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Treat the cause, not the symptom

If you’re already on the waiting list for the Northern Region Gender Dysphoria Service, you are still on the list and will (eventually) be seen. If you’re already a patient with NRGDS, things won’t change for you.

The people impacted are those seeking a referral to Northern Region Gender Dysphoria Service.

by Chay Brown (he/him), Director for Healthcare, TransActual

Towards the end of last week TransActual became aware that the Northern Region Gender Dysphoria Service have temporarily closed their waiting list.

What has happened?

On their website, NRGDS explain that they have have “temporarily paused all new referrals and transfers to the Northern Region Gender Dysphoria Service (NRGDS) service….”so waiting lists do not continue to increase, while we work with our partners on the future development needs of the service and ensure we maintain our standards for access to responsive services from a quality and safety perspective”. For context, their current waiting time is 5 years and 5 months.

What does it mean?

If you’re already on the waiting list for the Northern Region Gender Dysphoria Service, you are still on the list and will (eventually) be seen. If you’re already a patient with NRGDS, things won’t change for you.

The people impacted are those seeking a referral to Northern Region Gender Dysphoria Service. If this sounds like you, you might find it useful to know that you can ask for a referral to any of the main GICs in England. We’ve got a page about all these clinics. However, some people will find it hard to travel for appointments or to cover the costs of travel. There’s a page on the NHS website about claiming for the cost of travel, which will be helpful for some people in this circumstance.

Why has this happened?

Several factors are likely to have caused this situation. As always, lack of funds plays its part, and we imagine that it’s hard for NHS England to push for additional funds in the current political climate.

It’s clear that NRGDS have been making efforts to increase their capacity, and they state that they are recruiting for 3.5 full-time equivalent members of staff. Staffing has been an ongoing issue in NHS transition related care – we need more healthcare professionals willing to work in this specialised area. Unfortunately the current political and media climate will be acting as a deterrent.

The numbers of people being referred to GICs has been increasing year on year. That’s because, with more visibility, more people are realising that they’re trans. Waiting lists have been growing ever longer, yet actions to remedy this (via the 4, soon to be 5, pilot clinics) have come too late and, because of how the NHS operates, are taking a long time to come to fruition.

The traditional GICs aren’t fit for purpose anyway and rely on an overly medicalised approach. The system was broken from the very start, as Zoe Playdon explained in a piece for TransActual last year. Two signatures needed for HRT, two signatures needed for lower surgery. Gatekeeping at every stage. Some people benefit from lots of support and appointments, but plenty of people don’t want or need that.

The phallo and meta debacle has had a knock on effect on GIC waiting lists too. Most GICs keep patients on until they’ve completed their medical transition. The 4+ year wait for phallo or meta, and long waits between stages (and the fact that hysterectomy is now being done as a separate stage), means that there are a lot of trans men and non-binary people stuck on a waiting list and thus still having occasional appointments with their GIC. Which is important for them to access, given the impact that the situation with those waiting lists has had on the mental health of those affected.

What needs to happen?

Ultimately, the system needs to change. TransActual would like to see the NHS move to a system which prioritises an affirming approach based on a system of informed consent and without the need for specialist doctors (in most cases). Ideally it would be primary care based – we’re watching the pilot clinics and the progress being made by the Welsh Gender Service with interest. However, in a context where some GPs are refusing to even prescribe on the instructions of NHS GIC clinicians, there’s a long way to go.

Trans inclusive care is not a mandatory part of the medical school curriculum and it’s not in the curriculum for GPs, so it’s no wonder their knowledge and confidence levels are so variable. In order to move to the model of care that TransActual would like to see, GPs need training. Having had the training will likely help a lot of clinicians to understand that prescribing hormones for trans people really isn’t that complex.

Training is available, but we know that GPs are over stretched. Issues around GPs leaving the profession, GP funding and contracts and an ever increasing GP workload mean that, for many GPs, training in trans inclusion isn’t high on their list of priorities. We think it should be and would like trans inclusion training to be a mandatory requirement for all NHS staff, in the way that GDPR training is.

Whilst waiting for a workforce that is ready and willing to offer the model of care we’d like to see, there are other things that could be done to improve matters. GIC care pathways could be streamlined. Clinics could (and should) tailor their pathways to meet the needs of each individual, rather than following a rigid structure. One change could relate to surgical referrals. WPATH’s guidance states that one signature is enough for a surgical referral. This would need some co-operation from surgeons offering gender affirming surgeries – they would need to agree to accept referrals with one rather than two signatures. If you’re not sure of what a typical GIC pathway is like, watch our quick explainer for the English pathway (note that not everything we’ve included in the video is covered by the NHS, we’ve highlighted which aspects are not covered).

This video does not include spoken content and the information is conveyed in written format only. Read a transcript.

The situation around phallo and meta, which is exacerbating the situation with waiting lists, needs a different approach too. Whilst new NHS teams train up, we’re asking that NHS England pay for people to access phallo or meta abroad instead.

The political climate needs to change. Trans people are being used in a phoney culture war stoked by the government, the media and a global anti-gender movement. There’s no will from the government to support us and some within government actively working to make our lives harder. This of course impacts decisions made by the Department of Health and Social Care. Decisions around priorities, target setting, funding and whatnot. It’s also likely to deter medical professionals from working in transition related care and it’s almost certainly putting GPs off from offering bridging prescriptions too. (Not sure what a bridging prescription is? We’ve got an explainer.)

It would be quite easy to think that we’re in a hopeless situation but I can offer some reassurance. There are lots of people working to bring about change for trans people – the GPs that do offer bridging prescriptions, increasing numbers of GP practices and NHS trusts proactively seeking out trans inclusion training for their staff, positive feedback from the pilot gender clinics, and medical students working to make their university curriculum trans inclusive. And of course the many trans and LGBTQ+ organisations and groups working to make a change too.

What can I do to bring about change?

Whether you’re trans or not, give your GP practice TransActual’s resources for GPs and practice staff.

Write to your MP explaining the impact the current political climate is having on trans people’s lives and how it is having a knock on effect on our care too.

Support the organisations working to improve healthcare for trans people. Of course that can via a donation to TransActual, but it could be a donation to another organisation too. Support is not just financial – signal boost trans led organisations on social media (like, comment, share and save the posts for maximum boost) and you could even volunteer.

I’m impacted by this, where can I access support?

It’s important to reach out and seek support. You can find your local trans group on TranzWiki.

Contact the Gendered Intelligence support line or join their waiting list warriors group.

Contact another service offering mental health support, such as: