Transgender Healthcare in the UK

Hello, this is Dr. Helen Webberley. Welcome to our Gender GP Podcast, where we will be discussing some of the issues affecting the trans and non-binary community in the world today, together with my co-host Marianne Oakes, a trans woman herself, and our head of therapy. In today’s podcast, we’re going to be talking about trans healthcare in the UK today, what happens now, and what we’d like to see in the future, what’s blue sky thinking, and what’s really achievable. Marianne, you’ve just been through the NHS healthcare route, and you speak to a lot of clients who have been in that process. Do you want to kick things off? How does it work today? What’s the current process?

I think the first process for everybody, or I’m going to say most people, is to go to the GP. My understanding is that it’s supposed to be a straightforward process to the gender clinic, obviously the nearest gender clinic to you. Once you get that referral, you are basically on a potentially two-year waiting list. Just bear in mind that the two-year waiting time is just for your first appointment. I have heard recently that some gender clinics are doing interim appointments, where they’re not clinic appointments, but they just bring you in and introduce you to the service. I think that’s been introduced just to make people feel less anxious. Once you do enter the service, they will assess you, give you a formal diagnosis, and plan a pathway for you. The only issue I really have with that is, aside from the waiting time, is that everything is taken away from you. You have no control over it. So basically, these people go into a room, talk about you, and decide what’s best for you, then tell you what is best for you without your input. I think that’s really the early part of most people’s transition. The early steps. It’s a long process, and it’s a disempowering process. I’m thinking what we experience is people going to look for alternatives because of that process. People look for alternatives bridging prescriptions. For me, trans healthcare at the early stages of transition is about cross sex hormones and access to cross sex hormones. It is a crucial part for many people of their social transition. Without the cross sex hormones, they don’t feel able to start their social transition. That’s multifaceted and probably for another podcast. Hopefully, I’ve put it in a nutshell what is going on in the UK today.

