On May 12th, the Women and Equalities Committee held its most recent inquiry session on the Reform of the Gender Recognition Act. The Committee heard from two panels about the ways in which UK gender identity clinics operate and transgender healthcare more widely. Here is the transcript for those interested in finding out more.
You can watch the sessions here.
Women and Equalities Committee – Transcript
Oral evidence: Reform of the Gender Recognition Act, HC 129
Chair:
Good afternoon and welcome to this afternoon’s session of the Women and Equalities Select Committee and our enquiry into the reform of the Gender Recognition Act. This afternoon, we have two panels of witnesses. The first panel including Dr Harriet Hutchinson, the Community Organiser for Action for Trans Health in Durham and Dr John Chisholm, Chair of the Medical Ethics Committee of the BMA.
Thank you very much for joining us this afternoon. Can I start by asking Dr Hutchinson if you can explain to us briefly the process for getting a diagnosis of gender dysphoria in order to obtain a gender recognition certificate.
Dr Hutchinson:
Thank you very much. Well, the problem with trying to do a brief description is that the process is not at all brief, so the first thing that one has to do is to approach one’s GP and ask for a referral to a gender identity clinic. Now, in some cases this is straightforward and a doctor will simply make a referral, and in some cases a doctor will ask you a series of questions in order to determine whether they think they should refer you on to that service. This is an existing problem for us at the moment, where a large number of people aren’t supported in receiving that referral when requested.
Now, when you have had that referral, the gender clinic closest to Durham is the Northern Region Gender Dysphoria Service, and for example they will receive that referral and they will then send a form to your GP and you would fill out that form jointly with them and then they would send that back. The next step is that the Gender Identity Clinic will send you a letter to apologise for the length of the waiting list and then you will wait for an extended period of time, so currently people who were referred and are at the top of the list have been waiting three years and three months before they even have their first appointment.
Unfortunately you can’t be diagnosed at this first appointment so you will see a member of the clinic who is not a consultant who will take a history and will then ask you to come back in several months. This is potentially also quite a long wait and for your second appointment, which is the first time that you will see a gender identity consultant, the people at the top of the list had been waiting for four years plus. At that appointment, the consultant will go through a history, discuss your identity, your gender, your feelings about it, your sexuality, your relationships and a whole host of other aspects of your life. They will then decide whether or not you can be diagnosed at that point or that you will need further follow up appointments at which they would be able to make a diagnosis.
So, it’s a long, drawn out process that is dependent on the goodwill of your GP and dependent on the length of those waiting lists, but if somebody then meets the diagnostic criteria they should, theoretically, receive a diagnosis.
Chair:
Thank you for that. Right at the beginning, you referred to a number of people, you just said ‘requiring the goodwill of their GP’ but you said that a number of people would not get a referral from the GP, can you quantify that?
Dr Hutchinson:
I can, yes. So, in the national LGBT survey, 80% of trans people who manage to access gender identity services said that they had difficulty doing so, 25% of those GPs didn’t know where to refer somebody with gender identity issues to discuss, 12% of their GPs wouldn’t support them in accessing those services.
Chair:
So it’s not, not knowing?
Dr Hutchinson:
It’s both. We know that 7% of trans people have changed their GP due to discrimination. It’s not currently possible for us to make self-referrals to gender identity services, even though these are included within the current service specification, because the gender identity services require support from your GP in order to accept that referral.
Chair:
Thank you. In your written evidence, you referred to the requirement for trans people to prove their gender identity through medical reports as being ‘intrusive and degrading’. Can you expand a bit on that please?
Dr Hutchinson:
Sure. The current process of attempting to prove your gender to a clinician is a disturbing process because there is no way really of proving your gender to somebody. In the previous Women and Equalities Committee enquiry, one of the questions directed to NHS England was around whether or not there was a clinical way for somebody to determine what ‘living in role’ for two years looks like, and the answer was no. We followed up with that and there is still no clinical basis for this. But our service users have been in appointments where they’ve been criticised for not wearing lipstick or receiving lectures from cis-gender women clinicians telling them that the trousers that they were wearing weren’t feminine enough to be regarded as a female presentation.
So, the idea of having to prove your gender is very reductive; it forces trans people to conform to stereotypes in order to receive a diagnosis, and then of course receive criticism for perpetuating gender stereotypes. Whereas these things are enforced by the institutions that we come into contact with.
Chair:
Thank you very much. Dr Chisholm, can you explain to us what the clinical requirements are for a diagnosis of gender dysphoria and why many people seeking a certificate might not meet them?
Dr Chisholm:
Well, let me make a point in advance of that which is that I think that it’s unfortunate that we have a situation where gender recognition certificates are requiring a medical diagnosis and certainly the British Medical Association would like to move to a position where a gender recognition certificate is primarily a legal process, not a medical one. I think we need to separate the two issues of having recognition for your gender and accessing treatment.
But as far as the diagnosis is concerned, the medical requirements are a medical diagnosis of gender dysphoria provided by a registered medical practitioner or a registered psychologist practicing in the field of gender dysphoria, and also a report from a medical professional detailing any medical treatment that you have received, and that can be provided by any registered medical practitioner, not one who necessarily needs to be practicing in the field of gender dysphoria.
The NHS states that the signs of gender dysphoria in teenagers and adults may include certainty that your gender conflicts with your biological sex; being comfortable only when in the gender role of your preferred gender identity; a strong desire to hide or be rid of physical signs of your biological sex; and a strong dislike of the genitals of your biological sex. And I would very much agree with what Harriet has said, first of all about the difficulties of, you know, what is certainty in this field, that you gender identity conflicts with your biological sex? What evidence is a doctor going to require when essentially it’s about your own self-perception. And I would also agree very much with what Harriet said that this is very onerous and dehumanising to have to be asked all these intrusive questions in order to prove, in essence, that you are who you say you are.
Chair:
Thank you. I mean, the certainty point is very valid, isn’t it? It must be almost impossible to demonstrate that with certainty.
Dr Chisholm:
I would entirely agree with you that, you know, why should you have to convince a doctor that you are who you say you are? We’ve gone a long way from regarding gender dysphoria as a medical problem or a psychological problem or a mental health problem, and yet we are forced back into those paradigms by the way the law operates.
Chair:
In your written evidence, you referred to a diagnosis of gender dysphoria not being in the interests of either the patient or the GP, can you explain why you don’t think it’s in the interests of GPs?
Dr Chisholm:
I think that if somebody is seeking help, is seeking medical help, then we need to make that easier for people and I think that we’re still in a situation where transgender and non-binary people are marginalised, that there’s sometimes prejudice against them, and that is a human rights issue, but it’s also a healthcare issue. So I think if somebody is seeking medical help, then in a way the system is stacked against them, not least by the very long waits for access to specialist services that Harriet has already described.
I think that as far as general practice is concerned, I think that the involvement of GPs in a medicalised process of gaining a gender recognition certificate is not in the interests of either individual patients, or of GPs. That’s not what GP should be there to do, but GPs should be there to refer people to specialist services who are seeking medical help for how they perceive themselves.
Chair:
Thank you. You both highlighted the wait for somebody to get an appointment at a gender identity clinic. Could you perhaps – and if I turn to Dr Hutchinson first – could you explain how once somebody has that referral, the clinic can then assist the individual in getting that diagnosis.
Dr Hutchinson:
Once they’ve had the referral, and again, you’ll receive an apology letter for the long wait, and then precisely nothing happens. One of the major issues again with the waits that are built into the system, in some ways these are couched as support somehow. And there’s a similar idea embedded in the process for achieving a gender recognition certificate where you must have lived in role for two years before you’re eligible, with the idea that this is to teach transgender people the consequences and significance of their decisions, which frankly is deeply patronising.
Similarly, the waits built into the gender identity clinic systems, whether between the first appointment and the second appointment, or simply being on the waiting list being considered as thinking time is deeply problematic. The support during these periods is non-existent and we often find that non-profit organisations are picking up the pieces from this. So, our colleagues across at Be in Newcastle are picking up the pieces where NHS services and the gender identity clinics have failed. So, people who are requiring increased mental health support during the times that they’re on waiting lists or the times, months and months, between their first and second appointments, are ending up in crisis situations and being referred to unfunded third sector organisations to provide care that should be being provided by the NHS.
Chair:
Can I just ask, the time is not just about capacity, it’s deliberately built in to effectively send people away to think about their decision without any support?
