As the #transdocfail hashtag showed, many trans people are afraid of their doctors

Trans patients should not have to please medical staff before they can access treatment, writes Charlie Hallam.

There are a group of people in the UK who experience horrific abuse at the hands of people who are ostensibly responsible for their care. You might think that after the horrific revelations of the last few months that I am referring to children who are abused by those charged with caring for them, but no. I’m talking about trans* people. If you are a trans* person, not only are you required to live and behave a certain way to access treatment, but the situation is compounded by the fact that many trans* people are reliant for life saving treatment on the very doctors who perpetrate this abuse. They are prevented from speaking out to try and improve the system through the fear that if they are honest, they will forever be denied the treatment they need.

In most areas of medicine, the first stage when you identify that something is wrong is to visit your GP, discuss the problem, work out if treatment is necessary and then discuss with your doctor about what that treatment should be. From the stories shared on yesterday’s twitter hashtag #transdocfail, and from the stories I’ve heard from my partner and trans* friends, doing this with gender dysphoria would be the single worst thing to do.

Trans* people are scared of their doctors.

My partner came out and transitioned socially last spring, and our circle of friends includes a number of trans* people, some trans men, some trans women and at least one person who considers hirself agender. We know people who have finished the process of medical transition, people who are the middle of the process, and people who have transitioned and are receiving continuing care.

Bad experiences with GPs at the start of the process and experiencing difficulties in obtaining a referral to specialist services were a common theme on yesterday’s hashtag. Many people reported being dismissed in various ways at their first appointment, one being laughed out of the office, and another told, I'm not going to refer you (to GIC) because I don't believe in all that". In the last few months, I have myself heard an obviously female patient called up with what was clearly their male, pre-transition, name. Despite these obvious and apparently simple to fix problems, so many trans* stories about doctor’s failing patients end with the line, ‘but I daren’t say anything in case the clinic find out, object and decide that I’m not eligible for care.’

Half way through yesterday afternoon, I noticed a new presence on the hashtag – an anonymous account, @TransDocFailAno, where trans* people could submit their experiences via a tumblr to avoid having to out themselves to do so. Indeed, the only reason I am writing this article rather than any of the trans* people I know is that none of them are willing to do so. I checked.

One of the most difficult hoops to jump through is that of needing to spend a year living as the gender you wish to transition to before you are able to access any treatment at all. This is fraught with problems. Most people choose to start their year of ‘real life experience’ when they move from one setting to another in order to minimise the chances of someone using their old name or pronoun, but this isn’t possible for everyone. One of the things trans* people often prepare themselves for when starting to transition is the possibility of losing everything they’ve worked for so far, and stories abound of trans people losing partners, children, jobs, homes and lives as a result of social transition. However, the NHS still treat social transition as reversible, and a necessary prerequisite for the apparently irreversible hormone therapy to help trans* people pass as their proper gender.

I could go on for pages about the problems faced by trans* people accessing treatment, but at the core are two main problems. The first is the fact that gender is seen always and exclusively as a binary. It is assumed that if you were assigned male at birth and are not male, that in asking for any form of treatment you are asking the medical staff to make you as close to their idea of cis female as possible. For some people that’s what they need, but for others their gender identity doesn’t resemble what their doctors think of as correct, and the pressure that can be laid on them to conform to what is expected can be immense, and treatment that they need to eliminate their dysphoria can be denied because, for example, a trans woman would like to have a pixie cut, yet their doctor believes that all women should have long hair in order to present as properly female. There are a significant number of people who feel that their gender doesn’t fit neatly into either male or female, and would like medical help to change their presentation to more accurately fit their gender. At the moment, it seems that the only option available for these people is to lie, as if they tell their doctors the truth, it may be taken as evidence that they are not serious about transitioning, and they could forever lose the chance to access the medical care they need to cure their dysphoria.

The second problem is that so much of the process seems to serve the sole purpose of stopping you from making ‘a hideous mistake’. The process is lengthened by multiple appointments with psychiatrists and therapists whose role is to assess the mental health and sanity of those seeking treatment. Tweets yesterday on the @TransDocFailAno account and the #transdocfail hashtag made it clear that, for many medical professionals, depression and other mental health problems were considered to be barriers to treatment that in some cases were used as excuses to delay treatment for dysphoria, and in other cases only the dysphoria was treated and other mental health problems ignored. Mental health issues blocking treatment for dysphoria is dangerous when dysphoria creates those mental health issues, and depression is immensely common in trans* people.

As someone who writes regularly on the subject and is openly trans*, the Lib Dem councillor for Cambridge, Sarah Brown says, “The media are typically invested in presenting a rigid narrative about how trans people interact with medicine. The stories trans people would like to tell, stories of outrageous levels of systemic abuse and transphobia, don't fit this narrative and so go ignored and unreported. Social media is changing this. The stories trans people have to tell are reaching people who seldom hear them, and people are often appalled by what they hear. We can't even begin to tackle widespread medical abuse of trans people until there is wider awareness of just how bad it is.”

Reading this one sided article, one could be forgiven for thinking that all trans* people are on a one way road to misery and that transitioning is not worth it. I urge you, if you are worried about this, to check out the We Happy Trans project. Trans* people consider transitioning well worth doing it because in some cases the alternative is suicide. Just because the system is not yet perfect, it does not mean that trans* people should not seek treatment they think will improve their lives.

A hair cut should not lead to medical treatment being denied. Photograph: untitled by . ally/flickr. CC-BY

Fearless in the face of yarn, yet terrified of spiders, Charlie Hallam is a Sheffield blogger and activist. She can be found waffling about politics and yarn as @fearlessknits on Twitter.

Photo: Getty Images
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What's to be done about racial inequality?

David Cameron's words on equal opportunities are to be welcomed - now for some action, says Sunder Katwala.

David Cameron made the strongest, clearest and most high profile statement about ethnic inequalities and the need to tackle discrimination ever yet offered by a British Prime Minister in his leader’s speech to the Conservative Party conference in Manchester.
“Picture this. You’ve graduated with a good degree. You send out your CV far and wide. But you get rejection after rejection. What’s wrong? It’s not the qualifications or the previous experience. It’s just two words at the top: first name, surname. Do you know that in our country today: even if they have exactly the same qualifications, people with white-sounding names are nearly twice as likely to get call backs for jobs than people with ethnic-sounding names? … That, in 21st century Britain, is disgraceful. We can talk all we want about opportunity, but it’s meaningless unless people are really judged equally”, said Cameron.
While the proof of the pudding will be in the eating, this was a powerfully argued Prime Ministerial intervention – and a particularly well-timed one, for three reasons.

Firstly, the Prime Minister was able to root his case in an all-but-universally accepted appeal for equal opportunities. It will always prove more difficult in practice to put political energy and resources behind efforts to remedy discrimination against a minority of the population unless a convincing fairness case is made that values cherished across our whole society are at stake. Cameron’s argument, that any party which tells itself that it is the party of the ‘fair chance’ and ‘the equal shot’ must have a response when there is such clear evidence of discrimination, should prove persuasive to a Conservative Party that has not seen race inequalities as its natural territory. Cameron argued that the same principles should animate responses to discrimination when it comes to race, gender and social class. Put like that, wanting job interviews to be fair – by eradicating conscious and unconscious patterns of bias wherever possible – would strike most Britons as offering as clear a case of the values of fair play as wanting the best baker to win the Great British Bake-Off on television.
Secondly, Cameron’s intervention comes at a potential "tipping point" moment for fair opportunities across ethnic groups. Traditionally, ethnic discrimination has been discussed primarily through the lens of its impact on the most marginalised. Certainly, persistent gaps in the criminal justice system, mental health provision and unemployment rates remain stark for some minority groups. What has been less noticed is the emergence of a much more complex pattern of opportunity and disadvantage – not least as a consequence of significant ethnic minority progress.

Most strikingly of all, in educational outcomes, historic attainment gaps between ethnic minorities and their white British peers have disappeared over the last decade. In the aggregate, ethnic minorities get better GCSE results on average. Ethnic minority Britons are more likely, not less likely, to be university graduates than their fellow citizens. 

