Health: Lesbian, Bisexual and Trans Women

Baroness Gould of Potternewton Excerpts

Wednesday 3rd December 2014 Lords Chamber

[Baroness Gould of Potternewton (Lab)]

My Lords, I, too, thank the noble Baroness, Lady Barker, for introducing this important debate. It may have been a very short debate and there may not be many of us who have participated, but the words that we have said will be on the record, which is the most important thing. I thank also my noble friend Lord Cashman for his kind remarks and for his being able to participate with his great experience on the subject.

As we have heard, there is no question but that people in the LGBT communities are more likely to report ill health and experience unfavourable and negative responses from parts of the NHS. Like the noble Baroness, Lady Barker, I will concentrate my remarks on trans women, for they and trans people in general often require the services of medical staff in a way that lesbian and bisexual women do not. Many trans women who consider and embark on transition require medical assistance such as psychotherapy, cross-gender hormone treatment and surgery.

It might be useful to give a brief explanation of the process of medically assisted transition and of where treatment is available. Initially, the individual’s GP refers the patient to a gender identity clinic, sometimes via a local mental health service. After a minimum of a year attending the gender identity clinic, the individual may be referred for various surgical procedures. Cross-gender hormone treatment does not usually start until after the second appointment at the clinic.

There are seven specialist clinics in England dealing with adults and three providers of gender assignment surgery, which take referrals from all over the country. The question has to be whether this is enough provision to satisfy the need, for the number of people seeking such medical assistance has increased by at least 11% each year since 2004, thereby substantially increasing the demand for the few specialist services which provide care and treatment for patients with gender dysphoria.

Some 7,700 people are being treated or waiting to be treated at gender identity clinics. Such clinics are exempt from the 18-week deadline to provide treatment on the grounds that they are currently classified as mental health providers, despite a government statement in 2002 that gender dysphoria is a widely accepted medical condition and not a mental illness. However, I understand that this is now under review. Can the Minister confirm that that is the case?

There are two areas where waits can occur: the initial referral to the clinic and any subsequent referrals for surgery. The average waiting time on both lists is currently around a year, but that time is likely to increase. Extreme examples of waits are not unknown, such as that of the woman who waited eight years for her first appointment at a gender identity clinic. Long waiting times can inevitably lead to anxiety, depression and even suicide attempts, and there is little support during that time for those patients. Surveys repeatedly indicate that between 30% and 40% of trans women have attempted suicide before or during treatment, a rate which drops close to the national average after treatment, which in itself says an awful lot.

This specialist service is now the responsibility of NHS England, which inherited a mixed system from various historical commissioning processes. The new centralised commissioning body should provide a more consistent approach for the benefit of trans women, who are becoming more aware about what treatment to expect and about their human rights.

To date, NHS England has produced an interim gender dysphoria protocol to be completed next year, as well as service guidelines. A task and finish group has been created to look at key areas. The latter arose after concerns raised by Healthwatch England and local Healthwatch committees around the country about trans people’s healthcare and treatment. Specifically, Healthwatch England identified miscommunication locally about who commissions or funds the service, considerable delays in accessing services, individuals being put on waiting lists when “money has run out” and changes in timelines for treatment. There is terrible inefficiency that means that individuals fall out of the access pathway and struggle to reaccess the service. One can only imagine the despair of the trans woman faced with such a dreadful situation.

It is disconcerting that issues that have been raised over the past decade were still being discussed at a consultation only last week. The consultation heard of a lack of patient care and the reluctance of GPs to refer to clinics or take responsibility for prescribing cross-gender hormones. Wider concerns were also expressed about health professionals’ treatment of trans people. Although there are trans women who receive satisfactory treatment, many others do not. That can arise because of our GPs’ lack of knowledge. As the noble Baroness, Lady Barker, said, GPs play an enormous role in ensuring that proper treatment is provided right across the field. GPs need to be provided with more detailed information so that they can ensure gender identity services in the process to transition. Lack of understanding by GPs and their staff can cause great distress. It is difficult enough to confide feelings of gender dysphoria to a doctor without feeling fear, guilt, shame and ridicule. All too often, trans people leave a consultation feeling worthless.

As for lesbian and bisexual women, examples of humiliation abound. For example, one woman says:

“I asked for advice on a gender identity issue and the doctor told me to go away once he’d stopped laughing”.

That can continue for life, as clearly shown by the trans woman who had been a female for 15 years who went to her GP for a flu jab and was called “Mr” very loudly in reception. When she expressed concern about the lack of confidentiality, she was told that revealing her birth gender was relevant to the procedure. The mind boggles. What utter and absolute nonsense that was, as it was in the case of a woman who went to a hearing consultant. He decided that it was appropriate to question her about her trans notes on her medical file.

That is just the tip of the iceberg. There are many more examples of stigma, discrimination and ignorance. Any kind of abuse of a patient is unacceptable. It is crucial that NHS England and all the services within the NHS safeguard patients from abuse of any sort.

To find the level of discrimination, evidence was collected last year which identified a number of allegations, 98 of which were reported to the GMC. Of those, 39% related to GPs, 22% to gender specialist services and 17% to mental health services. The GMC expressed interest in pursuing 39 of those cases, but it is not clear that any action has yet been taken.

Paragraph 59 of the GMC’s Good Medical Practice guidelines states:

“You must not unfairly discriminate against patients or colleagues by allowing your personal views to affect your professional relationships or the treatment you provide or arrange”.

It is the breaches of that rule that have caused many patients to have a complete lack of trust in their clinics. Additionally, more than half the complaints related to both gender specialist services and general practice with allegations of refusal to treat or refer—also directly prohibited by the GMC’s Good Medical Practice guidance. It may be because of the complete lack of solid research that some GPs have such bad attitudes. Most are unaware of what basic monitoring they should be carrying out for trans women or how to translate those results. Also, linked to this lack of research, oestrogen and hormone-blocking treatment is not currently licensed or regulated and therefore not always prescribed, but hormone therapy is essential to maintain the health of the trans woman. Further, it means that trans people can be tied to a GP who will prescribe, and face uncertainty if they have to move their home.

There are, however, discriminatory practices within the NHS itself. There is currently no national policy on access to gender-specific screening, such as prostate screening for trans women. The NHS pledges to all patients undergoing treatment which might affect their fertility that they will have access to reproductive services such as gamete storage so that in future they can, potentially, have children via IVF but there is substantial evidence of storage clinics turning trans women away. I wait to hear from the Minister what advice he will be giving to NHS England to correct these examples of discrimination, which I am sure he agrees cannot continue.

The only way to solve these injustices is for treatment and care to be clearly patient-centred and non-proscriptive, while recognising individual preferences and circumstances. I welcome the changes in the NHS protocols which recognise this solution, but I ask the Minister to try and get some sort of speed in the timescale for full implementation.