Gender Identity Clinics

Gender Identity Clinics (GIC) provide specialist services in England and Wales for adults* who are seeking support with their gender identity. Staff are part of a multi-disciplinary administrative and clinical team, including psychologists, psychiatrists, endocrinologists, speech and language therapists, and nurses. They aim to provide holistic gender care, focusing on the biological/medical, psychological and social aspects of gender*2.

There are a number of services across England and Wales including London, Sheffield, Leeds, Daventry, Nottingham, Exeter and Cardiff. You can find more information about locating an NHS gender identity clinic here [add to resources page]. New services are currently being piloted in Greater Manchester, London, Wales and Merseyside, as well as being planned elsewhere (see website for up-to-date details). The waiting time for the first appointment varies across the services, but with high demand this can take a long time (measured in years). It is best to check each individual service for specific waiting times. For young people, see ‘Experiences of Gender Identity Development Service (GIDS)‘ as well as the experiences of crossing over between GIDS and GIC.

Young people we spoke to talked about their experiences with gender identity services across the UK. They talked about:

  • Waiting and the impact of COVID-19
  • Experience of assessment and NHS process
  • Communication and correspondence with NHS services
  • Concerns about power and gatekeeping

Waiting and the impact of COVID-19

The waiting times to be seen by an adult NHS gender identity service varied. People who took part in our study shared how long they waited to be seen before their first appointment or how long they were currently waiting. Freya described how she had been waiting a year and four months on the waiting list so far, and thought this was not even half way there: ‘[if] I think of everything I’ve done in that time [so far], I can do it all again and still probably not get there.’ Jack talked about making his referral to an NHS service in mid-2017 when he was told the wait would likely be 22 months. However over 2 ¬Ω years later he still hadn’t heard anything. Cassie had been waiting nearly a year with no contact from the service. Reuben said, ‘It’s just sort of an ongoing joke in the trans community about how long the waiting times actually are.’

Bay talks about being on the waiting list and the lack of contact causing them to panic.

Age at interview 28

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So the waiting list for the NHS was essentially that there was no, no contact between the point of getting the letter to say your referral has been received, to the point of receiving a letter to say your first appointment will be on this day. In those two and a, two years and a bit there was, there was no contact whatsoever. And I guess it kind of left me at moments sort of sitting there, sometimes I’d be like, okay, it’s, I knew it was going to take over two years, the process is slow, the letter will come eventually. As soon as it hit the two-year mark that was when I started to panic. Every sort of day that passed, or maybe my, maybe my names slipped off the list somehow, and how do I know if I’m still, how do I know that I’m still moving towards it? Should I ring them? Can I ring them? You know and I, it may just be me but the, the outward sense I get from the clinics is that they, you know, they, they’re short on resources, they’re short on time, they don’t want people ringing up all the time to say, When’s my appointment going to be? Do you know yet So, I was very shy in thinking okay maybe I should, you know just ring and just check that I’m still on the list somewhere, that it’s still moving. So I never actually did that.

But in, yeah in the first two years, I didn’t really think much about that at all, it was only once it got over that, past that two year mark, because my initial letter had said, In excess of two years so I thought well it could be any day now. So it was, it was in that period that I was sort of worrying like, oh you know, cos I think it was probably about two years and three or four months before I got the letter, so in those three or four months I was, that was when the panic sort of set in. But I, yeah I guess, I guess for me it’s, the, my thoughts around that are just that there is nothing you know even if it’s just a letter to say that halfway through or something, to say you are still on the list, don’t worry. Or something like that, and you know even before you start to think about the, that there’s no real other support offered in the meantime while you’re waiting. I think that’s a, you know obviously a, an even bigger thing. But yeah, just something simple as a letter just to reassure us that you know things are still moving in some sense, but for me anyway there was absolutely nothing from, from the point of referral to being offered the first appointment.

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Many found the experience of waiting for their first appointment frustrating, confusing and distressing. PJ described it as ‘very soul crushing, just overall lonely and you just feel like you’re not going to get anywhere.’ Noelle, who waited two years for her first appointment described the wait as ‘miserable, absolutely miserable.’ She said ‘in that entire time, I had to do everything on my own, transition related because I didn’t have the support of my GP’. This meant she was driven to self-medication.

Erion describes his super frustrating’ experience of being on the waiting list a long radio silence.

Age at interview 22

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How would you describe the waiting list?

Awful. Awful. Shocking. A long radio silence. Like they and there’s a lot of like I don’t know what the word is. There is a word for it. Let’s say it’s like different depending on where you look. On like the letter I initially got it was like, our waiting times exceed 18 months. I was like, oh, alright. And then on their website it says 28 months, right? Then you know, I kind of I was part of like a trans Facebook group like trans masc people and I said, okay, has anybody got a referral for [city]? and someone was like, yeah, Ive been on it for three years. [Laugh] Like, great. Like it’s just, I would much rather have known up front that it could have been that long. Yeah and I know it changes all the time as well. But even though at the time of that letter you know, their website is saying, 24 and yet their letter is saying 18 or 28 even. And you know the letter saying 18 —it’s just like what’s the point in saying that?

Because even adding in excess yeah, that can be any length of time. But it’s so frustrating if you’re, you know if youve got these people that have taken that step and then you are not even giving them a clear indication of how long or signposting them to the information that says, you know, how long you are expected to wait. But also obviously, because of how many people are on the waiting list, they cant tell you how long you are expected to be there for as well, which is super frustrating.