As a result of that progress, Cameron’s intervention comes at a moment of significant potential – but significant risk too. Britain’s ethnic minorities are the youngest and fastest-growing sections of British society. If that educational progress translates into economic success, it will make a significant contribution to the "Great British Take-Off" that the Prime Minister envisions. But if that does not happen, with educational convergence combined with current ‘ethnic penalties’ in employment and income persisting, then that potential could well curdle into frustration that the British promise of equal opportunities is not being kept.  Cameron also mirrored his own language in committing himself to both a ‘fight against extremism’ and a ‘fight against discrimination’: while those are distinct challenges and causes, actively pursuing both tracks simultaneously has the potential, at least, depolarise some debates about responses to extremism  - and so to help deepen the broad social coalitions we need for a more cohesive society too.

Thirdly, Cameron’s challenge could mark an important deepening in the political competition between the major parties on race issues. Many have been struck by the increase in political attention on the centre-right to race issues over the last five to ten years. The focus has been on the politics of representation. By increasing the number of non-white Conservative MPs from two to seventeen since 2005, Cameron has sent a powerful signal that Labour’s traditional claim to be ‘the party of ethnic minorities’ would now be contested. Cameron was again able to celebrate in Manchester several ways in which his Cabinet and Parliamentary benches demonstrate many successful journeys of migrant and minority integration in British society. That might perhaps help to ease the fears, about integration being impossible in an era of higher immigration, which the Home Secretary had articulated the previous day.

So symbolism can matter. But facial diversity is not enough. The politics of ethnic minority opportunity needs to be about more than visits to gurdwaras, diversity nights at the party conference fringes and unveiling statues of Mahatma Gandhi in Parliament Square. Jeremy Corbyn’s first speech as Labour leader did include one brief celebratory reference to Britain’s ethnic diversity – “as I travelled the country during the leadership campaign it was wonderful to see the diversity of all the people in our country” – and to Labour bringing in more black, Asian and ethnic minority members - but it did not include any substantial content on discrimination. Tim Farron acknowledged during his leadership campaign that the Liberal Democrats have struggled to get to the starting-line on race and diversity at all. The opposition parties too will no doubt now be challenged to match not just the Prime Minister’s rhetorical commitment to challenging inequalities but also to propose how it could be done in practice.

Non-white Britons expect substance, not just symbolism from all of the parties on race inequalites.  Survation’s large survey of ethnic minority voters for British Future showed the Conservatives winning more ethnic minority support than ever before – but just 29 per cent of non-white respondents were confident that the Conservatives are committed to treating people of every ethnic background equally, while 54 per cent said this of Labour. Respondents were twice as likely to say that the Conservatives needto do more to reach out – and the Prime Minister would seem to be committed to showing that he has got that message.  Moreover, there is evidence that ethnic inclusion could be important in broadening a party’s appeal to other younger, urban and more liberal white voters too – which is why it made sense for this issue to form part of a broader attempt by David Cameron to colonise the broad centre of British politics in his Manchester speech.

But the case for caution is that there has been limited policy attention to ethnic inequalities under the last two governments. Restaurateur Iqbal Wahhab decided to give up his role chairing an ethnic minority taskforce for successive governments, unconvinced there was a political commitment to do much more than convene a talking shop. Lib Dem equalities minister Lynne Featherstone did push the CV discrimination issue – but many Conservatives were sceptical. Cameron’s new commitment may face similar challenges from those whose instinct is to worry that more attention to discrimination or bias in the jobs market will mean more red tape for business.

Labour had a separate race inequalities manifesto in 2015, outside of its main election manifesto, while the Conservative manifesto did not contain significant commitments to racial inequality. The mid-campaign launch in Croydon of a series of race equality pledges showed an increasing awareness of the growing importance of ethnic minority votes - though the fact that they all involved aiming for increases of 20 per cent by 2020 gave them a slightly back-of-the-envelope feel. 

Prime Ministerial commitments have an important agenda-setting function. A generation ago the Stephen Lawrence case opened the eyes of middle England to racist violence and police failures, particularly through the Daily Mail’s persistent challenging of those injustices. A Conservative Prime Minister’s words could similarly make a big difference in the mainstreaming of the issue of inequalities of opportunity. What action should follow words? Between now and next year’s party conference season, that must will now be the test for this Conservative government – and for their political opponents too. 

Sunder Katwala is director of British Future and former general secretary of the Fabian Society.