and the approach is meant to be affirmatory (sort of) but structurally it's much the same. There are more clinics, and the teams are meant to be multi-disciplinary, but the mindset is that if you are going to expand trans healthcare to cope with demand the only answer is more clinics and more consultants. Even the Cass Review, for all its manifold problems, was actually arguing for this: not the removal of services altogether.

But it is not the right answer. Most of what happens at a GIC need not happen at a GIC. The monitoring of patients is a joke, whether that is in terms of emotional support (‘How are you?’ Fine.’) or the monitoring of hormone levels, given the irregularity of appointments and the delays between a given blood test and changes to medication. For example, as things stand, it has been three years since I started on hormones, and I am still not at the target levels. These levels are well-known, to the extent that my GP was commenting on the last blood test and trying to intervene, but lacking any sort of capacity to do so; nine months later, Sandyford remembered I exist and upped the dose. This is a bonkers way to proceed. Hormone levels could be perfectly adequately scrutinised at GP level. Indeed, GPs regularly prescribe HRT, without qualms, for cis people, so there is no technical reason for them not to do so for trans people. Testosterone, too, could be delivered through GPs (and again is not only a trans specific therapy). It's not actually as if the psychiatrists who run the GICs are endocrinologists anyway.

Many, if not most, of the ancillary services offered (however notionally) through the GIC are either non-surgical (voice therapy, hair removal) or, if they are surgical, have their own psychological apparatus anyway (facial feminisation surgery). There is no reason that GPs could not refer directly.

SO why do we need GICs at all? There are three occasions when we seem to need a psychiatrist, to satisfy the current model of trans healthcare:

1. to assent to the prescription of hormones in the first place
2. to approve gender-confirming surgery
3. to give a second approval for gender-confirming surgery

In addition, if you want a Gender Recognition Certificate, you need a letter from an approved psychiatrist: this may not be someone from your GIC, and your GIC may not offer this service anyway.

If the Scottish Government, or anyone else, really wanted to tackle the problem of NHS waiting lists in this area, they could make a start by taking care out of the hands of the GICs, either substantially or completely. The amount of staff hours released would allow the psychiatrists to focus on the parts they need to do, not the day-to-day management (or year-to-year, rather). There are a couple of reasons why complete abolition at this point could not realistically be attempted:

1. Regrettably, many GPs are ignorant, unhelpful or just transphobic, and so there will need to be a backup for those affected.
2. Politically, the myth of scrutiny needs to be fed, but that can be addressed by retaining the above moments of psychiatric intervention; but since there has been so much performative outrage about trans kids, perhaps the shrinks could focus their time there, and we might have some functional healthcare for them too.

It should, however, be an ambition to move beyond the GIC model. If gender reassignment is really a protected characteristic, then trans healthcare needs to be mainstreamed. Happily, this is both the right thing to do, would actually provide patients with a genuine service, and be significantly cheaper. It's a win-win.

Inertia

Unhappily, the force of inertia is strong. To some extent, the problem is that even sympathetic politicians are not aware of how broken the system is. On the panel today, the representative of the Scottish Government seemed genuinely unaware that there is a policy issue here, not just a budgetary one.

More worryingly, the NGO representative was content to repeat the financial line, rather than holding the government's toes to the fire on the question of delivery. Talking to them afterwards, there was vague allusion to disappointment about what was coming from the Scottish Government, but it was all rather tame. Yes, Scottish Trans are running a lived experience co-ordinator as part of the ongoing review, and they are supposed to be in the room, but this has all the hallmarks of the community being steamrollered by the vested interests of inertia.

I know from my own conversation with some of the various psychiatrists I have seen at Sandyford, that any thought of substantially changing their mode of operations is anathema. They need more staff. But for literally years they have been telling me they cannot fill their positions (or at least, they seem to be eternally trying to recruit, and the waiting lists just get longer). Clearly, for any consultant, the idea of giving up medical power is problematic, but when you cannot even staff your service properly, this is like asserting your rights to the position of deckchair attendant on the Titanic. It is certainly not about offering care, in any reasonable definition of that word.

The Scottish Government, largely because of the partnership agreement with the Greens, has spent a lot of political capital on trans issues, and I know that there is a sizeable portion of the SNP that regret that (to put it no mor estrongly). And so, there may not be the political will to do what needs to be done, to take on the dwindling vested interests of the medical profession and face down the transphobic press. On the upside, there is such clear water between Scotland and England right now in terms of governmental support for trans people that it is hardly going to change perceptions very much. The Cass Review has been handled with the long tongs that it deserves rather than the heady embrace that UK Labour have seemingly adopted (not to mention the Tories), and I am just baffled by where Scottish- Labour is at right now. There is a gap in health policy as well as general stance, and a sane approach to adult gender services would fit in that context.

Politicians are forever complaining that the NHS is a money pit. It needs reform. It needs efficiency savings. Usually this is a pretext for introducing arbitrary, fake competition models and spurious patient choice, even where it is not simply a pretext for privatisation. But here is a situation where the bureaucracy is genuine, the blockages entirely unnecessary, and the simplification of the service would benefit both patients and staff. My GP has a two-week waiting list these days, and that is far from ideal, but compared with trans healthcare through a GIC, I could cope.