A new decade for trans healthcare

Hello and happy new year. Welcome to 2020. Dr Helen Webberley here, and I am with Marianne. Just the two of us today. Hi Marianne, how are you? Happy new year.

Happy new year to you as well, Helen. I’m very well, thank you. I’m looking forward to the new year, I have to say.

So am I, actually. You sent me a text the other day and said, “Happy new year, how are you? Are you excited about 2020?” and actually, I really am. We’ve had some tough times over the last few years, as well as some really good times. And I just tend to see change, that the tougher times are getting less. It’s difficult because in the media, almost in a daily basis, we see challenges for trans people and cis people still not understanding or not wanting to understand trans people. But I just feel that voices are getting louder and stronger. And I think that more people who are not trans are coming forward and saying that we can’t treat people like that. So I do feel, although things sometimes feel a bit depressing, I do feel like we are moving forward. I don’t know whether that’s the same impression that you get?

Yes, I think we can get swept up sometimes in the negativity. And you know better than anyone else what we have been through at GenderGP is probably a metaphor about the place we find ourselves with trans healthcare. Almost (unclear 1:38) sometimes. Interestingly enough, coming into this new year, a little part of me thinks that we’ve weathered all of that. And then we look at what we’ve achieved last year, and it just feels, you know, wow. I think if we’d have gone and had a diagnosis people wouldn’t expect us to be thriving the way we are, if you know what I mean.

Absolutely. And I think, you know Abby and I, we were working on the annual report for what GenderGP had achieved over in 2019. I have to say it was amazing. When you work on a project like that every day, you kind of lose touch with it a little bit. And then we shared it with the team. And there are 30 people now working within GenderGP across different countries, which is just a phenomenal achievement. Everybody is working for the same aim, which is to give trans people the healthcare that they need when they need it. And the input from our friends and colleagues in Europe and beyond has been amazing. It’s been really amazing. And when we shared the annual report, which is on our website, with the team, I was really heartened by the comments. It was lovely to see it in pictures and in writing, how many people that we’ve helped, how many countries that we have reached since our international relocation. Marianne, you made a comment that you were surprised about the split between trans masculine, trans feminine, and nonbinary service users. It was about 30% were transmasculine, and 5% were nonbinary. Were you surprised by those figures?

I suppose that what surprised me is the people that I work with. And it tends to be the transmasculine patients. And I’ve been thinking about that, and part of that I think is because I see a lot of the under eighteens. And I just wonder if that’s where the growth is in numbers. because I do tend to see—trans boys tend to come out in the ages between 12 and 16. Trans girls are either before that or after that, generally speaking. So the feeling I had was it would have been 50 50. It is not negative, I have to say. It just shows you that when you have your eyes focused on what you are doing, that perceptions can be quite different from what it actually is.

Yes, I agree with you. It’s been wonderful that GenderGP has been a service that can help younger people. They are often the most targeted group, I feel, I don’t know about you. But certainly, the media find them the most challenging. And the medical regulators definitely have the most anxiety about them. And we’ve got these people who used to work at the Tavistock. I have to say that I haven’t worked at the Tavistock since 2015. And yet they are in the newspapers trying to cause havoc with our healthcare system. And because we are an international organisation now, we work very closely with healthcare providers in other countries. All I am seeing there is progression and acceptance and people, doctors, counsellors, nurses putting protocols in place to support trans people of all ages. And who inform healthcare practitioners so that they can best help. And that is what I am seeing come out of many countries. And what I am seeing in the UK just seems to be such a backwards step. It’s kind of, let’s see how many policies we can write to not help trans people, and certainly not let trans youth explore their gender. And I mean, you’ve worked a lot with trans youth, and I know the families get a lot of benefit from you. When I am reading stories that I come across, I am seeing these young people just trying to get their foot in the door of being accepted and helped rather than using that wonderful energy on exploring their identity, exploring what it means to them, and what it means to their families and how they are going to fit in in this world today. I don’t know. Is that something that you see, Marianne, when you work with these young people?

