The Transgender Issue: An Argument for Justice

by Shon Faye

When I was assessed at the adult gender identity clinic in Hammersmith, in London, I was asked extensive and intrusive questions about my childhood and family background, such as why my parents divorced and why I didn’t have contact with my father. None of this was relevant to an assessment of whether or not I had the mental capacity to consent to treatment and to understand the implications for my body, or whether I was physically suitable to start treatment. It seemed that my private history was being used to inform adjudication on whether my identity was real. Yet I felt obliged to answer all the questions in case they declined to treat me.

was still threatened with delays or postponement of treatment on two counts. The first was medical. At my initial appointment I was still a smoker who had struggled to quit despite numerous attempts. I was told that clinic rules required my having quit for at least three months before I could be prescribed oestrogen. (This paternalism also applies to fat trans people, who find themselves instructed to lose large amounts of weight before being allowed to access surgery.)

While my private doctor told me I should be making serious efforts to stop smoking, given the increased likelihood of blood clots in combination with long-term hormone treatment, they recognized that withholding treatment from someone with severe gender dysphoria might well make it harder to break a heavy nicotine addiction than it would be if they were in a better emotional state after commencing treatment. The doctor also acknowledged that refusing access to hormonal transition might have a worse overall impact on a trans person’s mental and physical health than allowing them to commence treatment while monitoring them for risks associated with smoking.

The threats of delayed treatment thereby led to a breakdown in trust between the clinic and me: I was not providing them with all the relevant medical information they needed to monitor me properly.

I hadn’t yet changed my name legally, I told the clinician, as I hadn’t needed to change my passport or driving licence. I was then told that I needed to make the legal change and provide proof. Treatment would be postponed until I had done so – meaning a further delay of at least six months. There was no substantive reason given for this demand. At the time, I had been on hormones for eighteen months under the care of a private doctor. I had grown breasts and permanently removed my facial hair. The insistence that my legal name be changed before the NHS would take over my treatment seemed punitive.

I have since met trans people who wanted to keep their ‘unisex’ birth names (for example ‘Alex’), who told me they experienced pressure to legally adopt a different name because of ‘gender clinic rules’.

There are more egregious examples of this power imbalance between NHS clinicians and patients. As recently as 2018, GPs seeking to refer patients to the Leeds and York Gender Identity Clinic were incorrectly instructed to conduct a physical examination of their patients’ genitals,30 guidance which has now fortunately been removed. Neither international best-practice guidance nor the NHS England specification for gender identity services endorses genital exams as being in any way routine; both explicitly state they cannot be required of patients. However, for some trans people who are told they must endure this invasive inspection (either because of clinician ignorance or intentional abuse of power), this instruction can lead to non-consensual inspection and touching of intimate parts of the body, which may be experienced by the patient as abusive.

To translate: trans people wishing to access surgery are tasked with demonstrating to doctors that they are actively seeking (and receiving) acceptance (or at least tolerance) from cisgender people within cisgender-dominated environments. This sense that you need the social consent of others to access surgery can be further intensified for trans people of colour or neurodiverse trans people, such as those with autism.

Statistics like these suggest that black patients may be taken less seriously, or are perceived to exaggerate their symptoms; both perceptions damage the quality of care they receive. Research suggests that anti-black racism may increase or intensify ‘gatekeeping’ around hormones and surgery for black trans people in clinical settings: black trans women, in particular, have encountered among counsellors prejudiced attitudes that their presentation was ‘too masculine’ for a woman, which they perceived to be grounded in racist perceptions of gender and femininity.33 It is clear that trans people of colour’s experiences of systemic racism in healthcare and surgery are still woefully under-investigated and under-researched and that the accounts of transphobic medical discrimination which receive most traction are likely to be those of white people.

Male doctors, Roche argues, often see the reconstruction of genitals as being about appearance, forgetting that the genitals are also sex organs designed for the giving and receiving of pleasure. In Roche’s own case, they felt some of the clinical attitudes came from ageism and sexism about middle-aged women: ‘gatekeepers saw a middle-aged woman who they presumed wouldn’t be having sex – because who has sex with middle-aged women, much less middle-aged trans women?’

In particular, Roche argues, the patriarchy inherent in trans medicine manifests for trans women with ‘the clinical reality of gender confirmation, which prioritizes depth over sensation, and confirmation over pleasure’. Roche recalls a particularly uncomfortable routine inspection after surgery, called ‘the depth test’, in which the surgeon checked the depth of the new vagina with his fingers while inattentive to Roche’s obvious pain and discomfort, as symbolic of the misogyny woven into standard clinical practice.

When I was a teenager in the early 2000s and started to experience acute gender dysphoria with the onset of puberty, I didn’t believe it was possible for doctors to help me. I felt – as teenagers so often do – that I was the only person in the world feeling what I was feeling. Yet I also experienced a growing sense that the profound discomfort with my body and the gender role I was being compelled to occupy was not the typical teenage angst of my classmates. I developed an anxiety disorder and withdrew from friendships.

