The 11th revision of the International Classification of Diseases (ICD 11), the global standard for diagnosis, produced by the World Health Organisation, reclassifies Gender Identity Disorder as a “condition relating to sexual health”, named Gender Incongruence. Nowhere is this more relevant than the UK, where the NHS’s treatment pathway is floundering in the face of vastly increasing demand. The average wait time for a first appointment at an NHS Gender Identity Clinic (GIC) is now almost 2 years, more than 5 times the NHS referral to treatment standard set out in the NHS Constitution. The average wait time for a first appointment has more than tripled since 2015, and at one GIC is now eleven times what it was three years ago.
According to the NHS Constitution, the NHS is legally required to provide a first appointment for a specialty service within 18 weeks of referral. If they are unable to do this, they are required to offer an alternative. This is the alternative.
In light of the recent reclassification, and the ongoing inability of the Gender Identity Clinics to meet demand, we propose that sexual health clinics be given the power to prescribe hormones to transgender people. Sexual health clinics are a clear and appropriate choice for addressing the healthcare crisis trans people are facing. Sexual health clinics are widespread, numbering in the thousands, compared to just 7 GICs in England. They already prescribe hormonal medications to cisgender people in the form of contraceptives and HRT to individuals with hormone deficiencies. They have blood testing facilities. Staff are trained in administering injections. It would also facilitate greater access to STI testing and would aid in preventing the spread of serious diseases like HIV and Hepatitis.
Several sexual health clinics cater specifically to the needs of transgender people, as a response to the generally poor quality of healthcare we receive. These include CliniQ in London, and Clinic T in Brighton. These clinics do blood testing and hormone level monitoring, administer injections for transgender people with existing hormone prescriptions, and perform examinations such as cervical smears and prostate checks that many trans people feel uncomfortable receiving from their GPs. They also provide all the other services offered by traditional sexual health clinics such as STI testing and contraceptives. Despite their wishes to the contrary, and the fact that staff are eminently qualified to do so, these clinics are not able to prescribe hormones to trans people.
We believe in an informed consent model for transgender healthcare. Access to hormone therapy, gender confirmation surgeries and other transition-related therapies is a matter of bodily autonomy. This right is denied by the fact that GICs exclusively have the power to prescribe hormones. Being assigned a gender inconsistent with our gender identity can cause extreme mental distress, and as a result, mental illness is common among transgender people. However, being transgender is in itself not a mental illness, and should not be treated as such. Transgender people are capable of making informed decisions about transition, and we do not benefit from gatekeeping. We are dissatisfied by not only the delays in providing treatment, but its delivery and the process by which the Gender Identity Clinics determine who is worthy of treatment.
The current treatment path offered by the NHS is based on treating trans people as mentally ill. Patients are subjected to extensive and invasive psychological assessments, in which we are expected to prove that we are in sufficient distress to warrant intervention, but patients are often denied treatment due to mental illness. Not only does this prevent trans people from reducing gender dysphoria, which causes or worsens mental illness, but also prevents trans people from seeking help for mental health problems in the fear that diagnoses might affect their prospects of transitioning.
During the assessment process, clinicians make judgements about the gender presentation of patients. These judgements are based on inappropriate gender stereotypes, and highly outdated ideas about the presentation of trans people, which have been widely rejected by the transgender community. Patients have been denied access to treatment based on not wearing a skirt, having their hair too long or short, or being nonbinary.
In addition, patients are also denied hormone treatment (estrogen based) entirely because they smoke. This is supposed to be because of increased risks of blood clots in these patients, but these risks can be mitigated by providing estrogen in the form of patches or gel, instead of pills. Smoking, like all addictions, is much harder to overcome for individuals with poor mental health. Being denied the ability to transition demonstrably worsens people’s mental health, so withholding treatment in these cases makes no sense. In many cases where people are denied treatment, they will self-medicate anyway. Pills are the cheapest way to self-medicate with estrogen, so the NHS is forcing people on a low income to take a more dangerous form of the medication.
The assessment process, requiring clinicians with extensive psychiatric training, leads to the long waiting lists and low numbers of properly trained clinicians. Such delays in treatment can lead to an overall greater level of dysphoria in patients, who will often require greater and more costly surgical interventions (such as facial feminisation surgery) where it would not have been required had the patient been allowed to start hormone therapy when they first sought treatment. Trans people have a far higher risk of suicide before access to hormone therapy, compared to afterwards. Delays in treatment have lead to the epidemic of self medication, and the associated risks of contaminated medication, patients taking lower quality hormones with greater side effects and associated health risks, poor blood level monitoring and dosage information. The trans community has rallied around this problem, learning and sharing as much information as possible about how to self medicate safely, but such measures are only necessary because the NHS is failing in its constitutionally mandated duty to provide timely and effective care.
Allowing sexual health clinics to prescribe hormones marks a clear and needed change from the current attitude of the NHS gender identity services. It is a change that is required in order to both meet the needs of the trans community and fall into line with the diagnostic guidelines provided by the WHO. After this change, GICs will still play a valuable role in the care of transgender people. The extensive psychiatric training held by clinicians can be put to better use, providing much needed mental health support to transgender people, and helping those who need help working through their feelings of gender dysphoria before they can make the decision about whether or not to transition.
For the purposes of this campaign, we have consulted with sexual health clinics about whether or not they feel they would be able to provide services to trans people. We have included a list below of clinics who have explicitly shown support.
We have the support of CliniQ, who are eager to prescribe hormones to trans people, and already perform monitoring and injections for thousands of transgender patients in London.
We have the support of Spectra.
We are making FOI requests to the NHS about wait times to demonstrate that current services are failing to meet acceptable standards. NHS England has confirmed in response to a Freedom of Information Request that Gender Identity Services are subject to the 18-week Referral to Treatment (RTT) standard. This means that Gender Clinics have a responsibility to treat patients within 18 weeks of referral. However, GICs do not report their data to NHS England, so we have made our requests to individual clinics instead.
We will post responses to FOI Requests as they come in.