Well, there are a few things in all of this. The first thing I want to say is about the media portrayal of children. And then the children are being used as a stick to beat the trans community with. They’ve taken the focus, I think, away from trans adults. And they’re focusing on children. They are becoming the victims. What that’s causing is parents being nervous, and so when a child is coming out, it’s all about protection and you getting mixed messages. So yeah, the parents are being supportive, but they don’t know what is supportive. Do I encourage? Do I discourage? And just this whole notion that I like to think is just let your child be. It’s just getting all confused in this chaos. And yes, you’re right, actually. Of course, there has got to be time to process what’s going on for the child. And the child has got to be able to have time to process. But it shouldn’t have to take months and months. We need to reset the dial and let them carry on with their education, with learning their social skills. And yeah, they’ve got this thing going on, but actually, it doesn’t have to be as terrifying as it is being portrayed in the media. I think the puberty blocker case, at the moment, for my mind, what they’re trying to do is advocate for reparative therapy or conversion therapy. If you are talking about a gay man or a lesbian and you’re saying you cannot let them experiment, you know what I mean, there would be an outcry. If I am honest, going in 2020, I honestly believe it’s not going to happen. I don’t believe people are going to allow that kind of therapy or that approach to come back in. So I am hoping 2020 is going to be the year where the media start to get it.

Yes, that would be nice. And the media, they’re the voice of society, I guess, aren’t they really? Let’s extend that. We hope that the media will continue to want to learn positively, as a society as well. I’m just going to unpick your language there, Marianne. Because we talk about children, and I think the word child makes us very, very emotive. Mike and I have been talking about this. From a medical point of view, there is no medical intervention that we use at all with children. The only time that we use medical intervention is actually once puberty starts. And if we’re going to get technical on it, once puberty starts, that child is then classified as an adolescent. And with puberty and with adolescence, and with teenage years, comes those years of growth and exploration and moving from being a child, which to me, conjures up an image of a child holding mum’s hand while crossing the road, you know? While an adolescent stops holding mum’s hand and starts experimenting in the world on their own. And it’s adolescents that are coming forward for medical intervention. They have a voice. And we need to listen to that voice. Abby and I were talking about Gillick competence. I don’t know whether people out there have heard the case of Victoria Gillick. But she was a mother whose daughter wanted to access contraceptive help—this was some years ago. And she went to the doctor, the daughter on her own, and got contraception from the doctor, and she didn’t want her mum to know. Mum found out and was furious, and she was like, “How ever can you give my child, who is under 16, medical treatment without my permission?” So went to court. And actually, Lord Fraser, the judge, said this young person was able to make decisions for themselves, they were capable of making that decision for themselves, and we have to listen to that young person when they are capable of making decisions. The adolescents that we have seen coming through, who are trans, who are seeking medical intervention, we have to go that assessment of Gillick competence, or Fraser competence as some people prefer call it, to see whether they are competent to make decisions for themselves. And if they are, we must respect that. It’s no different whether you’ve got a broken arm or a broken leg or diabetes or something really tragic like cancer, or whether you need medical intervention for gender affirmation. And we need to start listening to these adolescents.

It’s interesting that you say that. You made me think. I’m doing the talk in front of the year tens of that school, the once a year trip I have. I was just thinking, when I am standing in front of some fourteen and fifteen-year-olds, if I was to ask the question, who in here knows what their gender is, I am willing to bet they would all put their hands up. And I can’t imagine any adult challenging them on it unless we saw what we might perceive as a little boy put his hand up to say that he was a girl. And that would be the only one that—we don’t doubt the rest, but we’re going to doubt this person.

That’s a really good point, isn’t it? So the cisgender adolescents, we trust them and believe them, and we wouldn’t ever challenge them, and we never say, “You’re not a girl, you might be a boy. Have you thought about it? Have you thought about it?” For trans children or children who are questioning their gender, we would challenge them and say, “Are you sure? Have you thought about this?” And they are, “Yes, I haven’t thought about anything but this for the last 12, 13, 14, 15 years.” Very good point, isn’t it?