Dr Hutchinson:
That is correct. Built into the surgical specification at there is a requirement for 12 continuous months of living in a gender role that is congruent with their gender identity. And then it says, this requirement is not about qualifying for surgery but rather preparing and supporting the individual to cope with the profound personal and social consequences of surgery. Now, much of the time the results of these surgeries will not be visible to other people and similarly a period of waiting without any kind of training or assistance or literal support doesn’t teach somebody how to change dressings or in the case of genital reconstruction surgery for things like dilating and douching.
The idea that this is about support for the consequences of surgery is a nonsense. These are waits that have been built in historically, as an idea that we must be taught that this is such a life-changing decision that you must be certain and that you have to go away and think about this in a way that isn’t extended to other life decisions of a similar scale, of similar consequences, and are mostly about making the medical establishment and cis gender people comfortable and not about helping transgender people.
Chair:
Thank you for that. Dr Chisholm, is there anything you would like to add to that?
Dr Chisholm:
Well, I’m really saddened to hear what Harriet is saying because it seems to me to be entirely contrary to the ethos of the National Health Service, which is to provide people with access to timely care when they need it. The very idea that waiting lists are somehow good because they allow you to reflect on the seriousness of the choices you’re making and to give you thinking time seems to me abhorrent. Under NHS guidelines an initial appointment for hormone therapy and surgery should be within 18 weeks and as you’ve already heard, the waits are in fact measured in years, and obviously waiting lists for treatment throughout the NHS have escalated enormously over the last 15 months for reasons that are self-evident, but unfortunately in relation to patients with a diagnosis of gender dysphoria or seeking such a diagnosis, these waits have been endemic from before the Covid-19 pandemic began.
Chair:
Thank you, Dr Hutchinson did you want to come back in?
Dr Hutchinson:
Thank you, yes. Of course, the pandemic has had a huge impact on us, but even without taking those into account the waiting times are increasing. So, if we use the figures from 2019, before the pandemic hit, our local gender dysphoria service is increasing its waiting list at a rate of approximately five months year on year on year.
Chair:
Thank you for that.
Dr Hutchinson:
The waiting times on surgery are similarly very difficult, the contractor arrangements in particular have caused difficulties with some contracts lapsing, with clinicians retiring, and as well as that the reliability of the gender identity services in making timely referrals is problematic as well, so we know people that have had a recommendation for surgery who have then waited for a year before that recommendation has actually been provided to the surgeon responsible. So, after somebody has spent five years in a waiting list, then 12 months living in a role and also qualified for surgery because they’ve needed to have taken hormones for a particular length of time, they then have another period of waiting based on the administrative burden that the gender identity clinics have as well. So, somebody could be waiting 7, 8 or more years before they can have the surgical interventions that they are needing.
Chair:
Thank you. Dr Chisholm.
Dr Chisholm:
Yes, I just wanted to make three very brief points on this issue. First of all is, as Harriet has said, there is a very real increase in demand for services that’s developed in recent years, and secondly, there are issues with the clinical workforce in terms of recruitment and retention and those problems amplify the service provision challenges. And also there is a bit of a postcode lottery here because service provision and waiting times vary according to where you live.
Chair:
Thank you for that. I’m now going to bring in Kim Johnson for the next set of questions please.
Kim Johnson:
Thank you Chair and good afternoon Dr Hutchinson and Dr Chisholm, I’ve got three questions on the opening of the three new gender clinics and I’d like to start with Dr Hutchinson first please. What is your view of the government’s proposal to open three new gender identity clinics, Dr Hutchinson, thank you.
Dr Hutchinson:
I’m afraid my response is an incredibly cynical one. When the announcement was made for three new gender identity clinics around about the time of the results of the consultation on GRA reform, these were neither new nor gender identity clinics, so these were pilot programmes. These were two year-long pilot programmes who will take 500 patients each, so that’s 1500 patients out of an existing waiting list of 13,500 people across the across the UK. Locally, for our service users, it will have zero impact whatsoever. There is still fundamentally a problem with diagnosis as bottleneck and the major problem we see is not necessarily even the scale of funding required, but the gatekeeping of the need for a diagnosis of some kind, in order to access what are healthcare interventions comparable to, for example, sexual health services. The services that are coming into place are unable to perform all of the functions of the gender identity clinics, for example, the requirements for a particular period of time for the service to have existed before it can make surgical referrals, so those patients will need to return to the existing gender identity clinics in order to make progress there and, in addition, after two years, we have no idea what will happen to those services. So, in terms of their benefit, locally it makes no difference to us, we’ll still be waiting.
Kim Johnson:
Thank you for that information, Dr Hutchinson, and it does seem strange, doesn’t it, only 1,500 out of 30,000, but you also say that they should be completely replaced. Can you say why and what you’d like to see them replaced with.
Dr Hutchinson:
Thank you. Yes, I should clarify that was 13,500, not 30,000. We would like to see the replacement of a gatekeeper-based system. We have been systematically discriminated against in gender identity services. We have been poked and prodded and probed, sometimes literally, by psychiatrists who are trying to determine whether or not we are the gender that we claim to be on the basis of whether we are wearing the right thing on that particular day, even though these things are supposedly not things that are made judgement about, we still see those. Our service users report questions on their sexuality. The reports that are generated that would then go to the gender recognition panel include detailed sexual histories and intimate details of people’s current sex lives.
The medicalisation of this process is deeply troubling and I agree completely with Dr Chisholm that there is a problem with medicalisation element here. Fundamentally, trans people know who they are, fundamentally, people should have the right to make the changes to their bodies that they want to and fundamentally it is wrong that the psychiatric profession gets to decide whether or not we are who we say we are. We think the gender identity clinics as a concept should be removed and that access to healthcare for things like hormone treatment can be made through primary care and that where other referrals need to be made to other specialist areas, those referrals can be made as well, but the idea of a gender clinic that one has to attend where these structures have a history of gatekeeping of excluding and of discriminating against us and deciding whether or not we are who we say we are is wrong and they need to be scrapped entirely.
Kim Johnson:
Thank you, Dr Hutchinson. Dr Chisholm, do you have anything further to add in terms of what Dr Hutchinson said about the benefits of opening the three new clinics?
Dr Chisholm:
Well, I agree with what Dr Hutchinson said about the fact that these will not make a great contribution numerically of 1,500 or 1,600 new patients being seen when over 13,000 people are waiting, and I share Harriet’s concern about these only being two-year pilots and about the service being potentially withdrawn at the end of that time, but I think there’s also a wider problem with specialist capacity. I don’t think that you can just magic up specialists out of nowhere and that there is a need for trained clinicians who have both the resources and the experience to provide the necessary standard of care. It takes time to get fully trained clinicians in that way.
NHS England has neglected to commission local services for ongoing care for patients once they’ve been discharged from the gender identity clinic and I think that we do need a properly commissioned, comprehensive and quality controlled service for patients who need these services, and that could be either through specialist prescribing which could be facilitated through the electronic prescription service or through properly funded shared care arrangements with GPs who’ve consented to provide this service or through locally commissioned alternative providers within primary care.
So, I agree with Harriet that there’s a deficit here in between the specialist services and general practice that needs to be filled by services that are commissioned and by clinicians who are interested in providing the service and have been adequately trained.
Kim Johnson:
Thank you, it sounds like both you and Dr Hutchinson agree that the clinics aren’t going to meet the needs. But Dr Hutchinson, can I ask, the government has argued that the GRA reform is not the top priority for transgender people, and that the most important concern is trans-healthcare. What is your view of this assessment by the government?
Dr Hutchinson:
Thank you very much. It’s an interesting distraction. On the one hand, legal recognition of gender is important to a lot of trans people and on the other hand, a lot of trans people would like to see gender markers removed from most official documents. Obviously, we’re constrained by international conventions on many things such as passports, but for most purposes a concept of legal sex is a difficult one, and for the majority of the trans people that we come into contact with, the gender recognition act is not the primary concern for them at this moment in time. Their concerns are things like access to housing, access to jobs, access to healthcare, access to mental health services and access to basic needs being met without discrimination and in a timely fashion.
So, to say that it’s not our top priority, potentially true, because the scale of the remainder of the issues is so high that they need tackling now. However, to abandon GRA reform, which we feel like they have done, is unhelpful, unproductive and an abandonment of responsibility.
Kim Johnson:
Thank you, Dr Hutchinson. Dr Chisholm, do you have anything further to add to what Dr Hutchinson has said?
Dr Chisholm:
I would agree with what Harriet has said, I think we need both, I think we need an improved mechanism for achieving a gender recognition certificate and I think we need much better and substantially more capacitance services for trans people, so I think it’s an issue of trans-healthcare but also an issue of trans-rights and I think that we need to separate the two issues in relation to recognition. I think that we need to remove the requirement for medical diagnosis.