And the issue I’ve came across with [city] as well was when I was trying to find my information about their waiting list, they don’t have their own website, it’s part of like the you know, [city] Care Commission Group thing. And then it’s like in a tab, in a tab, in a embedded page sort of thing. If you don’t know how to get there, you are not gonna find the information you need. It’s not where you expect it to be and then finally it says like in a very small bit at the bottom like, we have recently invited people who are on the waiting list or like who had referrals sent out in, you know, 20-whatever. Weve invited those people. But then that didnt change for like 8 months. So it’s like, well, how accurate is that? Are you updating that? Like what is going on but then you obviously cant call them to be like sorry, is that right, or is it? [Laugh] What’s going? So yeah it’s long and arduous and super frustrating.

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Many felt it would have helped to have some contact while waiting, as Bay says, ‘even if it’s just a letter to say that halfway through or something, to say you are still on the list, don’t worry.’ Declan said, ‘I feel they should improve the communication when you’re on a waiting list; they should send you like a letter periodically saying that you’re still there because I feel that it’s easier to get lost in the waiting list.’

Finding sources of support was important while on the waiting list. Declan said, ‘They should offer like resources to help you cope’. He also suggested to ‘advertise youth groups and support networks and online communities and stuff because that can really get you through a waiting list and help a lot.’

The young people spoke about how they tried to support themselves during the waiting time to be seen by an NHS service. PJ said, ‘You’ve just got to think of other things, like for me going to uni helped a lot, cos that made me think of looking forward to something else’. He also said ‘surrounding myself with a good support network’. He said ‘my friends at the minute are like my family, and really, really helpful, and keeping me grounded when I’m really stressed out or really depressed that I’m not being seen yet.’ (See Experiences of mental health).

Anderson feels there should be support and contact offered to people while on the long waiting list for GIC.

Age at interview 26

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There isn’t any other words for that. it’s long as fuck, like it’s disgustingly long. I think I asked my GP to message them the other week, and I got, they got back to me and said I was 30 months away from the end of the list, I don’t even know how long 30 months is, but I’m pretty sure you can gestate an entire child in that space of time. So, I’m good, like that’s a long time. That’s a long time. You can have a baby in that time, that’s a long time. I’m okay. Innit, multiple children, like, I just can’t with these people. it’s really bad. To leave people in that situation, like if this was a spinal injury, if it was a bump on the head, like would they leave it this long? Never. They would have people out there, and I don’t understand why it’s not happening, why trans people are not being trained in this kind of healthcare, like why are we not just working for these people? I could do this job. I could do their job. I could probably do their job. If I, if they tried to train me I could probably do their job, you know, and it would be much nicer for trans people to meet someone like me than whoever the, they have in those services. it’s just such a weird space, like, I dunno. So yeah, their waiting list is long, and they don’t give enough information about where you are on the list, they don’t give you any hope. One of the things I really appreciated about MarketPlace and their counselling is that even though you’re on the waiting list for maybe a year and a half, they offer you Yoga classes, they offer you mindfulness sessions, they offer you support in that interim period before you get the counselling. So that you are being checked in on, like for no-one to have messaged me from May 2018 until now, to check that I’m even still alive is awful. I’ve got to go and find these people and do that. I just worry about all the people who are out there without the support, without the communities that I have, stuck with this crap.

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Those we interviewed also brought up how the Coronavirus pandemic had impacted the NHS gender identity services and the waiting time. Young people tried to come to terms with the realisation that the waiting times were very likely to increase further. Tyra talks about how she was given an appointment ‘for 19th March 2020, which obviously because of all this Covid shit didn’t end up happening.’ Pj said, ‘I got a call from [NHS service] in February [2020], saying okay your appointment is on the 7th April. He said ‘I screamed the house down, being like I’m finally getting seen’. However, ‘then the Coronavirus happened, and it got pushed back. He said ‘I don’t think I’m going to be seen till next year’.

Jack talks about the impact of COVID-19 on his wait for the NHS service coronavirus has put everything on hold.

Age at interview 22

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it’s quite demoralising to know I’m so far away and because I mean so Coronavirus and all that has put everything completely on hold so, but even without factoring that in you know, it’s kind of knowing that I’m still about two years away at least from getting my first appointment where the they kind of talk to me and do the interview and decide that yes I really am Trans which I’ve already been through once and that I’m already on hormones and they kind of go yes that’s fine and then with [GIC] particularly then have another waiting list you go on once you’ve had your first appointment besides whether they say yeah you’re Trans enough you then go on another waiting list to see someone who will then either refer you for hormones or for in my case it would be top surgery because I will not be able to afford top surgery privately, it’s about £7/8000 which is not money I have unfortunately so I now have to wait, have to wait two years at least plus another one year or more, it’s getting longer by the day obviously to then speak to the person who can give me my referral for top surgery and then I’d have to wait again for another referral, I believe they want two referrals so another years wait in theory for the next appointment so that’s four years and then by the time I’ve got my two referrals for top surgery I need a I need to wait for the top surgeon and all the top surgeons in the UK have like I think at least 8 month long waiting lists. So it’s kind of the knowledge that it’s gonna be another five years at least until I’m able to access surgery.

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Shash describes the impact of COVID-19 on gender services they had to put a pause on things’ but were still trying to do video call appointments.

Age at interview 23

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So, it’s at the moment it’s about the same as Charing Cross, which is about twenty, twenty-six months I want to say, something like round about two years. The hope is that it will ramp up, the issue was obviously Covid happened, so they were going to start ramping it up before the lockdown and stuff happened, obviously they had to kind of put a pause on things to get, because figuring out what’s gonna happen, so they’ve kind of figured out to, like they’d, things have started to get opened up and get rolling again, but also they were still trying to do appointments they could, so those were through Zoom, like Zoom appointments and stuff like that, so they were still trying to see people.