So from the medical point of view, I’m just going to go back to the grass roots, really. If you’re a transgender person, you’ll be assigned what we call assigned a particular gender at birth. When the midwife has a look at you when you first come out, they’ll say, “Hooray! You’ve got a boy” or “Hooray! You’ve got a girl.” So that is the sex you were assigned at birth. But as we know very well, not everybody grows up to identify with that sex they were assigned at birth. So a transgender person is someone who feels very different from what society thought they would be. The problem that we have from the medical point of view is you can identify with whatever gender feels more natural for you, you can present in whatever way you want to. and by identify I mean that’s how you feel inside and how you want to portray yourself to the world outside. When you present, it means what you look like to the world outside. So when you leave your home, and you’re looking in the mirror, that’s how you’re presenting to the world. So, you can identify with whatever gender feels comfortable to you at the time, and you can present in whatever way feels more natural or comfortable for you. But from a medical point of view, the hormone production which defines what your body looks like in many other ways, isn’t under your control. So if you were assigned male at birth, it means that your gonads – which are testicles – will be producing male hormones, which is testosterone. And that produces the very features which we associate with maleness, which is the beard and the rough skin, and the slight oiliness of the male smell, the angular jaw, the big hands, the big feet, the strong musculoskeletal body – that’s what testosterone does to you. If you were assigned female at birth, and you have ovaries, you will be producing estrogen hormone instead. Estrogen gives the body the things we usually associate with a female person. So that very soft skin, the gentle approach, the more emotional side of things, the breast formation, the fat on your body which gives you hips and curves; a much more feminine, or what the world sees as feminine, view. And however you identify with your gender, however you present to the outside world, medically, you are stuck with the hormone production that just carries on day after day. For many many trans people, that difference causes a lot of what they describe as dysphoria, which is the incongruence, the feeling that something isn’t right. However you feel you identify, or however you present yourself, your hormones aren’t quite right. They’re the wrong. I have to say, again, form a doctor’s point of view, that there’s nothing more satisfying than when you switch someone’s hormones to give them the right hormones instead of what their body is producing, and which is wrong for them. All of a sudden, it’s like the light switch comes on, and the emotions suddenly start to match with their identity and their presentation. The skin and their bone structure and the fat around their body all of a sudden start to fit much better with the way that they identify, and the way that people wish to present themselves. And although being transgender isn’t and shouldn’t be a medical condition, it’s not a disease, it’s not an illness, it’s not a disorder, it’s not a problem, the problem arises in that we need doctors to help people switch their hormones. And obviously, we want people to do that as safely as possible. That’s where the medical side comes in. that’s why we need doctors and nurses, to help people switch their hormones in the safest possible way. Now, you talked at the beginning about the idea of who makes the diagnosis. Or who makes the plan for you. In my experience, people have made their diagnosis on their own quite comfortably at home. And in fact, they made their diagnosis when they were very young. People will tell us time and time again, that from a very early age, they didn’t feel right. Something wasn’t right. And they weren’t able to put their finger on it, but something wasn’t quite right. And at some time or the other, the realization comes that what’s not feeling quite right is that everyone is expecting me to be a boy or a man, and actually I’m not; I am a girl or a woman. And we know, completely opposite the other way round, everyone’s looking at me saying you should be a happy little girl, but in fact, inside you’re felling that you’re not. You’re a big bustling boy. And then, not to complicate things too much, but there are people in the middle, who don’t feel that they fit completely with male or female. Or maybe they feel a bit of both. Or they don’t feel either. And that’s where we come into what we call the non-binary, or the agender, which I’m going to leave alone for this podcast, while we talk about the basics – the very basic medical care. So that’s why we need doctors and nurses to help trans people, not to affirm their trans status, not to tell them whether they are or aren’t transgender, not to try and say that you shouldn’t feel that you identify with that gender, or that it’s wrong or right in any way at all. What our job to do is to make people who are transgender feel comfortable and able to identify with that agenda, to present in the way they want to, and also to give them support to switch their hormones if they want to. So, switching the hormones – is that difficult or not? It seems to be quite a big mystery how one might do that. basically, it’s actually very easy. What we need to do is give the body some kind of medicine to stop the testicles from producing testosterone. And that can be done very easily by giving an injection which gives the brain the signal to stop the signal that goes form the brain down to the testicles to produce testosterone. So, give the injection, and it gives the signal to the brain to stop the pathway that produces testosterone. It’s very easy. It’s an injection that we use very commonly, because we use it when we treat prostate cancer. Because cancer of the prostate feeds on testosterone. If you’re unlucky enough to have cancer of the prostate, what we need to do is switch off the testosterone so that the cancer has nothing to feed off. So we’re well used to using these injections to stop testosterone production. And actually, we’re also very well used to using them in children. There is a condition called precocious puberty, which is rare, but real. It is a condition where children will go through a very early puberty, for example at age 5 or 6. Too early to be comfortable for that child. Again, we use the same injections just to stop the puberty happening. To stop the signals from the brain to the testicles to produce testosterone. So that’s the one thing that you need to do. Stop the natural hormone production. And then you need to give the opposite hormone. For people who were assigned male at birth, and who identify as female, the hormone that we need to give to them is estrogen. And it’s very easy because we’ve been doing it for years and years and years with women who have gone through menopause. Women who’ve gone past the age of 45 or 50, when their ovaries stop working, they get hot flushes and uncomfortable symptoms and what have you where they want their hormones back. And the way that we give them their hormones is either by a patch which is stuck on your bottom, and you change it twice a week, or by a pill which you take every day. And these are medicines which we have been using for many years, very successfully, and very safely. So it’s not complicated. For someone who is assigned male at birth, you give them an injection every 3 months to stop testosterone production, and you give them an estrogen patch which you put on their bottom and change it twice a week to give them their estrogen instead. That’s about it. I’d love to say it’s complicated for the other way round, but if you’ve got somebody who was assigned female at birth, you can use the exact same injection to stop the estrogen production. And then you need to give them the opposite hormone. We need to give some testosterone, either as an injection or a gel. Again, we’ve been using testosterone as medicine for a long time in men who don’t produce enough testosterone from their own testicles. We’ve been using testosterone replacement therapy for years very successfully and very safely. So what we’re talking about is a world and a situation where people need some medical assistance, not to affirm or confirm or tell them their diagnosis, but to help them with the medication that they are going to need to swap their hormones from one to the other very safely and very successfully. Does that simplify how it all works?

