It's spooky season! Drawing on Frankenstein and his Monster, a comrade reflects on Silvia Federici's Beyond the Periphery of the Skin from a trans- perspective.
Trans healthcare in Britain is in dire crisis. The Gender Identity Clinic (GIC) system, already woefully inadequate and under heavy strain prior to the outbreak of the COVID-19 pandemic, has been stretched to breaking point by the development of the crisis, leaving trans people across Britain without access to essential medical care. Shortages of a number of medications, notably including the commonly prescribed patch form estradiol, have been a serious and recurring issue, which has only worsened during the pandemic. This has greatly restricted trans people’s access to these medications, and the response of the GIC system has been one of apathy and callously dismissive reassurances.
These shortcomings make clear the need for a drastic overhaul of the entire system, abandoning the GIC model of diagnostics and trans conformity in favour of a model based around the principles of bodily sovereignty and informed consent - in order to provide a trans healthcare system that works for trans people. The existence of trans people is a threat to heterosexist capitalism and, as a consequence, their lives are made as difficult as possible.
Following a referral to a GIC, waiting times for an initial appointment are between two and four years. Even once under the care of a GIC, appointments can be so few and far between that it takes months, or even years, before patients are offered necessary treatments such as hormone therapy or surgery.
These problems with waiting times are further aggravated for those stuck between child and adult services. Many young trans people have reportedly been told that they are too old to be referred to child services, but they are still too young to qualify for adult services, extending their wait by several years. This blatant disregard for one of the most vulnerable age groups amongst trans people is yet another example of the narrow and antiquated model of trans healthcare forcing people onto lists and into boxes rather than treating them with the care and urgency that they require. Furthermore, with announcements made recently by Liz Truss to the Women’s and Equalities Parliamentary Select Committee, it seems that even this limited access will be taken from young trans people, with teenagers’ access to hormone blockers to delay puberty to be prohibited under the changes – despite their huge importance to young trans people.
With the onset of COVID-19, all non-urgent appointments with the NHS were cancelled or delayed. This, of course, included GIC appointments. Without a centralised or coordinated policy, how each GIC responded to the pandemic was left up to them. This is consistent with a cisheteronormative view of healthcare; trans people are not considered a priority under any circumstances.
Leeds and York cancelled all diagnostic appointments and did not offer any new ones. They have just announced they will be booking virtual appointments (at which they appear to be able to prescribe hormones) and have begun to acknowledge GP referrals again. Charing Cross, which covers London, also began a Zoom service. They said, however, that they wouldn't be making any decisions on hormone treatment or surgery until "lockdown is relaxed". In July, GICs in Scotland announced that they broadly support the use of video consultations to progress treatment to trans patients. The difference between these care outcomes highlight how much of trans healthcare in Britain is a postcode lottery.
In line with the government’s broader strategy of hollowing out the NHS to enrich private healthcare markets, the GIC system’s failure to provide treatment has given ample room to a smattering of private trans healthcare providers for struggling trans people to ‘choose’ from, if they can afford it. Providers like GenderGP and the London Transgender Clinic act as a paid fast-track past the waiting lists or as an expensive alternative pathway for those who deviate too far from the GIC’s chauvinistic norms. With the cooperation of the GP surgery (who can enter a shared care agreement to prescribe hormones), accessing treatment this way costs hundreds of pounds a year; without that cooperation, it is even more expensive.
The decision for GICs to move to online appointments also reveals a contradiction. GenderGP, who support a large number of trans patients, have faced extensive criticism and censorship. Both doctors who run GenderGP have, in the past, been suspended by the GMC or fined for running an “unregistered” clinic. It is clear that the press and the GMC did not appreciate the existence of GenderGP and tried to find ways to limit their effectiveness. One of the criticisms of GenderGP was that they exclusively used telemedicine and did not see patients in person. Now, because of the pandemic, the NHS is being forced to adopt telemedicine. Will those gatekeeping trans healthcare on these grounds have to adjust their position?
No pills, no pity
Even prior to the outbreak of COVID-19 there existed serious shortages of medications crucial to trans healthcare. Commonly prescribed estradiol patches in particular have been short supply, due at least in part to supply chain issues for two of the most significant manufacturers, Theramex and Norgine. This shortage was further exacerbated by uncertainty around medication supplies due to Brexit, and several online pharmacies, notably including the pharmacy QHI (which remains closed), were investigated by the state and the media leaving many trans women without the means to access these hormones altogether. It is against this grim backdrop that the challenges posed by COVID-19 emerged. The crisis has only served to intensify each of these issues: with supplies still short, shipping times drastically affected, many trans women find themselves unable to obtain their hormones at all.
The British Menopause Society acknowledges that there are ongoing HRT shortages which include Evorel patches (a commonly prescribed form of oestrogen). Despite their guidance that prescribers can consider an alternative (if an exact match is not possible) this is not often a route taken when prescribing hormones to trans people.
Trans communities have always shared their supply of hormones but with the restrictions imposed by the lockdown in Britain, this became harder. At the start of the crisis, shipping from online pharmacies was disrupted (although it appears at the time of writing several have resumed shipping to Britain). The result has been that what supplies do exist are often being shared within communities of trans women at reduced dosage while others are forced to go without altogether.
The effects of the pandemic have made clear the need for professionals to make advice and support available to those who might suffer under the shortages and loss of access to services. Unfortunately, the guidance that subsequently emerged from GICs was callous in its disregard for trans patients’ wellbeing, making no mention of the distress loss of access to their medications and services could cause to trans people, nor the interactions with conditions both physical and mental that rapid changes in hormones can precipitate. They claimed instead that the loss would not have any serious or lasting effects. Though later updated to make clear the importance of maintaining trans people’s access to their medications and the harm losing this could have on both their physical and mental health, the fact that such guidance was issued in the first place demonstrates a staggering disregard for the devastating impact such a loss could have on an already vulnerable community.
