Harsh realities of trans health

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trans-healthcare-Liz-Highleyman.jpg

A trans contingent on San Francisco LGBT Pride 2012. Pic: Liz Highleyman

Trans people face many barriers to accessing healthcare, from medics’ lack of training to funding cuts. Pat Clinton argues that access is a class issue intertwined with oppression.

Four years ago a trans person posted the following: “We need a hash tag for crap trans medical treatment. How about #TransDocFail?” The hashtag has yet to fall silent. Reading through people’s accounts on Twitter of problems they’ve faced trying to access healthcare, two things become apparent. First, this isn’t just about transition-related healthcare — many of the tweets are about run of the mill doctor and nurse appointments. Second, you don’t need to fly to the US bible belt to find a GP denying transgender people the most basic medical care; it’s happening right here in the UK in 2017.

In this article I will look at the difficulties trans people encounter accessing health services, both when transitioning and for everyday medical concerns. I will approach this with an understanding that oppression and class come together to shape trans people’s ability to access services — especially when those services are under increasing pressure from Tory cuts.

Transition-related healthcare is fraught with problems, from underfunding to ridiculously — and illegally — long waiting times. Occasionally these issues hit the mainstream press. Last year the BBC reported that “one of the largest clinics, based in London, has admitted that waiting times are between 12 and 18 months for an initial consultation”. It later reported on the misgendering of a patient during sexual reassignment surgery: “When she woke up from her operation, she remembers a member of staff on the ward referring to her as ‘he’.”

I could regale you with my own story of how the gender identity clinic (GIC) took months to take me on and now plainly say it has next to no protocol for how to treat non-binary patients but won’t sign off the treatment I want.

It is incredibly rare to see medical transitioning reported in a positive light. When the debate of where NHS cuts should come from, transitioning treatments are often brought up as an example of where money is “wasted”. “How should the NHS spend their money — on sex change ops or terminal cancer patients?” asked the Bristol Post in 2013. This ignores decades of research showing how essential this treatment is for trans people and overlooks how for many in the community being able to medically transition is literally life saving. It also stirs up transphobia and diverts attention from the real issue — that cuts are not necessary at all, as there is always money for war and bankers’ bailouts.

This negative reporting is at its sharpest when transgender children are discussed in the media. The recent BBC documentary, Transgender Kids: Who Knows Best? is an example of this. Another lighter piece was a BBC news item covering a human interest story on a ten-year-old trans boy and his family’s journey with his transition. The reporter explained that “Jason says this treatment is ‘amazing’, even though it means he has to have regular injections, of which he is usually terrified. ‘If I was to carry on living as a girl, I don’t think I could do it. I probably wouldn’t come out of my room’.”

The piece detailed how the waiting times strained the family to the point of them turning to private healthcare. “So instead of waiting, Leanne took her child to see a private doctor to begin a monthly course of temporary hormone blockers, at a cost of £100 each month.” Tellingly, the item mentioned that hormone replacement therapy is available on the NHS for over 16s but that such a limit does not exist within private healthcare, where treatment can start at age 13 or 14, the age at which puberty more commonly begins.

The Daily Mail published an article last December entitled, “Gender, Our Children and the Death of Common Sense”. It suggested that “common sense” is that all gender-questioning children are victims of the “powerful and very vocal transgender lobby”. However, good sense would tell us all that children, like everyone else, deserve the space and support to explore and express themselves safely. This well-funded hate piece began by noting that calls to ChildLine about gender identity have almost tripled in the last three years but then went on to ignore this fact, simply arguing that we must “put an end to this nonsense”.

But what of everyday medical treatment? What of trans people simply needing to see a doctor due to a chest infection or to go to A&E for a sprained ankle? The hidden side of the problem with transgender people and the NHS is getting to access it at all.

To me, as a disabled transgender person, this predicament is commonplace. Since coming out as trans I have struggled to find a GP who will treat me satisfactorily — I’ve been through about six. This has made it more difficult to get referrals to specialists, who are the only route to gaining specific forms of treatment, which has caused my conditions to deteriorate way beyond their normal rates.

I have been denied physiotherapy because my GP didn’t want to interact with a trans person. Some of this is straightforward bigotry, but a big portion of it is ignorance and lack of training in the medical sector about the transgender community.

Most of us within the community are accustomed to becoming our own doctors and having to educate experts on trans healthcare. At times it can be a positive but draining experience. But often you hit a brick wall — despite doctors having no official training in trans healthcare (your actual, lived existence), you as a patient are not allowed to know more than them. Disabled people, transgender or cisgender, are not strangers to having to become medical experts and always having knowledge of their own health questioned.

It also doesn’t help that when encountering transphobia from medical professionals in the NHS it is difficult to complain about it. A publication from the Women and Equalities Committee about transgender issues talks about some complaints which had come to its attention:

“Following a survey of problems with healthcare services, resulting in 98 complaints, a dossier of 39 cases warranting further investigation was submitted to the General Medical Council (GMC) in 2013. Those cases involved allegations of sexual abuse, physical abuse, verbal abuse, inappropriate and sometimes damaging treatment, treatment withheld, threats of withholding treatment, poor administration, and acting against patients’ best interests. There is a strong perception in the trans community that the GMC failed in its duty to take these complaints seriously.”