The World Professional Association for Transgender Health’s statement on gender recognition states that medical or other barriers to gender recognition for transgender individuals may harm physical and mental health and the World Professional Association opposes all medical requirements that act as barriers to those wishing to change legal sex or gender markers on documents.
The other point that I would make is that it’s not a binary decision and we need to actually have better recognition of people who are non-binary rather than just having people forced into stating that they are men or women.
Kim Johnson:
Thank you, Dr Chisholm and Dr Hutchinson, those are my questions, thank you chair.
Chair:
Can I just ask, Dr Hutchinson, did you want to come back in on that?
Dr Hutchinson:
Thank you, I wanted to thank Dr Chisholm for his pun and in particular for raising the importance of non-binary recognition. For a lot of non-binary people, recognition within legal frameworks is hugely important and this has obviously been abandoned in the current reform and access to services and, indeed, a feeling of self is not permitted in these current frameworks. So there is a desperate need for a gender recognition act reform to include non-binary identities.
Chair:
Thank you for that. Nicola Richards, please.
Nicola Richards:
Thank you, Chair. My first question is to Dr Hutchinson, could you expand little bit more about what the key concerns are for trans people accessing healthcare more broadly? So, for example, in primary health care and mental health services.
Dr Hutchinson:
Thank you for that. Access to primary health care is awful. Our service users report barriers at a whole number of different levels, whether that’s access to GP services, whether that’s access to the clinics where the GPs work, whether that’s access to mental health services. We know that support per surgery or GP group is very patchy, for example, we have some very supportive clinics locally and another that, for example, will not change any of the details on your medical records unless you’ve had – I’m just going to pull up the quote here – ‘the full sex change operation’. And we know that people are put off from accessing healthcare as a result and we know that 21% of trans-people said their specific needs were ignored or not taken into account when they tried to access healthcare services and 18% of those said they were subject to inappropriate curiosity, and 18% said they avoided treatment as a result of fearing discrimination and intolerance.
So, it’s not simply that, when at the services, people face discrimination. They’re put off from seeing practitioners where they have healthcare needs across different healthcare needs as a result of the system as it exists. We know that particular types of healthcare have problems; users of mental health services report their doctors outwardly and actively challenging their gender identity in ways that are entirely unrelated to their mental health issues. We know that GPs don’t understand that mental health needs can exist independently of gender health needs, so we see GPs referring people to gender identity clinics for mental health care that is not available through those services.
Other forms of support are widely unavailable. Several of our local hospitals refuse to see trans women for gynaecological examination; the clinicians aren’t comfortable to perform those examinations despite the parallel healthcare needs in those situations, and where there is provision through staff absence it can suddenly disappear because there aren’t robust processes to support trans people, even when their healthcare isn’t trans-related.
Nicola Richards:
Thank you. Dr Chisholm, have you got anything to add to that?
Dr Chisholm:
Well, first of all, I’m distressed to hear the examples of prejudice and transphobia that sadly are still sometimes out there, but I think there’s also a training deficit here. I think that we need more dedicated training for healthcare professionals on trans-health issues and that’s perhaps particularly so for general practice. I was a General Practitioner for many years, and general practice is the area of medicine where practitioners are most likely to encounter trans patients and the Royal College of General Practitioners recognises that GPs are not experienced in treating and managing patients with gender dysphoria and trans health issues.
Gender dysphoria and gender identity issues aren’t part of the GP training curriculum or GP specialty training, and the BMA has certainly been calling on the Medical Schools Council and the Royal Colleges to ensure that trans-awareness is part of both undergraduate and postgraduate training, and I think there are two separate issues there. One is a clinical issue, but the other is a cultural issue where general practice is welcoming of every patient that comes through the door of the practice and treats them with dignity and respect and tries to meet the healthcare needs that they have. And I recognise that whilst I think the great majority of healthcare professionals try to be respectful and to treat patients with dignity that sadly there are stories where that is failing to be the case.
Nicola Richards:
Thank you. Dr Chisholm, in your written evidence you argue that access to support has been made even more challenging by the pandemic and by consistent long-term underfunding of public health. Could you elaborate on this please?
Dr Chisholm:
Yes, I mean, the pandemic has obviously produced huge problems for the NHS, and an enormous backlog in respect of people with non-Covid related conditions. There’s been a huge increase in waiting lists for surgical treatment, for outpatient referrals, right across the board. There’s also obviously the issue of remote consulting. There’s been a big switch in general practice in particular to many consultations occurring virtually over the telephone, over video, by email and this will have had an impact on particular groups accessing services and I think anybody with a complex problem may find it more difficult to explain and also to get the treatment they need with remote consultations.
Staff also obviously throughout the NHS are under huge pressure and are experiencing burnout and there are worrying signs that many healthcare professionals are considering leaving their professions, and that’s going to have a knock-on effect on the NHS. Last month, the BMA did a tracker survey – I think we’ve done well over a dozen of them during the pandemic now – looking at changing views, and the April survey found that 32% of respondents said they were more likely to take early retirement and half reported being more likely to reduce their hours.
So we’ve, as a result of the pandemic, which obviously was something initially quite outside the control of the NHS and public health, was storing up a lot of problems for the future that need to be addressed with increased capacity and increased resources but also with avoiding unrealistic expectations about how quickly the service can get back to normal, it’s going to take a very long time.
Nicola Richards:
Thank you. My next question is to Dr Hutchinson. What more do you think the government should be doing to improve trans-healthcare more broadly?
Dr Hutchinson:
One of the major ways that trans-healthcare could be improved is improved training across the sector, clearer guidance for medical professionals and for trans people, as the information seems to vary day in day out. The ways of ensuring that the standards that people can expect from their doctors are upheld, because we know that, for example, the specification for various gender interventions are viewed by the gender identity clinics as more like guidelines, so in cases where Members of Parliament have made complaints about the levels of service, the gender identity clinics have responded that they are not bound by these.
The issue of funding is a difficult one because simply by pouring money into gender identity clinics, this would not solve the problem. Fundamentally, the way that trans-identity is conceptualised institutionally limits trans people’s access to healthcare. The government should be pushing for complete reform of the processes involved, a change to the understanding of trans-identity and how that relates to things like the gender recognition act, improving access to mental health services and making sure that provision is sufficient to deal with the needs of trans-people as well.
So, NHS funding more generally, to uphold standards and to push for changes of institutional response to gender issues away from psychological diagnosis through to support more aligned with sexual health services.
Nicola Richards:
Thank you. Dr Chisholm, you mentioned the push to train GPs about the health needs of trans people now but can you expand on what training healthcare professionals already do receive on this topic?
Dr Chisholm:
It varies. There isn’t any standard training because as I was saying earlier, this isn’t, at present, part of the specialty training curriculum for general practice. So I think in truth, the training is somewhat ad hoc that GPs and other doctors, most of their postgraduate medical education is done on a voluntary basis in the sense that they have to show evidence of training for their appraisal and their revalidation, but they have a relatively free choice of what training in what areas they receive. There are only relatively few areas of mandatory training that have to be undertaken and this is not an area where there is currently mandatory training. And so what that means is that across medicine, not just in general practice, some doctors will have received substantially more training than others in this area and some will be considerably more interested in receiving training in this area, and sadly, some may be unaware of their need for training, and perhaps that’s understandable in one sense in that some general practitioners and some hospital doctors will see quite a number of patients for trans-healthcare issues, whereas for others it will be very rare for them to encounter a trans patient.
There’s one other issue that I should raise, which is the importance of screening and some trans-patients may still require access to screening programmes which are predominantly provided to patients of another gender, and doctors must be vigilant and sensitive to ensure that trans-patients continue to have access to the screening programmes that they will continue to need on a lifelong basis.
Nicola Richards:
Thank you. Dr Hutchinson.
Dr Hutchinson:
Thank you very much. The issue of GP training is partly a real and present issue. For example, we are aware that across at Newcastle University the medical training involves zero information about trans-patients whatsoever, so the Student Medical Society took it upon themselves to organise a lecture at a lunchtime, to bring in a clinician from the local gender identity clinic, because they just weren’t receiving the training that they need. So there absolutely is a skills issue.
On the other hand, some absolute basics are being neglected. GPs are saying that they don’t understand how to interpret blood tests, whereas they will be very familiar with how to at testosterone or oestrogen levels for cis gender people. They do this all the time in clinic, but as soon as it becomes a trans-issue, they suddenly lack the confidence to do the same, even though the basics are very, very similar, and this is one of the things that pushes trans people towards informal routes, towards informal medication, unlicensed pharmacies, and trans people for a very long time now have been reading the literature themselves, self-medicating, monitoring their own levels, simply because this isn’t available in GP practices.
