Trans Representation within the NHS – Tara Hewitt

Hi, everybody. Really excited to be back after some holidays. I’ve got Tara with me, and I’m going to let her introduce herself to you, really looking forward to having a good chat. So over to you, Tara.

Hi Helen. It’s lovely to see you be on here today. I am the co-founder of the Trans Equality Legal Initiative, and I’m a leadership and inclusion consultant.

Brilliant. Tell us a bit more about your work with TELI, to start with.

So basically, the Trans Equality Legal Initiative was set up probably two and a half years ago now, with a number of trans people came together with some of our leading UK human rights lawyers, solicitors, and barristers, to try and increase access to justice for the trans community, but also to inject some factual basis and some evidence basis into the discussions that were happening around trans inclusion, with a lot of myths popping up there in the media. And even when engaging with public bodies, we really felt it was important that I read what the experts said to make sure that decisions were in based on evidence rather than ideology or just lay opinions.

And in that two and a half years, how have things been? What have you achieved? How has it turned up? Because clearly in the trans world, in the last two and a half years there’s been an explosion in the visibility of trans people, which I think has been amazing. But it must that two and a half years. You must’ve seen a lot.

The last two and a half years, really. I think as you get older, times do seem to get a bit faster as well. But with TELI, we’ve submitted responses to the consultation with you as the adult gender services protocol in the UK. We’ve contributed to a number of parliamentary group reports into a hate crime. Some of our lawyers have been involved in some as the important case law that’s happened in the UK through their independent practice. We’ve had a number of conferences. So earlier in March, I know how long you were there at the large health conference that we ran in partnership with Mermaids and the University of Bristol where we had a leading voice and not just in the UK, but around the world in terms of young people and trans health. So we’ve really tried to sit to look at how we create forums and space where the evidence drives the agenda but puts trans people at the heart of what we’re doing rather than talking about trans people as if they’re not in this space and not in the room which I think happens still quite a lot within the government and within organisations. I’m quite active on Twitter, and if anyone sees my tweets recently about LGBT groups happening without trans people there but still being called LGBT freaks, I think it’s important that we centre our work around trans people’s experiences.

I couldn’t agree more. Marianne, Tara there was talking about submitting responses to the NHS gender protocol. You’re someone who’s been going through that gender protocol over the last two and a half years, or maybe not that long actually, but certainly waiting I guess for that long. Have you seen any shift or change or talk from the inside as it were?

I have to say no, I haven’t if I’m honest with you. I’ve been in the system probably five years to be fair. It’s difficult for me to comment on people that are coming into it now because obviously I’m kind of part way through and it certainly it’s just about monitoring my care at this stage rather than assessing me. But I did find the whole process quite, for somebody who was probably a bit weaker than me, traumatising. The idea that we have to have a diagnosis of gender dysphoria whether we feel we need it or not, I found it quite jarring.

So Tara when that when you were submitting your response on the NHS gender protocol, what were the kind of glaring things that TELI saw in that protocol?

I think I think what we just had it actually resonates with what some of our concerns were with the response that NHS England made to the changes in the protocol. A lot of trans organisations and TELI included were absolutely focused on this idea that care should be provided around the concept of informed consent, that actually we will allow people to make decisions about their lives, their bodies, their wellbeing, based on what matters to them with an understanding of what the risks are, where their actions stand and what the benefits are. But unfortunately the original draft—there was criticism that that wasn’t doing enough and going far enough around informed consent, particularly because of that they’re still focused on that idea that somebody else needs to diagnose. And TELI gender is which I had quite a lot in the medical profession that actually it’s still a doctor’s role to decide what your gender is, which is for me a strange concept. But even though there was virtual consensus across the LGBT organizations that they responded, including TELI, the response that came back from NHS England was is that there are multiple definitions of informed consent. They felt that that fear was delivering not informed consent outcome even though that they just heard from the people that would be accessing those services and the leading organizations that advise on that, they felt that their model wasn’t—I do think there’s been some progress in the wording and the concept that non-binding people should be included within the pathways. I can’t speak from lived experience, but I know historically the wording has been explicitly exclusive of non-binary people. And I know that they go much further to be more inclusive at least on paper that those experiences will be valid. But actually if you don’t have a model that’s grouped around informed consent, I’d probably say there are people that don’t fit the normative that society wants to impose on us that tends to suffer the most, and tend to be those that fall foul of the hoops and the barriers that some of the clinicians complain about.

Absolutely. I think it’s worth just exploring that concept of informed consent, because actually in medicine, in healthcare, informed consent is just bread and butter to a doctor and the patient and their relationship, and them discussing the management plan. So whatever the condition is, whatever the medical issue or the medical needs of that patient, the patient will tell the doctor or the nurse or the therapist what they are feeling and experiencing and give them their perspective from themselves as an expert in their own body and their own brain. And then that doctor can then come back with chipping in with their expertise which is about medicine and about interventions that might or might not help that might be beneficial or might be harmful. And then the informed consent means: you tell me what you want and what you think you need, and I’ll tell you whether I think that’s safe for you or whether the pitfalls or which option might be the safest one for you. And there’s a good ongoing discussion then about where we go where and how we navigate the plan and come up with a joint decision on the best treatment for you. And we do that all the time when you’re treating somebody for blood pressure or diabetes or for cancer at any medical intervention informed consent, it is a two-way situation where you tell me, and I’ll tell you, and then we’ll come to a plan together. And I think you’re right. I think in gender care, certainly, when I’ve been shocked at it. Because it’s another one of those things, Tara, that you use those words a bit like you are saying that you’ve got LGBT groups without trans people in it, but that proves that we’re inclusive because we’ve got an LGBT group. If you say we operate a model of informed consent it’s kind of like yeah, tick box; we’ve done that. But actually, do they? And I hear so many stories of difficulties in that area. And Marianne I don’t know whether you understand the GenderGP model of informed consent. Did you feel you had a two-way discussion on what was best for you?

