Why are NHS doctors are still treating trans people like they’re mentally ill?

“You’re an attractive girl, why do you want to do this?”

“You’re an attractive girl, why do you want to do this?”

“Do you ever wear make-up?”

“Are you domineering in sex with girls?”

The questions above come from a NHS psychiatrist.

On the receiving end, JR*, 23, polite, wide blue eyes, job in video production, started crying five minutes into the interview. She kept crying for the remaining hour and twenty-five minutes with the psychiatrist, a man in his fifties. Through other questions about why she had only got her hair cut short aged 19, whether her past relationships with women as a lesbian had been casual or serious, whether she was capable of forming lasting relationships, details of how she behaved in bed with them, and what age she’d thought she was gay, she had to explain the expression “gay scene”.

He asked me: ‘When did you cut your hair short?’ I said, ‘When I was 19’. You kept it long till then? Did boys come up to you?

It was harder to explain that having a short haircut was not the main sign of the creeping sense of misaligned gender that JR had begun to feel five years ago.  

That particular techniques in bed didn’t mean that she wasn’t like a woman. And that issues of fashion, haircut even sexuality were in many ways irrelevant to the feeling of being in the wrong body.

“He wasn't rude at all,” JR said of the psychiatrist, “just coming from a completely different angle at every point.”

Well-intentioned, he seemed uninformed about transgender people, gay people and, to an extent, women.

The question about whether she was “domineering” in bed is a case in point.

“I said that I had generally been with more feminine women, but that I didn't associate being feminine with being passive” JR recalled.

Raising her worry that being more gender-ambiguous would affect her job prospects, JR got this reaction:

“He said: ‘No you don't have to worry about that. The only time that would be awkward is if a more senior male colleague made an advance on you and that might affect your promotion chances’.”

That interview was four months ago and JR was sent to the psychiatrist because she is transgender and the NHS sends all transgender people to psychiatrists.

Uncertainty about gender is still listed in the psychiatrist’s diagnostic bible - the Diagnostic and Statistical Manual of Mental Disorders (pdf) (DSM) - produced by the American Association of Psychiatrists and used globally.

The most recent NHS guidance states that being trans is not a mental illness, but the feeling of a mismatch between biological sex and gender identity, and the discomfort that comes from thatIt is caused by brain development, they say:

The condition is increasingly understood to have its origins before birth. Research studies indicate that small parts of the baby’s brain progress along a different pathway from the sex of the rest of its body. This predisposes the baby to a future mismatch between gender identity and sex appearance.

Yet the institutions we have in Britain still route trans people through psychiatrists, and in many cases still treat them as though they are mentally ill.

“Psychiatrists often get asked to play a role in sorting out problems when other people can’t, and it’s not always very admirable,” says Christopher Cordess, Professor of Psychiatry at University of Sheffield.

“This sort of reference – when you have to go to a psychiatrist to get a signature – is society’s way of coping when it doesn’t know what to do but wants to keep a cap on something.”

He cites the case of abortion, also still “gatekept” by psychiatry.

“Psychiatry is horribly political.” said Cordess. “When I was training, homosexuals used to be referred to psychiatrists, now that’s slightly embarrassing.”

It was in 1973 the American Psychiatric Association declassified homosexuality as a mental health disorder.

And while the NHS is strapped for cash, changing attitudes doesn’t need to be expensive.

The 6,000 British people who are trans and who would like help for gender issues must first approach their GP, and then the GP must refer them to a psychiatrist. The psychiatrist refers them to a Gender Clinic where the patient can finally receive specific counseling, hormones, or if they wish reassignment surgery. The patient’s local Primary Care Trust must be prepared to pay for that place.

“We actually wrote a paper called ‘Not so much a care path.. more a kind of steeple chase’” said Christine Burns, activist and member of an Advisory Group on trans issues for the Department of Health. Each of the three players in the referral process can be obstructive.                             

Doctor training is one reason why. Christine says:

“Gender issues are treated probably less than one day in their whole medical training. There is a wide-spread attitude that trans people are so rare that you’ll never come across one.  You get people who say ‘we don’t need to know about that because we don’t have any of those here’.

“That means you get people with unmet needs.”

Then there are the Primary Care Trusts who believe that trans people don’t exist.

“Some PCTs have not invested in enough places at the Gender Services Clinic” Christine says.

There are ten English regions with PCTs covering approximately four to six million people. Each of those will see 80-100 patients presenting to GPs each year. Some PCTs are not planning/ paying for enough places. You’ll hear things like ‘oh we don’t have those here’.