I think the question that I have is, you know when I went to see my doctor, I can talk about my experience but I can also talk about the experience of others I’ve seen in the therapy room. When you go to see a doctor, it’s almost like they are caught in the headlights. The thought of giving cross sex hormones to a trans person feels like such a big decision to them. I suppose what that does then is make me think how safe is this. Is this going to make me grow a second head? There seems to be a big fear amongst doctors. I don’t know if that’s a fair analysis, but that’s how it came across to me. When you see a GP, there is a fear. Listening to you talk about it, Helen, and seeing how a doctor responds, it feels like there is a disconnect.

It’s interesting because historically and currently, in the NHS, gender care services are at a very highly specialized level or provision. I’m going to explain that briefly because it’s important. So, there are three or four levels of care in the NHS. We start off with primary care. Primary care means your GP. That’s what everyone has access to, and you can just make an appointment and go and see your GP. Everybody in the UK has access to that. that’s primary care. Secondary care is for something a bit more complicate that the GP can’t manage; something like a specialised opinion or a specialist procedure that the GP can’t make happen. So secondary care is your local hospital, where your GP will refer you for a procedure. Then we have tertiary care, which is specialist centres. So not every secondary care hospital or local hospital will do liver transplants, because there just aren’t enough liver transplants going around to make the skills available in every single hospital in the country. So what we do is have specialist hospitals which will do very specialist procedures like liver transplants. And so we have a core of doctors and surgeons working there who get all the referrals, so that they keep their skills up to a maximum with a lot of patients going through the system so there is utmost safety is paramount and is concentrated in those special tertiary centres. And unfortunately, that’s where gender care sits. Gender care sits in those very specialized services because it used to be rare. They didn’t get many cases of it, and so we needed super specialists to deal with it. It was unknown, it was scary, and it was rare. What we’ve seen over time is that it’s not rare at all. It’s not super specialised. It’s not scary. It’s common, and the newspapers are full of how many referrals are going up and up and up in this very specialised units who cannot cope with it. And on one hand, you’ve got the NHS constitution, which promises people that if you are referred, then you will be seen within 18 weeks. And that doesn’t mean being seen or have an interim appointment or a quick chat or a group discussion with other patients. That is a referral to treatment time; you will see somebody, and have the start of your treatment plan put in place within 18 weeks. And that’s what the NHS constitution is promising us. And actually, if you look deeper into the NHS constitution, it says that if that is not available to you, then it should make something else available to you. And that’s where we’ve seen people who are, for example, waiting for a hip operation, and then they wait for a long time and when it reaches a certain point, they are offered a hip operation in their local private hospital on a Saturday morning. Because they waited the prescribed amount of time, and you’re not allowed to wait any longer, because that’s what the NHS constitution promises you. And so the NHS make alternative options for you, and that would be by using private services to bridge that gap. So what we’re seeing with gender services is that they currently live in a very super specialist place, which is not the best place for them. There are far too many people for spaces and appointments available, and the waiting times are very long. The NHS hasn’t been able to provide alternatives because they haven’t looked at options and there don’t seem to be many available. So then, really, what we need to do, is take gender care out of this very highly specialised area, and bring it back down into secondary care and primary care. And what we really need is a situation where we start again. Trans people who don’t have any problems with their identity, and are completely happy with the gender that they identify with, you know they’ve got no problems going on at home in their family, in their relationships, in their workplace, what they need is the medical help. And that medical help should be available from your GP. In cases where your GP is like, “Hang on a minute, this person has had a blood clot in the past, or has had a heart attack, so can we still switch their hormones?” – if it’s a more difficult question, then that question should be dealt with in secondary care. You should be referred to your local secondary care hospital. And they will put in a treatment plan that makes sure it is safe for you. And then, if there are super super difficult cases, perhaps somebody who just doesn’t understand their gender at all, and is completely confused and has lots of different issues going through their life, and through their body and mind, anyone like that maybe that’s who should be going to the super specialist services, where they might have a big team of gender specialists, psychotherapists, counsellors, gender specialist support teams, nurses, doctors, voice therapists. That’s what the super specialist centres should be made of. That, I really hope, s the vision for the future. Where every day, transgender care is easily carried out by a GP, and the trickier cases are carried out at local hospitals.