There was an irony in my process in as much as to put you through this gatekeeping, which I failed, I have to say. I followed the first attempt, and the truth of the matter is that when it came to when they finally offered me the treatment, then it suddenly became about informed consent, and had to have this whole session where they were explaining the treatment to me. I just thought if we were coming from consent, then what had gone before just seemed like a waste of time. Finally, they were listening to what I wanted. You know, it was the first time I felt heard, which was the last session if that makes sense.

Can I share an experience as well, where the amount of paternalism actually harms patients? So actually not as an expert, as a trans person, I remember several years ago now, a few years into my transition and several years actually to my transition, I was running a conference for an NHS organization at the time with leading experts on trans health and across the system come into this. And at the end of the conference to one of the speakers who’s connected to one of our gender clinics, I asked if my GP could write to them for some advice on the medication I was prescribed, because the anti-androgen which I was taking was quite an old-fashioned methodology, because I had it described quite a while ago, and I had heard that there was actually a more modern regime that was safer and that had less risks, side effects to it. And would my GP be able to get some advice so that I could make my prescription over? Now, I went down the private care route. The consultant I accessed was a private doctor, so I didn’t access the NHS pathway. And this obsession with you having to have gone to an NHS gender clinic before they’ll give you advice was so evident. So the consultant who I spoke to basically said that he wouldn’t view me as a woman until they gave me a diagnosis so that actually he couldn’t give me GP advice to make my care safer because he wasn’t sure whether I would get a diagnosis until I’ve accessed his NHS pathway, despite me having lived for numerous years having access to hormones that is under the guidance of an NHS GP after a private diagnosis. But I was seeking some safer care input from a consultant, and I was left blocked out, and so that’s a real example of where the pathway isn’t safer. It’s actually harming people.

(unclear 11:35) wouldn’t recognise you as a woman until you’ve had a diagnosis.

And that’s basically what they were saying, was that they couldn’t provide advice to make my prescriptions safer in terms of the medication regime, despite it being prescribed by an NHS GP and me having been prescribed it by a private consultant numerous years earlier and having lived as me, in case I got to a gender identity clinic and started at the beginning of their pathway. And having gone through that assessment, they deemed me not trans. That’s why they couldn’t provide advice to my GP; they didn’t recognise that this diagnosis from a private consult because they weren’t a psychiatrist. So unless your consultant was a psychiatrist, they weren’t happy with providing my advice to my GP. So I was left on what he said was a more unsafe regime compared to what they were using now. But yet in limbo and not able to get that guidance from my GP. So it’s nonsense that the model it’s all about safety. It’s about control. And I think we need to really challenge and break up that monopoly so that trans people can get the cab they deserve.

Yeah, I mean we’re hearing so much—the negative that we’re beginning to describe, the nonsense, the paternalism, the danger. You know these are scary things. And I think actually if we just pop back a minute that informed consent model that people say is in use at the moment, and the service users are saying well I don’t think it is, preceding the informed consent to treatment—we’ve just mentioned what those horrible words that I hate: the assessment, the diagnosis, the proving your gender to a doctor. And actually what we need to go right back to the beginning, and go to self-identification of gender in the medical world. And somebody goes to their doctor says, I am transgender, and I have got some ideas about how I would like to navigate this journey and the rest of my life. And I would like to share those with you, and I’d like to get your help as an expert in medicine to help me to do whatever intervention, or whatever transition, whatever we want to call it more safely. And we’ve got to go right back to the beginning and permit, allow, empower trans people just to be their own judge of their agenda. And we must trust what they say. And it’s ridiculous this idea that at that any trans woman has to go through some kind of pathway to prove that they are trans to their doctor Is just ridiculous.

It’s very similar to this idea that you would make women jump through more hoops in terms of accessing HRT for the menopause. But ultimately we need to make sure that whether you’re cisgender, whether you’re trans, that actually you’re in control of your body and having more of the health care that’s going to keep your wellbeing safe and you able to go in the direction that works for you. And a lot of medication that is described as risky or scary for trans people is routinely prescribed by GP for cisgender or non-trans people. But they’re scared as often those that are really standing in opposed to trans people’s health, scare the public who maybe don’t have that broad understanding of what is safe and what isn’t with this idea that these medications are risky and unusual when they’re not. And I think we really need to bring it back to the idea that a lot of this description and the medication has been prescribed that some people will have complex care needs, and that absolutely it’s the role of the health care practitioner to manage that and so identify that and support that person in keeping themselves safe.

Absolutely, I really couldn’t agree more. Marianne, have you got anything that you want to add to that?