It is attitudes that Stuart Lorimer, a leading gender specialist in the NHS’s Charing Cross Gender Identity Clinic, wants to change:

“By far the most difficult, obstructive phenomenon that we face as a clinic is the attitude that we face from medical colleagues – GPs, other psychiatrists” he says in a 2009 interview on Burns’ website.

“I vaguely remember a time in the past when nobody knew anyone who was gay. And there were very peculiar mythologies about gay people. And then that seemed to change with increased visibility and now everyone knows someone who is gay, and that gave people a human view of things.

“Generally speaking, doctors who have helped someone through their transition, experience it as positive. I think the negative feelings usually spring from ignorance.”

According to a 2006 survey about trans medical care, 80 per cent of GPs have good intentions and want to help, but the majority of them – 60 per cent – lack information.

'Engendered Penalties' by Stephen Whittle surveyed 872 trans people and also found that  19.5 per cent of GPs were not trans friendly, in fact the opposite.

A negative attitude, and even just ignorance can have a bad impact on a vulnerable patient. And these people are vulnerable.

An August 2012 survey into trans mental health by the Scottish Trans Group and Sheffield Hallam university – found that depression affected 62 per cent of the 889 trans people questioned, anxiety 56 per cent. In the general population it affects one in ten.

These people were having a bad time in all areas of the NHS: 63 per cent reported one or more negative experiences in mental health services, 65 per cent in general services and a shocking 62 per cent at a Gender Identity Clinic, according to the survey. 

Of those, just under a third felt that their gender identity was not validated as genuine, instead being perceived as a symptom of mental ill-health. A quarter felt uncomfortable being asked about their sexual behaviours.

The first-hand experiences quoted by The Scottish Trans survey tell some shocking tales:

My doctor sent me to see a gynecologist instead of the Gender Identity Clinic. He said he didn’t see trans people but he wanted to have a look at me. He then called in my husband and asked if he was ok with me transitioning - I felt abused.

Another quotation cited a bad experience with a psychiatrist who suggested the only appropriate pronoun for the patient was “it” and claimed that bisexual people didn’t exist.

A third reported:

Questions were overly irrelevant, prying and sexual. My first doctor asked about masturbation repeatedly, which made me very uncomfortable...

A fourth simply detailed the mental stress caused by the delay, confusions and misunderstandings.

On the other hand, Jay* a 24-year-old languages student in London who saw a psychiatrist and received a referral to the Charing Cross gender clinic earlier this month, said the psychiatrist was pleasant and reasonable.

Christine urges a balanced view:

There are good doctors and there are bad doctors, and there are good doctors having a bad day and there are bad patients.

There are people who have bees in their bonnet, and think they can cure transgender people by talking. It depends really on whether you are the first person that that doctor has seen.

There may also be an economic argument for a more sensitive system: happier people cost less. The Scottish survey showed that 44 per cent of trans people used mental health services more before transition, and none used mental health services more after having been through gender services.

Questioned as to why there was such a variable quality of treatment for trans people in the NHS and such a high incidence of negative feedback, the Department of Health said that they were moving to regulate care commissioning from Primary Care Trusts so that there will be enough places at Gender Clinics, and to create a national body that would be responsible for keeping care standards consistent across regions.

The Department of Health reiterated that being transgender is not considered a mental health disorder by the NHS but that the role of psychiatrists was an important one to ensure that   “gender issues have their root in gender dysphoria and are not caused by other more complex psychiatric problems”.

The spokesperson added that the psychiatric assessment “could be a useful opportunity for the patient to discuss their condition with a professional.”

As for the psychiatrists calling patients “it”, and trying to work out what gender someone should be based on their haircut, the Department of Health said they would be commissioning a clear guide on transgender treatment that will be published this year.

* Names changed for the purposes of the article and pronouns used with agreement of interviewees.

Photograph: Getty Images
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Bernie Sanders is America’s most popular politician – and he’s coming after Donald Trump

Sanders, unlike Clinton, had a clear and coherent vision. As of now, he is the best hope the Democrats have of retaking the White House in 2020.

“I like Bernie Sanders,” my four-year-old niece in Texas said to me last month. “Why isn’t he president?” More than six months on from the defeat of Hillary Clinton, it’s a question that countless frustrated progressives across the United States continue to ask aloud.

