Nonbinary healthcare (UK)

Medical assistance with the transition process in the UK has historically only been endorsed under strict conditions, the most consistent condition being that the transitioning individual identifies as either male or female. Though the medical establishment lack recognised treatment protocols for nonbinary individuals seeking assistance with their transition, health professionals are beginning to recognise the need for the provision of relevant services.

Overview

Historically, eligibility criteria for medical treatment have presented a barrier for nonbinary individuals, specifically the 'real life test' (RLT) component which was later renamed the 'real life experience' (RLE). On the NHS London Gender Identity Clinic website there is a section regarding the RLE; "There is a two year Real Life Experience (RLE) of living in the reassigned gender role at the GIC for people who want to have genital reconstruction surgery (GRS). This is dated from the start of full-time gender role transition after which they can be assessed for referral for GRS. The RLE includes at least a year in some form of agreed occupational activities... The RLE sometimes called the Real Life Test is the period of time when a person lives 100% in their preferred gender. This means that they are known to their friends and family as well as at work (paid or voluntary) or at their place of study or daily occupation as their preferred gender. The literature and our own clinical experience, as well as the national and international guidelines, are very clear that people have fewer regrets after surgery and hormones if they have had experience living all the time in their preferred gender. Consequently, before referring for surgery we do ask people to have completed the RLE" [1]. Nonbinary individuals requesting genital reconstruction surgery (GRS) may not be able to meet the RLE criteria for treatment as there is little social or legal recognition of the nonbinary demographic.

At the Public Panel Discussion of Gender Reassignment Services in London in 2007, the panel “...was asked for an opinion on whether presenting as gender queer would be a barrier for services. The panel reflected that the language of queer is something quite specific to the LGBT community and hence it would probably be best to avoid this as the more general NHS and commissioners would not understand gender queer in this context” [2]. Many nonbinary individuals have felt pressured to present as transmen or transwomen in order to access treatment. In 'Archives of Sexual Behaviour (Volume 16), "Heterosexual and homosexual gender dysphoria"' (1987), Dr Ray Blanchard (who served on the American Psychiatric Association DSM-IV Subcommittee on Gender Identity Disorders) writes, "(there is a) well-recognized tendency of applicants for sex reassignment surgery to distort their histories in the direction of 'classic' transsexualism in an effort to gain approval for such surgery".

An article in the Independent newspaper published in 1995, includes a short interview with Dr Russell Reid in which he references people who have a 'desire to live between genders; “...many British psychiatrists regard the desire to live between genders with scepticism. Dr Russell Reid, a consultant psychiatrist who worked at the United States' first gender identity clinic, at John Hopkins University, Maryland, and now practices privately in London, believes that most androgynes suffer from a personality disorder, or are rebelling against society. “Unlike transsexuals,” he says, “their gender disorder stems from socialised behaviour and their own personality, rather than what some hormone has done to their brain”. He adds, however, that they are often “very unusual, very bright, very alienated, very individualistic and feel strongly that they are who they are”... Dr Reid says his androgynous patients “have a terribly hard time in society – to be sitting on the fence just isn't acceptable””. Dr Richard Green, former research director and consultant psychiatrist of the Gender Identity Clinic, London, was also included in the article as saying, “It's easier for us to put everything into pigeon-holes. We don't want to think about anything that’s in the middle. There are people, he says, who simply don't easily fit into our existing categories and their ambiguity can be threatening”. The article begins by interviewing a small number of individuals from the UK who have undergone some form of 'gender'-related transition. One of these individuals, Zoltar Kattse, has had surgery privately to remove identifiable aspects of their 'sex' physicality as they felt from early childhood that they were neither male or female. Prior to medically assisted transition, Zoltar attempted suicide several times due to the intensity of the symptoms of gender dysphoria they were experiencing and was 'committed to a psychiatric hospital' where treatment consisted, says Zoltar, of “trying to force me to be female” [3].

Speaking in an article in the Guardian newspaper in 2004, Dr James Bellringer “the leading Male to Female Gender Reassignment Surgeon in Britain” [4] states, “There's genuinely a group of patients who wish to be asexual... Psychiatrists are beginning to recognise this” [5]. Despite the recognition in the national press of nonbinary identity given by London-based clinicians, dating back here as far as 1995, the minutes from various 'G3 Gender Governance Group'[6] meetings obtained through the Freedom of Information Act 2000[7] reveal that elsewhere in the UK nonbinary type identity appeared to be virtually unheard of;