The bit that I think people forget is that not one model will suit everybody. What I tend to feel is that what we’re doing is being railroaded to fit a model, instead of having more than one model. We just have one model, and then you’re trying to manipulate everybody to fit that model. So I think the choice would be quite nice. I’m sure there are some people where the gatekeeper model works. You know that maybe they aren’t as confident as other people. But we also need the other side where we can just walk in and at least be believed without having to validate our feelings.

Yeah, absolutely. Tara, you mentioned earlier that evidence drives the agenda. What did you mean by that?

So I was saying that TELI, one of the things that TELI wanted to do is really bring evidence back to the discussion around trans inclusion. Say, particularly with the discussions you’ve seen in the media around self-I.D., I’ve often spoken to journalists that would be talking about what makes trans people able to get a passport without any diagnosis and then having to inform them that actually they already can. Passports are self-I.D. So actually, TELI’s role is really to say that, if there is going to be discussion and human rights of equality law, the process is that we should go through intensive health care reform, that we need to stick to the facts and let evidence drive the agenda rather than allowing scared coats—and also misinformation. So sometimes you end up trans people end up not having the right facts because they’re hearing in the media what the law says. And I think it’s important that whenever we are speaking out, that we’re not just giving a lay opinion, but that we’re always referencing that back to what does the evidence say.

And I don’t know whether we see it in law because I’m obviously not so in favour with the law, but certainly we see it in medicine that the evidence drives the agenda. But what I’m seeing at the moment, and certainly this was that I was shocked by the Royal College of General Practitioners, and their position statement and some contributions from key members of the RCGP recently in the British medical journal The Lancet, of people saying that there isn’t enough medical evidence, and therefore we should be withdrawing or withholding care to trans people. And it’s almost like you can use the words in any way you want to make it fit what you want, isn’t it? And yes, everyone is saying we want more evidence to support Trans Healthcare, and you can use that as your position statement. Or you can say; actually, we have plenty of evidence, and there’s never enough, and of course we need more, but we have plenty of evidence as you were saying a minute ago, Tara, that actually medical trans healthcare and hormones for trans people are absolutely safe and we have so much research and case study and clinical experience to show that these are safe interventions for all ages. And yet we have powerful people making statements and making suggestions that we withhold care to people who really need it because we haven’t got enough evidence and it’s just appalling.

I think what I was saying is that if we’re making statements that we all back our statements up with the evidence that does exist. And I think a really good example of what you’ve just described is some of the comments we’ve seen in national publications, national media from what’s alleged to ex-staff from the (unclear 19:15) gender service that we need to end this transgender experiment on children and it’s hormone blockers we’re experimenting with these dangerous medications. And it’s like the majority of people that take medications which delay puberty had nothing to do with trans young people are often still to do with choices in terms of what will allow somebody, a young person, to grow with their peers and fit in socially within their narrative that they’re not often driven by this faux idea of proper health issues vs. this drummed up trans condition. Actually they’re based around what works for the young person, and we’ve got the evidence base that that medication is safe when it’s managed appropriately, and trans people shouldn’t be viewed any different and if we are treating trans people differently, then it’s not a health issue, it’s an inequality issue and it goes back to the inequalities that all LGBT people still face in society. And recently, we saw the BBC saying we’re going to allow same-sex couples on Strictly Come Dancing as if it needed that permission. I think that’s still the attitude that exists around LGBT issues, that trans people actually are still fighting for the same rights that cisgender young and adults already have in society.

You mentioned hate crime earlier, which is not something that we’ve really touched on very much in our series. And I was reading an account of a young person who was going through terrible bullying at school recently just for being different. And it’s hard enough to come to terms with these feelings yourself, isn’t it? Never mind being pushed and bullied and hurt. How are we doing there? How are we progressing? What could the people listening in today, if they are experiencing hate crime in the workplace at school in the street in the shops at home, you know? Have we got something to make things better and easier?

I think firstly from a positive point of view, we do have some fantastic LGBT organizations that are there to provide support in the UK. We have organizations like the LGBT Foundation who are predominately based at Manchester that have trans staff and service and regular trans events, can be a real good place to go for advice. We’ve got organizations like Gendered Intelligence which is one of the biggest trans-led and run organizations in the UK, again a great place to go to for support and advice. We’ve often got local support groups and local organizations that are doing great work. We’ve got campaigns and people like Sparkle in the National Trans Charity which are getting that message out there to try and challenge perceptions. So firstly if you are struggling, reach out for support from your peers and from people that that will be there for you even if you don’t realize that they are. I think secondly, though, is the really important issue that we need to be honest that these things are post-Brexit. But yet most of the narrative that you get from the police force at the moment is their increased level which isn’t good, and that’s a sign of increased reporting rather than a reflection—that they’ve done some good work and got reporting numbers up. Now whilst we might have seen a higher proportion of people reporting, I’m sure than we had 15 years ago, actually over the last couple of years where we’ve seen actually dramatic increases of over 80% in trans hate crimes in the UK, for me a massive chunk of that is actually just the increase in hostility that you don’t have to be an expert to have seen by just looking at the newspapers. There’s been an increase. And the solutions that we’ve seen from organisations is just to stick a rainbow patch over everything and say we’ve got a rainbow now, we’ve got rainbow lanyards, we’ve got a rainbow at the home office on their Twitter account. At the same time while deporting LGBT people back to countries where they’re facing abuse. And so I think we need to challenge our organisations, whether that’s our employers to support people that are victims of hate crime at work, whether that’s wider third sector support services, or whether that’s the police and the government, that a rainbow logo isn’t enough. We want to see actually a reduction in hate incidents. We want to see that people that are fueling that in the media and generating that actually challenged and acknowledged and actually seeing progress around that because it’s action that supports people that are victims of hate crimes, not a rainbow logo. And I think there’s too much of this idea that you stick a rainbow in it and it makes everything better.