You just made me think of something listening to that. You think there would be a case for separating out hormone treatment from surgeries. In other words, the specialist centres could still look after the surgeries, and you would get referred there after they’ve gone through the hormone treatment. Does that make sense? Because somehow, I don’t want to say I support the gender clinics where the heaps everybody has to go through, but I don’t think that if I was a surgeon and I was about to cut somebody open, I could imagine that being a different circumstance than somebody saying we’ll help you with your hormone treatment.

What we hear a lot of patients talk about is gatekeeping situations. By gatekeeping, what people mean is that they know they have a right to a certain treatment. And this is something that comes up quite a lot. Should the NHS be paying for gender affirming treatments? Why should the NHS pay for women and men to switch their hormones because they feel that they identify differently to the way they were assigned at birth? Why should the NHS pay for that? why should taxpayer money go into the NHS to pay for that? if it’s not a medical condition, if it’s not an illness or a disease, why should the NHS fund it? And actually, that discussion is finished. That decision was made some time ago, that the NHS does fund gender care. And it doesn’t fund everything that a transgender patient might want, but it does fund a list of things. One of those is psychological support. One of those is gender affirming hormones, so switching your hormones to the ones that feel right for you. And the other one is some elements of surgery, so genital surgery is funded on the NHS. As it top surgery for trans men. You know, we can debate on many things that the NHS fund, for example, obesity surgery. It’s quite emotive. Surgery for people who have lung cancer through smoking can sometimes be quite emotive. Funding stopping smoking therapy can be emotive. But the NHS higher powers have debated on that, and decided on that. Gender care has been through that process. End of discussion. So now people feel like they shouldn’t have to jump through hoops unnecessarily in order to access that treatment. And that’s where we talk about the gatekeeper. When you go to your GP to ask them for a referral for gender care, the answer should be “How can I help you best to get that referral?” not “I don’t think you need that referral” or “That’s not right for you” or “The NHS shouldn’t be doing that”, which, incidentally, are things that we hear every day from our patients. What the GP should be doing is saying that they can refer to gender care, and that they will see how to make this journey best for the patient. And I think, going back to your point about surgery, Marianne, is that we need to be careful of not having this gatekeeper approach on any level. for some people who were assigned female at birth, who identify as more masculine, they’ve got female hormones and therefore have got breast tissue. But the thing that bothers them most – and this is only some men – is that they’ve got big breasts and it doesn’t feel right with the way that they identify, the way they wish to present to the world is that they shouldn’t have breasts, because breasts are for women and this person doesn’t feel like a woman. But some trans men don’t want to switch the hormones. They don’t necessarily want to have the things that testosterone will do to you, such as the beard and the angular jaw and the muscultoskeletal and the voice breaking. They don’t want that. the way they feel they identify, and the way they want to present, with the current natural hormone pattern, but without these things on top of their body which gives them great dysphoria. And the problem that we have at the moment is that in order to get surgery, you have to have gone through several hoops with the gender that you identify. And there’s only two. There’s only men and women. There isn’t an in-between one. You have to have been on treatment with hormones for a certain amount of time. And if you saw somebody who doesn’t want to switch those hormones, but surgery for you would be the right thing to help you identify and present and live comfortably with your gender, then it’s almost like you have to have hormones to get the medical procedure that you need. And that’s wrong. You need to be very careful about any level of gatekeeping. Whether it’s primary, secondary, or all the highly specialised care, really.

Definitely. I think the whole social movement has a lack of understanding where trans people are concerned. Do you think that that influences the doctors? I know the part I wanted to come back to is should trans people get care on the NHS? Should the public be funding this care? I just wanted to clarify for my own benefit and hopefully the listeners’, the NHS was actually set up to help people to stay in work and to be valued members of society. That they could contribute to society. And my understanding is that the research can show that when trans people do get the care that they need, that they do go on to be valued members of society, that they do contribute, that their earning potential rises. Actually, that’s the part of the NHS. And that would be every reason to give support.

