by Evie (aka SleepyCatten)
My name is Evie, a trans woman / trans fem in England, who uses she/they pronouns. If you were to ask me how I feel right now, I’d answer: “I have no gender-affirming care and I must scream.”
But I’m getting ahead of myself. Let me explain how I got to this point.
After finally realising / accepting I was trans in April 2021 (after a lot of self-doubt and questioning), I went to my NHS GP and politely asked to be referred to an NHS gender identity clinic (GIC). By late May 2021, my GP finally obliged, albeit after a lot of dithering and delays.
In January 2022, I learnt about an NHS GIC pilot scheme, so I got myself moved to the waiting list for this. Doing this saved me potentially years of waiting, as some folks are still routinely waiting several YEARS for their first appointment alone!
In the time between my egg cracking and my first appointment, I’d changed my name; updated all my IDs; started laser hair removal on my face; began my social transition; started voice training; and even started feminising HRT, after first obtaining a private diagnosis for “gender incongruence”: all at my own private expense.
A first appointment was offered out of the blue for mid November 2022. However, it was essentially useless. A medical practitioner interviewed me, but, per NHS protocols, this didn’t lead to me being offered any care yet whatsoever. Instead, they needed a second “specialist” to interview me exactly the same way again to ensure that I was indeed trans enough to be accepted on to their care pathway (i.e., to receive any care whatsoever).
Whilst waiting for the second appointment, I moved from laser to electrolysis on my face; switched from private HRT to DIY HRT, so I could move to weekly oestradiol injections, as patches were causing me skin irritation and constantly falling off; and even applied for a Gender Recognition Certificate (GRC).
I was meant to receive a second appointment within 6 months. About 9 months later, in early August 2023, I finally got the coveted second appointment. However, this didn’t make me feel happy: instead it just made me feel anxious and angry.
You see, since I’d come out, I’d absorbed every bit of information I could about gender-affirming healthcare, particularly the science behind HRT and gender-affirming surgeries. I’d read about countless other trans folks’ successes in other countries, particularly the US, as well as the pains experienced by others in the UK, especially England. I’d shared vicariously in others’ trans joy in other countries, whilst simultaneously knowing that NHS England did not offer all of the transition related care that I need.
Allow me to provide some context to explain that last point, before describing how my second appointment went.
The World Professional Association for Transgender Health (WPATH) sets out recommended standards of care for trans folks. There are many recommendations in the latest version (SOC8), including, but not limited to, the following for trans feminine folks like myself:
- Oestradiol valerate or cypionate injections for HRT.
- Hair removal (laser and electrolysis) for the face, body, and genital areas for gender affirmation or as pre-operative preparation from some surgeries.
- Facial Feminisation Surgery (FFS).
- Glottoplasty, aka Voice Feminisation Surgery (VFS).
- Bilateral orchidectomy.
- Peritoneal Pull-Through (PPT) vaginoplasty.
NHS England, however, in its infinite dispassionate hubris, does not follow WPATH standards of care at all. As such, there are:
- No oestradiol injections.
- Limited laser or electrolysis for facial hair removal (typically 8 sessions of laser OR 8 hours of electrolysis, out of an estimated 100 to 400 hours typically required).
- No standalone orchidectomies.
- No FFS.
- No VFS.
- Various types of vaginoplasty, but PPT does not appear to be routinely available.
So, I finally reached this second appointment, answered their invasive questions, and was told that I was indeed trans enough to receive care. I was then asked what care I was seeking. I put forward my requests, only to have all but one (an orchidectomy) denied outright. And even for that, they advised it would need to go to my local Integrated Care Board (ICB) to approve funding.
I’d known this was coming for the longest time, but I hadn’t been prepared for the complete lack of any flexibility or caring. The NHS is meant to provide trans patients with care, but all my reasonable requests were met with a callous indifference. I was not being treated as a patient in need of care, but a problem to be managed. It was effectively a tick-box exercise, with no consideration for my mental well-being.
The only concession I achieved was getting my assessor to agree to review my requests if I put them in writing, which I sent off that same day. I expect this to be reviewed within about 3 months, as that’s when my assessor wants to follow up to agree to any potential care. Yep: further waiting for basic care.
I don’t expect to win any battles over gender-affirming healthcare with NHS England. They’re too big and I’m just one person from a small community. They treat their own guidelines with impunity, as they’re constantly given permission by the courts to ignore their own legally-binding constitution. They reject international best practice, as they genuinely believe they know best, irrespective of the medical evidence.
However, I have to keep on fighting, because the potential gain of winning any battle might make life just a little bit easier for the next trans person to get care. Plus there’s no way I could ever afford any surgeries privately without resorting to years of crowdfunding. If nothing else, I will keep wasting their time with my requests until they’re sick of me.
It’s not, and has never been, a money issue for the NHS. They could actually save money by dismantling the GICs and switching to an informed consent model, allowing for better care for all trans patients. However, they’re clinging to a pathologised model, along with the control that stems from it.
Ultimately, I don’t want or need their apologies, their excuses, their sympathies: I just need gender-affirming care that’s appropriate to my needs, in line with international guidelines and best-practice, and within a reasonable timeframe.
For I still have no gender-affirming care, and I must scream.