I’m, like I’m happy to say like the people who are working in the Gender Service do really care about their patients, and do really want to see, like I, are actively trying to make it better for their patients, their care and stuff so like they feel like there’s trans people working in the service too, and stuff like that. So it’s, like it’s lovely to see and like having seen it, so like yeah, the hope is that eventually it’ll ramp up and the waiting list will get smaller. Because like this was, there was like, this is, this service has been in the talks for like years, like, and I mean years. Like I’ve not been, like I’m like I’ve been involved but nowhere near the one of the people, like it’s been two decades at least, and talking to the, some, some of the trans people involved in the fighting of this, for this, it’s like, it was a slow process and the hope is that like now that we’ve shown to an extent that this is working, and it’s benefitting trans people, that we can get more things moving essentially.

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Experience of assessment and NHS process

People talked about their experience at the Gender Identity Clinic (GIC). This included the assessment sessions, and the process. They described their sequence of sessions with the NHS services, often there were many months between appointments. Summer said, ‘This first appointment was half of my assessment. I have the second appointment in a year and that’s when I get the [gender dysphoria] diagnosis and that is when the [NHS service] write my prescription [for oestrogen]. That is when they take over my hormone care. Even though,I’ve been living full time as a woman for two years now.’

Rahul talks about his experience of the sequence of sessions at GIC and what he spoke about.

Age at interview 25

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I did three appointments. The first one I was mainly talking about my childhood again, like really fabricating this narrative that I was very focused on having a trans identity from the beginning. I think the second one was more focused on my relationship with my parents. It had very little to do about gender identity in general. It was about my personal relationship with my family and friends and predominantly with my parents. That one was cut short because I was stuck in traffic. At the end of it, she told me she didn’t feel comfortable basically allowing me hormones yet, even though what I’d said was sufficient because she didn’t personally feel comfortable giving anyone hormones after just two meetings. I don’t really think is a good excuse. We waited another month and the last one was the one where she asked me about my general mental health and we talked a little bit about it.

I ended up lying about how I felt and then that conversation was mostly because we knew that I was probably gonna get green lit for hormones so that conversation was supposed to be about [coughs] life after hormones and how my family and friends would react and what expectations I had about my life and then she was very stuck on the fact that I had not come out to my parents yet and insisted that I give her some sort of verbal promise that I come out to them before starting hormones because she, even though I was financially independent of them and lived in a different country and had been identifying and living as trans for more than a year at this point, she didn’t feel comfortable signing the papers until I guaranteed her that I would come out to them that following month because I was going home for Christmas [coughs] because she was essentially convinced that if someone’s parents have a very, someone’s close relatives or friends have a very bad reaction to them coming out as trans then that can put them off transitioning essentially or getting hormone treatment for it. So, she didn’t want to put me in a position where I no longer wanted to transition, but was on hormones even though I assured her several times that that would not be the case. But those were the three.

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CJ talks about their experience of answering questions at their first and second NHS GIC appointment.

Age at interview 34

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My first appointment was great. My first appointment was with Doctor [name], on, and he was, he was very understanding, for essentially one of the most invasive areas of my life, when you go to the clinic they want to know everything from jump, and that involves talking about your childhood in incredible detail, talking about everything from, from how you felt as a child to how frequently do you masturbate. It was, it was the levels of, of information to give a stranger in a room while also worrying that somehow you were going to give the wrong answer. And I found that really difficult. I thought he did great, I thought that the situation, it was one of those difficult bits of, I didn’t judge him for it, I understood what he had to do, and he was very open and frank about how uncomfortable it was going to be, and he understood that and apologised for it. So, there was a very sort of human interaction there, which was really great, but in general, no. I mean I’d rather have a root canal than go through any of that again.

So, after the first appointment, I then had to wait for my second appointment, and my second appointment was horrendous from start to finish. My second appointment was horrendous from start to finish. I cannot remember the name of the doctor, I feel like I’ve actually blocked out the name of the doctor, he was an older gentleman and it started going wrong when I realised that I’d been in the room for about twenty five minutes and I hadn’t said anything, but he had talked a lot about his theories of genders and names and expressions and how people do things, and it, I remember there being, a, I’m one of those people where I’ll make a lazy joke to make someone laugh in a situation because it’s easier for to me to get through it, that’s just who I am as a person. I am a walking Dad jok in most cases. And I remember him asking me why I didn’t use men’s rest rooms. And I said because they smell worse. And he told me that I wasn’t taking it seriously. And there was a minute where I was like, I don’t think I understand what’s happening here

He also had very strong opinions on what trans people should or shouldn’t name themselves, and the names that they should pick and whether or not it outs you as being trans. And I think in a lot of ways, I suspect what he was trying to do was do that like, the notion of passing for a trans person, the idea of being in society and instantly being seen as cisgender, for some people is the absolute aim. I have always been another or some variety, and I’m very comfortable in that way. So, if someone wants to ask questions and, again I’m, I’m, these are not things I have not considered. He was very certain that, you know, calling myself [name] would be inappropriate, I should pick a different version of a name. Here are the names that I should and shouldn’t do. And it just got very, his opinions that I didn’t agree with, and also, I felt like that had very little bearing on me.

The end result, I mean the, the bit that, and of course at this point he is the, the person between me and testosterone, so he is the person between me, and as far as I understood it as well, it was I wasn’t sure if medical transition was going to be the right thing for me. But I knew that I needed to give it a go because nothing else had worked. If it didn’t work, it was then going to have to be further exploring about like what’s going on with me. I never really had the trans identity that the, my trans, knowing about my transness has fixed things. I think partly because I was just so much older when it really occurred to me, and doubt is one of my natural sort of states of being. I doubt everything. So, this is, he was also this person that’s standing between me and testosterone, I mean and being able to work out if this is going to help or not. And so I found it incredibly challenging but at the end he was like, You can go on testosterone, but I want you to change your name And a stipulation for me going on testosterone was the legal name change. Which I refused to do. And I still refuse to do because I’m a grown-up. But also, it’s my name, it’s my, and nobody has the right to tell me where I should feel dysphoric or where I should feel bad about something.