GPs are abandoning their responsibilities to their patients in managing bloods, in simply arranging bloods, for people who have accessed services through gender identity clinics, accessed care through private providers or through self-medication. These are people who should be able to have bloods taken and they aren’t getting that service because the GPs aren’t comfortable doing it. There is a training issue, but there’s also a cultural issue as well that needs to be addressed.
Nicola Richards:
Thank you. Dr Chisholm, are you aware of any work done by the National LGBT Health Advisor to help improve awareness in this area, and if so, what?
Dr Chisholm:
I personally am not aware, and I should say that I am no longer in clinical practice, so perhaps that is a reason why I’m not aware, but I am certainly aware that the Royal College of General Practitioners is seeking to develop and improve its electronic learning materials in the field of LGTB health, because it’s realised that there is a deficit there. And I agree that, as Harriet was saying, there are cultural issues as well as clinical and capacity issues, and one of the issues is that some GPs who are generalist rather than specialist practitioners feel that they don’t have the competence or confidence to prescribe, for example, while patients are waiting to access specialist services. They come to GPs on issues such as prescribing hormone therapy and whilst some GPs will be content to prescribe in those circumstances, others will be more reluctant to do so. So, yes, we do need to improve the training but also to recognise that there is a need to commission services that, if you like, are in between the most specialised services and the generalist services of GP’s.
Nicola Richards:
Great, thank you very much both, that’s all my questions, Chair.
Chair:
Thanks, Nicola. The next set of questions are from Bell Ribeiro-Addy.
Bell Ribeiro-Addy:
Thank you very much, Chair and thank you panel. My questions are directed to Dr Hutchinson, however, Dr Chisholm, if there are any points you do want to add, please, please do jump in. In my first question, Stonewall’s 2018 LGBT Britain Trans Report, they found that two in five trans people who respond to their survey said that healthcare staff lacked an understanding of specific trans-health needs when accessing general healthcare services, and in your own written evidence to our committee, you state that misgendering and transphobia are rampant in medical spaces. Could you expand on the type of treatment trans people are experiencing when they access healthcare services, anything you might not have touched on before.
Dr Hutchinson:
Thank you very much. At one of our recent meetings, a number of our service users discussed some of these issues exactly, they describe, a lot of people describe problems changing their records and the sorts of issues with untrained staff not knowing how to do it or demanding strange things like, GRCs in order to change their medical records. We’ve got one person who said their GP started laughing at them as soon as they noticed a badge they were wearing saying ‘queer’. We’ve had people being referred to with the wrong names, the wrong titles, the wrong pronouns over and over and over again throughout primary care, including letters from gender identity clinics to people’s GPs and back again, where the wrong names, the wrong pronouns are used throughout. We are aware of clinicians asking entirely unrelated questions about people’s histories, about their genital status. We’re aware of one of our service users who was accompanying another person to a mental health appointment for somebody else and that service user was asked what their plans for genital surgery were.
So, these basic discourtesies and intrusions are perfectly usual. And we know of GPs who have said that they would play devil’s advocate before permitting referrals to gender identity clinics. We’re aware of practitioners at all levels who simply refuse to refer to people in the way that they have asked to be described. It is endemic. I don’t know of a single one of our service users who hasn’t reported this. It makes people reluctant to seek treatment; I gave the statistic earlier about 18% of people avoiding seeking treatment as a result of these experiences. It’s not just in trans-medicine, it’s in general medicine as well.
Dr Chisholm:
I would just add, all of those examples are abhorrent and deplorable and inexcusable and they should not be happening. My hope and belief is that such intrusive and inappropriate questioning is a minority practice. I would be very appalled to learn that the majority of general practitioners were behaving in that way. I don’t believe they will be, but any examples of the sort of problems that are being encountered that Harriet has described are unforgivable and I can well understand how distressing that must be and why people are sometimes forced to change their doctor in order to find somebody who is more sympathetic and respectful.
Dr Hutchinson:
Often, doctors are in a position of power. They have a very strong knowledge of the very specific things that they work with. They’ve undergone a great deal of training about the issues that they know a great deal about. But when it comes to transgender identity, which is something that is very close and known by trans people themselves, it’s almost challenging for a GP to be in that situation. So, often some of this discrimination comes through ignorance, but also some of this comes through the power dynamic between doctor and patient. This is another reason that we need to fundamentally re-conceptualise trans-medicine.
Bell Ribeiro-Addy:
Thank you very much and thank you for raising that point. I know I’ve had young constituents approach me about that issue themselves in terms of accessing just general healthcare from their general practitioner, which is quite a worry, simply because they are trans. Now, thinking of what can happen next, the Stonewall Report also found that three in five trans people who have undergone medical intervention for their transition reported that they were unsatisfied with the length of time it took to get an appointment and the LGBT action plan highlighted that many LGBT people face inappropriate questioning and curiosity. Now, you’ve touched on this already and I just wanted to ask, what sort of impact did these delays and inappropriate questions have on treatment overall?
Dr Hutchinson:
The trans community is left picking up the pieces. The impact of long waits on mental health care extracts a huge toll. The need for support is hugely increased. People find themselves faced with a five-year wait before seeing somebody and feel that there is no future for them because they may have gone through an awful lot to be able to get the point of asking their GP for a referral and then find this huge let down, this sort of very deflating feeling of, what next? Nothing’s going to change for years, how we possibly can cope with this? So trans people are at significant risk of worse mental health. The incidence of addiction in trans communities can be up to 20%, depending on which studies that you look at, and in a community like this, adding that additional waiting time means that people end up needing treatment for addiction that they wouldn’t have otherwise needed, treatment for mental health crises that they wouldn’t have otherwise needed.
The way that trans people respond as well is, we know people take less care of themselves, particularly in connection with self-esteem issues which are endemic within the trans community. So, the lack of access to these things has a very literal cost to the NHS and is very damaging to the people involved.
Bell Ribeiro-Addy:
Thank you very much, and just finally, Dr Hutchinson, again in your written evidence you argued that many trans people face data protection violations. Could you elaborate on what exactly happens in these cases?
Dr Hutchinson:
Yes, so there was a high-profile case, I want to say in 2019, where a clinic sent two emails where their service users were all copied to all of the recipients, so two emails of about 900 people apiece, so that was a very large user base of gender services that was exposed to a large number of people so in that way, being outed is a risk. We see confidentiality breaches made by the gender identity clinics themselves. In the most recent patient experiences report, 5 of the respondents out of the sample of about 109 had reported the clinic was breaching their confidentiality in the way it had forwarded documents.
We risk being outed in all sorts of venues where the information is not necessary. It’s another reason why things like the gender recognition process worry us. Our group, after a reasonable discussion on the issue, pointed out that when you apply for a gender recognition certificate, you will end up on effectively a register of transgender people and this is a great worry to us because this register is a target. It’s a target for data breaches, it’s a target for blackmail. In terms of information security, we usually regard a data breach as a when not an if occurrence and so these deeply, deeply personal issues being exposed to the general public and potentially hostile actors is very worrying to the trans community.
We not very well protected at the moment. The gender recognition act allows for liability with disclosure of information received in an official capacity, but outside of that we are very vulnerable and once information has been made public, it doesn’t go back into Pandora’s box.
Bell Ribeiro-Addy:
Thank you very much, I think that that’s all from me. Thank you so much panel, back to you, Chair.
Chair:
Thanks, Bell, and can I take this opportunity to thank Dr Hutchinson and Dr Chisholm for your evidence this afternoon. That is the end of your set of questions but do please feel free to stay on and listen to the second panel if you would like, but thank you.
Our next panel this afternoon is Dr Michael Brady, the national adviser for LGBT health at NHS England; John Stewart, the National Director of Specialised Commissioning at NHS England; and Leigh Chislett, who is the Clinical Manager at 56 Dean Street. Can I welcome the second set of witnesses this afternoon and turn straight to Elliott Colburn, who is going to ask the first set of questions.
Elliot Colburn:
Thank you very much, Chair, and welcome, panel. My set of questions are all going to be directed towards John Stewart, but Michael and Leigh, if you want to jump in on any of them, please do wave at me and I will try to notice you. John, could I open up and begin by asking you to briefly explain the role and the purpose of the Gender Dysphoria Clinical Programme and how it came to exist in the first place?