Marianne, what about in the therapy room. I mean you must have heard some sad stories of hate and bullying and discrimination. Is the support out there. You know, when we recommend a group such as that Tara mentioned. And Tara, we’ll put those links in those groups if you wouldn’t mind on the bottom of the podcast so people can access those, but Marianne are you seeing people accessing that kind of support in a positive way and getting some help? Have you got any tips for people listening?

My experience of hate crime is mixed. I have to say I’ve worked with people that reported hate crime and they’ve been to the police. I don’t want to include myself here because I had a hate crime two years ago. I’ve never seen it go to court. I’ve not seen a prosecution, and I had people in the therapy room who’ve built up one person, in particular, the day they booked the hotel to be ready to go to court, and then the day before it was due to go to court the Crown Prosecution Service kicked you out with no right of appeal even though the police had told you this was nailed down and they got all the information they got the photographs the videos. So I kind of wonder whether it is a hate crime—just something that we put into legislation with no serious intent to actually do anything. I don’t know what your feelings are with that, Tara.

I think one of the challenges is making sure that the attitudes and culture of the police are such that they really understand the issues. So, for me the recent rise in hostility towards trans people, one of the areas that’s fueled that, is people that are claiming to be feminists that are pushing an anti-trans agenda, but they’re coming from a point that they hate trans people for being trans. It is targeted at the protected capitalistic of being trans. But often when you speak to the police about it, their position is that if everybody is critical of what they’re doing, they must be doing the right thing. They must be being impartial. And that actually it’s a political discussion of whether trans people should be included. I mean when if the police are taking this impartial stance when a hate group and hate groups are targeting a minority by claiming that there’s some sort of faux balance, for me that’s often where the challenge comes from. And it’s probably not from that that they think that they’re intentionally negative. I genuinely think a lot of people think that they’re trying to be this balanced view and that’s the right angle. But we really need to work harder to show them that there isn’t a debate. There’s a group of people targeting another group of people for being from a minority group. And that’s the very definition of hate, and that’s the very definition of what being a marginalized group has met. I really think more work needs to be done on that to bring the police to see that and be more proactive with understanding that. And we often see it with lawyers as well in terms of if you’re defending a client or if you’re bringing a claim for a client you need to understand trans people’s lives to be able to actually deliver the best service and present the best arguments for trans clients. And so more learning and more opportunities for people to understand trans people’s lives and reality. I think just quickly that oftentimes people are prepared to portrayed as the perpetrators when actually we’re five times more likely to be the victims of murder in the UK, we’re seven times less likely to be in prison for a criminal offence in the UK, significantly less likely to be a criminal offence for a sexual offence compared to non-trans people. And we really need to reverse that narrative that both trans people have put us out is dangerous, when actually we’re more likely to be the victim and we need society to protect us.

So it’s interesting you mentioned when you were talking about the action that people take towards the small and marginalized group or a minority group. You talked about the police and how they somehow kind of feel they must be a balanced view of this. And you mentioned the case of the lawyers, where maybe the way we interpret the law is different if you’re trans. And it’s the same in healthcare. Every single trans person who has had a suicide attempt or a self-harm attempt, those people will have seen doctors those doctors would have seen those people before or during the harm, or before or during the suicide attempt. And what have they done? They’ve done nothing. You know they can’t just sit there and say well we can’t do anything until we, until you, have that diagnosis that we were talking about earlier from an NHS gender clinic, which has a four-year waiting list. And that’s what we’re seeing in healthcare. We’re seeing people hurting inside and out while they wait. And their doctors are just watching the pain. We wouldn’t allow that in any other medical walk of life. And the three of us Abby and Marianne and I went out to America to see Johanna Olson-Kennedy and her team and had an amazing weekend of education and inspiration and they were saying it’s just like somebody get what gets run over and they break their arm and it’s really painful. But you have to wait for years to get to A&E before you’re going to get that fixed. It’s just ridiculous. And why is it that the rules are different for trans people and different for those who hope trans people, like myself?