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A few of our young people described the frustration of needing multiple diagnoses of gender dysphoria from clinicians and different levels of healthcare. Ari was annoyed that the NHS services ‘had to diagnose me with gender dysphoria again which I’d already been diagnosed with’. They said ‘I’d seen four psychiatrists, diagnosed with the same thing at this point so that was really a hassle.’ This was similar for Declan who was frustrated he needed another diagnosis of gender dysphoria by new clinicians after previously being seen by the GIDS. He said, ‘they didn’t believe that I’d been to The Tavistock before or had a diagnosis yet so I had to get diagnosed again despite me bringing all my evidence ,I was like, ‘Look, I’ve been diagnosed,’ and they were like, ‘We still need to diagnose you again.”

H shares his experience of the process of NHS GIC appointments and trying to get signed off for surgery.

Age at interview 28

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With the gender clinic they like to start from the very beginning. So when you first get seen they just basically get to know you and then you’ve got to wait for your next appointment, so they tried to say to me, Well cos you have been on the hormones, we’ll give you your first signature today, and then your next appointment you’ll be getting the second signature So the next appointment came about say three months later, two or three months later, and I was under the impression that you know I had told them in the beginning that the most important thing for me now is my top surgery, because I’ve been on these hormones for a long period of time, I’ve had changes, my body has changed, so now I’m feeling more distressed because my body is, my body is masculinised however I have these feminine features. So, this is something that’s urgent for me. So, I was under the impression that you know I’m travelling, I’m doing a ten-hour round trip because at this point I was no longer driving, and I’d moved to [city]. So, I was under the impression you know I’m going to go there, I’m going to get the second signature for hormones, and they’ll talk to me about the top surgery. Why wouldn’t you? But that wasn’t the case. Then they basically said we can’t do that in the same appointment, you’re gonna have to wait and so the doctor even lied to get me out of the room, because I was obviously I was like, No, tell me why you can’t do it And he said cos I had to have a full body examination, he said, with like some nurses, he basically said to me, They will sort out your referral for you So, if So obviously when I spoke to the nurses they were like, Well no, obviously you can’t do that with just nurses, we can’t do that for you So I was really, so I left them very disappointed, not knowing, the thing is they don’t give you your next appointment date in that appointment, so you don’t know when your next appointment is going to be. They always say around four months, so yeah so, I had to wait, and I wasn’t happy with the service that I received so I put in a complaint to PALS.

And I said they haven’t justified why I’ve got to wait and they’ve obviously put my case across, and they spoke to the people, you know the doctors who were in charge of me, and they basically lied and said that well, I, they need to make sure that I’m steady on the hormones before they do the, any referrals and I didn’t know the dosage that I was taking, I wasn’t sure of what I was, what I was taking so therefore they couldn’t, they didn’t have an accurate description of what was going on so they couldn’t do, so they were not able to do a referral at this point. But if you look at my notes that they done, which, you know get sent to me after, it said, it said all the doses that I, all the information that I told them was on there. And it isn’t even highlighted that I’d expressed a need for top surgery etcetera etcetera, so they were trying to say that you know I didn’t give them enough information for them to make that that call. Which obviously it wasn’t true. So I wrote back to them, to the complaints service again, and I said, I’m not happy about that, and I’ve done all this research saying that your hormone treatment does not affect your top surgery, whether you can have top surgery or not There’s a couple of things in the guidelines which you need to qualify for, which I’ve qualified for, which they say it in my notes, it’s says that and so there’s no reason for them to delay my surgery, so, in the end I didn’t get another appointment until I think maybe four or five months later, and when I got there they didn’t apologise to me or nothing, they just basically spoke, talked to, spoke to me about the top surgery and said, Yep, happy to do the referral today And I said, What? Are you going to do that today So, this was August of 2019, and they said, Yep, we’ll do it today So, I left there feeling very hopeful that this was going to happen, cos I’d already contacted the hospital of like so this is in [city], near me. I’d already contacted them to find out the waiting times, so I, I roughly could estimate when it was going to happen to me. But as usual I was let down again, because five weeks later when I contacted the hospital to find out about the referral, kind of how long it would be, they said they hadn’t received it. So obviously I’ve contacted the gender clinic, and they basically said ah they’ve got a backlog haven’t got round to doing it, and I said, This is quite unacceptable and I just said to them, Do you know what, I’m going be seeking legal action, because I feel like there’s obviously something dodgy going on here and I said, You need to do this referral or else I’m going to actually turn up, I’m going to turn up to the clinic again, and I will not leave until I know it’s sent off, because this is very important to me Anyway, somehow, by some sort of miracle they was able to do it that day. Cos then they tried to say to me, Oh we need a second signature So, I thought, don’t you dare, don’t you dare tell me I’ve got to have another appointment. Because this was not disclosed to me in that last appointment I had So they said, No don’t worry, we can get that done electronically today, and it will be sent off today And they done it. That same day. So yeah, called up to the hospital a few days later and they said they received it, gave me a guideline of the time, and so I think they received it in September and then I had my consultation at the start of March, this year, and my surgery was supposed to be last Friday, but obviously because of Covid, [laughs] so after all [laughs] after all of that fighting, all of those years of just being let down and I finally got a date, finally got that date, I’m like Yes Like doing this big announcement on Facebook, finally getting my tits off on this date, it’s happening 15th, Friday 15th May, this is happening. Obviously, it was at this point it was only a ten week wait from when I got told, so like Yes, I can’t believe this is happening And then April time when they told me it’s cancelled. I can’t believe it. I was like, Of course this would happen, to me, this would happen. I’ve finally get that one thing, that, that one, that one, the thing is the hospital is a ten minute drive from me, it’s a two hour procedure, something that could have just been done years ago if people had hurried up, and then now it’s been caught up in Covid. And I’ve just, I really truly believe that if that second appointment that I had, where they, they, you know they can’t, they authorised my, technically it was for the hormones, if they had just done the referral then, I would have had my surgery by now. So, it’s a very frustrating position to be in, it’s the waiting that is the massive barrier for me.