It remains true that a lot of these problems could be solved by moving to a different model of trans healthcare, one that is not characterised by gatekeeping but one that is built on the principles of bodily sovereignty and informed consent. We must recognise gender as an ever developing, redefining process in constant change, one that is affected by material circumstances and therefore focus on making people safe, supported, secure and informed, rather than having to meet arbitrary standards set by cis doctors.
The lottery of care
This blatant de-prioritisation of trans people’s healthcare needs is by no means an anomaly; it exists as part of a wider lack of care from medical professionals across Britain with regards to trans issues. With the diagnostic nature of the GIC system as it is, GPs and GIC staff are given unjust power to decide trans people’s fate with regards to their medical care. Two trans people can have radically different experiences in the early stages of referral onto the GIC system purely by virtue of accessing it through different GPs, as there is no guarantee that any one GP will be sensitive and understanding on trans issues. Trans people are forced to carefully choose their GP based on reports and recommendations from other trans people in order to avoid transphobic professionals that would make the experience of coming to terms with their gender unnecessarily traumatic. It’s not uncommon to hear stories of GPs refusing to support trans patients, or even expressing their contempt when trans people are forced to explain the existence of the very systems to which GPs are supposed to refer patients. Further to this, GPs and even GIC staff have often been known to deadname or use incorrect pronouns for patients, amongst many other instances of mistreatment. To be a provider of healthcare yet harbour such glaring ignorance regarding a vulnerable community to whom there is an ostensible duty of care is entirely unacceptable.
In line with this systematic lack of understanding, the diagnostic nature of trans healthcare in Britain requires that trans people fit within a narrow and chauvinistic conception of what transness looks like to the “professionals” in the GIC system in order to qualify for treatment. With this in mind, it comes as no shock that many young trans people are forced to lie about themselves in order to access care. In particular, trans women are expected to fit within a deeply transmisogynistic framework that conceives of them only as hyper-feminine stereotypes, and deviations from this come with the risk of being denied that care. Since the experience many trans women have of their gender bears little resemblance to these diagnostic criteria, their identity is wrongfully brought into question by this system which then seriously curtails their access to this healthcare.
Similarly, this system causes great harm to non-binary people who are often forced to pretend that they fit neatly onto one side or the other of the prescribed gender binary or risk going without treatment. This traumatic expectation for trans people to suppress their identity is yet another brutal consequence of the broken GIC system.
The myth of a standard transition
Given the difficulties in place that prevent trans people from accessing treatment under the NHS, it would be easy to assume that merely making this existing system easier to access would be a simple solution; but there is a far deeper issue at hand that means the long-awaited treatment sought by trans people is often inadequate for their actual needs. The British healthcare system fundamentally does not understand the trans community and has little regard for the case-by-case needs of different trans people who seek treatment as part of their individual relationship to gender.
This one-size-fits-all approach to trans healthcare forces people down a narrow pathway under the assumption that all trans people will undergo a neat and simple process of getting hormones, getting surgery, then being discharged from the GIC service. This assumption completely ignores the many trans people who do not wish to undergo any surgical procedures or who may wish to undergo a more customised hormonal treatment. Many non-binary people, for example, may choose to take a lower dosage of hormones than are typically prescribed to other trans people.
This assumption also ties in with the harmful stereotypes harboured by the GIC staff and system as a whole, leading to trans people undergoing degrading experiences under GIC care. As an example, trans women that are happy with their voice and make this clear may still be told that their voice isn’t ‘feminine’ enough according only to the personal standards of the GIC staff and subsequently be referred for speech therapy they never asked for. Despite the humiliating irony of forcing certain parts of the available healthcare onto trans people whilst simultaneously restricting their access to what they truly need, experiences like this are far from uncommon, and it just goes to highlight the blatantly transphobic attitudes and lack of understanding that is inherent within the GIC system.
A system not for the people
This mismatch between what is needed by an individual and what is provided by the GIC service, even after enduring gruelling waiting lists and humiliating encounters with ignorant professionals, shows the absolute lack of care within the trans healthcare system Britain. As with other parts of the NHS, the GIC system exists only in order to keep the working class functioning, but not thriving. The system does not care that trans people are happy and content, nor that they may live at peace with their gender. As long as they are provided with the bare minimum that is necessary to maintain their productivity in the economy, the NHS is functioning as intended by the ruling class.
This is not just a fault of the NHS in practice, but the primary inherent flaw of any healthcare system that the bourgeois class maintains in order to keep the proletariat ticking over. We use the system to be fixed when we’re broken, but it cannot cope with people feeling they deserve to live happy and fulfilling lives. Simply increasing the funding for the existing system is categorically not enough; nor is there any inclination amongst the ruling class to provide such funding anyway, for just as Britain’s benefits system intentionally keeps social security at levels that are inadequate to live on, the catastrophic underfunding that characterises the GIC system is by design. This is where the need for a radical and people-oriented solution to healthcare is most exposed.
There can be no doubt that the pandemic has only served to exacerbate the existing shortcomings of the healthcare system as a whole, with particularly negative effects on vulnerable trans communities. The narrow-minded diagnostic approach to trans healthcare is an unnecessary strain on the healthcare system’s time and resources, and now more than ever we must demand a better system.
We need a new model based around bodily sovereignty and informed consent which would allow trans people autonomy over their transition and avoid the need for the often clouded judgement previously required by so-called health professionals. This would significantly reduce the strain on trans healthcare infrastructure by removing the dependency on the outdated GIC model whose limited resources serve as an unnecessary and often traumatising choke-point on trans people seeking to access healthcare.