Do you know what I had to go through to be brave enough to tell you, if they could articulate in an adult way, nobody would doubt them. Because they have been through the same agonies as everybody else. Nobody would ever articulate this without it being an agonising process, an internal battle. And it’s only at the point where it can’t be held in that it comes out. I genuinely believe that. I am sure there will be one or two people out there who are going to be saying that it wasn’t that difficult. But for the vast majority, it’s a massive deal. The other thing I was thinking about, because I have done a lot of information gathering sessions, and I was talking to one of the other counsellors recently, and I said, there are times when I just sit with this child in front of me and think, “What am I asking them?” You wouldn’t ask any other boy, “Have you always liked Actionman? Do you always befriend boys? Did you always—” You just wouldn’t have that conversation. And if people could hear the answers that we get back. Sometimes there is a bit of confusion. Actually, these children knew who they were. And it isn’t about who the best friends were or whether they played with Barbie or Action man. It just isn’t—it’s so much bigger than that. But unfortunately, even we have to have these conversations. What I said to this counsellor, was that sometimes I want to write on the paper “just help”. Help this child. We don’t need any more. You can see it. You can feel it.

I agree with you. It’s interesting what you were saying. I think with Action man and Barbie, in the future, I wonder in the future what it’s going to be. Is it what colour mobile phone case did you get for Christmas? Not sure Barbie and Ken are going to be around for much longer, are they?

Just on that point, I was talking to somebody recently, and they told me that you can get a whole array of Barbies now. You can get a trans Barbie, and you can even get a Barbie in a wheelchair. The whole array. I don’t know how popular they are, but I thought that was a step forward. It gave me hope.

Speaking of hope, bring me on to something I wanted to talk about. We’ve heard a lot of patients say that their family doctor was not being helpful. And if you look back at the women and equality report in 2015 16, there was a lot of talk then about GPs not listening, GPs not referring, GPs trying to talk people out of it. There were some quite distressing stories. And of course, we still see that. But I was really heartened, when we actually do the figures, that 80% of people who have been through GenderGP have had support from their family doctor. Not all of those were in the UK. Some of them were abroad. But to me, it is really heartening. And I think it’s to see the change that is coming. And in the older days, I think doctors felt that they could get away with not helping at all. And I think that is changing.

That goes back to what we were saying earlier. You know what, when we are in the middle of it, the cases that shout loudest to us are the most difficult ones. So where the GPs are not being supportive, we’ve got to work harder to offer the support. It feels like there is probably less support there than there actually is. And when you see the figures, it made me smile. And maybe that’s a message to get out to the other 20%. You are the minority, for once.

Yeah, absolutely. While we are here, I am going to say, if there are any health care professionals, doctors, nurses, counsellors, clinical assistance, anyone who wants to know more about helping transgender people in any kind of way, then we are always very willing to have a chat. I know you are, I know I am, and I know the rest of the team are. And also, just rewinding five minutes, I was thinking about doing the information gathering sessions with our youngsters—if there are any youngsters, if there are any young people who would like to share their stories, so that we can share those words, the words that we are privileged to hear. So time and time again, if there is anyone out there would like to share their words to help other people understand what it is like to be a transgender adolescent going through navigating the system, then do get in touch, please. Marianne, you had some exciting news from the BACP? Is that how you say it?

Yes, the British Association for Counselling and Psychotherapy. Interestingly enough, four years ago when I was registering as a female, or a trans female counsellor, whichever way people want to perceive me, I am happy, I asked that I have my preferred name on the membership and the card. And they could have my full details in the background. But, it was one of them “computer says no.” And I argued and argued to the point where it was starting to get me frustrated and upset if I am honest. And I gave up the fight. And what they did, they kind of compromised and I had to have both names on. So I had my old name, and I had Marianne on the card. I gave up the fight. And then last year, they gave a survey, and I kind of said that I was really upset and disappointed that an organisation which presents my profession is so backwards on this. And I got an email the other day saying that they’ve listened to me and they would change all my details and use my preferred name. So I am going to get a new card and a new certificate. It will represent who I am today. So yeah, that was highly emotional, if I can say that. I might sound silly to some people, but it was one battle that’s been won.

