Dear Healthwatch,
Trans Safety Network was shocked by the dangerous recommendations of your recent trans healthcare report. We find it hard to believe that any trans organisations or persons were involved significantly beyond the initial survey, given the transphobic language used in the initial blog post talking about this, citation of reports written by known anti-trans authors, and the harmful recommendations made against broader trans community wishes.
To start with, the report suggests that various screenings are "sex based". This is factually inaccurate even if we accept a trans exclusive definition of sex - they are either anatomy based or hormone level based. Cervical screening depends on presence or absence of a cervix. Breast screening will depend on presence of breasts- something many transgender women and transfeminine non binary people have, and something many transgender men and transmasculine people will lack. AAA screening is under researched in transgender people, but as testosterone exposure (as opposed to anatomical differences) is the major factor in AAA risk profile it would likely be appropriate for transgender men and transmasculine non binary persons taking testosterone to be screened. It may or may not be appropriate for an individual trans woman or transfeminine person to be screened depending on their endocrine profile and how old they were when starting hormone treatment.
Trying to simplify these differences down into "sex", meaning "sex as assigned at birth", ignoring that HRT and surgery change many physiological aspects of a persons sex is ignores patient needs and biology. Misgendering trans patients in this way leads to disengagement from healthcare, and inappropriate medical decisions. As an example, if screenings were to be done only based on assigned sex at birth, as Healthwatch appears to suggest with its endorsement of "sex" and "gender" as discreet fields, transgender women who have breasts will be missed for routine reminders. The Healthwatch report completely fails to acknowledge this problem. These separate sex and gender fields can't be used, either separately or together, to determine which screenings are appropriate for a particular patient because this depends on surgical and hormonal history, not sex or gender. The solution to this is the one currently implemented in the NHS England system after years of it being requested by transgender people - the ability for GPs to opt people in and out of various screening programs depending on their actual needs as per anatomy and hormones, and not based on assumptions from the sex they were assigned at birth.
This brings us to the next point. The Healthwatch report suggests, citing only a review led by a known anti-trans researcher and featuring contributions from several more anti-trans ideologues, that the NHS ceases allowing patients to change their NHS number and redacting previous records when changing sex marker, and suggests that in the future all records should record so-called "biological sex" (i.e. sex as recorded at birth) and gender separately, preventing any trans person from being able to change their sex marker. There are many issues with this recommendation:
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As Healthwatch itself notes in the report, being outed as transgender in healthcare settings often leads to discriminatory treatment such as trans broken arm syndrome, excessive scrutiny from healthcare workers and admin teams, invasive and irrelevant questioning from healthcare professionals, and misgendering and deadnaming. All of these experiences are likely to lead to worse health outcomes, distress for the patient and patient disengagement from healthcare services. Given a forced "biological sex" marker would out trans patients in all healthcare situations where their record is accessed, it is hard to understand why Healthwatch considers this to be an appropriate recommendation.
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It ignores both that it is currently possible to change sex marker without generating a new number, and the reasons people may want a new number and redacted records. Some people will not mind having a clear link between their previous name and identity and current, and, afterseveral years of trans people requesting this from the NHS, it is now an option. Other transgender people will want their previous name and records redacted so there is no risk of staff discovering and using a trans person's previous name and significantly reduced risk of misgendering. Whilst this Healthwatch report only covers England, it is likely any adopted recommendations around sex markers will be mirrored across all four UK nations, which will significantly disadvantage anyone accessing NHS services in Scotland, as unlike other UK nations Scotland encodes the original sex marker in a patients CHI number, meaning that any trans person with an unchanged CHI number will be outed to anyone who sees it, even if that person does not have any access to the trans persons record itself. Under the GRA 2004, disclosure of someone with a GRC's transgender status is a criminal offense with a large fine attached, and GDPR maintains that people have a right to rectification of records. Under the ECHR, it has been ruled that this includes a persons sex/gender on anything used to identify them. Under the current system, when done correctly, there should be no loss of data or care from an updated sex marker on a new GP record and number. It is unconscionable that Healthwatch is recommanding removing transgender patients' privacy, right to choose when to disclose, and increasing legal risk for medical professionals, because some GP practices fail to do admin tasks correctly, instead of suggesting that GP practices should receive better training and instructions on how to correctly transfer records across.
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As covered above, this will result in transgender people missing out on essential screenings, whilst ignoring that we already have a solution that does not invade privacy, risk legal action, or forcibly out people and ensures people would not be missed - opting in/out of screenings as appropriate. It also risks other health issues being missed- for example, recommended haemoglobin and haematocrit range depends on a persons testosterone levels, not their assigned sex at birth.. If a transgender man with cisgender male levels of testosterone is incorrectly tested against "female" range due to a "biological sex" marker suggesting that is appropriate, if his levels are below standard male range, i.e. suggesting he is anaemic, but within the lower end of female range, this anaemia is likely to be missed, leading to delayed treatment and investigation and worse health outcomes. This is not a hypothetical - Trans Safety Network is aware of multiple cases of transgender men on testosterone reporting they had anaemia missed due to having their haematocrit levels compared to female ranges, who were out of male range for months but were only identified as having issues when their levels dipped below female range. Whilst there may be some circumstances in which some medical tests or considerations a transgender person's results or needed investigations may differ from a cis person of the same genders, this could also be accounted for without reducing to a single "biological sex" marker, which would do nothing to fix overall accuracy of test ranges or needed investigations, and entrenches harmful beliefs about trans healthcare needs. The "gold-standard", which trans advocacy groups have been requesting, would be the ability to change lab ranges on an individual basis (whilst defaulting to male/female as appropriate for marker, and supplying both for people listed as indeterminate), so a trans patient could have this adjusted according to their individual care need. As well as this, an "organ inventory", hidden behind a "break glass" to ensure privacy where it is not relevant, listing reproductive organs as relevant could be used - e.g. has Uterus Y/N, has testes Y/N. Again, this would default to what would be expected as standard for a person of that gender, but would be able to be edited by a GP or other appropriate health professional as needed.
This would not only benefit transgender and non binary people, but also cisgender people who do not have anatomy one would assume, be that due to surgery, being intersex or another reason.
As a final example of the lack of engagement with trans community, the Healthwatch blog announcing the report initially referred to cervical screening as "a critical check provided to women to see if they are at risk of developing cervical cancer." Whilst this has now been amended to read "people with a cervix" instead of women, the fact the original sentence made it to publication without anyone noticing suggests Healthwatch has a lack of familiarity of basic inclusive language, and has failed to get trans oversight on this report.
Overall, the Trans Safety Network is extremely disappointed that what could have been a beneficial report highlighting health disparities and specific trans health needs has instead been used to deepen healthcare harms further, whilst citing a thoroughly transphobic report which has been widely criticised by trans advocacy groups to do so. Healthwatch is supposed to enable and advocate for the voices of patients and their voices to be heard, not to use them as a prop whilst pushing for more inequalities. Nothing about us without us means that we need to be listened to and our views accurately carried across, not to be ignored.
We are aware Healthwatch has responded to complaints from members of the community, claiming that "the report reflects the wide range of views we recovered". It is hard to square this claim it the fact it recommends that sex marker changes are stopped with the fact the majority of respondents had either changed or intended to change their sex marker, and that all issues that arose from this change are down to administrative failure on behalf of the GP surgery and not an innate feature of changing this. Additionally, it fails to reckon with the points raised above that preventing sex marker changes will cause harm, including missing vital screenings, and that the solution is to improve training and not to punish trans people for administrative incompetence.
We demand that Healthwatch immediately retract the report and remove the recommendation to ban NHS number and sex marker changes and medical history redaction and apologise for having suggested this. We also ask that Healthwatch produces a new report, this time working closely with trans advocacy groups and transgender people, focusing on concrete actions such as increased training for GPs in prescribing transgender HRT, and ways to actually ensure equitable healthcare and screening access, and not to act as a mouthpiece for anti-trans groups.
We will be publishing a copy of this letter on our website. We hope you will carefully consider this and respond accordingly.
Regards,
Trans Safety Network