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Many of those we spoke to talked about a clash between expectations, hopes and the reality of the service. Ari said they were expecting questions such as ‘when did you start feeling this way? How do you experience dysphoria?’ Whereas in reality the questions felt ‘very check box.’ They were asked more direct and practical questions such as ‘Have you changed your name legally? Have you changed your passport? Have you changed your driving license?’

Summer talks about her experience of answering questions at her first NHS GIC appointment you have to tick a certain number of boxes.

Age at interview 25

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Once I actually got there to the appointment it was, you know, there were instructions to get there and it was fine. It was pleasant. The clinician who spoke to me was very pleasant and respectful on the surface of it. The thing is, I know how this works and I know that you have to tick a certain number of their boxes and you have to get through a certain amount of stuff and so I was giving the longest answers to the shortest questions where the guy would ask me something about, what’s your gender history and I realised five minutes later, I’m already talking about my penis, you know. Because I know that we have to cover that, don’t we, you know? I kind of oh, it came up very naturally in conversation that he asked me, do I use my penis in sex. But, I think he was always gonna ask that, you know? And it’s really none of their business. And so that, so the experience was actually was pleasant and he was a pleasant guy and we had a nice conversation. But there were these questions that shouldn’t have been there and. You know and there were things like where he didn’t know what non-binary was. Like he kind of you know, he said, Oh well, so your partner. So you, you know. I’d mentioned about some of my sexual history about fancying men or women or whatever. So, and your partner—kind of as way of conversation and he was like, Oh and your partner at the moment is a woman. I’m like, No, I told you earlier they’re non-binary.

But and you know and he was like, Ah, but born female, I’m like assigned female at birth, yes, but that’s not important because they’re non-binary. There’s like clinicians could do with a bit more a bit more education like the actual bedside manner, not bedside manner, but the manner, great for this particular clinician. And I had a good time and he made me feel relaxed, but, but they need to really separate out the sexuality stuff and realise that’s none of their business. And, and yeah, just learn what non-binary is, really and [Laughs] like yeah.

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Henry says in light of his expectations of the NHS gender identity services, they have been pretty good.

Age at interview 25

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For what they are, and for my in light of, you know of my expectations of the gender clinic and what they are, my experiences with them directly, when I’ve been in the room have been pretty good. So the clinicians I’ve seen, I think I’ve seen an array, and they have all been I think in contrast to the GP’s that I’ve had, I’ve never had to fight for anything when I’ve got in the room, I never, never had to explain anything beyond what I’d been expected to explain, I’ve always been made to feel comfortable, and I’ve always felt listened to.

And that’s been really important. I think outside of that, it’s been more challenging, so where, I guess when, when you’re in the room with them they give you their full attention, they give you and they give you support and they give you exactly what I felt I needed. But then outside of that room trying to co-ordinate things with them has been really challenging. And that’s something that I think potentially, not that I want to point out their flaws cos I’m just forever grateful that they exist, but that needs work.

So I know at the moment it’s a struggle to even speak to somebody on the phone, over the past kind of year, so I’ve, again trying to get on, get away from Sustanon, cos the last, the last appointment I had last October with a clinician at the gender clinic they said, I can’t believe you’ve been on Sustanon for two years, you shouldn’t have been on this for two years So, I’m like, Oh my goodness, okay, I need to sort this out

So I they, they kind of gave me a list of things to do and I went away and did them, I got my blood test sorted which I obviously had to send to them, cos my GP didn’t want to. And I had to sort all of, all of this out and, but then actually getting hold of someone at the gender clinic has been really, really difficult, and time has gone by now, where so I needed an ultrasound scan for them to sign off on me switching, and various different things like that, and because that’s all taking time, obviously the current situation and Covid 19 taking that into account as well, I’m now at a point where I’ve done everything they’ve asked me to do, but my blood tests are out of date, so they’ve now come back to me and said I need to do my blood tests again.

So then that, that’s why I’ve been for one this morning, so that’s shifted back again and it’s, I feel like I’m going to be at my next appointment in, you know maybe, I dunno, it would have been six months but probably a year’s time, and in terms of my hormones, nothing will have changed, well I’m hoping something will have changed but potentially nothing will have changed and the fact that they then, so I think they tried to get in touch with me a couple of weeks ago to discuss, to tell me that I needed to get more blood tests and they rang me twice in the space of five minutes while I was at work, I didn’t have a number I could call back, and they basically left a message and said we’ll write to you. So I then had to wait for a letter, thankfully they’ve sent me an e-mail, which is good, and I think about time, they’ve just shifted onto e-mail, so I had to, I had to wait for the, for the email for then for them to basically tell me that I need to go and do my blood tests. And I’ve got no way of then getting back to them, and even though I can I can leave the voicemail messages saying please can somebody get back to me, I’m sure there are thousands, millions of voice mails like that, and I appreciate the stress that they’re under, but yeah, that communication again is missing, and it feels like there’s a lot of onus on, on you as a person to sort things out. Which is exhausting.