John Stewart:
I’m very happy to. So, first thing to probably just explain is that NHS England first took on commissioning responsibility for gender dysphoria services for adults and children back in 2013 when it was first formed, and our first task actually back then was to try and make sure that we addressed some of the inconsistencies there had been across the country through our existing arrangements in place and one of the real benefits I think for NHS England taking on sole commissioning responsibility. Our gender dysphoria programme board was then formally established at the end of 2017, really to provide even more enhanced focus, advice, challenge and leadership to NHS England’s direct commissioning responsibilities around this area, and it took over from a dedicated task and [inaudible 01:03:51] group that we’d established almost at the start of when NHS England was formed.
So, membership of our board includes people with lived experience, clinical experts, representations from the devolved administrations, as well as national and regional commissioners.
A few kind of things to say about what the board has done since it’s been set up. So, first of all, it’s developed two new service specifications for the adult service following the outcome of extensive stakeholder engagement and public consultation. It’s overseen the process of awarding contracts for the provision of specialised services for adults, both for surgical and nonsurgical services. It’s developed a framework for the establishment of the new gender dysphoria pilot clinics in primary care, which I’m sure you all want to hear more about in due course, and it has established a national referral support service to assist individuals in choosing surgical providers that can best meet their objectives. So, a quite extensive and ongoing programme of work.
Elliot Colburn:
Thank you, John, you have just touched on some of my later questions, but feel free to add to them when I come to them. If I can move on to ask you how often the board actually meets and how does it conduct its reviews of specialised gender identity services?
John Stewart:
So, the board meets on a monthly basis. It is chaired by the Medical Director for Specialised Services within NHS England, who works with me, Dr James Palmer, and I kind of gave a bit of an overview just in my previous answer of the work programme it’s established. So, it has a work programme, it’s been focused up until recent years on the development of new service specifications, around both surgical and nonsurgical services, working very closely with our clinical reference group on some of the clinical advice that we need to inform those, and has played a critical role in helping to shape, following the extensive consultation we’ve done, around the design and development of the new pilot clinics that we’ve launched.
Elliot Colburn:
Brilliant, thank you for that, John. What assessment has the board made of the current role played by specialist gender identity clinics for adults?
John Stewart:
So, clearly, you know, the current gender dysphoria clinics have a really vital role. So, we have seven clinics across the country and one of the things that’s worth saying is, actually when we went out to retender the service, I think in 2019 it was, we were very conscious of the kind of constraints and waiting list challenges facing people wanting to access the service. And actually, it was very disappointing that when we did around that tender process, we didn’t actually manage to attract any new bidders willing to provide new and additional services to support these patients.
So, that is precisely why, having listened very carefully to some of the feedback that came through the extensive engagement and consultation process that we ran in developing the specifications, we really began to understand the important role that primary care could potentially play going forward. And so that is what led us to developing and designing these three new pilot clinics that I think you will be aware of, three of them now up and running in London, Dean Street, which Leigh will be able to say more about; in Greater Manchester; and in Merseyside. But I’m also really pleased to be able to just formally let you know today that there is a fourth pilot in the East of England that will be going live this summer and combined we are expecting these pilots, over the next two to three years, to see about 3,500 patients, and we are deliberately targeting those patients that have already been waiting for access to one of our traditional, one of our seven gender dysphoria clinics.
So, I think some really exciting developments there, particularly recognising the potentially really important role that primary care can play, but as you will probably hear from Leigh, particularly how we can also integrate with other services like sexual health services too.
Elliot Colburn:
Thanks, John. Just picking up on that point there, that’s quite a big announcement, that you’ve gone for a fourth pilot, that’s news to this committee, I think it’s fair to say, so that’s exciting. Could you tell us a little bit more about how that decision was made? So, have you been awarded new funding to do this fourth pilot, is this an NHS decision, has this been pushed from a GEO or GH – where did this fourth pilot come from?
John Stewart:
So, the fourth pilot would have come out of the discussions and deliberations of our programme board, Michael Brady actually I forgot to mention sits on that programme board as well, it’s very much an NHS England led initiative, as were the three original pilots, and I think it’s worth saying that we are open minded about whether additional pilots might be something that we should be considering, particularly given the challenges we recognise around some of the long waiting times.
Elliot Colburn:
So, this hasn’t been a central government push, you’ve not been given specific new funding to try and do this, this is a board decision and an NHS decision?
John Stewart:
It is, this is, yes, an NHS England decision. We are the direct commissioners of these services, funding for the four pilots is additional funding that NHS England, from within its specialised commissioning budgets, has made available and absolutely is not money that is being taken away from existing services.
Elliot Colburn:
Thanks, John, that’s incredibly helpful. I was going to move on to ask you to outline the specific pieces of work that the board has undertaken since 2018, I think it’s fair to say you touched on quite a lot of that, but just before I move on to my next question I just wanted to give you the opportunity to add on anything that you feel you’ve missed so far.
John Stewart:
No, I think that’s fine, please do move on to your next question.
Elliot Colburn:
Fantastic. My next question then is, if you would mind explaining the changes that you’ve made to the 2018 service specifications for adult gender dysphoria services.
John Stewart:
So, as I said, we’ve got two service specifications which are relevant here, the first being around nonsurgical services, which is really principally being delivered by our seven gender dysphoria clinics. But there’s also then the surgical service as well, and the key objective really in developing these service specifications was to make sure that across all these services we are providing patients with consistent high quality care, particularly given the context I explained at the start when back before NHS England existed, the arrangements were taken forward by ten kind of specialised commissioning groups which all had to respond to their constituent BCTs, and what that did was lead to very significant variations, I think, across the country.
So, we work with these specifications very extensively through stakeholder engagement. We had a 15-week public consultation which we held in 2017, published a report of that consultation afterwards and I think overall it would be fair to say that respondents are being supportive of the changed service specifications. I think the benefits, just to summarise though, include kind of a consistent, kind approach to how services should be delivered; a consistent approach to assessment and diagnosis including expectation that assessments will usually comprise two appointments; emphasis on shared decision making with the patient; and also a real focus on preventing unnecessary physical, intrusive examinations.
The other thing I think I would say, just picking up on some of the comments made at the previous session, is that the service specifications for the nonsurgical service do allow for patients to self-refer into those services, and that is absolutely a response to some of the concerns we had had raised with us about sometimes reluctance by GPs to make referrals, and we’ve also been very clear in those service specifications that clinicians should not expect from a patient self-referring an inappropriate, unnecessary amount of detail. So I think that’s an important step.
I think the final thing I’d say is, all of our seven gender dysphoria clinics are signed up to those service specifications and in fact delivery against those specifications is a contractual requirement.
Elliot Colburn:
Thank you John, that’s incredibly helpful and I will hand back to the Chair.
Chair:
Thank you, Elliot. The next questions are from Theo Clarke, please.
Theo Clarke:
Thank you, Chair. My first question is to John Stewart, but to all of you, which is, what impact do you think the opening of the three new gender identity clinics will have, and I’m particularly interested in waiting times.
John Stewart:
Shall I kick off on that? Thank you. So, look, I think they’re important for two reasons, these pilot clinics. Firstly, I think we recognise the potentially really important roles that primary care can play and also your potential role of sitting these services alongside others, like sexual health, and so for us, this is absolutely about testing really quite a new and exciting, modernised service. But in terms of waiting times itself, so we are planning on the assumption that four clinics now combined against the 3,500 patients, at least 3,500 patients over the next two to three years over the lifetime of the pilots, and that represents about a quarter of the current total national waiting list. So I think, really important impact, it’s not going to solve everything, but our aim is to try and evaluate these pilots then as quickly as possible. We’ve already appointed an organisation to conduct that evaluation. And then to make sure that we can fairly seamlessly move into the commissioning of a new routine service going forward.
Theo Clarke:
Thank you. Dr Brady?
Dr Michael Brady:
Thank you. So, John’s covered the waiting list thing, so I think what I would just like to focus on, what I think is really important about these new models of care, is that it is the beginning of a paradigm shift in how we think about the service model of gender identity services, and the shift that reflects the approach that we’re making in other clinical areas across the NHS of a more integrated, community based model with less specialist hospital based input, with some degree of specialist hospital input but a model where delivery is by a newer workforce in a newer model. So I’m very optimistic about these pilots and these new models – I’m sure we’ll hear more from Leigh presently – because what they will do is move us from where we’ve been until now with a kind of very focused seven specialist services into a completely different model, predominantly primary care based but also I think it is really important to assess this in other settings like sexual health services, which will improve not just the capacity and the ability to meet the needs within those services but will hopefully, as we’ll hear probably later, have a knock-on effect, particularly into the wider primary care community of upskilling colleagues who are working alongside but perhaps not directly within those services.