I’d go further to say that we often don’t hear enough on it. One of the messages from our conference with Bristol University earlier this year was trying to get people talking about not just the specialist gender services, which shouldn’t be specialist gender services. Actually, most of the health care that I access in my life is nothing to do with the fact that I am trans. It is as you said you could break your leg. You need your tonsils taken out. But from a mental health point of view, actually, all swathes of us have mental health issues. So some of my mental health issues come from some of the issues that I’ve had growing up, and generally, mental health issues that aren’t linked to me being trans. And I remember seeing mental health practitioners when I was at university, and they almost put throwing their hands up in the air and go, “you just too complicated. I don’t know how to help you,” immediately when they hear the word trans. It scares people. And it’s because we don’t have the training on the curriculum in the mainstream curriculum in a meaningful way, or if we do, it’s watered down. So we’ve seen the Royal College of GP recently about to publish a new training package that they’re going to say is amazing but it’s just a watered-down version of a previous package that they didn’t like because it focused too much on what help trans people should have. And we’re seeing this move more towards awareness packages that it’s softer than just say trans people exist. OK. That’s right. But actually what blood tests? What’re the benchmarks for someone that’s been on hormones for 20 years? How do you use a catheter on a post-operative and lower surgery trans woman? What’s the methodology behind that as a clinician? What are the health inequalities and risks around heart disease and cancer? And we’re not seeing that focus, and so from when you were saying about suicide and mental health issues is when trans people need to access mental health services, what we face is people that want to blame all of our mental health issues and the fact that we’re trans, new treatment pathways which are designed actually to include our whole selves and meet our care needs. And so for me, that worries me as well as just the that the care that’s targeted at gender services.

Absolutely. I’ve got so much I want to say, but Marianne, I don’t want to steal your moment. I know you’re going to have things to say about what Tara was saying about when you go into the therapy room and it’s just mentioned, that word “trans” and then all of a sudden it’s just far too complicated. You’ve told me that before.

If I’m honest, there is a theme here. We’re probably 20 years late for some people, but I think it’s that old saying when is the right time to plant a tree? And it’s twenty years ago. All we can do is plant it now. And the truth of the matter is it’s about education. And actually, the theme I am getting just listening to Tara today, and just in the therapy room, is just a lack of belief and faith in that we know who we are. And when we walk in to see a doctor, whether it is a psychiatrist or whether it is a mental health professional, whether it is because we have got a cold, they are blinded by the trans label or the trans thing. So yeah, in the therapy room, you know the amount of people who say I’ve spoken to a therapist once and he said you have to teach me. Teach you what? That I exist, that my feelings are genuine, and I want to talk about my depression, I don’t want to talk about my gender. It’s so infuriating, but I think it comes down to education, trans people have been airbrushed out of society for so long. People actually believe that we don’t exist. And when we walk into their world, that basically they are going to go into meltdown.

Marianne, I think you are absolutely right about the airbrushing. And I think the implications of that come into the fact that our decision-makers in the health system are all cisgender, and not trans. Say I’ve got a job in the NHS, and I don’t know anybody more senior than me employed in the NHS, I don’t see trans people employed as senior leaders, as executives for the NHS. And so the people who are making the big decisions about education about pathways, or even some of the specialist decisions about the medical records and areas like that, don’t have that lived experience or access to diversity in their circles by other leaders being trans in those spaces to make sure that the decisions being made are evidence-based, that expertise is in it. And I think this is one of the issues that health service has recognised more broadly around the snowy white peaks and the lack of minority ethnicity staff in the NHS, is that research on people like Professor David Williams at Harvard in America has shown that when you don’t have representative workforces it leads to health inequalities and communities of people of colour, et cetera. And it is exactly the same when it comes to all of our underserved communities. It is like your workforce should represent your community. That has a direct knock-on effect to the health inequalities, both because you are designing health services that don’t meet their needs or don’t have the access to know where we can get the evidence from, or ask the right questions, but also because you reduce the economic potential for people, which means that the NHS is the biggest employer in the UK. So if they are not employing trans people, and we know that over a third of employers refuse to employ trans people according to the latest surveys. Trans people are less likely to be able to access the educational opportunities they need to advocate for themselves. It creates this vicious cycle and so we really need to see more trans people directly employed in a whole variety of roles across the NHS. We’ve got trans people as receptionists, junior doctors, as students, nurses, and in some junior management roles. But I want to see trans commissioners. I want to see trans people as executive directors not responsible for trans services, but responsible for all services that bring in their perspective as a trans person into that realm. And so we’ve got that. I think we are continuing to see that airbrushing out of trans people from services and what are needs are, and not always maliciously, but we are not considered because no one is asking that question in the room.

You mentioned your twitter. I follow you on Twitter, and I smile every time you pick it up you’re like, hang on a minute, guys, just waving that flag and changing your icon and avatar isn’t good enough. Where are the trans people to actually consult on this? And I agree with you. I wanted to take you back just a couple of minutes when you were talking about curriculum and the RCGP because this is something I feel very passionately about. So the RCGP are creating their new guidelines, their new e-learning module, because of the difficulties –I won’t go into that now—that they had with the one that they created with Giles, we don’t know what it’s about. I asked them directly who was involved in creating it, and if they wanted any help from me. And I had a kind of polite “No, thank you.” And you mentioned the guidelines: what test do you do, what dose of estrogen do you give, how do you give a blocker if you have a heart problem? Is it safe to be on HRT for the rest of your life if, for example, you have a heart rhythm that’s not right? That work has all been done. We’ve got some amazing guidelines for really good things. We have some from America. I’ve got some fantastic ones, some recent publications in Australia and New Zealand about treating transgender youth just phenomenally good guidelines which are really easy to understand from a doctor’s point of view. You don’t have to be a massive specialist, a super-specialist to understand them. These guidelines are there. And actually, if you have a look at the Royal College of General Practitioners’ curriculum, so this is the curriculum which after medical school if you want to train to be a GP, there’s a big curriculum and it takes you through all the skills and core competencies that you need, and that’s recently been updated in 2019, and signed off by the General Medical Council—and guess what? The care of transgender people does not exist. Again, you mentioned, as LGBT, you must consider the needs of LGBT groups. End of story. Not one single concept of how to actually give somebody some hormone therapy that is going to make their body align better with their identity better and make them live their lives more easily. We are in 2019, and these curricula are being signed off, and it is not there. It’s not there in the GP curriculum. It’s not there in endocrinology, it’s not there in paediatrics, not there in psychiatry, not that I would want to see it there in psychiatry—where is the education? But having said that, there is education out there. I am someone who has taught. I am a doctor, and there is no training in the UK for the care of transgender people, but I wanted to learn, and I wanted to find out. I read everything. I read all the beautiful guidelines which are very evidence-based from other countries where they are practising gender-affirming care. I listened to every single trans person I ever met. I listened to their stories and heard how they explained their gender to me. I learned, and I am passionate about the healthcare of transgender people. So there is plenty of education there. There is none in the UK, which drives me bonkers. But anyone who is listening who would like to have skills in helping transgender people, there is a lot of guidance out there.

