WIDLIMS ep #21 – ‘The NHS is letting down trans people’ – barriers to equality in trans healthcare

In this week’s episode, I was delighted to be joined by not one but TWO guests. Dr Kate Nambiar (she/her), and Dr Sophie Quinney (she/her), both involved in care for transgender and non-binary individuals in the United Kingdom. Dr Nambiar works in England, and Dr Quinney in Wales, and while there are differences in healthcare systems within the UK, there are similar challenges and issues relating to the treatment transgender individuals receive in the NHS, whether it be directly related to transgender-specific health issues or other reasons for which trans patients seek healthcare. There was no way I could do this massive field any justice in a short podcast episode, but I hope it serves as an introduction to those of you who do not know very much about this topic, but who want to be better trans allies, and want to ensure any transgender and gendernonconforming individuals you encounter in healthcare settings or elsewhere are being treated with the respect and dignity and compassion they deserve.

I will not tolerate transphobic discussion around this area.

CW: transphobia, suicide

Mentioned in this episode

• Glossary and some more good information on LGBTQ+ healthcare at 16point6 here
• House of Commons Women and Equalities Committee Transgender Equality report from 2015-16, access here
• Causes of mortality for transgender individuals, Asscheman et al. ‘A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones’ – find it here
• Gender inclusive perinatal guidelines in Brighton – see documents here and here
• Book: Ben Vincent Transgender Health: A Practitioner’s Guide to Binary and Non-Binary Trans Patient Care.
• Sophie Quinney & Ben Vincent in the British Student Doctor Journal April 2021 What all doctors should know about trans health – a conversation between a medic and a sociologist, access the article for free here
• Disclosure on Netflix – trailer here

Being transgender in the UK

CW: transphobia, suicide

I think many people are unaware of challenges faced by trans people. If you have paid a bit of attention, you may be aware of the importance normalising asking for people’s pronouns or displaying them on social media and in work email signatures for example, and you may have heard about having gender neutral bathrooms, and allowing all women (not just cis) have access to ‘female’ toilets. However, as illustrated by this PinkNews infographic, there is so much more which matters and needs addressing, to even begin to push for change and health and wellbeing inequalities for trans people in society.

In the episode, we start off by discussing care related to the process of transitioning itself. Most people have a vague idea about medical transitioning with gender-affirming hormone therapy or surgery, but forget about social transitioning (changing your name, ‘coming out’ to friends, family and colleagues etc). Dr Kate Nambiar discusses in the episode how there is a misconception about how these follow on from one another (first social, then medical, then surgical) when in reality they should be more like three ‘pillars’ which are built up together. Also, it is worth noting that not all trans people want all interventions, and that they should also not need to have any to prove their transness. Different countries have different regulations in terms of what is needed to legally change gender. For example, in Finland a trans person still needs to be sterilised in order to have their gender legally recognised (!!!!) source

Because I myself do not know enough in this field myself, but believe I have a vague idea what many cis people’s FAQs might be I thought it would be worth addressing common ‘concerns’ people wrongly have when it comes to caring for trans people. Many get unnecessarily worried and worked up about hormone therapy, which is why we discuss this in some depth in the episode. There are different types of gender affirming regimens, and all come with some risks. However, these risks can be mitigated and monitored.

And most importantly: hormone therapy is not a leading cause for mortality in trans people. Therefore, why on earth do people get so worked up about gatekeeping hormone therapy, rather than addressing much more critical issues such as: high rates of HIV and AIDS, suicide and substance misuse. There is some more information about this in Asscheman’s paper below.

So hormones are not the biggest threat to trans people’s health by a long way – and can improve wellbeing.

Now, let us remember that it is an established fact that ‘the NHS is failing trans people’. See the quote below.

High levels of transphobia are experienced by individuals on a daily basis (including in the provision of public services)—with serious results. About half of young trans people and a third of trans adults attempt suicide. [emphasis mine] The recent deaths in custody of two trans women, and the case of a trans woman who was placed in a men’s prison, are particularly stark illustrations of the issues.

[…]

The NHS is letting down trans people: it is failing in its legal duty under the Equality Act.

Trans people encounter significant problems in using general NHS services, due to the attitude of some clinicians and other staff who lack knowledge and understanding—and in some cases are prejudiced. The NHS is failing to ensure zero tolerance of transphobic behaviour. GPs too often lack understanding and in some cases this leads to appropriate care not being provided. A root-and-branch review must be conducted, completed and published by the NHS.

House of Commons Women and Equalities Committee, report on Transgender Equality available here

Therefore, we eventually move away from honing in on transition-related health care and focus on wider social justice issues which are making life for trans individuals incredibly difficult and distressing, even killing them. I was so grateful to Dr Nambiar and Dr Quinney for highlighting so many important points and provide some inspiration for change among disheartening statistics.

If you feel that you would like to read more about trans health, start off by checking out the links under ‘mentioned in the episode’. Then turn your attention to the links under ‘further reading’ below.

Further reading

Trans terminology, education basics: https://16point6.wordpress.com/a-z-glossary/

Dr Sophie Quinney’s talk on transgender healthcare in Wales: https://www.youtube.com/watch?v=Ym1jWVdcWFs

Sexual health resources for trans and non-binary people: https://www.tht.org.uk/hiv-and-sexual-health/sexual-health/trans-people

The Terrence Higgins Trust: lots of information on sexual health including PrEP for HIV, testing and other aspects of sexual wellbeing (which Dr Nambiar has been involved in) https://www.tht.org.uk/hiv-and-sexual-health/sexual-health/trans-people

GMC guidance on caring for transgender persons, including prescribing and mental health: https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare

National Gender Identity Clinical Network for Scotland: https://www.ngicns.scot.nhs.uk/

Trans Youth factsheet with lots of myth busting and useful resources: https://ruralgp.scot/wp/wp-content/uploads/2017/03/fs_transyouth.pdf

Is your practice LGBTQ+ friendly? https://ruralgp.scot/lgbtq-plus/

The state of trans healthcare in the UK (GenderGP): https://www.gendergp.com/the-state-of-trans-healthcare-in-the-uk/ with YouTube video

How NHS care could be improved (GenderGP): https://www.gendergp.com/revolutionising-nhs-care/