There are so many stories we could swap about gender identity – some harrowing, some hilarious, some both – and I hope we will. In one respect, my story is probably the same as everyone else’s: If I hadn’t transitioned, I would have died.

But what I want, no, need, to talk about today is the difference between my privileged transition from female to male in California, and what I discovered when I returned to England.

After living in England for ten-plus years and gaining citizenship, I moved back to California for two years, during which time I transitioned.

At first, I was optimistic about returning to the UK as a trans man. My 17-year-old godson, who lives in Derbyshire, had told me that tolerance for gender-queer folk was now on the school curriculum.

I was also fairly confident about continuing transition care in the UK because, before I left California, I had already had top surgery and my testosterone was stable at normal levels for a man.

All I needed was for a gender-specialist to confirm the continuing prescription for testosterone with my GP and advise her about my regular blood tests.

“All I needed” indeed.


Trans healthcare in California

There is one health care organisation in the United States that is likened to the NHS. Kaiser Permanente is both a healthcare provider and a healthcare insurer, and I’ve always sung its praises. When I returned to California from England two years ago, I immediately re-enrolled.

In November of last year, I told my Kaiser psychiatrist that I wanted to transition.

She knew I’d always identified as male, with chapter and verse dating back to nine years old, so was happy to diagnose gender dysphoria, in addition to the major depressive illness and anxiety disorders I’ve carried around since puberty.

Immediately, the Kaiser Permanente system kicked into high gear. They have a program that my UK psychiatrist calls “world class”. Kaiser calls it the Multi-Specialty Transitions Department (MSTD), and I had my first appointment the day after the diagnosis.

If I hadn’t already had a psychiatrist familiar with gender dysphoria, they would have assigned me one. They also assigned me a gender therapist, a trans man, to explain the options for treatment and hold my hand through any that I chose to have. Throughout transition, he provided encouragement and support and educated me about potential difficulties ahead.

The MSTD also offered a weekly transmasculine support group. Those men became my lifeline, and still are.

The department assigned me a GP who specialised in gender transition. She ran blood tests and prescribed testosterone injections.

I chose to have “top surgery”, a phrase that is so polite it makes me giggle. I called it “having me tits off”.

I was then invited to attend a top surgery prep class, in which we heard from one of the department’s social workers, a specialist surgeon, and a panel of transmen who had had the surgery.

During the period before surgery, the social worker (also a trans man) walked me through the legal and administrative changes. He guided me through the civil court process, which resulted in a legal name and gender change. He also helped with the procedures required for banks, credit cards, driving license, Social Security number (the same as a National Insurance number), passport and birth certificate.

The Multi-Specialty Transitions Department also included a roster of specialist surgeons. Although the surgeon I chose was one of the top plastic surgeons in Northern California, he still had been required to shadow his colleagues in the MSTD for two years before he was permitted to perform top surgery.


A note about taxes and medical care

Given my profession, I pay shed-loads of UK tax, every penny owed to the HMRC and always happy to do it, because it means free medical care at the point of service.

In the States, of course, we have no such socialised health care, but we have somewhat lower taxes. The extra I pay in UK taxes is about the same as what I pay to Kaiser Permanente for health care coverage when I’m in the US, so it’s always balanced out.

Or it did until I returned to the UK as a trans man.

Note! I received all the services detailed above from Kaiser at no cost other than my monthly insurance premium. Even the cost of my surgery and after-care? ZERO.


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Trans healthcare in the UK

When I returned to Cambridge this past June, I brought letters and lab results from my Kaiser GP and psychiatrist. I was hoping to see a UK gender specialist right away.

And here’s where the culture shock began. My GP told me that it could take years for the NHS to get me an appointment with an endocrinologist who specialised in gender transition, and I’d better go private.

Private, with what I pay in UK taxes?

So, starting in July, I looked for a specialist endocrinologist and found exactly one in Southeast England who came recommended. Despite casting a wide net among psychiatrists, psychologists and trans friends, I kept being referred to the same doctor. Who couldn’t see me until January.

In California, I’d had a choice of four facilities within a 40-minute drive of my home.

But before I could make an appointment with the endocrinologist, I had to see a gender-specialist psychiatrist to confirm the diagnosis of gender dysphoria. Also privately, if I didn’t want to wait years.

Despite the fact that my US psychiatrist had sent a letter already confirming it. Despite the fact that my UK psychiatrist, who I saw immediately upon returning to Cambridge, had confirmed it – he wasn’t a gender specialist.

And I had to laugh about this; the irony was too exquisite: I was required to get a UK psychiatrist to confirm gender dysphoria, despite the fact I had already transitioned.

I do understand the need for all this. The NHS has standard practices and they’re pretty inflexible for good reason, especially if the doctors in this “new” field of gender transition are to protect themselves against medical malpractice lawsuits.

I’m still waiting to discover whether the UK endocrinologist is willing to send my prescription for testosterone to my NHS GP and let her supervise my blood tests. If yes, I receive both for free – I’m over 60. If not, I’m stuck paying a whopping great fee for those, too.


I can’t find any services or even community-led support groups that provide anything like what I had in California. I’m paying out-of-pocket to see a psychiatrist just so I don’t go without psychiatric medications and I pay for a therapist for counselling, because my GP said that seeing either of them on the NHS would have taken months to arrange.


I feel most at home in the UK, which means I have chosen to live in a country that is enlightened enough to insert trans equality into the school curriculum, but whose healthcare system is unable to provide support for trans folk who have little money or can’t wait for years.

It took me 61 years to transition; I don’t have that much time left to live as who I am. Bless my dad who left me a small inheritance. It’s paying for my care.

What can we do to help? How do we encourage more professionals to go into these fields? How do we help our friends who can’t pay for private care and can’t continue living in their birth bodies? Literally, can’t continue living.

Here is the headline take-away, the realisation, the kicker: At Kaiser Permanente of Northern California, after the diagnosis of gender dysphoria, every service I subsequently received was considered medically necessary for a reasonable prognosis of mental and physical health.

Not a choice. Not nice-to-have. A medical emergency that required immediate referral.

From my own case and anecdotally, I know that untreated trans folk are at high risk for mental illness, inability to deal with social and work environments, drug and alcohol abuse and suicide.

It’s a bloody miracle we’re still here.




J Laurence Sarno is a dual US/UK citizen and a communications specialist for deep-tech companies.


Photo by Sterling Davis on Unsplash