Theo Clarke:
Thank you. Leigh Chislett.
Leigh Chislett:
Well, I have quite a lot to say, I don’t know if you want to come back to me because I would like to describe the whole service as a whole, would you like me to do that now?
Theo Clarke:
That’s fine, I’ve got a few more questions so maybe I’ll come back to you. And just finally, John Dean.
John Stewart:
I don’t believe John is with us, John is the Chair of our Clinical Reference Group.
Theo Clarke:
No problem, well John if I could come back to you, it’s also been argued that these gender clinics are not new but in fact they were already established by the gender dysphoria clinical programme, I’d be interested to know your thoughts on that.
John Stewart:
So, these clinics were absolutely a new development and design was absolutely overseen by our gender dysphoria programme board, and they are new. The three clinics went live over the course of 2020/21 and as I said, the fourth clinic is going live later this summer.
Theo Clarke:
I’d like to know what progress is being made by each of the clinics since they opened. Do you think that waiting times have now been reduced for these services?
John Stewart:
I might bring in Leigh here, but I certainly know because we are very deliberately making sure that the new pilots are seeing patients who have already been on the waiting list for one of our gender dysphoria clinics, it is having a huge impact for them, which is fantastic. And I think we are probably talking as soon as those patients are referred into the new pilots, we’re talking about waiting times of potentially weeks or months but certainly not years. But maybe I could ask Leigh to say a bit more about the impact he’s seeing at the Dean Street clinic.
Theo Clarke:
I’d love to hear that, Leigh, but also any progress that you think the Dean Street clinic has made, particularly since it’s opened, and any issues that you think it’s facing.
Leigh Chislett:
I think we’ve come up with an extremely lean model that has got huge patient, positive patient, satisfaction. Obviously we’re slightly thwarted by Covid but you know, we’ve seen 177 people for a first assessment, 163 for a second. We’ve referred 37 people for gender affirming surgery, 78 people for epilation which is a service we set up from Dean Street as well, 30 people are currently having psychological input that they’ve chosen and 76 for speech and language therapy. So, I will go on a little bit more when it comes to my turn but I’ve heard a lot, like Dr Hutchinson, I’ve heard a lot of similar things to what she has and those experiences, but we are getting extremely positive feedback from the service users at Dean Street with this pilot and I think it potentially could be transferred.
Theo Clarke:
Just to clarify on that, the Dean Street clinic appears to focus more on LGBT sexual health than it does on gender dysphoria, so could you just explain to the committee what services it is providing to trans people.
Leigh Chislett:
Absolutely. So, the clients will be seen by a nurse or a social worker in our case, we have to go with the current guidelines of course, and they will get a psycho-social appointment and get relevant tests and then they will get a named nurse at that appointment as well that will see them through their care package. Two to three weeks later, should they wish to proceed, which most do, they’ll be seeing our medical doctor or one of our psychologists, and that’s where they can get their gender dysphoria confirmed. Sometimes people want further appointments and want to discuss it, and we’re saying that we’re very keen that clients come absolutely as their authentic selves. Just on a point that Dr Hutchinson was saying, we make that very clear from the upshot.
At Dean Street as well what we do is, on that appointment, if their gender dysphoria is confirmed between the client and the doctor, is that they get their hormones on that day, they get the prescription, they are not referred back to the GP, they go to the pharmacist who will go through the treatments with them and the nurse will also teach people to inject. So it’s a very quick, lean service and the feedback we’re getting, which of course is the most important thing, is extremely positive. Obviously at the moment we only have two clinicians who do the second assessment, but obviously my job is to get public money, is to prove that this is an efficient model that will work and has good, positive outcomes for clients.
John Stewart:
Perhaps also I could just clarify that all of our pilots are providing and able to offer exactly the same services as our traditional seven gender dysphoria clinics. So, following assessments and diagnosis, that includes psychological support, hormone treatment, as Leigh said, referral onto surgery if required, voice and communication therapy, facial epilation, the full range of services are being provided by these pilot clinics.
Leigh Chislett:
Just to add, like you were saying, we do have a psycho-sexual therapist, a psychologist, it’s one to one and we’ve got some groups. Some of our most recent groups that we’ve been running, it’s how to manage stress, how to manage body dysphoria, and they’re really well attended, we’ve done one recently on how to get the sex you want. So we’re very, very engaged with the community. I think Dean Street is known for its innovation. We see, before Covid, about 12,000 patients a month and 70% are from the LGBT community, and we have an established relationship with the trans community because we have been running trans sexual health services for over 10 years.
Theo Clarke:
Thank you. Dr Brady, if I could come back to you, I’m interested to know what discussions you previously had with the Government Equalities Office regarding the three gender identity clinics before they were opened?
Dr Michael Brady:
I have a regular meeting with officials from the Government Equalities Office. In the first couple of years when the GEO was funding my post and my team, we met fortnightly and now that funding has stopped and has moved over to NHS England we have a monthly meeting, which is broad in its breadth. It’s a catch up on progress in terms of our work plan, it’s an opportunity for both of us to raise any particular issues that are current, and it would have been during those meetings that there would have been discussions around the development of the pilots, because as John said, I also sit on the Gender Identity Programme Board, so I’m involved in the discussions as that model was being developed.
Theo Clarke:
Brilliant, and one of the commitments made in the LGBT action plan is to improve the way that gender identity services work for transgender adults. Do you think that that commitment has been met?
Dr Michael Brady:
I would say that that is one of the commitments in the action plan that is partially met, and a work in progress. John has gone through a lot of the things that NHS England have been doing over the last couple of years which will contribute to meeting that particular commitment. So I would put that in the ‘partially met, work in progress’ category.
Theo Clarke:
Thank you, and my final questions are back to John. The NHS website states that NHS England will assess how useful these pilot services are. When will that be, and does the NHS plan to make this assessment?
John Stewart:
Thank you, so, we are evaluating these pilots, we’ve already appointed an evaluation partner, Rocket Science, who are already on board and working with the initial pilot sites. That will be an ongoing evaluation over the lifetime of the pilots, which is over the next two to three years depending on when they started. And what I would say is, we’re really keen to kind of extract the learning as quickly as possible so we can make quick progress in rolling out the successful pilots right across the country. So we’re committed to evaluating as fast as we can.
Theo Clarke:
Great, and just finally, the NHS website also states that those gender dysphoria clinics will initially be available to those people who are already on the waiting list, but my question is, when will they also be available to those not on a waiting list?
John Stewart:
So, we’ve been clear that the priority for the pilots is to focus on those patients who have already been waiting a long time, but you know, we’re absolutely clear that if and when they clear that group of patients they can open up to accept new referrals in line with their referral criteria. So, I think first step is to try and make sure that we can support those patients who have been waiting a long time.
Theo Clarke:
Thank you, Chair.
Chair:
Thanks, Theo. Can I bring in Kate Osbourne please.
Kate Osbourne:
Thank you, Chair, and good afternoon to everyone on the panel. First of all, can I ask you, John, it’s really interesting, this fourth clinic that’s been mentioned, it would be really useful to know where you are planning on opening it, could you share any of that with us?
John Stewart:
I might need to write back with precise timescales, but I’m confident that we are going to be opening it this summer and I’m hopeful that that will be in the next couple of months, a real summer timetable.
Kate Osbourne:
And location, please?
John Stewart:
So, it’s East of England, probably in the East of England. It will cover patients registered with a GP in Cambridge, Norfolk, Suffolk and Essex. As I said, plans to see patients from summer 2021. It’s going to be led by the Nottingham Gender Clinic in partnership with the Cambridge and Peterborough NHS Foundation Trust, and it’s going to work on a specialist hub and [bespoke 01:28:28] basis with GPs and clinical nurse specialists working in local settings linking in with the specialist hub in Nottingham. But it sounds, given the interest from the committee, that it would helpful if I did write and provide a bit more detail about the nature of that pilot and when it will go fully live.
Kate Osbourne:
That would be great, John, and I very much, as do all the committee, appreciate you giving the information you’ve given there. But if you would write, that would be fantastic. One more point regarding this, a point was made by the previous panel that there aren’t enough staff with specialist knowledge, so can you tell us how you might ensure that there are enough specialist staff to work in these new clinics?
John Stewart:
Absolutely. So, alongside a real significant growth in demand and referrals into the service, the other challenge we’ve got is absolutely around workforce capacity, and although workforce issues are principally the responsibility of Health Education England I think it’s important to say that this is such an important issue for us in NHS England to tackle that we have taken a direct action to increase the clinical workforce in this respect. So we have funded the Royal College of Physicians to develop a credential programme in gender dysphoria medicine, delivered by the University of London. This is the UK’s first sequestered training programme in gender medicine for clinicians who wish to specialise in this field and it will provide greater reassurance about the quality of the national service, and it’s hoped it will encourage new recruits.