So, the gender clinic, generally, when I’ve been with them face to face, they’re great. Outside of that not so much. And I think as well, you know the space between the times when I see the gender clinic, often things have happened and they’ve, they’ve got no idea what’s happened in between, and a couple of times as well, so you know I’ve, I’ve had to try and communicate with them that for example I’m looking into getting a gender recognition certificate now and I know that I need a psychiatrist from that team to provide some evidence. I’m in the phase now of contemplating trying to contact them to ask them for that piece of information, because to be honest trying to get that before I see them face to face again, I think it’s just going to be such a mission I might as well just wait until I see them again. So that’s, that’s my frustration really with the gender clinic, and I get there are rational reasons for all of those things, but it doesn’t make it any less frustrating, I guess, so.

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Tyra moved to NHS care from private care and was impressed by the number of resources available, it was a lifeline.

Age at interview 25

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I feel like it was good that I had a black woman to speak to, who had been around other trans people, like because it was a trans service I felt like, it wasn’t like going to the doctors and being told, Oh no sorry, can’t do anything They, they had options and solutions like, I was very thankful for [name], like she was a very, she was a great woman, like it was different to, with the private doctor it just felt like that was me trying to access something, really with no outcome to it, like I didn’t know what was going to happen. Like what I was going to go and see a doctor, get hormones, and have surgery. Like that was the goalposts that I was setting to myself.

But when they accessed, accessed the NHS like yeah there was alternative things, they made me aware of like voice training, like groups that was around the UK that was doing like trans outreach stuff, like they just had so many resources, that in itself was actually like it was a lifeline.

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Young people also talked about barriers they experienced at the NHS services that delayed their progress to starting hormone therapy. Jaz said she ‘turned up [to the GIC] with the expectation [thinking] if this goes well, we’re giving you a prescription’. However she said ‘because I didn’t have a life plan, [the GIC] were like, ‘Oh, you don’t know what you’re doing with your life. So, we’re going to delay your treatment.’ Jaz felt this was unfair because she was just finishing university at this time and was unsure of what to do next.

Bay talks about their experience with the NHS GIC as a non-binary person.

Age at interview 28

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I’ve found my experience quite positive there I guess at the moment. They, you know there was definitely both, both the people I’ve seen there have been quite open in saying, Okay this is, you know non-binary people and, and their experiences are something we’re, you know we’re quite quickly adapting our systems to now. And so there was, you know certainly, I guess my worry, my only anxiety going into that first GIC appointment was that I was still reading things online that said that GIC’s weren’t geared up for non-binary people, that I’d face a lot of barriers, and stuff like that. So actually, so to hear those two people both say you know we acknowledge that there are limitations to the way we do things and we are actively changing things at the moment, made me feel a lot more comfortable about that. Cos, I thought this, okay this, in for me, in this clinic, it doesn’t feel like this is going to be a barrier to, to me moving forward in any way. So from that perspective I haven’t perhaps faced any of the barriers that I thought I might, going into that.

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The young people we spoke with talked about their experiences with practitioners at the NHS services. Some felt that they established meaningful bonds with their clinicians over the course of the sessions. Tyra was grateful to have a black female practitioner at their GIC. They said, ‘it was good that I had a black woman to speak to, who had been around other trans people, like because it was a trans service’. They said, ‘she was a great woman ,I just felt like she understood the issues that I faced’.

Noelle talks about her GP not allowing a referral to the gender identity services without seeing a psychiatrist.

Age at interview 23

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Saw the GP in February, early February 2017 to ask for a referral to the Gender Identity Clinic what I found is that [clears throat] he wouldn’t give me the referral unless I saw a psychiatrist first because I had read online about what was absolutely required. I knew that wasn’t necessary. So, I decided to go for a second opinion. What I found is my second opinion didn’t know anything about it. So, they went to my first opinion doctor for a second opinion. Because this has all taken place like multiple [clears throat]. Because this had gone on like multiple weeks, multiple appointments and I was training to be croupier in the casinos. I just got, got exhausted by it and I was just like, fine, show me the hoops and I’ll jump through them. They referred me to a psychiatrist, but it was a telephone appointment rather than a in person’ one, which never happened to me before. And I thought it was quite odd cos it’s something at least you’d think it was something that you’d want like quite, if you are gonna do a psychiatrist’s assessment, you’d want it to be in person where you can get like a full impression of someone.

Anyway, the telephone appointment comes around and I call at the designated time and the nurse picks up says he’s too busy right now. Call back in like fifteen, twenty minutes. So, I do that and the nurse picks up again says, the psychiatrist has handled the case and sent it back to the GP. I was thinking, what’s the point in a psychiatrist appointment if they are not gonna see you or speak to you. But I also naively assumed that because he just sort of handled it and sent it back so casually, it was because he knew he didn’t need to do anything with it and it could just be sent onto the Gender Identity Clinic, anyway. Went back to the GP in a couple of weeks and they said they had received nothing from the psychiatrist which was disappointing. But I thought maybe it’s just stuck in the bureaucracy, the system, maybe. And I again naively assumed that my GP would contact me with the results. Two months pass, still no contact at this point I am quite frustrated because I already knew how long the waiting times are and I know the sooner I get on it the better. So, I go back, he says, he got the letter two week two months prior and so not long after I visited them and the psychiatrist had advised them not to refer me to the Gender Identity Clinic, which was just bizarre. Again, this person hadn’t seen to me. Hadn’t spoken to me. And decided all on their own that I wasn’t fit for a referral to the Gender Identity Clinic which again by NHS standards shouldn’t even be required. So, like I started tearing up in the GP appointments, because I was not only angry that it’d been rejected, but I was angry that the GP hadn’t even told me it’d been rejected. And because of that response, the GP sort of begrudgingly gave me the referral which was just eye rolling because they could have done that in the first place. So, that was August, I think, August 2017. So, if you think I’d gone for the referral in February and I got it in August that delayed my entire referral by what like five, six months which as we know now, waiting times that are like a year and a half at the earliest and up to like two and a half, three years for some services.

