Content warning: body dysphoria, secondary sex characteristics

This is part of the Struggle for trans healthcare equality mini-series, looking at issues affecting local transgender, nonbinary and gender-diverse (trans) communities, driven by people’s lived experiences. While focusing on healthcare, we hope the stories will help shed some light on what life is like for the people actually facing these issues, challenging the stigma and lack of information which often affect their public perception.

“I’m made to feel like it’s done on purpose to ‘punish’ me for being an ‘awkward’ patient.”

Jack Doe*, a 25-year-old transgender man who lives in south Bristol, is on the waiting list for the Gender Identity Clinic (GIC), and like many trans people, he had to go private to obtain hormones, as after three years he is still waiting for a first appointment with the NHS.

But Jack’s trials don’t end there.

On top of the long wait for GICs, GP surgeries, hospitals and waiting rooms can be hostile places for trans and nonbinary people, who face discrimination and inadequately trained health professionals at every turn. The lack of training and goodwill within the healthcare system doesn’t only keep us from accessing specialist, transition-related treatment. Ignorance and hostile attitudes also stop us from accessing basic healthcare of all kinds.

It’s an everyday occurrence for trans people to be refused treatment, or misdiagnosed for unrelated conditions, by healthcare professionals who can’t see us for who we are. The situation is so bad we’ve even got a name for it. We call it ‘Trans Broken Arm Syndrome’ – the feeling when you turn up at A&E with a broken limb and they turn you away because they ‘don’t know how to treat trans patients’.

When cisgender people hear ‘trans healthcare’, they tend to think of obvious ‘sex characteristics’ such as facial hair, breasts, or genitals. And they’re not wrong – these are all features that can be altered by gender-affirming medical care.

But for those who want them, transition-related medical procedures such as hormone management or surgery are often about much more than binaries and body parts. And barriers to trans healthcare are about much more than access to specific gender-affirming procedures.

Hormones and surgery can affect a person in ways that are intensely personal: from how your body moves and what types of clothes you can safely and comfortably wear, to the feel of your skin, your natural scent, the shape your facial features; even how you experience thought and emotions, mental wellbeing, and sleep patterns. Any or all of these things can help an individual achieve a sense of being at home in their own mind and body.

Having a body that feels right isn’t just a social thing, affecting how people perceive you and what kinds of intimacy you can enjoy. It’s also about your relationship with yourself: how it feels to curl up on a sofa to read; to get dressed, take a shower; go jogging or swimming; even to roll over in your sleep.

Your body gives you constant messages and feedback about your place in the world. For many trans people, those messages feel mostly wrong. Medical transition is about getting more of the right messages.

The same goes for social transition – it’s a question of getting more of the right messages about who you are and where you fit in. But more often than not, the messages society sends back to us are the wrong ones. Too often, the messages we receive in healthcare settings tell us we don’t fit, we are not understood, and we are not welcome.

When IT developer Jack first changed his name, the receptionist at his GP surgery refused to update his records because his new name was “too masculine”. Even with a deed-poll, Jack has been unable to change his gender and title in the GP’s records.

“All communications from the surgery address me as ‘Miss Jack Doe’,” he tells me, “meaning that I’m automatically ‘outed’ in the waiting room when my name is called, and at the pharmacy when I pick up my prescriptions.” This is contrary to the law and to NHS guidelines, which stipulate that such information should be updated on request.

For many trans people, simple things like being out in public spaces or making a phone call can require a lot of courage and effort. Being publicly misgendered in pharmacies and waiting rooms can prevent trans people from trying to access care. But even when we make it to the clinic, we aren’t guaranteed appropriate treatment.

Since Jack started on testosterone, every single medical complaint he’s experienced was somehow blamed on the hormone. At asthma check-ups the GP makes vague reference to testosterone potentially interfering with treatment, but becomes evasive when pressed for details.

When Jack sought treatment for acne, the GP suggested estrogen-based birth control (a ‘female’ hormone likely to exacerbate dysphoria). Only after Jack questioned whether such treatments are routinely prescribed to other male patients did the GP concede that they are not, and offer something more appropriate.

Even before prescribing routine medication, such as antibiotics for an infected wound, Jack’s GP won’t act without clearance from the private gender clinic. “This means I end up waiting extra days before starting treatment, which may put me at risk of conditions worsening,” he explains.

Trans-appropriate healthcare doesn’t need to be complicated”

Thankfully, not all clinics are this way. Some are welcoming, respectful and well-informed. Lily*, a freelance stage manager in Bristol, says her GP surgery is fantastic: “Being trans there is routine and doesn’t get in the way when I’m seeing them about unrelated things.”

Many speak glowingly of specific clinics, such as the Speech and Language Therapy service at St Michael’s hospital. While most referral pathways for trans people are lengthy and fraught with bureaucratic obstacles, I know from my experience and others’ that access to the expert and supportive voice feminisation training at SLT is swift and hassle-free.

Last year, University Hospitals Bristol NHS Trust formed a working group to create a Transgender Care Policy to improve the experience of both patients and staff right across the trust’s healthcare facilities. The group, to which I was invited as a consultant, aimed to tackle problems such as misgendering, inappropriate questioning, loss of privacy and harassment that affect trans patients and colleagues. But like many longer-term initiatives, the project has been put indefinitely on hold since response to the Covid-19 crisis became top priority.

These examples show that trans-appropriate healthcare needn’t be complicated. Services would be transformed by appropriate training and policies to give healthcare staff the confidence, competence and information they need to provide an inclusive service.

Other barriers could be significantly reduced by simplifying referral pathways. Requiring a formal diagnosis of dysphoria from a GIC to access treatments such as fertility care creates an unnecessary bottleneck, when these services are readily available from local providers. But until a concerted and unified effort is made across the NHS, healthcare services will continue to be unequal and sometimes deeply alienating or even dangerous for trans and nonbinary people.

The Cable approached North Bristol NHS Trust about their policies but have not yet received a response.

*Names have been changed to protect privacy