The Transgender Issue: An Argument for Justice

by Shon Faye

For trans women and other trans people who were assigned male at birth, there can be anxiety about accessing appropriate women’s services because of trans women’s perception that they are not welcome, and media narratives framing them as a risk to cisgender women. While most of the key women’s organizations in the UK state publicly that they can and do support trans women survivors, hostile attitudes to trans women are still found within the sector.

That people in leadership positions within the support sector will openly call trans women ‘men’, and conflate trans women’s existence with the gaslighting of cisgender male perpetrators, may go some way to explaining the institutional barriers many trans women have come up against while attempting to access support in gendered services. The British media conversation about trans women and ‘women only’ domestic violence services has been instrumental in blocking legal gender recognition reforms and has prevented genuine engagement with the reality of trans women’s experiences of domestic abuse – which are, as a result, simply erased.

Here, it’s crucial to point out that the struggles faced by trans women in this regard are very similar to the struggles faced by BAME, lesbian and disabled women.31 There is a wider structural reality at work: the hostility and bad-faith discussion of trans inclusion in domestic violence services is in the interests of a right-wing government that does not wish to fund these services at all. This manufactured controversy over trans inclusion is a deliberate distraction:

Instead of solidarity, transphobic commentary rejects any responsibility towards trans survivors, often insisting that trans people should create their own services and refuges if they need them so badly. While specialist provision for trans survivors is to be encouraged, there is a difference between advocating for tailored services designed to help people with specific experiences and championing enforced segregation.

Nearly half of transgender people who do have children have no contact with them.

The prospect of entering care homes, however, is daunting, as trans people worry about a loss of personal agency and hostility from care workers and other residents. Speaking in a video about older trans people for the My Genderation campaign ‘Growing Older As Me’, Cat Burton, a sixty-six-year-old retired pilot, described some of the simple ways in which trans people may lose control over their appearance and self-expression:

For older trans people who come out late in life, particularly those who wish to surgically transition, there can be anxiety about requiring intimate and personal care when their genitals or other sex characteristics are ‘incongruous’ with their gender.

talking to trans people about their own priorities demonstrated to me that an urgent redirection of focus and political energy is needed. School bullying, family rejection, homelessness, domestic abuse and discrimination in care services are major issues that continue to affect huge numbers of trans people, even as societal attitudes appear to be growing more tolerant.

In all this, it cannot be emphasized enough that the political demands of trans people align with those of disabled people, migrants, people with mental illnesses, LGB people and ethnic minorities (and, needless to say, trans people can be found within all of these groups). This overlap between the needs of different marginalized people must be stressed because the illusion that trans people’s concerns are niche and highly complex is often a way to disempower them. The

Such narratives, of demanding and entitled trans patients expecting a surgical shopping list to be paid for by the public purse, have shaped a culture in which it’s still considered acceptable to discuss trans people’s bodies in this way.

One notable characteristic of Cox’s advocacy was a categorical refusal to discuss her own medical transition, insisting that this was the wrong focus. In an exchange that went viral online, she told the television host Katie Couric: The preoccupation with transition and surgery objectifies trans people. And then we don’t get to really deal with the real lived experiences. The reality of trans people’s lives is that so often we are targets of violence. We experience discrimination disproportionately to the rest of the community. Our unemployment rate is twice the national average; if you are a trans person of colour, that rate is four times the national average. The homicide rate is highest among trans women. If we focus on transition, we don’t actually get to talk about those things.

Yet trans people in Britain have tried to bring about change in healthcare. In February 2013, the General Medical Council (GMC) was presented with ninety-eight cases of alleged misconduct by British doctors and other medics towards their trans patients. After a grassroots campaign on social media had allowed hundreds of ordinary trans people to speak out about medical mistreatment, their cases were compiled by the campaigner and Liberal Democrat parliamentary candidate Helen Belcher.

While the GMC displayed an initial interest in taking formal action, technicalities and the anonymity of the complainants meant that only thirty-nine out of the ninety-eight cases were taken forward. Of these, in the end only three of the complaints were fully investigated. Ultimately, none were upheld.

As with so much political activity for trans liberation in the 2010s, the GMC investigation was only made possible by social media. The details of widespread abuse of British trans people by those who were supposed to be helping them wasn’t a story broken by a newspaper or uncovered by an inquiry. It began with a hashtag. #TransDocFail was created by a trans woman in 2013 as a space for British trans Twitter users to discuss failures in healthcare publicly and with each other. Within twenty-four hours of its creation the hashtag was used over a thousand times.

