Transgender Equality

Lyn Brown Excerpts

Thursday 1st December 2016 Commons Chamber

[Lyn Brown (West Ham) (Lab)]

I have listened with real interest to the arguments made by Members about how the Gender Recognition Act 2004 and the Equality Act 2010—the first legislation I ever whipped—ought to be amended to better protect transgender equality rights. I hope the Government take these arguments seriously and respond appropriately, even if it takes them a further couple of months to do so.

I want to focus on the health aspect of the excellent report by the Women and Equalities Committee: the services provided for transgender people by the NHS. Trans people experience worse health, both physical and mental, than the general population. The Equality and Human Rights Commission has found that a higher proportion of transgender people say that their physical health is “poor or very poor” compared with other LGBT communities and non-LGBT communities. Levels of poor mental health are also higher in the transgender population, with about half of young trans people and a third of trans adults reporting that they have attempted suicide. It is therefore imperative that transgender people have full access to general medical services—appropriate ones.

Transgender people also have specific health needs; untreated gender dysphoria, which, as Members will know, is medically defined as when a person experiences discomfort or distress because of a mismatch between their biological sex and gender identity, can and does take a real toll on someone’s mental health. Dr John Dean, the chair of the NHS national clinical reference group for gender identity services, has said that

“not treating people is not a neutral act—it will do harm.”

I could not agree more with Dr Dean. Some trans people’s health and wellbeing would be greatly improved by gender confirmation treatment through our specialist gender identity clinics. Trans people have to be able to access those treatments on our NHS if they need them.

[Angela Crawley]

The Committee heard from individuals who had gone through harrowing experiences. They had gone to quite extreme lengths to receive the treatment that they wanted in order to have their gender identity recognised in countries where the practices were not as safe as they would be here in the UK. Does the hon. Lady therefore support the aim that the UK must ensure that we can cater for everyone who needs to access these health services?

[Lyn Brown]

I do indeed. The Committee’s report demonstrated that our NHS is not providing even a basic service, let alone a good service for trans people. The Committee report found:

“The NHS is letting down trans people”.

One of the first problems identified by the report was discrimination faced by trans people when they tried to access general medical services. Dr James Barrett, president of the British Association of Gender Identity Specialists, told the Committee:

“The casual, sometimes unthinking trans-phobia of primary care, accident and emergency services and inpatient surgical admissions continues to be striking.”

CliniQ, a specialist sexual health and wellbeing service provider for trans people, told the Committee that

“there is at best considerable ignorance and at worst some enduring and mistaken and highly offensive stereotypes about trans people among the public at large, amongst whom we must unfortunately number some health professionals.”

Sadly, this discrimination has real consequences. Terry Reed, of the excellent Gender Identity Research and Education Society, told the Committee that trans people were often nervous about accessing services because they were “not treated sympathetically” or even “politely” by doctors and staff. Brook, an organisation that provides sexual health and wellbeing services and advice for young people under 25, told the Committee that

“prejudice against trans people among medical staff”

was one of the reasons for poor health outcomes in trans people.

In addition, trans people report real difficulties in accessing specialist treatments and gender identity services. GPs have a legitimate role in acting as gatekeepers to NHS specialists, but I am afraid there is evidence that prejudice and ignorance among our GPs is preventing those who experience gender dysphoria from receiving the services they need. Dr James Barrett has said that there is a “persistent refusal” on behalf of some GPs to make referrals to gender identity clinics. The Beaumont Society has heard of one trans person being told by their GP at their first assessment—and let us think about how much courage someone needs to go to their first assessment:

“You’ll be taking money away from more deserving cancer patients.”

How wicked is that? It is a complete disgrace.

Where someone experiencing gender dysphoria is referred to a gender identity clinic it can take a very long time for them to receive specialist services such as hormone therapy or genital surgery. The process requires an independent assessment from two separate consultants, and a large amount of information needs to be gathered by the consultants about the individual before they can begin to proceed. That process typically takes months and spans several consultations. An additional precondition for genital surgery is that the patient must undergo at least a year of “real-life experience” of living “in the role” of their affirmed gender—it is an enforced pause. I have read the guidelines that explain the rationale behind this enforced pause, and I understand that the social aspect of changing one’s gender role is challenging and that clinicians do not want people to take on surgery until they are fully aware of those challenges, but that does not explain why the pause is often much longer than 12 months. The Government should assess the arguments made by some in the trans community that decisions over whether to go ahead with surgery should be based on the informed consent model. Under that model, doctors could immediately approve medical interventions if they are satisfied that a patient is fully aware of the implications of their decision. It is my understanding that the model is already used in parts of the United States of America. Given that it has already been tried and tested, the Government should be in a position carefully to assess its strengths and weaknesses, and bring that back to us.