We currently have 43 clinicians taking the course who are all due to graduate this year, and just to put that number – and we hope that number will grow – but to put that number in context, there are currently, I think, only around 90 clinical full time equivalents working across our established gender dysphoria clinics. So, already in the first year I think important progress. All of the clinicians and other staff involved within the pilot sites will be going through this new accredited training programme.
Kate Osbourne:
Thank you for that. Leigh, did you want to come in there?
Leigh Chislett:
Yes, I just wanted to add that we’re, at the moment, we’re doing an online platform and a portal for training GPs. Now, with this platform, what we’ve got is people from the trans and nonbinary community to contribute to this, so they have been really involved in the content of the curriculum, and that’s been incredibly empowering both for us as staff and for the clients as well. So there’s a real investment in their care as well, just a point I wanted to add there.
Kate Osbourne:
Thanks very much. The rest of my questions are directed to Dr Michael Brady. So, Dr Brady, what work have you done to implement the health commitments made in the LGBT action plan, please?
Dr Michael Brady:
Thank you. So, I think it’s important to recognise that in the health section and the 12 health commitments in the LGBT action plan, there’s probably not one commitment that could be delivered by one organisation, and certainly not one individual working part time with no budget. So, it’s been a partnership working. So I have been involved in a number of the commitments, and less, it would be fair to say, in some of the others. I think if we look more broadly at where we’re at with the action plan, which I think is still an important document and I’ve alluded to this before, there are a number that have been achieved, and there are a number that are works in progress, I would suggest.
I think also the other thing to keep in mind is that there is a lot of work, certainly that me and my team do, to address LGBT health inequalities and to address the health inequalities in trans and nonbinary people specifically that’s not even reflected in the action plan, so it’s not all-encompassing.
So, if we think about the things that have been done, the first commitment is to appoint a National Adviser, that was done quite quickly and we’ve been in post since 2019. The work to change the rules around surrogacy, changes were made quite early on in the action plan. I have been very involved and sat on the committee that have made recommendations regarding the deferral period for blood donations for men who have sex with men, and it’s pleasing to see the announcement yesterday or the day before that those changes to a more individual risk based approach to blood donation are coming in on the 14th June, so that’s something that I have been particularly involved in.
One of my other hats is as a sexual health and HIV clinician, that’s what I do with the rest of my time, so I’ve also been very involved in Prep rollout, so that’s the fourth commitment that we have achieved in the action plan, which is around achieving NHS commissioned pre-exposure prophylaxes for the prevention of HIV.
So that does leave us with eight which are works in progress. Some have had some work done, I think the action around improving mental health that have been both published by government and a considerable amount of work by NHS England, particularly in terms of meeting their commitments under the long term plan around improving mental health across all areas. We’ve talked already about gender identity services and we can see the progress that is being made there but as I’ve said, another work in progress.
One of the areas that I spend a lot of time on and I think is a really important commitment which still does remain a work in progress is around sexual orientation and gender identity monitoring. It’s one of the key areas of my work and it’s probably the thing that I spend the most amount of time on. We are still too far behind across the system, and I would include government and healthcare in this, at not systematically collecting information on sexual orientation and gender identity and trans status. It’s, to me, the fundamental starting point about addressing health inequalities, the often-used but really powerful message of, if you don’t count us, we don’t count, kind of says it all. Too often, we talk about health inequalities but we don’t have the data to back it up, and I think we need to do a lot more to put sexual orientation and gender identity and trans status at the same level that we have around monitoring disability or ethnicity or postcode when we’re thinking about deprivation driven inequalities. So, data collection monitoring I think is an important work in progress.
We have made quite a lot of progress, I would say, in the NHS, we have a sexual orientation information standard, SOM, members of the committee may well be aware of that. I would say that we are not fully rolled out with that, but it does exist in all NHS experience surveys, it exists in some data sets. We are about to get it in a few other data sets. So we’re making progress on sexual orientation monitoring and me and my team will be having a relaunch, we’ve commissioned the LGBT foundation to refresh and relaunch their supporting and advisory documents around sexual orientation.
The main area of focus though, because it is much further behind, is monitoring of gender identity and trans status. I think there has been a lot of momentum put behind this by the really important changes of including those questions and the questions on sexual orientation in the national census, but we don’t have a nationally agreed information standard about how to ask those questions, so that’s further behind. We have made progress and this still is an area that myself and my team, working with colleagues in the Insight and Feedback Team at NHS England are very pleased to say have got an inclusive gender identity and trans status question into the national GP patient experience survey which is one of our patient experience surveys and very importantly, not least because it’s the largest, usually with around three-quarters of a million responses. We’re soon to get the question into the cancer patient experience survey, into the mental health service data set, and into the NHS staff survey. So, progress but not completed. I’m conscious I’ve been talking a lot, I’ll stop.
Kate Osbourne:
No, that’s fine. My second question was around what you’ve done to improve the provision of healthcare for transgender people since your appointment and I think you’ve covered a large amount, but is there anything you want to add?
Dr Michael Brady:
I would add a couple of things, some of them are ‘watch this space’. There’s been, like everyone, a degree of delay in terms of Covid and most of us getting redeployed to do other things. But there’s a couple of things that I would like to highlight. We’ve mentioned already my seat on the Gender Identity Programme Board focusing specifically on especially gender services, but as previous witnesses, particularly in the previous session, have highlighted, there are other areas whereby I would say every area in healthcare to a varying degree, trans or nonbinary people face considerable inequalities. But we’ve been doing some specific work in primary care because I think, as has been mentioned before, so I won’t labour the point, there is a need to provide better guidance and support and training more generally for general practitioners around trans-health, not just gender identity but trans-health in general, to make the workforce more comfortable managing trans and nonbinary people, more comfortable using correct pronouns, to really understand what is actually, or should be, a relatively simple process of changing names on systems and so on.
So, that’s a piece of work that we will be publishing in the next few months. The other thing I would like to mention is an items project. We are working with the LGBT foundation on a piece of work which will publish some guidance and recommendations around improving trans and nonbinary people’s experience of maternity services, and we have some broader things which are not just trans-specific but are across all areas of improving and addressing LGBT health inequalities. So we have commissioned the phase two of the rainbow badge project which is going to work with NHS trusts to improve their approach to addressing health inequalities. We’ve commissioned Anglia Ruskin University to do a mapping piece of work which is going to focus specifically on education and training, that’s come up a number of times and that’s going to be able to give us both some examples of best practice but also make recommendations about what good looks like, and we’ll be working with other organisations like Health Education England and the Royal Colleges and the medical schools on that.
Kate Osbourne:
You’re doing extremely well at guessing my questions and answering them before I’ve asked them so well done for that. One thing I do want to ask you, Dr Brady, is, I don’t think you’ve covered this, how often do you engage with transgender groups to assess their healthcare requirements?
Dr Michael Brady:
Frequently, I would say. I strongly believe that robust and meaningful engagement and coproduction is the way forward. I think it’s absolutely essential for those of us who make decisions or set policies or legislation that has impact on other people’s lives involves those people’s lives over whom we have influence in that decision-making process. So we never make decisions or plan things or develop and deliver projects without robust engagement with trans-individuals, trans and nonbinary individuals or trans-led organisations or trans-inclusive organisations. In fact, quite a lot of our work we commission to those organisations to deliver on our behalf, because they know the communities that we’re trying to support better than we do. They connect better with them, they have a better level of trust, I would say. You can imagine for obvious reasons that you’ve heard sometimes having NHS on your badge doesn’t necessarily encourage people to be trusting of your approach, and I can understand why that is. So, working with those organisations is really important so we do that all the time.
We also have ongoing ways that we communicate with the sector; we have a regular newsletter and something that we set up to support organisations during Covid but we’ve kept going is that we have a monthly video call with sector leaders, so pretty much all the LGBT and trans organisations in the voluntary community sector join that call.
Kate Osbourne:
That’s great to hear. And one final question from me, you talked earlier about the importance of capturing information and one of the concerns that we’ve heard from trans stakeholders is around data protection, so can you tell us what you’re doing, if anything, to mitigate those fears?