And I think what you are saying is that there is a new package that I know the RCGP are going to release in the e-learning package. What is upsetting me is that they are pitching it as an equality initiative, whereas those that have been involved or who are following this for a longer period of time and will have heard the message know that it stems off them not wanting GPs to focus on pushing prescriptions, or making trans care more of a specialist service that the GPs won’t handle. It’s a way going backwards rather than having a direction of travel. I’ve got no faith that they are actually really going to build in and look at best practice evidence. And my rationale for that isn’t because I am quite critical of their approaches; it’s based on the evidence. They issued a new statement recently, which is a new equality statement, which they’re going to campaign on, and I have got to take them on their words, and some of it is so clumsy. One of the elements in it is that they are going to lobby for biological sex markers on people’s records, which is actually what the anti-trans people want to campaign for. And their language behind it is that well, it’s important that trans people can access things like screening. And that’s the route we want to go around. They only need to nip over the border. I believe the RCGP is meant to be a UK-wide group—I’m not an expert on their own governance in Scotland, but definitely from an NHS perspective in Scotland, the work that the Scottish Trans Alliance has done means that trans people actually call for groups of people that have a variance in their screening needs. That is what it says on their records. That the national screening database is notified and they are actually included in their screening. There is no need to have biological markers. So what the RCGP is lobbying for in this new position, they are clearly not going to look at the evidence even here in the UK, in Scotland where something is working, so when it comes to this training package, until I see it, I haven’t got faith that they are really going to build in what you just described, Helen, which is some of the fantastic guidance and evidence base that is out there. I am worried it’s going to be driven by what we hear out of the RCGP form some people sharing that there are lobbying voices there that are completely opposed to trans people’s care. Now for me, that is prejudice. We shouldn’t be seeing that in the health system, and we want the RCGP to talk and oppose that rather than building it in as if it’s some type of legitimate voice into their service pathways.

How do we do that, though? How do we see it? I mean, you see it, Marianne sees it, I see it.  I see it very clearly, what’s happening, and I am scared, and I think I can hear the fear in all of our voices in what the RCGP are going to produce. We haven’t got faith that it’s going to serve the people that it should serve. We don’t think it’s going to make healthcare, or your GP surgery more easy. And so we are fearful of what is going to come out, of this new guidance. How do we actually action this? You know, once they create their guidelines, and it’s signed off, not for review for another two years, what do people do? What do they do for healthcare from their GP in the next two years while they finish their guidelines? I feel so powerless. How do we actually make a difference?

I think, unfortunately, we live in a system where things take time to change. I think all we can do is make sure that we are highlighting where the evidence should be coming from, not just saying that something isn’t right or that we don’t like that the GPs have done. So the example I gave is the biological sex markers and screening. The argument that people power for—all that sounds sensible and I’ve heard quite senior LGBT people say it’s well-intentioned and it’s about trans equality monitoring, or it’s about that trans people should have access to screening, so this really seems sensible. So it’s making sure that they are having trans voices being clear that this is what we want, but then also here’s a solution. Here in Scotland, this is what works, and in some ways if we look at it like a comparator, their self-I.D. and their Gender Recognition Act reforms, I don’t feel that maybe in England, in particular, we’ve been as open to focusing on what happened in Ireland, and the great work that the trans and the LGBT organisations in Ireland have done, and the progress that they have made in getting self-I.D. recognised in law, and that impact that it has had there. I think we had a much stronger lens on that in showcasing that the Irish are leading on this from a human rights perspective, rather than what often is the case that we live in our own bubble and we think we’re the best at everything here. And I think Brexit has particularly focused on that sort of lens. And so for me in England in particular, it’s saying, here is something that is working in Scotland, it works really well, the trans community supports it, the experts and organisations working with the trans community worked and lobbied this, and this is what worked, and then ask RCGP and NHS England to provide rationale why you wouldn’t use a solution that is already there. Why do we need a new solution? Here is one that works. If we want to keep people safe, surely it’s about using existing practices out there. And I think it’s the same when it comes to their protocol, whether it’s for young people and whether it’s for adults and this, there are different challenges with both of those groups. I think we keep banging that drum as you say. As you were saying you flew to America, and there is some fantastic care that is happening for trans people. Just sadly, a lot of the times it is not happening here in England. And we need to really need to look at the places where it is really happening and showcase that and celebrate it rather than just talking about the negatives. Because I think if we can focus on what is working, it can be much—