Because of enduring misinformation, it is important to clearly restate the fundamentals of what is meant by ‘transition’ in relation to children. To emphasize: no trans child in Britain can have genital reconstruction surgery, both because of clinical protocols that establish a minimum age of seventeen for signing-off on surgery, and because no British surgeon would perform it on anyone under the age of eighteen. In the UK, referral for trans surgery can only be made by one of the twelve adult gender identity clinics for over-eighteens. The use of ambiguous and dated terms in media headlines referring to ‘sex change children’ misleads the public, implying that genital surgery is being carried out on children when it is not. More often than not, when the term ‘transition’ is used to refer to children and young people, it signifies social transition.

Clinically, the first time any medical intervention can be made is with the onset of puberty. In puberty, a child’s body starts to produce sex hormones in the amounts required to trigger the development of secondary sex characteristics that typically distinguish cis men and women. While biological puberty is primarily about the ability to reproduce, socially it fixes how a person’s gender is perceived. Unsurprisingly, for children with acute gender dysphoria that has been alleviated by social transition in childhood, the onset of puberty can cause intense distress.

It is in cases like these, usually, that medical intervention may be sought: it is possible to arrest a child’s puberty through the use of drugs to suppress the release of sex hormones. Puberty blockers have been used since the 1970s to treat precocious puberty, a natural variation that causes some children to start puberty early, but which can cause restricted height in adulthood and result in social stigma, bullying and distress from being visibly ‘out of step’ with peers. In their more recent use for children with gender dysphoria (in Britain, from the 1990s onwards), blockers are primarily intended to give the child and their family more time to consider their gender identity, as well as their future medical options, without the irreversible changes of puberty taking place.

To the astonishment of many trans health advocates, the High Court ruled in Bell’s favour. It ruled that referring any child under the age of sixteen for blockers would require express legal permission from the court. No other medical treatment given to teens in Britain demands this interventionist approach.

Thank the gods and the Court of Appeal that this has been correctedhttps://genderedintelligence.wordpress.com/2021/09/17/bell-v-tavistock-quashed-on-appeal-easy-read/

Again, there is a parallel with individuals who regret having abortions being used as a principle by which to judge access to abortion for all.

Bell’s solicitor, Paul Conrathe, is a lawyer with a long history of taking anti-abortion cases. In 2001 Conrathe, working with the single-issue anti-abortion party Pro-Life Alliance, sought an injunction on behalf of Stephen Hone to force his ex-girlfriend to continue an unwanted pregnancy. That this is the man successfully arguing for the legal review of a different kind of bodily autonomy should give us pause for thought.

In April 2021, NHS England announced that a new independent review group would be created to help determine if existing GIDS patients under sixteen should be able to continue treatment but that the blanket ban would remain for new patients. Whatever GIDS’ policy, it is clear that only trans children with parental support may once again be able to access treatment; those without parents onside cannot. While this is an undesirable distinction in terms of trans children’s own right to access care, it was always the case in reality.

An independent review of gender identity services for young people in England, chaired by a former president of the Royal College of Paediatrics and Child Health, Dr Hilary Cass, was announced in September 2020, and its findings are yet to emerge. It is clear that the legal status of trans youth healthcare is an ongoing maelstrom unlikely to be settled in the immediate future.

Current waiting times for a first appointment at GIDS are over two years. The GIDS assessment process for referral, and the waiting times involved in commencing treatment once referred, mean roughly another year will elapse before those teenagers approved for blockers start taking them. Three years from first referral to starting treatment is a long time in an adolescent’s life. Yet, medically, to be at their most effective in suppressing the development of secondary sex characteristics, blockers should be started at the outset of puberty, or what paediatricians call ‘Tanner Stage 2’ (at ‘Tanner Stage 1’ the child’s sex characteristics are entirely prepubertal). The precise timing of this optimum stage of course varies from child to child; typically it occurs at any time between the ages of nine and twelve. In cases of precocious puberty, blockers are usually first administered to children under the age of eight without any need for court oversight. As a result, international consensus outside the UK is that it is not clinically prudent to specify a blanket minimum age for blockers in cases of gender dysphoria.

figures shown to the court in 2020 indicated that, in the year 2019–20, just ninety-five people under the age of sixteen started using blockers and only twenty-two under the age of thirteen. According to GIDS’ published figures, in the financial year 2018–19 it received 2,406 new referrals; of these, only 230 (9.6 per cent) were aged ten or under at the time they were referred. This means that, even before the Bell case, over 90 per cent of children who were referred to GIDS had no practical chance of ever starting blockers before their puberty began anyway.

