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[top]Introduction

Current Issues and Strategy

In legal terms a great deal has occurred in the last few years to transform the backdrop for trans people’s lives:

  • The Sex Discrimination (Gender Reassignment) Regulations of 1999 transformed trans people’s economic security on the back of a 1996 European Court of Justice ruling.
  • The Gender Recognition Act (2004) has similarly transformed trans people’s overall position in law.
  • The 1999 Court of Appeal ruling in the case of A.D.& G. vs North West Lancashire Health Authority also had significant ramifications for Health Authorities (now PCTs) in terms of the funding of treatment of any kind relating to gender identity issues. This ruling recognised that gender reassignment is the appropriate medical response to “Gender Identity Disorder” and that it unlawful for Health Authorities (PCT’s) to operate anything that amounts to a blanket ban on funding in such cases.

In the wake of these significant legal landmarks, considerable social advances have taken place too. The stigma attaching to gender variance is being rapidly eliminated in British society, along with a great deal of the ignorance and disapproval. This sea change in official and public opinion is set to be strengthened by Government commitments to address remaining vulnerabilities of trans people in discrimination law, and promote greater knowledge and awareness through the forthcoming Public Sector Duty on Gender and through the promotion and enforcement roles of the new Commission for Equality and Human Rights.

With both of those significant changes in mind it is disappointing that attitudes towards trans people in medicine, and especially the National Health Service, have changed very little. Indeed, this failure to advance significantly can be seen to apply at every level:

  • The conceptualisation of gender variance, developed by medical practitioners and sexual theorists in the 1950’s and 1960’s, fundamentally reflects Western cultural beliefs of that time. The legal and social advances of recent years lead to medical thinking in this area being seen as increasingly anachronistic and reactionary. As this fossilised thinking underpins so much else, a part of our campaigning effort takes place with reformers at all levels and in other countries, challenging medical classification itself. It’s a serious matter to classify mere difference as a mental illness.
  • The last ten years have undoubtedly witnessed some change in medical ideas, though not yet as sweeping as to dislodge the “mental illness” label. The Harry Benjamin organisation is changing its name. Out goes the built-in pathology-based vision of “Gender Dysphoria” in the title. In its place the emphasis conveyed by the “World Professional Association for Transgender Health” (WPATH) signals a different and more client-centred emphasis - though no corresponding change yet in the protocols.
  • Closer to home, Britain’s Royal College of Psychiatrists has been working for two years to develop guidelines more tailored to the UK environment. Our place is at the centre of developments like this, where the struggle again involves the tension between the old and the new. Our challenge is to shift conservative medical attitudes sufficiently for services to begin to mirror social change and prevent the harm which present approaches can be seen to cause.
  • Anachronistic “standards of care” or guidelines lead in turn to a system of regimented Gender Identity Clinic (GIC) services that are perceived by many as controlling and even abusive
  • Commissioning restrictions that remove choice from service users create an unhealthy “take it or leave it” monopolistic attitude in many GICs. Attempts to write the new care guidelines in ways that serve to prevent diversity in service provision are another way of trying to cement the status quo. Our task involves advising people who feel harmed by the process, and drawing attention to the need for review and change.
  • All these factors then combine with financial constraints on the NHS, plus ordinary ignorance and prejudice, to create what is now becoming an increasingly problematic situation with the commissioning and funding of treatment for gender issues, and the non-availability of choice. An increasing part of our effort is therefore also directed towards this problem.

In order to have an effective strategy it’s necessary to grasp all these related dimensions of the problem and to campaign at all levels:

  • Through PFC-News and our regular analyses and papers we provide materials which explain the issues involved. Documents on this web site highlight the politics of dealing with medical professionals and academics, document the obstructions which people face, and provide the background resources to help others help us as well.
  • We are involved in working actively for change at all levels - from the question of medical classification to local funding. Angela Clayton and Tracy Dean are working on the Royal College of Psychiatrists committee developing new guidelines. We work through the Parliamentary Forum on issues such as the adoption of guidelines for commissioners, and the need for licensing of hormones and hormone blockers for prescription in this area. Christine Burns also chairs the trans workstream in the Department of Health’s Sexual Orientation and Gender Identity Advisory Group, works closely with leading LGB health reformers, and liaises transatlantically with campaigners challenging the American Psychological Association to bring about reforms.

Trans people’s issues are not restricted to support and funding related to transition either:

  • We only have one transition in life, but all of us will experience many other needs for healthcare, preventative medicine and social care during our post-transition lives, just like everyone else.
  • The National Health Service is also Britain’s largest single employer. The health and social care field is also one of the biggest overall employment sectors, and many trans people want to be able pursue careers at every level. As in other sectors of employment this brings issues of employer preparedness and training. Our approach has also required us to demolish many barriers too - in access to medical and nursing training, Criminal Records checks and professional registration to cite just three.

Our overall strategy therefore demands that we work on many fronts at once. The interrelated nature of the issues requires that. It also requires us to come at problems from all angles — using complaint and legal process to force change by confrontation of the issues, and simultaneously working in partnership with politicians, civil servants and medical professionals to encourage changes in approach from the top.