Excerpt from November 2006 meeting: “...(Dr Kevan Wylie, specialist in gender identity disorder working at Sheffield Gender Identity Clinic) had received an email from the (Royal College of Psychiatrists) about an application to a Member of Parliament asking if they could be noted as “no gender” and wanted to know if it was a recognised condition. Kevan had discussed it at a previous meeting but no one had heard of it before...” [8]

Excerpt from October 2010 meeting: “...Glasgow currently have [sic] a patient who has highly intellectualised the gender issues, he is biological [sic] male and in between somewhere... Equality bill only mentions the male to female or female to male.” [9]

The London NHS GIC released a statement called 'Gender Identity Clinic (GIC) myths' [10] produced by consultant psychiatrist Dr Stuart Lorimer with full agreement from the Psych team in November 2010 [11], the document includes the following:- “(Myth) You have to give a standard trans narrative (Answer) As the UK’ s largest gender clinic, we see a huge diversity of people, and neither wish nor expect you to tailor your own experiences to a set of clichés. Just be honest”.

On 1 December 2010, the University of Cambridge Centre for Gender Studies hosted the final public forum in its series on gender and radical biomedical advances, “Transitioning gender: the challenges of radical technologies”, in association with the Guardian and supported by Cambridge University Press [12]. One of the speakers was the aforementioned Dr Richard Green, who referenced “third gender or no-gender person(s)” seeking surgery to “remove breasts or male genitalia” and calls this a “medical dilemma for physicians because there’s no real life experience. Its either surgery or not”. In the audio recording of the event, Dr Green ponders how NHS physicians decide whether to assist these persons and suggests there are three factors to consider; how persuasive is the patient's argument? Does the patient have enough money for private care instead? Is there a surgeon willing to perform the requested operation?

On the 9th January 2013, New Statesman magazine published an article entitled, “As the #transdocfail hashtag[13] showed, many trans people are afraid of their doctors”[14]; the author of the article remarks, “...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'...”. The article also includes a contribution from the Lib Dem councillor for Cambridge, Sarah Brown; “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”.

Provision of care: the law

Under the “Legal Responsibilities and Obligations” section of the 'Guidelines For Health Organisations Commissioning Treatment Services For trans people' [15] it references case law confirming the obligation for UK Health Authorities to make treatment available for gender dysphoric individuals (North West Lancashire Health Authority v A, D & G, Court of Appeal, 1999) [16]. The Authority had denied funding for three gender dysphoric individuals to receive medical treatment via the NHS by effectively operating a blanket ban on funding for such treatment. In the court case the Authority's argument was “...challenged by a large body of evidence on affidavit and in written statements from leading experts on the subject relied on by the respondents. They included Dr. Ludovicus Gooren from the Netherlands, Professor Russell Reid from the Hillingdon Hospital, Professor Richard Green of the Charing Cross Hospital and a number of other consultant psychiatrists... They all asserted that hormonal and surgical treatment was recognised as the only suitable and effective treatment for the condition”.

“(Mr. Nicholas Blake, QC for the respondents)... prefaced his submissions by making the point that, although the Authority is exercising delegated powers of the Secretary of State under sections 1 and 3 of the 1977 [National Health Service] Act in its area, it must nevertheless give effect to the overall purpose declared in section 1 of promoting an improved comprehensive service throughout England and Wales for the prevention, diagnosis and treatment of illness. He accepted that it was for each Regional Health Authority and its medical advisers to devise a policy of priorities for the treatment of illnesses of various sorts and severity. However, he submitted that policies should be sufficiently flexible as not to impose a "blanket" denial of treatment even where in individual cases a clinical need for it could be demonstrated... an outcome clearly contrary to the object of the 1977 Act”. Although affected nonbinary individuals are covered under the above case law as gender dysphoric individuals, the Real Life Experience requirement in current healthcare guidelines for medical treatment such as GRS presents a barrier to services equivalent to a “...'blanket' denial of treatment even where in individual cases a clinical need for it could be demonstrated”.

At the Public Panel Discussion of Gender Reassignment Services in London (2007), Dr Stuart Lorimer confirmed that “the [London NHS] GIC follows a modified version of the Harry Benjamin Standards of Care... this was judged on a case by case basis” [17]. The Harry Benjamin International Gender Dysphoria Association (HBIGDA) is now known as the World Professional Association for Transgender Healthcare (WPATH) [18], they released version 7 of their Standards of Care in September 2011 which includes the following excerpt;

"The SOC are intended to be flexible in order to meet the diverse health care needs of transsexual, transgender, and gender nonconforming people. While flexible, they offer standards for promoting optimal health care and guiding the treatment of people experiencing gender dysphoria – broadly defined as discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) (Fisk, 1974; Knudson, De Cuypere, & Bockting, 2010b). As for all previous versions of the SOC, the criteria put forth in this document for hormone therapy and surgical treatments for gender dysphoria are clinical guidelines; individual health professionals and programs may modify them. Clinical departures from the SOC may come about because of a patient’s unique anatomic, social, or psychological situation; an experienced health professional’s evolving method of handling a common situation; a research protocol; lack of resources in various parts of the world; or the need for specific harm reduction strategies. These departures should be recognized as such, explained to the patient, and documented through informed consent for quality patient care and legal protection. This documentation is also valuable for the accumulation of new data, which can be retrospectively examined to allow for health care – and the SOC – to evolve."