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Communication and correspondence with NHS services

Communication and correspondence with the NHS services was a key topic of discussions for our interviewees. Some of the young people felt that the NHS services were difficult to contact and there was a lack of communication about appointments. Theo said it’s ‘impossible to contact the [GIC]’. Sally described the administration of the service ‘a mess’. She said ‘they deal with more people than they can handle, and things get lost.’ Summer said the NHS services ‘send you a letter in the post, which is not great.’ She felt that a text or an email would be better. She said as a student ‘I move house every year.’ She explained how she felt anxious at them not recording her new address and getting discharged from the service due to not responding to missed letters.

In contrast some of the young people were satisfied with the communication from their service. Sophie said ‘I have had very limited phone conversations [with people at the NHS service], but people I’ve spoken [to] on the phone have been very helpful and have explained things very well.’ Sophie thought ‘their website is fairly good, fairly easy to understand. It’s not brilliant, but it’s fairly good.’ CJ felt that his service was ‘really good with keeping on top of contacting patients’. His experience was that the GIC contacted patients and answered emails in good time.

Max shares his experience of the slow progress with appointments at the NHS service and a lack of updates.

Age at interview 25

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I had my appointment with the [GIC] in 2017, so almost three years ago now. I haven’t been seen since. Still waiting for the second appointment of officially being diagnosed, yeah. It got that dire. I’ve been always contacting them constantly like every few months, wanting to get some updates. But every time I do it, either they don’t give me any proper details and they just ask to refer to the website and the website, the website only says to wait X amount of time for your first appointment, but I’ve already been seen. So and yeah, I’m supposed to have someone to have like a case worker in between. Yeah, a case worker in between. But she cancelled on me twice and I did ask and left her an email and I still haven’t got a call back.

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Communication with the service was important for a number of reasons. A few of the young people we spoke to wanted help from the service with progressing applications recognising their gender identity. Noelle talked about asking the NHS service for a letter to ‘get the F on my passport.’ She also wanted help from the GIC with getting a Gender Recognition Certificate (GRC)*3. You can find more information about applying for a GRC on the GOV.UK website. She had heard that the NHS services could ‘provide a letter saying the change is likely to be permanent’.

Communication with the service was most important for accessing hormone therapy and getting prescriptions for oestrogen or testosterone. Some of the young people we spoke to talked about their frustration with the communication between the NHS services and their GP when it came to issuing a prescription. Declan said, ‘It was a bit annoying waiting for the gender clinic to communicate with my GP and then it took me asking my GP if a letter had come through for them to give me a prescription.’ He said ‘a lot of it is just me nagging the healthcare system trying to get what I want.’

Summer talks about her experience moving from private healthcare to NHS care with the NHS services.

Age at interview 25

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So, this first appointment was half of my assessment. So, I have [Laughs] the second appointment in a year and that’s when I get the diagnosis and that is when the GIC write my prescription. That is when they take over my hormone care. Even though I turned up to them and I was like so yeah, I’ve been living full time as a women for two years now. I’ve been on hormones for a year. Here’s my gender history. Oh okay, we’ll take over your hormone treatment at the next appointment in a year Like, I mean in my case, at least it’s like well, I’m not gonna die. I do actually have a supply, you know, of the—but no, because in that meantime I’m now gonna have to pay another £250 for another appointment at the private clinic and so they’ll keep treating me. You know, it’s just rubbish. Like, one a year, yeah, it’s usually and that’s what the guy said to me, it’s probably like a year’s waiting time and it was, until very recently, I think six months or nine months was standard in between appointments. So, should be a year plus inflation, right, [Laughs] for my second appointment and then also there’ll be some speech and language therapy session I think maybe a year after that, the consultation for surgery, which will probably be the orchidectomy, but who knows.

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Concerns about power and gatekeeping

The young people we spoke to raised a number of issues they had with how the NHS services in the UK were run and what improvements could be made. A key concern was the levels of gatekeeping within NHS pathways and the power imbalance between patient and professionals (see ‘Diverse journeys and pathways‘ and `Experiences of GP surgeries‘).

Young people expressed that they were dissatisfied with the current system. Theo said, ‘The current state of trans healthcare is appalling.’ Summer said, ‘I feel frustrated.’ She describes it as ‘a game you have to play’. She said, ‘I don’t like that [the GIC clinicians] have this power over me and that they can choose to prescribe or not to prescribe and you know they can choose to give me my trans diagnosis or not.’

H talks about the imbalance of power between patient and professional in NHS gender identity care.

Age at interview 28

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Oh it’s, it’s not equal, it’s not an equal decision at all. it’s the attitudes from my experience from the gender clinic that I’ve been at it’s like you’re lucky to be seen at the minute, like anything, like any questions that you have like, Why did it take so long and they’re like It just does and you know everyone’s got to do the same and wait the same and if they’re, it’s them making all the decisions for me because when I was doing my research on it, like the whole pathway it said that you can do, so there ain’t no specific order to your transition, so if the patient experiences a need for surgery like over hormones then you should go with what the patient what you basically work within the patient, patient’s best interests. That’s what it said. And they’ve not done that whatsoever. I went in there and I expressed the need for this surgery, above all else, obviously I was on the hormones and I said to them, it’s costing me a lot of money to do this, so you know I need that on the NHS as soon as possible. But the most important thing to me is, is surgery because this is the thing that’s giving me a lot of stress And it’s like they basically told me, Well we can’t after everything that’s obviously they know about me, We can’t approve your hormones today Like so I had to wait an extra couple of months for them to just say, Okay we’ll put your hormones on the NHS When I’d already been taking that for, for like two years.