How we campaign

In summary, our methods are to:

  • Collect and document evidence through the problems we see, and by encouraging people to tell their stories
  • Use this background to build awareness of the problems which real trans people experience
  • Develop from that awareness an agenda for change among decision makers
  • Ensure we are involved where those decisions are made, rather than simply being outside on the barricades. Some of the main areas where we work are :
        - In the Department of Health, through the Equality and Human Rights Group
        - On the Royal College of Psychiatrists’ Committee developing new guidelines
        - In PCTs, developing local commissioning strategies
  • Feed the pressure for reform by encouraging people to complain and engage with quality processes
  • Work with our natural allies and as part of wider movements for healthcare reform

Who is involved

  • Christine Burns is chair of the trans workstream in the Department of Health’s Sexual Orientation and Gender Identity Advisory Group (SOGIAG). She is also involved in the growing LGBT Health movement and has written extensively about all aspects of the user experience and politics in this field.
  • Stephen Whittle is now President-elect of WPATH (the World Professionals Association for Transgender Health - formerly HBIGDA). He will become President of the Association in October 2007. As Professor of Equalities Law at Manchester Metropolitan University Stephen is also PFC’s expert in all matters concerning the legality of trans healthcare experience.
  • Angela Clayton is a member of the Royal College of Psychiatrists Working Group on standards of care for trans people. She is also a member of the priorities setting committee for her local strategic health authority and the Department of Health’s SOGIAG Transgender Workstream. She is a former Chair of The Gender Trust charity.
  • Tracy Dean was chair of The Gender Trust for 6 years and a trustee for 9 years and uses her consequent knowledge of the difficulties faced by trans people undergoing transition and medical treatment to make improvements through the Royal College of Psychiatrists “Standards of Care” Working Group, the Parliamentary Forum on Transsexualism and her local (Brighton & Hove) Trans Focus Group.
  • Other trans people, not directly involved in Press for Change, have very significant roles in the reform process. Persia West, for instance, produced a comprehensive report on behalf of Brighton’s Spectrum Group, for the former Brighton and Hove PCT, conveying widespread criticism of the Charing Cross Gender Identity Clinic, on which that PCT depended. She is now working with Tracy Dean and others to encourage the development of alternative service approaches in that area. Other trans people are similarly engaged with processes in other PCTs.

How people can help

The most important ways in which trans people and their friends / families can help is by

  • Complaining when services do not measure up to the standards now promised within other areas of healthcare, or when choices are restricted or funding is withheld. Don’t be a victim. Use the instructions below for guidance on the processes available.
  • Contributing evidence of the experiences you have when seeking help and support within the health service.
  • Lobbying at all levels to demand that problems be investigated and that change should be forthcoming. Get involved, like other citizens in the running of your Primary Care Trust (PCT). Learn how commissioning works and how to influence the system.

[top]Good Practice

[top]Department of Health Publications

All the following Department of Health titles publications are available in printed as well as electronic format. To order printed copies you will need the stock number for the document, which is usually printed on the back cover. Then go to www.dh.gov.uk/publications for instructions on how to order.

Trans specific titles

These titles (and others soon to join them) are the product of work by the Department of Health’s Sexual Orientation and Gender Identity Advisory Group. To listen to the latest report on the work of that group click here.

For official copies of these and other resources connected with the Department of Health’s SOGIAG programme, including how to order hard copies, please see the Department’s own index.

Equality in Healthcare

[top]Standards of Care

[top]Overseas Care Services Literature

Services for Young People

[top]Licensing of Drugs for Hormonal Reassignment

Sustanon 250

[top]User Experience and Politics

First hand personal accounts

Waiting lists, “patient rules” and protocols for the various GICs

[top]How To Challenge and Complain

In 1998, following the A.D.& G. vs North West Lancs Appeal Court decision, Press for Change published the following guidance. Since then the structure of the NHS has changed and the way in which commissioning and funding decisions are made in this area has moved on. It is still valuable to understand our earlier guidance; however the above procedures are the correct ones to follow in the case of current complaints.

See also the legal reports on court cases related to access to medical treatment.

[top]Evidence Based Medicine and Research

[top]Medical Overviews

  • Transsexualism: The Current Medical Viewpoint.  This document provides an overview of current best practice in providing effective health care for persons with the transsexual syndrome.  It describes the nature of the syndrome, its diagnosis, treatment and outcomes; recognises its biological aetiology; and makes recommendations for the legal status of people experiencing transsexualism.
  • Medical Report on the Affidavits of William Jenkins.  A report prepared for a 1996 court case, considering the classification of Transsexualism and its treatment and the criteria for deciding the sex of an individual;

[top]Health Authority Policy

Despite the term “National Health Service”, access to medical treatment is in practice determined by the priorities allocated to different services by local health authorities.  Their policies on funding gender reasignment vary greatly.

North West Lancs Response

Other Judgements Relating to Funding Refusal

Current PCT Funding Policies

Other Historical Health Authority Policies

NHS Trust Gender Equality Schemes

Consultations

[top]Wider Sex and Gender Diversity Issues in UK Health Provision

[top]Sports Participation

[top]Further Reading

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