Yes, and well done. I’m really pleased. And actually, well done for that even when it was getting frustrating, tearful, annoying, hard work, too much, just keeping the pressure on and keeping it open and not losing that important battle. We’ve seen, haven’t we, how misgendering by a pronoun or by name can be so hurtful. It’s just a word, but it’s a really important word because it’s about you and your identity. We’ve seen how important that is.

Historically, whenever I’ve had conversations with people, and you mispronounce their names, they’ll bite your head off. Because it is important to us. You know, when I have mispronounced somebody’s name, and they tell me, I feel a sense of guilt. Even if it’s understandable, it’s still doesn’t make me feel any better. And yet when trans people are concerned, it’s like people in the media are so dismissive of it. And it’s important to all of us, trans or not. We could even extend this to, you know, pet owners, you only have to meet someone who is out walking their dog and say, “Oh, he looks like a lovely little boy, doesn’t he?” They will seem to snap your head off and say, “It’s not a boy, it’s a girl.” You know, identity is really important on so many levels. At the risk of kind of labouring the point, you know, titles like doctor, sergeant, you know, people strive to get them titles. And actually, a trans person is going through a similar process. What’s difficult in respecting that?

Interesting point, isn’t it? They work hard to earn that title and to be able to use that title. And we should respect that and try and get it right, even if it is difficult, even if it is a they or them and it doesn’t roll off the tongue easily. It’s important.

Well, let us be fair. We can struggle. We do get some patients who are coming to us, and they are still exploring their gender, and they move from transgender to nonbinary to genderfluid. They change the name, they change the pronouns. And sometimes keeping up can be difficult. We’re all human, but we never stop trying. There is no point where we sit back and say sod them. And it’s not difficult. It’s never difficult to be nice, isn’t it?

Can I share some exciting news from my side? Last year, I was invited to join a debate about the medical provision of gender care. I was delighted, love talking about it. A few weeks later, I received an email, and it said oh, sorry, we’ve just done a bit of googling and we see the difficulty you’ve had with the GMC and what have you. We don’t think you will be appropriate. I had also, in the same year, been invited to talk on a sexual health conference on issues of gender. And the same thing had happened a few weeks later, they replied with, sorry, we’ve seen that you are under investigation by the GMC and we don’t want you anymore. That actually really hurt, because I love to teach, I love to talk, I love to share my knowledge. I love embracing the community. And those things really hurt. I shed a tear at the second one, and I wrote a blog about it. Last year, I remember. And kind of shared my tears on paper. But at the end of last year—there’s a fertility conference coming up in January up in Leeds, run and hosted by trans people, which I think makes a difference. I applied to speak and to share some research that we’ve been doing. I was accepted. I haven’t really been waiting for the email that says, sorry, we don’t want to taint our conference with your name. And I haven’t had it. So next week, I am going to Leeds to share some data that we’ve had on people who have taken up gamete storage, which is sperm or egg storage prior to starting treatment. I’m really excited. And once again, thank you to the trans community for being the ones that didn’t said, oh, sorry, we don’t want you, you’re too tarnished. So I am really excited about that. I think, Marianne, this is an important piece of work because everyone talks about fertility. We had that wonderful blog, didn’t we? That podcast, sorry, with Freddy, when he was talking about fertility. And it goes back to these adolescents, who are in such turmoil, and they’ve got lots of decisions to make, and then someone else is saying, well, hang on a minute, have you thought about having children. What are you going to do? What are you going to say? What are you going to store? And I think fertility preservation issues for trans people, I think its something that we’ve got to do some work on to make it more accessible and make it easier to talk about and perceive, I think.

Well, two things there. I am excited for you being able to do that talk. I got slightly emotional there when you were saying about the two (unclear 22:20). I just know how it hurts, but yeah, you know, fertility. I was talking about a completely separate subject, it’s to do with the news and stuff. But there’s not a lot in the media giving anybody hope. Everything is all really negative. And I am just going to equate that to the fertility with trans people. Nobody ever said there’s a chance you might lose your fertility, but there’s a chance you might not, and we just can’t measure it. But, actually, it doesn’t mean to say that it’s gone, and offer some hope. Because it’s terrifying for someone to just say, are you sure you want to make this decision? Are you sure you want to make this decision? That’s it. It’s done. That was how it was delivered to me. That was how it was delivered to a lot of trans people. And maybe that is true, I don’t know. But talking to the likes of the Freddy McConnell, and some of the other people that we’ve come across, it proves to just not be the case. You know, offering a bit of hope would be quite nice.

