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Gender Identity Clinics, I think it is fair to say, are not very good. By any measure. Perhaps you’re most horrified by the shocking, mind-bending waiting times measured in years rather than weeks1 and, with the application of some simple maths, projected in decades2. You may be more alarmed by the legal table tennis played with the UK’s primary service for children and young people last year3. This led to the breakup of the service4 and ensuing chaos which, although potentially beneficial in the long term, has now subjected families to more turmoil and uncertainty. Maybe it’s the thick-of-it-esque breaches of confidentiality outing and exposing the personal contact information of their trans service users5. Instead of waiting, of course, many trans people take matters into their own hands — with sources of life-improving hormones ranging from understanding GPs to grey market internet pharmacies half the world away6.
The interventions provided for trans people able to endure the wait are seemingly arbitrary and subject to, as far as anyone can tell from the outside, no public oversight or practical recommendations7 contrary to almost any other aspect of regulated healthcare in the United Kingdom. I should know: I’m a nurse.
I’ve worked within the NHS for most of my adult life. My training was paid in part by the NHS. Until a recent move to (nursing) academia, I had never known anything different. I’m also trans, and in what is now becoming a rarity, transitioned under the NHS.
This is viewed by some of my trans, nonbinary, and other gender-nonconforming comrades as more-or-less working for the enemy. I’m not sure they’re wrong.
My work has never overlapped with transition-related healthcare. I’m not sure I could stomach it. However, when we hear the health of trans people discussed there’s often something we overlook: quite literally everything else. The bulk of my working life has been in A&E. Trans people accessed our department every day, for reasons from sprained ankles to acute mental health crises. Trans people access outpatient departments, specialist wards, cancer service, and GPs for all sorts of reasons not directly related to their trans status. So, how does the rest of the NHS stack up for trans people?
The headline figures are shocking8. Fourteen percent have been refused GP care on the basis of their trans status. More than half report avoiding going to their doctor when they are unwell. Mistreatment is compounded by factors such as ethnicity and disability, as in any other area of institutional discrimination. We even have a good idea why this may be: studies from Europe9 and the US10 (UK academia is years behind in this area) point to a lack of knowledge that begins with early professional training and contributes to a vicious cycle of anticipated or direct discrimination, health service avoidance, and worse health outcomes. It’s no wonder, then, that trans people have a higher incidence of conditions ranging from communicable diseases to Diabetes via depression and substance dependence.
Should you as a trans person feel able to access healthcare services at an appropriate time, then you may be subject to Transgender Broken Arm Syndrome. This is the baffling but common phenomenon of healthcare professionals doing their utmost to blame, for example, your broken arm on the hormones you take rather than the bike you fell from, or the concrete you landed on11. It’s not just broken arms – this fantastic resource12 documents one individual who was denied antibiotics for an obvious, simple infection until their clinician “heard from a specialist” out of fear of some kind of awful reaction with the strange, unknowable transgender hormones the person took. Exogenous (not-made-in-your-own-body) hormones aren’t magic and should be familiar to any professional working in primary care.
To summarise: you as a trans person have a bad experience with one GP or clinic, or hear a horror story from someone else, and that makes you less likely to access care in the future. This starts with the initial training and continuing professional development that all of the professionals in any given patient journey have had.
Or rather: the training that they haven’t had. There is no concrete requirement for GPs and emergency healthcare workers to be familiar with the care considerations that trans people need. In fact, they—we—are actively discouraged from anything close to “involvement” by our professional organisations13. Institutions such as the universities training new nurses, doctors, paramedics, and other allied health professionals may never bring the trans community up or offer just a passing mention. Only rarely might they invite an actual expert, someone with both lived experience and clinical knowledge, to interact with their learners.
So, how do we get enough experts in front of enough professionals? How do we encourage more trans people to enter healthcare and gain the insights necessary to bridge this gap? Can we ever break the cycle?
These are open questions. I don’t believe anyone has a simple, foolproof, all-encompassing answer.
With that said, I’m now going to tell you why I’m here, and what I’ve been doing alongside my day job for the last two years.
This is We Need to Talk About Trans Health Inequality14. Through a series of projects, grants, and fortunate encounters, I’ve been able to lead and collaborate on a resource designed for my NHS colleagues. This isn’t meant to be mandatory training, or a well-meaning but uninspiring equality and diversity package. The series starts with basic definitions and finish with the minutiae of trans parenthood, via emergency and mental health care. It’s informative, accessible, and (I hope) engaging; and as relevant to those new to healthcare as it is to the most senior doctors and service managers.
The facts are tough to swallow, and speak for themselves. Instead, I hope viewers find genuine advice and reassurance. I hope this inspires confidence and better practice. If even one trans person in the UK notices a difference, it will be worth it.
I hope it’s more than one, though, and I think this is where I’m supposed to do a call to action. If you’re able, please spread the word. Share the original post15 anywhere you can, and if you know someone in education or healthcare, send it to them.
And if you’re a healthcare worker or educator? Well, to quote the final few words of the series: this is on us. We need to be better, starting from today. Please share these films with colleagues, incorporate the information into your policies and guidelines, and practice positively.
We all share a duty of care, and this is one area that we continue to fail in. If nothing else I implore you as both a nurse committed to evidence-based, inclusive, effective care and as a trans person who has had my share of horrific healthcare experiences to open your mind and engage with the trans community.
Thanks for reading.