So I don’t feel like, I feel like they take, there is no power, there is no patient power because no matter what you’ve done to, for yourself in the past they don’t take that into consideration whatsoever. They do it, they do it at a pace that they want, and whatever happen, they basically treat you how they feel that they, that it should go. So you know the two appointments for your hormones, and then they’ve said that you need two signatures for top surgery, when I’ve looked at the guidelines and it says you only need one. So they’re making their own rules for things and you know if I said to them I needed this surgery and they know I’ve been, they know I’ve been on this, these hormones for like two years, so what’s the best thing to do in my interest? Obviously sort me out with the surgery referral. That would have been what would have been best for me at that point in time. What difference did it make waiting, now honestly what difference did it make because nothing would’ve changed in my, in the way that I felt nothing, there’s no, there was no way it was gonna change cos I’d already been doing this for years. So I’d already started my transition so what difference what would be the difference between doing my referral when he first saw me, or maybe the second appointment to when they actually did it, in, so all them months passed, what was the difference?

Not because of the actual medical reason why you need to wait at least six month for something, there was, there is no medical reason, no medical like, if they say, say things like, Oh you need to, you have to be on the hormones for at least three years because something to do with your capability for the surgery or something, then I’d be like okay because that’s a reason which is, it’s a justifiable reason which is, you know, under a medical basis, but there isn’t none. There is no medical reason why they couldn’t have done it in that, Say if they were like oh no, you, there’s something in your blood whic, or, You’ve got a health condition which you need to resolve before you can have the surgery I could understand that, why it would need more time. But there was no, there’s no reason and for that reason, for that instance, sorry for that example that’s why I’m saying there is no power, because you go there, no matter what you say, they will always do what they want.

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These concerns about gatekeeping often related to whether the person seeking care conformed to traditional performances of gender (see Changing names, gender expression and appearance). Cassie felt that there was a distrust within the trans community of cisgender professionals in positions of power in healthcare. She said ‘I constantly feel like I have to justify my existence to cis [gender] healthcare professionals in general.’

Noelle said, ‘Unfortunately, I hear from a lot of trans people that they’ve had bad experiences even within the NHS GIC speaking to doctors who don’t seem that well informed or [are] a gate keeper.’ Ezio said, ‘One of my friends went to their initial appointment and she got told that because she doesn’t come across as massively feminine that it would be a problem.’ He went on to explain that ‘the way she dresses is for her own safety because a lot of her family don’t accept her and I think she’s very afraid of being attacked.’ He said it’s like ‘telling a woman, you’re not a woman until you walk like a lady, look like a lady, act like a lady, it’s very strange’.

Max talks about the balance of power at the NHS GIC services I have no control over anything.

Age at interview 25

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A lot of times I feel like everything is out of control, like I have no control over anything, really. I mean, it’s not so much with GPs but it is with the GICs definitely. Even just basic, basic information like, okay, what number am I on this waiting list. Like I don’t even get that or even like, okay, can you just give me like a rough estimate. I don’t even get that. So, literally in the dark like I have no idea what happens next. Like the GIC is like, okay, I’m in the system and that’s about it. And if one of the admin makes mistakes, you know, there’s people who slip through the cracks and they have to start all over again. So, yeah, I think there is a big balance, imbalance of power I would say.

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Some of the young people and adults had messages of support for other trans people navigating the system. Jaz said, ‘The more power you can build for yourself in terms of like your own knowledge and what you need, and the confidence you can pull that off with, it’s gonna improve your experience in terms of like what you get and what they give you and how fast, and if they delay your treatment or not.’

Other people we interviewed wanted to share their messages with healthcare professionals. Sophie said, ‘I was very nervous about the appointment, because of the fact that [the NHS practitioner] in the first appointment holds a lot of power over being able to start the transition process’. She wanted practitioners to ‘understand that it is stressful having to deal with when you are effectively being the gatekeeper about whether someone is transitioning. And, therefore holding the keys to potentially their future happiness as well and being able to have a meaningful, good, life.’

M says there is a major power imbalance’ in trans healthcare that is harmful on so many levels.

Age at interview 25

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Yeah I think that there is like a major power imbalance especially given the power imbalance is with people that don’t know anything about Trans people or about transition yet they’re allowed to hold the keys and for the most part they’re cis. So yeah I think there is a major power imbalance and I think that that power imbalance forces a lot of Trans people into a position where you just have to like just live on the like how can I, which one is it the, I can’t remember if it’s defensive or offensive, I don’t know, but it just makes you, it just makes you live in a place where you’re always having to legitimise yourself to a healthcare professional but in their frame of what Trans people are, as opposed to like your truth or your understanding of what trans people are or of your experience and it just creates like this like self-perpetuating cycle where you’re holding Trans people in a place that is like immovable and you’re not allowing like for fuller understandings of Trans experiences because we all have to adhere to this one narrative if we’re going to get access to the things that we need access to. And so I think it’s just so harmful on like so many levels.

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See also:

Experiences of Gender Identity Development Service (GIDS)

Improving healthcare

Hormones 

 

* The Gender Clinic accepts referrals for patients who are aged 17 years and older onto their waiting list. Accessed at https://gic.nhs.uk/referrals/

*2 Gender Identity Clinic [London], 2021. About us. Available at https://gic.nhs.uk/about-us/

*3 ‘A Gender Recognition Certificate is a legal document that changes the gender listed on your birth, marriage and civil partnership certificates, with effects on your pension, prison and marriage rights.’

Gender Construction Kit, 2021. Obtaining a GRC. Available at https://genderkit.org.uk/article/obtaining-a-grc/

https://www.gov.uk/apply-gender-recognition-certificate

Puberty and puberty blockers

Content warning: discussions of self-harm and suicide attempts. Puberty is a difficult time during many young people’s lives, but for trans and gender diverse young...