Definitely. We talked about it before, haven’t we, where the medical profession are so scared to get sued or criticised that we make it so terrifying on consent forms and such things? It’s interesting, we have an Egyptian doctor who works with us, Yasmeen. She transcribes the podcasts for us, as a kind of part of the learning and expansion and what have you. And she was really—she loves, loves, loves the podcasts, as many people do. And you know, the Freddy one, do you remember how that was, the crying, then laughing, then crying again. And she was saying that it was just a really special episode, that one.

And gave hope.

I think we saw this week that BBC had something on about waiting times again for trans people. What makes me not smile, I don’t smile at this, but what interests me, let me put it that way—the BBC has this shock article that waiting times are 18 months, two years. And the world is shocked. Whereas actually, if you read the comments and if you listen to trans people, they’re like, are you having a laugh? Eighteen months would be really short. What we are actually saying is 3 years, 4 years, 5 years. That’s the reality. And it just shows you how you can skew figures a little bit. Waiting time to what? Waiting time to get the first letter to say you are on the list? Or waiting time to say that you have an appointment? What is the waiting time from the time you go to your GP to get referred, to actually being able to start the medication that you deserve to have to help you live your life more easily? And that’s a long time.

Well, yeah, I think the waiting time is a little bit of a smoke and mirrors. Waiting time to be seen, waiting time to complete your treatments. It could be anything up to ten years, probably. And again, I know I’ve gone about this probably a bit too much, but this gatekeeping system. I had my discharge appointment from the GIC just before Christmas. And I actually came away feeling really invalidated and dismissed. You know, this issue they’ve got over with the name change, and the way the doctor kept phrasing this in my case. You know, they’re happy that I stay on the hormones and so. But you’re still going to have to change your name. We can’t recognise your transition till you change your name. But it went deeper than that. It was the way they talked to me. It was everything else that came after that. And I just thought, I am pretty strong. You know, I think I deal with these things very well. I would imagine somebody more fragile, it could be really damaging. And when we talk about the wait times, there is no need for me to be having that appointment. There is no need for me to, you know, even have had to go to the GIC to get this fairly straightforward treatment that’s not life-threatening, that’s life-enhancing, and which means the difference between being able to go out into society and contribute, or be introverted and stuck in the house. To me, the whole system needs looking at. And actually, we need to bring some of this care back into—and I’m hoping you’ll agree—primary care.

I do. I agree. It’s interesting. I’ve been under investigation by the GMC since 2015. Looking at the issues of whether a GP like me can provide care, transgender care, to patients of all ages and all genders. It’s been a big question. That process will be coming to an end this year. And the result of that is a really important one. And I hope that the outcome will be that they recognise that any doctor that has the skills and knowledge, however you’ve got them, whatever training you’ve done to help people, should be allowed to help people. And that’s the way we should be going forward. I think it’s going to be a really landmark case. I am just a GP. I’ve fought against that phrase all my life, and now I am using it in my favour. But I am just a GP who has a very special interest in gender health. And if I am validated in providing care for transgender people of all ages, I am hoping that will give a lot of confidence to lots of other doctors to be able to do that too. So we’ll see, I think 2020 is going to be an interesting year from that point.

Fingers crossed, really. Well, if nothing else, this just goes in your favour, Helen, because it’s time. I didn’t realise it’s 2015 either.

It’s funny because when you start these things, it’s horrific. I mean, I remember the first letters I got, you actually want to dig a hole and climb in and never come out. It’s just horrific. And you just said a minute ago I’m strong. I’m strong, but I have had goosebumps, I’ve had butterflies, I’ve had tears, I’ve had thoughts of actually, it’s not worth it anymore. It’s hard. It’s really hard. But with the team that have become GenderGP, and the community that I have helped, that support has just taken me through. Absolutely, one hundred per cent taken me through. Every minute is worth it. And if the outcomes can help more doctors like me to go forward and help other transgender people who have also helped me, you know, that is a very (unclear 29:15) worth it, I guess.