Remember that the election of Donald Trump was not the only political earthquake to shake the US establishment last year. A 74-year-old, self-declared socialist and independent senator from the tiny state of Vermont, in a crumpled suit and with a shock of Einsteinian white hair, came close to vanquishing the Clinton machine and winning the Democratic presidential nomination. Sanders began the campaign as the rank outsider, mocked by the former Obama strategist David Axelrod as the candidate with whom Democratic voters might “flirt” and have a “fling” before settling down with Clinton. By the end of the campaign he had won 13 million votes and 23 states, and raised more than $200m.

In this dystopian age of Trump, it is remarkable that Sanders is now by far the most popular politician in the US – and this in a country where “socialist” has long been a dirty word. Increasing numbers of Americans seem nevertheless to “feel the Bern”. As such, Sanders supporters cannot help but ask the big counterfactual question of our time: would Trump be the president today if he had faced Bernie rather than Hillary in the election? Throughout the campaign, polls showed him crushing Trump in a head-to-head match-up. In a poll on the eve of the election, Sanders trumped Trump by 12 percentage points.

Democratic voters were told repeatedly that Clinton was more “electable” – but had they opted for Sanders as their candidate, there would have been none of the backlash over her emails, Benghazi, Bill, her Iraq War vote, or her Goldman Sachs speeches. So did the Democrats, in effect, gift the presidency to the Republican Party by picking the divisive and establishment-friendly Clinton over Sanders the economic populist?

I can’t prove it but I suspect that Sanders would have beaten Trump – although, to be fair to the much-maligned Clinton, she, too, beat Trump by nearly three million votes. Also, one-on-one polls showing Sanders ahead of Trump in a hypothetical match-up fail to tell us how the independent senator’s support would have held up against a barrage of vicious Republican attack ads during a general election campaign.

Then there is the matter of race. Clinton, despite deep support in African-American and Latino communities, was unable to mobilise Barack Obama’s multiracial coalition. Sanders would have done even worse than she did among minority voters. Trump voters, meanwhile, were motivated less by economic anxiety (as plenty on the left, including Sanders, wrongly claim) than – according to most academic studies, opinion polls and the latest data from the American National Election Studies – by racial resentment and an anti-immigrant, anti-Muslim animus. Sanders, who at a recent rally in Boston defended Trump voters from accusations of bigotry and racism, would probably have struggled as much as Clinton did to respond to this “whitelash”.

Nevertheless, Sanders, unlike Clinton, had a clear and coherent vision and I would argue that, as of now, he is the best hope the Democrats have of retaking the White House in 2020. His support for greater Wall Street regulation, debt-free college tuition, universal health care and a higher minimum wage is not only morally correct and economically sound but also hugely popular with voters across the political spectrum.

The Democrats have a mountain to climb. They have to find a way to enthuse their diverse, demoralised base while winning back white voters who are concerned much more by issues of race and identity than by jobs or wages. A recent poll found that the party had lower approval ratings than both Trump and the Republicans as a whole.

Yet press reports suggest that at least 22 Democrats are thinking about running for president in 2020. This is madness. Few are serious contenders – thanks to the dominance of the Clinton machine in recent years, the party doesn’t have a deep bench. There is no new generation of rising stars.

The only two people who could plausibly prevent Sanders from winning the nomination next time round are the former vice-president Joe Biden and the Massachusetts senator Elizabeth Warren. The good news is that all three of these Democratic contenders are, to varying degrees, economic populists, willing to stand up passionately for “the little guy”. The bad news is that the Democratic base may fantasise about a young, dynamic Justin Trudeau or Emman­uel Macron of their own but, come the 2020 election, Sanders will be 79, Biden 77 and Warren 71. (Then again, they’ll be up against a sitting Republican president who will be 74, behaves as if he has dementia and refuses to release his medical records.)

Bizarrely, that election campaign has already begun. On 1 May, Trump released his first official campaign ad for re-election, 1,282 days before the next presidential vote. Biden visited New Hampshire last month to give a speech, while Warren is on a national tour to promote her new bestselling book, This Fight Is Our Fight.

Sanders, however – riding high in the polls, and with his vast database of contacts from the 2016 race as well as a clear, popular and long-standing critique of a US political and economic system “rigged” in favour of “the billionaire class” – is the man to beat. And rightly so. Sanders understands that the Democrats have to change, and change fast. “There are some people in the Democratic Party who want to maintain the status quo,” he said in March. “They would rather go down with the Titanic so long as they have first-class seats.”

Mehdi Hasan is a contributing writer for the New Statesman and the co-author of Ed: The Milibands and the Making of a Labour Leader. He was the New Statesman's senior editor (politics) from 2009-12.

This article first appeared in the 18 May 2017 issue of the New Statesman, Age of Lies

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