Dr Michael Brady:
So, I think there are multiple stages to the data collection journey. The first part is agreeing the question and deciding exactly how we’re going to ask. We’ve done that and we are testing that in some settings, but it’s not a perfect question. I think in the broader data protection sphere, I actually – I mean, this is slightly with my National Adviser but probably more so with my clinician hat on – think that there are wider provisions that should be protecting everybody, not just trans and nonbinary people. So our responsibilities under UK GDPR and the Data Protection Act and really very strict info government policies and procedures that we all should be following in the NHS. It is worrying and troubling to hear those examples of data breaches, it must be said that they are not unique to gender identity services, they happen too frequently but across the board.
My personal view about this is, I think it’s that that’s most important, less so anything that’s particularly trans-specific, but the only other thing that I would just add on this, and this reflects back to a discussion that I know you’ve had at a previous hearing around section 22 of the gender recognition act and perhaps some unintended consequences of that, I think you were hearing evidence about the impact of that on HR, there is an unintended consequence in healthcare as well. The presence of that legislation is misunderstood by most people in healthcare, they think that sharing any information about any trans person is illegal and that’s not the case, and it also is seen as a real barrier, so quite often when I’m going to organisations to support them or encourage them to collect information on their trans service users and patients, they use section 22 as a reason why they’ve not done it, because they say it was illegal to collect that information. And so I think there is an unintended consequence in healthcare as well as in other settings about the misinterpretation of section 22 of the gender recognition act, which is very easy to address but it’s quite time-consuming, just in the sense that for me it’s all about consent. You know, if you explain to people why you’re collecting the information, you only collect the information that you need and is relevant, and you explain who you share it with and how it will be used, then there are no concerns under the legislation, either data protection or GRA.
Kate Osbourne:
Thank you very much, thank you to all the witnesses and back to the Chair.
Chair:
Thank you. Dr Brady, can I just stick with the issue of data collection. We know that the Government Equalities Office is very keen on improving the quality and the amount of data it holds across a whole range of issues. Could you give us some indication of how much engagement you have with the GEO.
Dr Michael Brady:
On that issue specifically or generally?
Chair:
On that specifically, and more widely.
Dr Michael Brady:
So, more widely, as I said earlier, I have regular meetings, me and my team have regular meetings with GEO officials, monthly. In the first two years of our jobs they were fortnightly. We dropped them down at the point the GEO stopped funding us and we moved into NHS, and it was felt that that frequency wasn’t needed. We have really good relationships with the officials at GEO.
Data collection and monitoring is probably, as I’ve alluded to, the single biggest thing that we talk about and work on. So that will have taken up quite a bit of those meetings on quite a few of those occasions. So partly around the work that we were doing to improve monitoring of sexual orientation and gender identity in the NHS, partly around other pieces of work that were going on, like the unified information standard for protected characteristics, apologies for throwing that in just now but I know that has been discussed at previous hearings, but that essentially is a piece of work across healthcare and potentially government looking at how we collect data on protected characteristics.
There was a particular period, just because there was a lot going on, probably in the run-up to the census, because we’ve worked closely not just with GEO but with other government department officials, with the ONS on data harmonisation, because as I say, I think it is an important step forward that we have questions on sexual orientation and gender identity in the census. But clearly to make that data the most useful it can be, we have to be able to cross-reference it across other data sets. So probably the bulk of the time was on that six or eight months leading up to the signing off of the census and that being passed through parliament, because there was a lot of work to do to make sure that the work that we were doing in healthcare settings was aligned with the work that ONS and other government departments were doing around those questions.
Chair:
Thank you for that. Can I just ask how much contact you’ve had from ministers?
Dr Michael Brady:
Let me think. I’ve had a couple of meetings with Liz Truss over the last year, I would say, with other MPs that were interested to get together and talk particularly about a lot of the things that we’re talking about now in terms of trans healthcare, particularly…
Chair:
But other ministers, so Kemi Badenoch and Baroness Berridge.
Dr Michael Brady:
I don’t think I’ve been in any meetings with… I’ve been in one meeting with Kemi Badenoch but not with Baroness Berridge.
Chair:
Thank you, and you’ve highlighted to us that your role is still part time. I get the sense that you’re jamming a full time job into 20 hours a week, but would you say that that is an asset, that you’re continuing your clinical work?
Dr Michael Brady:
Absolutely, I think it’s an asset that I continue my clinical work. I do juggle quite a lot but it’s worth it and it’s really enjoyable. I think the reason that it’s important is that I bring things to the National Adviser role by still having a clinical job, and for many of the things that I work on, my clinical job is extremely relevant – I work in sexual health and HIV, I’ve set up and run a specific sexual health service for trans and nonbinary people – so I’m really live to the issues on the frontline. And I understand how the NHS works from that side as well as how it works from the NHS England side, so I think it is definitely of value, even if it is sometimes a little stretching of my time.
Chair:
Do you get any sense that your role is going to be extended beyond 2022?
Dr Michael Brady:
Well, my role has been made permanent now, I’m pleased to say. It was clear from early 2019/20 that the funding from the Government Equalities Office was going to end, where they’d had kind of a pump priming model, and NHS England has taken up my funding and now I and my team have permanent roles at NHS England.
Chair:
You’ll be conscious that recently, three members of the LGBT advisory panel resigned, one using the phrase that the government had created a ‘hostile environment’ for LGBT people. Has that been your experience?
Dr Michael Brady:
I think… what do I think? I think that if we look back two or three years, so the time that I’ve been working on this, there was a lot of energy and optimism and activity around this area on the back of the LGBT survey, on the publication of the action plan, on the appointment of the National Adviser, on the appointment of the Advisory Panel. So I think there was a lot of energy and optimism around at the time, which I would say is not there to the same degree now. I think that going back to what I’ve said before about how I like to work in terms of engagement, I think it is really important that whether we’re government or policy makers or service providers, that we have a way of engaging with the communities that we are impacting on. And the Advisory Panel was one way, it’s not the only way, to engage with and to communicate with. So I think there’s a gap now, yes.
Chair:
So, is it your expectation that a new panel will eventually be formed?
Dr Michael Brady:
I don’t know if there are any future plans?
Chair:
Do you think it would be an asset for a new panel to be formed, is it necessary?
Dr Michael Brady:
I think the means of engaging with the community, listening to their voices and putting them at the centre of what we do is essential. Now, there are many ways that you could do that, an advisory panel or similar group is one of them because you can get a broad range that covers all of the communities and do that in manageable way. So I think a way to keep that dialogue going and to put the people who we are here to serve at the heart of what we do should be the way forward.
Chair:
You’ll have heard, as the rest of us did yesterday, the inclusion in the Queen’s Speech of legislative plans to ban conversion therapy. Do you think enough has been done to date around conversion therapy and the concerns that have been raised for trans people, and has there been enough done by healthcare professionals to support trans people who might have experienced conversion therapy?
Dr Michael Brady:
So, I think the announcement the other day in the Queen’s Speech is very welcome. Many people have been calling for a ban on conversion therapy for a long time and indeed I think it’s about three years since it was announced as a direction of travel by Theresa May, so to get to this point is very welcome. I think we need to continue that pace and move further and faster towards that point. I think it is important that we are robust in ensuring that we ban conversion therapy in all of its forms for all individuals that it is attempted upon or offered to and in all settings.
In terms of the healthcare approach, I mean, I think you cannot underestimate the harm and the damage that is done to people who are – I hate to use the word ‘conversion therapy’ because it’s not a therapy – so-called conversion therapy. I think there definitely is more that can be done to support them. We have some generic services, but I suspect it takes a particular level of knowledge and skill and insight and it’s good to see that there is some commitment to provide or to deliver that kind of service, because I think banning it is essential but only one part of the picture. We need to be sure that we are fully supporting those who have gone through it.
From the medical point of view, I suppose the only other things that I would add is that NHS England has been a signatory to the memorandum of understanding on conversion therapy since its first iteration in 2015 and again re-signed in 2017 when it was broadened to take into account gender identity as well as sexual orientation, I think that’s important, I think that’s welcome, I think that’s a public commitment from the organisation alongside many others that this awful practice needs to be ended.
Chair:
Thank you. I was a little bit worried when you said you wanted to see the pace continue, because as you said, it’s been three years.
Dr Michael Brady:
Accelerated.
Chair:
Accelerated, absolutely. Thank you very much. Can I just ask if any members of the committee have any follow up questions that they wanted to come in with, I’m sorry I haven’t checked the WhatsApp group. I’m seeing shaking of heads… no, Kate’s happy. And can I thank the witnesses for coming and giving evidence this afternoon, it’s been hugely appreciated and very useful and I would just like to conclude the meeting. So, thank you very much, and order, order.
The proceeding has ended.
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