That is such good advice. I am want to summarize what you just said because I want to take that away with me. So basically, what we’re saying is we spot it, and we say no, that’s not right. This is what we would actually like. And this is how we know it works because they are using it over there, and we’ve seen it work, and it goes back to evidence-based, doesn’t it? Marianne, do you think people have a voice? I mean, I was asking Tara, how do we get people to listen to trans people and what they want, and what they feel is good for them because they’ve seen it happening, for example, in Scotland? Do you think trans people have that power? Have they got the strength? Have they got that voice?

I think there are two things here. I think one of them is most trans men and women just want to go about their lives. We are there in society. We are getting on with our world. A little bit of brute force and ignorance, but you know, we don’t want to be there thumping every desk and having to fight all the time. So I think one of the issues is as we go through we disappear. I think trans visibility is definitely important, that people recognise that there are trans people in their community and that we need better support, if not for ourselves, but for those following us. I think that’s definitely one area. But you’re right about the trans voices, because—I’m just going to go back to the very beginning of this conversation—we walk into the GP practice, or we walk into the gender clinic, and straight away our voice is removed. They stop listening to what we want and what we need and start telling us that they know what’s best for us. And straight away, we are erased from our own journey, from our own pathways. So yes, I do think that in short our voices are missing. It’s great listening to Tara, by the way, because I am focused on delivering therapy, and I am focused on empowering people, and it is fantastic to know that there are people out there taking this, picking up that mantle, and championing the cause in this educated way. It’s not just part of the fight that is going on in the media, if that makes sense, between turfs and activists.

I’d say that we have some really strong allies, as well. As much as we are talking about some of the challenges, I know many NHS chief execs and directors who are incredibly supportive of the needs for our health services to do more to include trans people. If there is anyone who follows me on Twitter or follows the national trans NHS network on Twitter, Trans NHS, you will see numerous allies in senior roles talking about this agenda, and actually highlighting it and raising it. We’ve got people like Lord Cashman in the House of Lords, who is a passionate advocate about getting this right, and that actually we need to do more. And I think as trans people, or all of those people that are experts working with the trans community, whether it’s in healthcare, like yourself, Helen, or whether it’s our lawyers, it’s equipping our allies with that evidence. Like we’ve set examples of where things have worked, so that when maybe I am not in the room—because I am not an NHS exec or an NHS chief director—then a trans person or an ally have got evidence they can use to make the case and to actually really influence that decision making. And I think that’s maybe where we need to focus some of our attention to broaden that group of people that can really help push back against what’s been a rise in anti-trans ideology. And we saw this idea recently in the newspapers that our Prime Minister would like people to see whether trans issues should be a culture war or something that they should campaign against as a government. I think we really do need those non-trans people, or cisgender people, who are in senior roles, who are already generally supportive that haven’t been engaged and maybe haven’t been given some of the evidence base that they can go shout about and that they can go champion about. So I think if trans people are looking for something to do, or for people who are experts in particular fields, go and have a conversation with someone who is generally supportive that maybe has a position of influence and share some of what you know with them so that they can go and have a positive impact. And I think a lot of those people have a lot to be positive about. Rather than just focusing on the negatives. We have a growing group of people that are wanting to stand up and speak out about this in the UK.

This is just my observation, is that the establishment or the state in England, in particular, are reluctant to look outside of England. We didn’t talk about the evidence. If they look into the NHS, it’s poorly put together any research in the NHS because the model was flawed in the first place. And if all they are trying to do is rig that model, I worry that it will never change and that the stigma and our voices will never get heard, until people look outside.

I think that that comes from where our focus often is with providers like the Tavistock, for example. And trying to change their opinions, I don’t think that is going to work. For me, I am looking for a much more senior than that. We need to make sure we fill that empathy gap with some of the senior leaders in places where services are commissioned, is that they need to see that it’s broken and not working. And I know that we know that. We just talked about it. But actually, for a lot of people, they don’t come into contact with the real voices and the real experiences of trans people, and they don’t come into contact with the evidence base that we’ve seen from Johanna Olson-Kennedy in America, for example, that we can all roll off our tongues because we spent a lot of time working on this. A lot of people, we’ve been fair to them, have big portfolios of work. And actually, this is an area that takes a massively small percentage of their day-to-day thinking and their day-to-day work. And so I think we need to make most of any time that they are engaged on this, and really try and raise that platform into some of those fears, not where there is already hostility because I don’t think that works. But I do think, looking at some of the senior commissioners, and people like Simon Stevens and NHS England, to really try and get them to see the need to change. We can win them over. I think that will then lead the providers having to take a different tact.