The reality, then, is this: the number of children receiving timely medical intervention was vanishingly small even before the legal challenge to its use in December 2020; the UK’s approach to puberty-suppressing treatment is highly conservative compared to other Western countries; and the waiting times, already almost unendurably long, are getting worse, with no plan in place to bring them under control.

Then, Henry says, they asked him to describe his experiences of gender. Henry found this line of questioning difficult. ‘There were questions about gender that I find really hard to describe. Because even though I’m a trans man, I find it really hard to describe my gender without resorting to stereotypes that I don’t fit because I’m not particularly masculine.’

The process was so long and drawn out that Henry knew that, by the time he was finally able to take blockers, it would be too late.

Henry’s frustration was not just down to the difficulty of the clinical approach in his face-to-face sessions with GIDS staff, but the nature of the medical protocols themselves. Aged sixteen, he still hadn’t been referred for blockers, and many of the irreversible pubertal changes to his body had already occurred.

‘I just felt like I was stuck because of some arbitrary rules that don’t actually make any sense. It felt,’ he continues, ‘like this wasn’t for the benefit of trans people. It’s for cis people who feel uncomfortable with the idea of trans teenagers going through the puberty they want at the age other kids go through puberty.’

A few months after turning eighteen, Henry was seen at the adult Gender Identity Clinic in west London. This was, he thinks, at least the sixth appointment with a clinician in which he had to answer the same questions he’d been answering for years. At the end of the appointment, the clinician said he should have yet another appointment before starting hormones and Henry broke down. ‘She wasn’t very understanding,’ Henry says of the clinician. ‘She was like, “Why are you crying like this?” and I said, “Because I’m so disappointed.” In the end my mum came in and explained everything. Even then, the clinician answered, “I don’t get why you’re still upset.” I don’t think they can be very understanding sometimes of how emotional and how draining it can be, and how much emphasis people put on these appointments. It means so much to people.’

There is intensifying critical media attention on referrals to GIDS of people assigned female at birth who identify as male or non-binary. In 2009–10 the number of new referrals from this group was forty; in 2017–18 it had risen to 1,806. Whereas young people transitioning from male to female were once the largest group, now two thirds of GIDS patients were born female. This is a trend reflected worldwide, and it has caused significant speculation. Though the root cause is unknown, the general explanation offered by trans communities – that it is a result of increased visibility, acceptance and openness about trans people and gender variance in society – is met with widespread media scepticism.

In September 2018, responding to a welter of press coverage on this issue, the then Women and Equalities Minister Penny Mordaunt MP announced an inquiry into the increase in the number of ‘girls’ seeking support with their gender identity (the inquiry was later quietly shelved when Mordaunt was sacked in a cabinet reshuffle by Boris Johnson). Evidence for such a social contagion is spurious and based on the subjective and hostile impressions of commentators.

I ask Henry what he makes of this narrative. ‘Oh I’ve had that so much online. It’s so frustrating,’ he responds. ‘If you talk to a teenage girl that had anorexia or body dysmorphia and then hear a trans man talk about their experience you realize they are so different.’ The crucial difference being, of course, that anorexia can cause you to starve yourself, in some cases to death, whereas medically transitioning does not kill you, it alleviates psychological pain.

the press-fuelled idea that autistic people are mistaken about their gender is similarly harmful. ‘It’s so ableist and insulting that autistic people can’t make decisions or know themselves – being stereotyped does nothing but harm actual trans people.’ Henry thinks that, ironically, the negativity of the media narratives around healthcare for young trans men is due to the way this group is routinely infantilized, which he believes is connected to sexism.

Henry’s subtle analysis of the gendered ways in which he sees himself versus how society sees him resists the simplistic story that he’s just a lesbian trying to escape homophobia and misogyny. In fact, Henry says, he’s unclear of his precise sexual identity because his teenage years have not involved romantic relationships. ‘I don’t know yet if I’m just uninterested or if it was because I was struggling with untreated dysphoria.’

Back in 2013, the medical ethics expert Simona Giordano published a clinical, ethical and legal review of treatment for children with gender dysphoria, in which she concluded that, ‘omitting to treat, or deferring treatment, is not a morally neutral option.’

As Giordano put it in a 2020 paper: Puberty blockers are not ‘novel’ treatment. They were recommended by prominent bodies of medical opinion in the UK and internationally over two decades ago and have thus been part of standard medical treatment for many years.

The psychiatric model of assessment and diagnosis must end, and be replaced with multiple options for elective therapy and counselling for those who want it. This approach is already common in other countries. Here, it is due to be trialled in small pilot schemes in London and Manchester. In the 2020s, timely access to transition-related healthcare will be the most pressing issue facing trans communities in Britain.

Both trans men who have sex with men and trans women who have sex with men are in higher risk categories for certain sexual health issues, including HIV. Though the data on Britain is scant, worldwide 19 per cent of trans women are estimated to be living with HIV; globally, trans women are forty-nine times more likely to be HIV positive than the general population.