Back in 1972, a group of transsexuals and transvestites, meeting regularly in Notting Hill, in London, as a branch of the new Gay Liberation Front, wrote a piece for the activist pamphlet Lesbian Come Together. As many as 60,000 people in Britain were taking cross-sex hormones, they stated; more wanted to do so but were refused by doctors. They described the stigma to which trans people were subjected by the medical profession

This is not simply a matter of a few ‘bad apples’ practising psychiatry, or well-meaning ignorance on the part of GPs’ receptionists that can be quickly remedied by an afternoon training session. The medical establishment in Britain is systemically and institutionally discriminatory towards trans people. This may come as a surprise to those who argue that transgender identity is a fad being pushed by ‘Big Pharma’, private plastic surgeons and a nefarious global medical industry: a conspiracy theory rehearsed among groups as apparently disparate as the US Christian right and some anti-trans feminist writers.

But the idea that trans people and their doctors are in cahoots is laughable: the reality is starkly different. The entire trans healthcare infrastructure emerged in the course of the twentieth century under the mantle of the highly patriarchal field of psychiatry. Institutionally, doctors came to understand hormone treatment and surgery as a means to police the parameters of what they deemed was or wasn’t an ‘acceptable’ trans person – and, by logical extension, the boundaries of gender itself. When medical transitioning was first devised as a technology, its primary purpose was not to help the trans patient, but to control and manage gender variance in society while leaving the gender binary intact.

Historically, then, transgender health has been less about empowering trans people and more about tying up the loose ends of binary gender in a society where some people’s lives seemed to threaten such a notion.8 In this sense, the development of trans healthcare is more analogous to that of women’sfn1 reproductive health – particularly access to free, safe and legal abortion – than it is to the cosmetic-surgery Ponzi scheme dreamed up in the fevered minds of conspiracy theorists.

For those who need them, medical transition and contraception or abortion are – or should be – about the bodily autonomy of the individual, their right to mental well-being and the freedom to carve out their own destiny in defiance of prevailing gender roles. (These roles, should we need reminding, frame women as vessels for reproduction and trans people as threats to the strict separation of male and female sex roles on which patriarchy depends.) Access to abortion and access to trans healthcare are often attacked in similar ways: principally by overstating the incidence and likelihood of regretting either process, and an intense, disproportionate focus in the media on the stories of individuals who do regret their personal choices, as a way to undermine the principle of choice generally. Only about 5 per cent of women experience any degree of regret over their abortion.

The analogy with abortion is useful primarily because people are generally less aware of the struggle for good trans healthcare than they are of the political warfare over reproductive rights, which affects so many more people. But it is also a helpful comparison given the general confusion among the public about whether they ought to consider being trans as a mental illness and, if not, why the NHS provides treatment for it. I think the distress associated with unwanted pregnancy (which is not an illness but may require medical intervention) serves as a better analogy for explaining why trans healthcare is available on the NHS: to preserve wellbeing and prevent personal distress.

Both trans and cis patients alike have good reason to fear the increasing NHS reliance on the private sector, which drives up costs and introduces a profit motive to healthcare, including gender identity services and surgeries. There is an irony here: it is generally conservatives who make specious claims about money-making schemes preying on trans people, but, in fact, it is conservatives’ own policies of cuts and privatization that actually allow the private sector to behave vampirically.

From the 1990s onwards, things started to change: worldwide, trans people and progressive medics have pioneered affirmative models, in which the patient’s informed agreement to specific treatments – rather than their psychiatric diagnosis – is the key criterion. Worldwide, that is, except for Britain, where, sadly, large parts of the system remain unreformed, anachronistic and unfit for purpose. The model of trans healthcare in Britain is still built around specialist gender identity clinics, which have long since been phased out in Canada, New Zealand, the US and many European countries and replaced with a more flexible approach. How on earth did Britain slip so badly behind in its duty of care to trans people, with waiting lists that often last years?

Historical accounts of gender-variant people who lived in a social role different from the one assigned to them at birth occur in almost every recorded human culture. Sometimes, they lived their lives with the encouragement and licence of their community, which recognized the existence of a third gender – or even several other genders – beyond man and woman; sometimes, their perceived ‘transgression’ of gender norms was understood to merit punishment.

As early as the seventh to fifth centuries BCE, the Book of Deuteronomy’s explicit ban on cross dressing, at Chapter 22, verse 5

in the third millennium BCE, the ancient Sumerian goddess Inanna was worshipped by a cult of transvestite priests known as the Gala,

in third century BCE Rome, the teenage emperor Elagabalus, who reigned from 218–222 CE, appears to have openly displayed his desire to be regarded as a woman.