Will they have a voice? Will they be heard? Will they be welcomed? I mean, I wouldn’t put myself as a senior leader, but I would put myself as a very strong woman and a doctor with some medical power if you like, and I have spent many hours writing to the General Medical Council, the Care Quality Commission, Healthcare Inspectorate Wales, NHS England Specialist Services, asking to meet with them, asking to go in and discuss what I know as a doctor, what I have learned from the trans community, and share with them that this community are facing in healthcare. And every single one of those organisations has refused me through the door. I am not allowed to go and see them. I am not allowed to go and speak to them. My letters go unheeded. I give them really good examples of poor care. I show them excellent examples of good care coming out of guidelines, and case studies from other countries. None of those other people has wanted to listen to me; none of these people has wanted to sit down at the table and hear what I have to say. It really feels quite scary that although these senior leaders have a lot of power, it is a very small part of their agenda, and if they hear the kind of thing that I have opened my ears and listened to, what will they do with that information? How can we admit that healthcare for trans people in the UK has been so bad for so long?

I agree with you. What you said describes some of the challenges in an incredibly hierarchical traditionally set up institutions that we still have in the UK. It doesn’t help. And I say this often, when I am talking to people working in the health system, when you see your boss—Matt Hancock who came out and was openly hostile as the secretary of state towards trans people in relation to trans patients and trans women on women’s wards and implying that trans people might be more risky to people. That’s really scary because ultimately, he’s the boss boss. And already, I mentioned that we’ve seen the prime minister talking about polling on a culture war against trans people. So yeah, all of what you’ve described is the environment, and that is why we see rises in hate crime. That’s why we are seeing trans people really worried and really scared. I include myself as someone who is white, middle-class, relatively privileged, as trans people do—I am petrified, so I don’t know how other people are feeling. But I am trying to look at what it is we can do. Cause for me, we’ve always got to focus on where is it that we can have an impact. So whilst I might not get in that room, or you might not get in that room, Helen, there are people who are more open to these conversations that are one or two degrees of separation away from those rooms that we are talking about. I do see those positive voices like I said, that are really supportive chief execs, NHS chairs, who haven’t maybe been activists, they’re not going out there spending their time on trans issues, but actually, when it doesn’t come across their radar, they’re horrified at what they see. And if they are in a room with someone like Simon Stevens, he’s more likely to listen to somebody who is an NHS chief executive or who is an NHS chair, or who is the Shadow Secretary of State for whatever and whatever. So for me, it’s looking up where are those allies already in the system. A really good example recently in the NHS staff network, there was a story of a junior doctor who had been discriminated against in work by a colleague. NHS Chief Information Officer retweeted it and said (unclear 56:37), and it was awful. That person ended up with hundreds, if not over a thousand abusive messages, death threats. Like anti-trans campaigners, and it was awful. That for me, for someone I know that some of the senior leaders that I spoke to after that said that it really opened their eyes to what it was like, because they’d sort of heard about it, but they had never seen it in precative and they always felt there must be another side to it all. It’s been exaggerated, and they just saw an example of a senior leader just sharing a story from a doctor, and then ending up being completely abusive. I totally agree. There are real challenges in the system. But I think if we are looking for constructive things we can do if we see these positives, let’s throw evidence at them, let’s get them on board, and let’s get them to advocate in their rooms.

I have to say, Tara, it’s been an absolute pleasure talking to you. Your eloquence is amazing. And I sometimes think when you’re feeling really angry and cross, all fired up, it’s difficult to have those words so clearly. And you clearly have to play a very positive and strong message. And actually, your hope and your, again, positivity for the future and the difference that you can make is really empowering. And it’s been wonderful to use it, and I shall certainly take away from this your clear vision, and you know, the way that you feel that getting somewhere is by having clear evidence and clear examples. You know, spotting changes that we want to see using the examples and evidence that’s already there to help trans people live their lives more easily. It’s been a real pleasure talking to you. I don’t know if there is anything you wanted to say, Marianne.

I just thank you, Tara. It’s been a great conversation. I really enjoyed it. And I felt quite empowered, so thank you.

I just wanted to say, Helen, that positivity also comes from the work that you all are doing with GenderGP. I think with so many challenges in the health system. It’s important that we’ve got people actually willing to put -as you have done- themselves on the line to make sure that people get the care that they deserve and need. And I think, actually seeing clinicians willing to do that, and the hope and quality of care that I know you deliver to many patients is so important to the trans community. And I only wish that some of those people that you spoke about actually listen a little bit more to what you have got to say. So it’s been a pleasure to be in the show, and thank you for having me.

That’s really lovely. I mean, I actually like you. I am an incredibly positive person, and I am not going to leave this battle ever on a negative note. I am going to carry on with this fight and this battle for these people who really, really deserve that strength and power behind them just to access the healthcare that they deserve. We are not asking a lot. I remember I wrote the five things that you can do to help trans people for Pulse right at the beginning when I was starting my work with trans people, and I just wrote for Pulse, just five good tips, easy peasy, and the comments from GPs—I was astounded. One of them said, “oh my goodness, she wants us to go out and do surgery.” And said we’d be performing sex-change operations. And I am like, oh goodness what is going on here? We have just got a group of people who are asking for basic healthcare, basic rights, basic rights at the reception desk, and some hormones, which, as you said, Tara, we use in cisgender postmenopausal women all day, every day as GPs. And yet, if it’s trans, then it is too scary and too dangerous. Well, it’s not. It’s life-saving, life-changing, and life-affirming, and that’s what I’ve learned from the community.

Thanks, Helen.

Lovely to talk to you. Bye, Marianne.

Bye.