Many trans people fear ever making a complaint against their medical practitioner, no matter how serious the incident. “Many people stay quiet and do not complain because they are fearful that the NHS will withdraw treatment if they make a fuss,” concludes an NHS symposium report from 2015.

Another common problem for trans people, when they do manage to access healthcare, is that their gender and transitioning are assumed to be the reason they are sick — no matter the actual ailment. This is so prevalent it has its own name, Trans Broken Arm Syndrome, commonly defined as “when healthcare providers assume that all medical issues are a result of a person being trans. Everything — from mental health problems to, yes, broken arms” (Pink News, 9 July 2015).

A large factor is the lack of training for medical professionals on trans people’s needs. But once again the problem of not listening to trans people’s own assessment is key. Because trans people have to fight so hard for every step of their medical transition they are acutely aware of what side effects medication and/or surgeries might have. If something looks like it could be connected, we will say so. Another popular Twitter hashtag on the subject is #transhealthfails, which has examples such as: “Me: I’m not feeling well. Dr: I can’t help you transition you need a specialist for that. Me: I transitioned 18 years ago.”

This causes a ripple effect because trans people have repeated negative, or even dangerous, experiences trying to access even the most basic of medical care. According to a major US study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, 28 percent of trans individuals postpone medical care because of fear of facing discrimination, 28 percent had been subjected to harassment in a medical setting, 26 percent had been physically assaulted in at least one health care facility and 19 percent had been refused care because of their gender identity.

Many transgender people eventually stop trying to see a doctor at all, which has devastating effects on the community.

This is seen most sharply in the rates of HIV in transgender people, in the UK and internationally, as reported at aidsmap.com:

“Susan Buchbinder of the San Francisco Department of Public Health said, ‘There is probably no population that is both more heavily impacted [by HIV] and less discussed around the world than transgender people.’ One worldwide meta-analysis of 39 studies from 15 countries found that transgender women had an HIV prevalence rate of 19 percent — 49 times higher than that of the general population. In high-income countries the prevalence was 22 percent, with the highest rate among trans women of colour.”

Comparative data about transgender men, regardless of sexual orientation or practice, is either nonexistent or too small to note in studies. And so far I have been unable to find any studies that even include non-binary people within their remit, including studies devoted to HIV rates within the transgender community.

There is no doubt that large measures of these infection rates are due to overwhelming poverty and social exclusion causing many trans people to go into sex work. But the difficulties in accessing everyday medical care exacerbate this problem.

There have been some great strides in the UK LGBT+ community as a whole to try to increase testing and therefore personal knowledge of HIV status, but these tests are not always easy to get. It is great for events like Birmingham Pride to announce that there will be a tent over the weekend which will provide free HIV testing, but those who would need it the most probably can’t afford £20 for a day ticket. It’s great that the LGBT foundation in Manchester offers free testing drop-ins, but at least half of them are only within normal day working hours and only one on a weekend.

It is important to look at all this through the filter of class. Yes, transphobia from the medical community and in general will exist for all tiers of society. But if you can afford to pay for your treatment, transition based or otherwise, privately then you won’t be limited by catchment areas or bigotry. If one doctor doesn’t wish to treat you (less likely since when paying them directly they tend to want you to stay and keep paying them), you can move to another. When it comes to transition related medical care the whole disgusting system is cut through if you can afford it.

One trans blogger describes the process: “The wait time for an initial appointment with the [NHS] Gender Identity Clinic in Charing Cross is about 12 months… If you go private, you can self-refer to a gender-specialising clinic — that is, if you have wealth, you can bypass the barriers of the GP referral and the referral from a CMHT [Community mental health team]. They’ll do their own assessment and prescribe hormones as appropriate like at Charing Cross, but the wait times are only two weeks for the initial appointment, and one further week of waiting for blood work before you get a prescription. It costs about £725, plus follow-up appointments (£140 each) and prescription refills (£195 for three months’ worth). Sometimes the private clinic prescribes mandatory counselling, which costs £150 for an hour-long session.”

People like Caitlyn Jenner and Chaz Bono don’t have to sit through months of waiting times or wrestle with insurance companies — everything they need is on demand because they can afford it. There are many treatments, like facial feminisation surgery or trachea shave surgery, which don’t exist at all on the NHS and so are out of reach to working class trans people.

As with all medical treatment there is a two tier system. One tier is exclusively for those who can afford it, where waiting times are virtually non-existent and discrimination is based on cash rather than any other social factor. And there is a lower tier with devastating cuts, brutally long lists and treatment decisions based on how much those providing it think you deserve it rather than whether you need it. As Pink News wrote in 2015, “A few years ago, a survey was done on a mix of GPs and hospital doctors, and 84 percent of them responded that they didn’t think public money should be spent on ‘lifestyle choices’.”

We need a healthcare system that provides for the needs of all, that does not discriminate and that is adequately funded; a system where professionals receive adequate training and patients are listened to. This is something we all have to fight for — and something that, I believe, will require a much more radical transformation than will be granted under a capitalist system.