This risk increases for BAME trans women and/or sex workers, who make up a significant proportion of the trans population. The data on trans men and non-binary people living with HIV is extremely poor.

Trans-run sexual health and wellbeing services like 56T and CliniQ offer a vision of how more holistic trans healthcare could be administered in Britain. Both also provide counselling and, though they have not thus far been able to prescribe hormones, have the capacity to administer necessary injections as part of hormone treatment for patients whose GPs are less cooperative. Increasing the breadth of these kinds of services beyond sexual health to mental and transition-related health, outside London, would be one step towards dismantling the oppressive structures trans people have experienced for almost a century in their interactions with the medical establishment.

In the early 1970s, Sweden became the first country in the world to allow trans people to change their legal sex. However, it simultaneously enforced a strict policy of compulsory sterilization, on the grounds that such people were mentally ill and unfit to care for children: eugenics, pure and simple.

The Swedish courts finally overturned this foul policy in 2012 – but, in the intervening forty years, the practice had spread to many other European countries, including France, Belgium, Bulgaria, Cyprus, the Czech Republic, Finland, Greece, Latvia, Lithuania, Luxembourg, Romania, Slovakia and Slovenia. Astonishingly, all were signatories to the European Convention on Human Rights when they enshrined this coercive violation of trans people’s bodies. The United Nations has recognized the mandatory sterilization requirement to be a form of torture, cruel, inhuman or degrading treatment, and the Council of Europe has, in the past decade, finally established that member states must abolish this requirement: in 2017, the European Court of Human Rights ruled that coerced sterilization violates trans people’s right to privacy and family life.39 Yet sterilization of trans people is still demanded in many countries around the world, including Japan.

Gamete storage, otherwise known as freezing one’s sperm or eggs, is expensive. It costs several thousand pounds up front and several hundred pounds every year thereafter in ‘rent’ for the clinic’s storage of the cells until they are used. Coming in the midst of the upheaval and expense of transitioning, such a cost is out of all but the richest trans people’s reach – unless, that is, it’s available on the NHS. The availability of free fertility treatment for British trans people, though, is a postcode lottery. While there is a clear funding approach for other patients who may be rendered infertile (such as those undergoing chemotherapy), the approach to transition-related fertility treatment is highly inconsistent.

Trans healthcare must be revolutionized urgently: it was created not to help us but to conceal that which is unpalatable to cisgender people and to erase the implications of our existence for the rest of society. That is why we were not permitted families in so many cultures and why authoritarian governments always attack our access to care. Yet in this we are not unique. Cisgender women, disabled people, fat people, black people, HIV-positive people and trans people are all groups that experience high degrees of medical discrimination and abuse, historically and currently. Our struggle is, then, a shared one – and it should not be left to us alone.

A recent Stonewall report provides a sobering statistic: one in eight British trans people have been physically attacked at work.

A 2015 EU report found that trans people living in the EU were more likely than their cisgender counterparts to be in the bottom 25 per cent of earners.3 In the UK, as many as one in three employers say they would be less likely to hire a trans person.

in its near neighbour Ireland, trans unemployment is running at 50 per cent.

According to the British Social Attitudes survey, British people are much more transphobic than they think they are. While 82 per cent of people say they are not prejudiced against transgender people ‘at all’, only 41 per cent of Britons believe trans people should ‘definitely’ be able to teach kids, and only 43 per cent agree that trans people should be allowed to become police officers.

Given the way in which LGBTQ+ people have historically been portrayed as a threat to children or as seducers of the young, this lack of trust in trans teachers strikes a depressingly familiar note. The damaging effects of this kind of suspicion on trans people themselves are clear from the tragic case of Lucy Meadows, the trans schoolteacher we met in the Introduction who took her own life in 2013 after becoming the focus of a media frenzy.

Historically, transition meant financial ruin, even for those who were better off to begin with. Jenny-Anne Bishop, a seventy-year-old British trans woman who has been prominent in community-led activism in north Wales, estimates that ‘over the years, I reckon in lost salary, seniority, and pension interruptions I have lost at least £250,000, just for being trans.’

Under the Equality Act, any person who takes steps to reassign their gender or is perceived to have done so is protected from discrimination on that basis. It means that you cannot refuse to hire a person for being trans, fire them for being trans or refuse them goods or services for being trans. These protections also extend to family members and partners of trans people who are discriminated against because of their connection to the relevant trans person. While legislative protections are crucial, and their presence should not be taken for granted (only twenty-two US states currently protect trans people in employment, for example), they alone cannot change the underlying prejudices. As Jenny-Anne Bishop recalls: ‘Even after the gender reassignment regulations were added, particularly in the private sector, there was always a way found to get rid of you.’