The NHS referral process

”If you feel that you would benefit from referral to the GIC, you should first speak to your GP. They will ask you some questions and, if they are satisfied that it’s appropriate for you to receive specialist gender care, they will refer you on to your local community mental health team (CMHT). You will probably see a psychologist or psychiatrist at the CMHT for an assessment to make sure you are able to determine whether changing your gender is right for you. If you have any mental health problems which might be affecting your judgement you should be given the opportunity to discuss these further with a professional. After you have seen the clinician at the CMHT, they will refer you to the GIC. Once (the GIC) receive your referral (they) will apply to your local Primary Care Trust (PCT) for funding” [19].

“Many PCTs have limited budgets so some may defer funding, perhaps until the next financial year. If they refuse to fund outright, or you feel they are delaying unnecessarily, you can make a complaint to them or contact the Health Services Ombudsman” [20].

The Gender Identity Clinic

On the 'Treating gender dysphoria' page of the NHS website [21] it states: Once you have been referred to a gender identity clinic, it is likely that you will have another full assessment, for a period of approximately three months. This will usually be with the input of a psychiatrist (a doctor who treats mental and emotional health conditions). This assessment is necessary to confirm your diagnosis and, if you want to have hormone therapy, means that you can take the necessary health tests first... For some people, support and advice from a clinic are all they need to feel comfortable in their gender identity. However, others will need more extensive treatment, such as a full transition from one sex to the other... The amount and extent of treatment you have is completely up to you. They can also provide support and advice about living in your preferred gender role, including:

mental health support
hormone treatment
ways to dress in your preferred gender role
ways to behave in your preferred gender role
language and speech therapy
hair removal treatments
peer support groups to meet other people with gender dysphoria
relatives' support groups for your family

The NHS London GIC website outlines what typically follows a referral to that clinic [22], “Generally, the waiting list for a first appointment is six months... although there may be further waiting for other visits, a second opinion, funding, surgery, endocrinology, speech therapy etc. We work as fast and efficiently as we can, but we have limited resources and as we are a national service there may be waiting involved” [23];

Receive appointment letter.
Attend the Clinic.
Discuss what you might gain from coming to the GIC and what we can do for you.
Talk about current life, past history and any problems you have or have had.
Discuss and agree appropriate referrals at this stage e.g. speech therapy.
Assessment for suitability for hormones if requested and if two-part initial assessment is completed.
Assessment for suitability for ENT Surgery if requested and if two-part initial assessment is completed.
Assessment for suitability for Genital Surgery if requested and if ongoing assessment is satisfactorily completed.
Referral for counselling and/or psychotherapy if needed and if two-part initial assessment is completed.

Note that the process of endorsement and application for funding for treatment currently varies between NHS Gender Identity Clinics, for example the Laurels Clinic in Devon directly refer applicants for laser hair removal to a private laser clinic in the area, whereas London residents must get their GP to complete a PPWT form for laser hair removal to send to the individuals local Primary Healthcare Trust (PCT) for consideration - if funding is arranged, the individual will be advised by the PCT where treatment will take place.

Healthcare for under-18's

In 2008, the Gender Identity Research and Education Society (GIRES) produced a booklet called "Medical care for gender variant children and young people: answering families questions" for the Department of Health (download pdf);

“It seems that most parents with gender variant children do not seek specialist help. We know that about 800 adults per annum are referred to the ten NHS gender identity clinics throughout the UK, and although most say they experienced the discomfort as far back as they could remember, only about 50 children per annum are referred to the one specialised medical centre in the UK, the Gender Identity Development Unit (GIDU) at the Tavistock and Portman NHS Foundation Trust, in London... There are different medical opinions about the timing of blocking medication for young people. There are, as yet, no very long term studies of the different approaches to treatment, although data are now being collected, particularly in the Netherlands. There, the treatment as outlined above (providing hormone blockers to suspend puberty before physical changes become marked) has been followed, according to strict protocols, for several years... Young people are eligible for treatment in the adult NHS clinics (once they are 18 years old) or by private practitioners (from 16 years old)”.

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