It is important that the Government understand that delays in receiving treatment can, and do, cause real suffering. In the 2012 trans mental health study, one trans person said:

“Not having had my gender confirming yet has a constant effect on undermining my self-esteem and self-confidence as well as social transition—I hate every day that I have to live with ‘boy parts’ and I can’t wait to get rid of all recognisable ‘boy bits’.”

Another person told the same study:

“Permission for my chest surgery was delayed and I waited double the usual waiting time...This caused me to go into a deep depression. I had panic attacks when I left the house. I lost my job and then found I couldn’t leave the house.”

Such suffering could be prevented if we improved the speed at which our NHS works for trans people. Delays should not be any longer than is strictly necessary from a clinical point of view.

As a result of the problems that I have outlined, the Select Committee recommended that the Government conduct a root-and-branch review of how NHS services can be improved to better serve trans people and completely stamp out transphobia in our NHS. I am disappointed—I am sure that I speak for many Members here today—that the Government did not accept this clear recommendation. Instead they responded by stating that they will look into broadening the terms of reference of NHS England’s existing task and finish group for gender identity services. When such systematic failure has been identified, the Government should question the governance arrangements that are in place, rather than relying on them even more. I say that gently to the Minister and hope that she has had those conversations with her opposite numbers in the Health team. I invite the Government to give fresh consideration to a root-and-branch inquiry as part of their commitment to the cause of gender and transgender equality.

--- Later in debate ---

[Caroline Dinenage]

I will come to that. Detailed guidance has been provided to staff on how to implement the changes. An advisory board has been set up to inform policy and establish best practice on the treatment and care of transgender and non-binary offenders in prison custody and under the supervision of the national probation service. I will write to the hon. Lady about immigration detention services. I know that the advisory board had its first meeting on 25 November.

Several hon. Members spoke passionately about health, particularly the hon. Member for West Ham (Lyn Brown). As she said, ensuring accessible and prompt health services for trans people is of continued concern. I am pleased that good, collaborative, progress is being made. Discrimination against trans people in the NHS is not allowed and is unacceptable. NHS England has convened a number of multi-agency symposiums to begin to address this issue. The hon. Member for Brentford and Isleworth (Ruth Cadbury) will be pleased to know that NHS England and the General Medical Council have acted on the Select Committee’s recommendations by publishing new guidance on GPs’ responsibilities in treating trans people. We are also tackling the very long waits to access gender identity services, and we are beginning to see results: the average waiting time for patients to receive reconstruction surgery at Imperial College Healthcare NHS Trust has dropped from 94 weeks to 61 weeks, and is getting better.

[Lyn Brown]

The Minister is doing a remarkable job on the Front Bench at the moment, so I thank her. May I ask her to push her colleagues in the Health team on a root-and-branch review of transgender and LGBT health, as the Select Committee requested? That is fundamental, rather than having small working groups working on small bits of the matter.

[Caroline Dinenage]

I will of course pass that sentiment on to my colleagues in the Department of Health.

NHS England has increased financial investment in gender identity services from £26 million to £32 million this financial year. In addition to funding, we need to increase capacity in this specialism. That is why a joint initiative between NHS England and Health Education England was launched on 20 October to develop a programme of work to address national workforce and training constraints in that specialty. The planned outcomes will be recommendations for the future workforce, and will include curriculum development, continuing professional development and general awareness training among NHS staff.

The GMC and NHS England are also currently considering piloting a formal process for accrediting competencies in gender identity. To provide a better service nationwide, we will revolutionise service provision. We are seeking new providers to host gender identity clinics, and we will tender for them via national procurement in 2017. We will ensure that they can deliver the requirements of the updated service specifications for adult services. That means not only clinics offering better services, but ensuring better geographical spread.