I’ve said before, you know, what you’ve experienced is transphobia. There is no other reason that GenderGP, or you and in particular and Mike, have got into the position you are in. The only cause is transphobia. Because, yes, they can bring it into primary care, trans healthcare. But I do believe that there are a lot of doctors out there that just don’t get it and have no empathy and have no interest. But, it is the ones that are willing to help that should be able to do it without fear. So yeah, everything you described there, I just thought, if you had put transition in front of it, I carry on, I am strong, you know, is it worth it, there is not a trans person who are going to listen to this podcast who has never said them words.

Yes, it’s interesting. We’ve often made that analogy. And it’s interesting. But I think the number 2020 to me is quite exciting. It’s a new decade. It’s 20 years since the millennium. I mean, I had my first child, actually. So yes, very interesting and exciting times ahead. I am so delighted that I never gave up. Because if I had given up, GenderGP wouldn’t be what it is today. I am really excited about GenderGP continuing to deliver massively good healthcare, and always learning and always developing. Interestingly, you were talking about information gathering sessions earlier, that you’ve got to try and get some information out of these people to validate them in order to get them through on the next step. Sometimes you just want to write, “This person needs help.” And and of story, this person needs our help. There are these long assessment processes that we are supposed to make trans people go through in order to validate their gender in order to access healthcare services. Maybe in 2020, it’s going to be enough for someone to come forward and say, “Dear doctor, I would like to try hormones to see whether they are going to make me feel better to have the hormones of a woman rather than the hormones of a man.” And it would be—maybe that is a really good goal to look for in the future. That’s again in 2020. A new decade. Let’s hope that these tides keep turning and changes come.

I’m hopeful. I came into the year, as you know, I had a little bit of a cold. And that would normally drag me down, but actually, I’ve started the year off quite energised. The little leaflet that Abby put together for us to show us what we have achieved just really lifted me. And actually, has inspired me to do more. I can’t be any more positive than that. It really has ignited me.

Yeah, good. And I think one thing that I am really delighted about is something we’ve talked about giving up. We’ve talked about, “I can’t do this anymore” or “I can’t transition anymore”. And one of the things we could have easily done is, I’m sorry to all you young people. You’re too hard work. You’re too a risk to us. We can’t help you anymore. And I am so glad that we have never done that. When we were at my house having the Christmas party—the GenderGP team came to my house and tasted my cooking and tried some wine. When I said to everybody in that room, I said each one of you here will have helped save a life. And I really meant it. I really, really meant it. That slide that Johanna Olson-Kennedy often puts up, all the tragic pictures of trans youth who have taken their lives, and she adds multiple pictures to it every time. I want that to stop. I want that to stop. I don’t ever want a trans youth or adult to take their life again. To take their life because they can not go on anymore. And if GenderGP can just help any of those people, and everybody in our team has been implicitly helping people and saving lives, and that is just absolute privilege.

I always tag something else on there. It’s not only that we save lives, but we also make lives. Because, I know—I’m going to get tearful again now—I know how life can be when you don’t have that hope. And we give it.

I wish I could come and hug you but I can’t. You’re in my computer screen.

But yeah, it’s true. We give hope. And that, to me, is the thing we are fighting for.

Well, Marianne, as always, an absolute immense pleasure to talk to you. I love talking to you. I hope our conversation has been useful and interesting to those listening. If anyone is touched by the things that we talked about, please, we do talk from time to time about things that make us cry, and we have that emotion. We also talk about the hope, the life, and the love that we give to the trans community. I’m so pleased with that day you emailed me and said, “Hello, I’m Marianne, I’ve seen the work that you do, and I do fancy a chat and a coffee.” And I am really glad that you did that day. It is a real pleasure working with you. And I am so excited about 2020. And 30 and 40 and 50.