Rituals of body modification and castration were in fact a feature of sects and cults in which adherents led cross-gender lives. In 2002, the remains of a Roman gala (a eunuch priest of the goddess Cybele) were found in Catterick, north Yorkshire. She was dressed in women’s clothes and jewellery. The galli castrated themselves during an ecstatic celebration called the Dies sanguinis, or ‘Day of Blood’. They bleached their hair and wore makeup. The discovery of the remains in Catterick provides evidence that there were ritually castrated feminine galli present in Britain as long ago as 4 CE: the earliest evidence of gender diversity on this island.

like the discovery of sex hormones in the late nineteenth century and the realization, in the early 1930s, that members of both sexes produced both oestrogen and testosterone. These discoveries challenged the binary idea of sex based on external genitalia, indicating that ‘sex’ was a concept less consistent and immutable than it had previously appeared. Furthermore, they seemed to suggest that changing sex was a possibility.

It must be stressed that the non-consensual, coercive and violent use of hormones to interfere with the bodily integrity of LGBTQ+ people and those born with intersex conditions destroyed countless lives and should be considered a stain on the history of Western medicine. This shared historical experience is also a point of unity for trans people and cisgender lesbians, gays and bisexuals, demonstrating our shared struggle against our pathologizing and mistreatment over the past century and more.

The first known case of a British person medically transitioning from one gender to another with the assistance of hormones and surgeries was Michael Dillon, a trans man (or ‘female-to-male transsexual’). Born in 1915 into an aristocratic family, from adolescence Dillon consistently presented in a masculine way at school,

Given the British media’s recent pained wrangling with the very idea of gender affirmation as a potential ‘slippery slope’, the fact that more straightforward access to medical transition and legal gender recognition was available during the Second World War than is often the case today is astonishing. The mainstream media’s presumption that strict ‘controls’ on transition are and have always been necessary relies on the suppression, and ignorance, of trans medical and legal history.

In 1945, Dillon moved to Dublin, to train as a doctor at Trinity College; there, he underwent several genital reconfiguration surgeries. These were carried out by one of the pioneers of the emerging field of plastic surgery, Sir Harold Gillies, who during wartime had performed several surgeries to restore the genitals of wounded soldiers.

Cowell had obtained sexual reassignment surgery on a technicality, by managing to get herself inaccurately diagnosed as intersex. Medical support for trans people, however, was still rare. Throughout the 1960s and 1970s, individual trans patients continued to use the ambiguous and contested link between physical intersex traits and the psychological experience of gender dysphoria to get certain doctors to treat them – though, even then, few doctors would. A 1966 study in the British Medical Journal found that only ‘9% of psychiatrists, 6% of GPs, and 3% of surgeons’ would agree to actively assist transsexual patients.

a very small number of British doctors. None became more influential – or more notorious – than Dr John Randell, who practised at the very first specialist gender identity clinic, which opened that same year at Charing Cross Hospital in London. The vast majority of British people who medically transitioned between 1960 and 1980 will have had some direct personal contact with John Randell; all will have heard of him. Most British memoirs by well-known trans people – for example those of the travel writer Jan Morris and the transsexual Bond girl and Playboy model Caroline Cossey – mention him. Few speak of him fondly.

his criteria for allowing medical transition were rooted in his own highly idiosyncratic, patriarchal ideas. He would, for instance, refuse trans women whom he considered too tall, or who would not consider taking up a more feminine profession after transition, to ‘pass’ as female. ‘I think if they are going to be ladies,’ he wrote of trans women in 1969, ‘they should be lady-like. Conformity … is surely what we are looking for.’

Even when Randell had assisted with transition, patients often found him brusque, even cruel. ‘It hasn’t made you a woman, you know – you’ll always be a man,’ he reportedly told one trans woman who thanked him after surgery.

It’s worth pausing to consider that the most powerful pioneer of trans healthcare in twentieth-century Britain was a cisgender male psychiatrist who believed neither in the reality of trans people’s deeply held identities nor that gender norms were socially constructed ideals that could be relaxed, challenged or abolished. He believed trans people were delusional about the reality of their situation and that at the same time they also needed to be highly competent mimics of gender stereotypes. He did not believe that they should be allowed freedom over their interpretation or expression of gender.

However, it is important to realize that the framing of trans people as ‘parodies’ who reinforce stereotypes cruelly disregards the ways in which those same British trans people – whose gender expression, dress, hairstyles, makeup preferences and so on have, it clearly needs to be said, always varied as much as their cisgender counterparts’ – have spent the past fifty years being coerced into narrow gender conformity by their doctors, then mocked and derided as too stereotypical and regressive by cis onlookers. If it sounds like a catch-22, it’s because it is.

Non-binary trans people in particular still struggled to access care, or had to withhold information in order to fit a more ‘acceptable narrative’ of simply wishing to transition from male to female, or vice versa.

despite improvements in the past two decades, British trans health providers have retained the same basic route to transition since the 1960s. In the US and in Canada, the gender identity clinic – a centralized institution that holds a monopoly on access to care – slowly gave way to a more flexible model, in which multiple health centres could initiate hormone treatment more quickly on the basis of the patient’s informed consent, without any need for a formal process of diagnosis.

The crisis in healthcare for trans people in Britain is endemic and requires urgent change, especially given the ways it has been exacerbated further by the temporary cessation of clinical care during the coronavirus pandemic. This is a question not simply of funding, but of the structure and approach of transition-related care.

Currently, adults in most of the UK who want to access specialist gender identity services need to approach their GP and ask for referral to one of the UK’s seven NHS gender identity clinics. The only exception is Wales, which has recently introduced a reformed, modern system.

All of which has left some 24 per cent of trans people saying they receive insufficient support from GPs,20 compared to 6 per cent of the wider population expressing the same dissatisfaction.

Contrary to NHS guidelines, which recommend eighteen weeks from referral by GPs for a first appointment, as of June 2019, British gender identity clinics were telling trans patients that they had to wait at least two years. The Laurels, the Exeter-based gender clinic for the south-west of England, said it had nearly 2,000 people on its waiting list; this means a patient could expect to wait up to three years for a first appointment. The pandemic lockdowns have only intensified this catastrophic backlog.

many trans people are looking at a minimum period of three to four years from first speaking to their GP (a step that in itself can take a great deal of courage and time) to a point when they hope to start medical transition. Moreover, when hormones are recommended, gender clinics do not themselves prescribe. Instead, they direct the person’s GP to prescribe. This can bring with it another problem: it is not uncommon for GPs to refuse to prescribe hormones – even with the direction of the gender identity clinic – as they believe prescribing to trans patients is beyond their competence.

The 2016 Trans Inquiry report expressed grave and robust concern at the state of transition-related healthcare in the UK. Yet in the years since the damning conclusions of the Trans Inquiry, nothing has been done to address this crisis. In Britain, there is barely any political will to reform trans healthcare. The Conservative government, never particularly keen on increasing public spending for minorities that don’t wield much economic power, instead hoped that reforming the Gender Recognition Act 2004 would be a cheap way to signal its benevolence to the trans community.

If such a ‘shopping list’ of trans political priorities existed, the reform of healthcare would be near the top: such reform would have a greater impact on the daily lives of trans people than the ability to change their legal sex, a factor only relevant in limited contexts, such as (formerly) one’s pensionable age or one’s legal gender at one’s wedding ceremony.

Ria Cooper, a trans woman, was described by the Daily Mail as ‘Britain’s youngest sex swap patient’, who now wanted to ‘reverse her sex change treatment’. In fact, Cooper did not fully detransition, instead stopping hormone treatment for a few years because of mental illness. She later told Vice, I’d never say that I made the wrong decision in transitioning because I didn’t, but I was going through so much. I was doing escorting and then I got attacked by a client. Everything just went wrong for me and that’s why I had a breakdown … the press will do anything for a story, they chat so much shit.

Such stories have left many with the impression that medical transition is a questionable practice that occurs too quickly and in which regret is common. The truth is very different. Universal medical consensus is that appropriate medical intervention is highly effective for the alleviation of gender dysphoria. The genital surgery satisfaction rate is at 94 per cent 27 (which throws into relief the reported satisfaction rate for elective cosmetic surgeries among the wider population: as low as 28 per cent, according to one survey). Trans people and clinicians alike also acknowledge – again, pretty much universally – that access to treatment is far, far too slow.

But something more fundamental is required: a change in the culture of trans healthcare. Trans people’s trust that they, their bodies and their identities will be respected in all healthcare settings – from the GP surgery to A&E to specialist oncology or sexual health clinics – is low. This trust dwindles even further in the case of gender identity services, whose practices are still clouded by the ongoing perception of clinicians as ‘gatekeepers’. While many modern clinicians refute the idea that they are gatekeeping, the nature of gender identity services – with its continued emphasis on assessment and diagnosis – nevertheless ensures, as the sociologist Ruth Pearce points out, that ‘they do play this gatekeeping role, thereby exercising power as “gender experts”.’