That’s something I’ve never thought of before, and I thought it was an absolutely brilliant way of putting it. What we tragically see so often is young people who won’t leave their bedroom. They won’t go to school or socialize at all with their friends in the street or in the park. They barely go downstairs because what looks back at them every day and what they see in the mirror, what they see of themselves just doesn’t fir with what and who they are. Tragic stories of children crying away in their bedroom for the whole of their adolescence. And we see it as well with adults. People who are scared to go out into the world because everything just feels so wrong. And if we give them the support that they need, whether that’s support and help to socially transition, or at medical transition, or surgically transition – what we see is those people coming out of there bedrooms, coming out of their houses, joining school, going to the park, going down to the club, ad trying to get jobs, being contributing to society. That is the vision for the future of integrating trans people into society. And that’s what we should all be aiming for.

That’s linked perfectly, actually. Whatever we are doing now with trans health care, I think it would be easy to suggest that the age when people are presenting in the doctor’s surgery is coming down. You know, historically, I’m sure it was potentially forty plus. The ages are coming down. So it’s important that we start thinking about the healthcare on younger people. Two things, really. Are the doctors ready for that? Have they got an understanding of the social aspect of this, but also the medical aspect? You know, it’s (unclear 27:38) trans boy or girl. Because the sense I get is that the first thing people that are faced with a young person is we’ve got to make sure that they are (unclear 27:56) is it over nurturing from the mother? Did things traumatize the child? Did the child internalize shame that they are probably already feeling? And to see adults around you can kind of go into meltdown and shut off. It doesn’t help the child. But actually, if we don’t get the help to the child, a lot of parents say to me, what if they change their mind when they are thirty? And I reply with at least they’ll be qualified. At least they’ll have a career. That they will be in a better position to change their mind at 30. And actually, if they don’t get past fifteen because they committed suicide, they couldn’t get into school and they couldn’t get exams, so they won’t be able to find work, they wont’ be able to go out and socialize and get the social skills that you need to be able to go out into the world and get to the job interview. That doing nothing is equally as damaging as doing what’s needed. So, the long term effects of not working with children resonate throughout their lives if we are not careful. Just one of the things I wanted to say as well, going back to the NHS, one of the things I’ve found – we can talk about hormone therapy, and this is particularly with young children I have to say – if they don’t get the help they need, potentially puberty blockers or hormones, then what I see is that the mental health issues set in. And by the time the child comes to me and they started self-harming, or they’ve got an eating disorder, by the time it’s progressed to that, then dealing with the gender identity becomes far more complex. Because yes we can help them, and we can help them to socially transition, and we can help them to feel better with their gender, but actually, the mental health cycle can become for some people be impossible. I don’t want to talk about a subject I’m not qualified, but my understanding is that an eating disorder you never get free of it. You know, once you’ve got an eating disorder. So not dealing with the root cause or denying it or not being competent enough to deal with is, actually, is then going to cause more problems down the line. And in young children in particular, because we do see the mental health deteriorate very quickly we’re talking about a nosedive, we’re talking that they come out and then the parents say that it’s just a phase and they ignore it for two years. And the only time they listen is when they find that they’ve been self-harming. And then suddenly, there is this desperation to fix the self-harming, and it gets them to listen to the gender identity.

The mental health issues are crazy. We see a lot of children and young people and adults with eating disorders, anxiety, stress, depression, suicidal and self-harm ideation. Often, what happens is that those people go to their GP with those kinds of symptoms and the GP is trying to sort out why their depression is there, why is this person so anxious, or why is this person not eating. And then you try all the mental health drugs, the anxiolytics, the antidepressants, tranquilisers to try and abate those symptoms. But actually, when you address the gender issue, the mental health issues fall away. When you’ve got a young person who is developing through puberty with anguish and it’s causing them such deep distress, instead of giving them all the mental health drugs – if we stop the puberty, their mental health settles down and they can breathe and live again without this fear of puberty. Once puberty has happened, and done its damage, as it were, then people are just desperate to get the help that they need to live and to affirm their gender, and to be able to identify and present, as we said, in a way that is comfortable for them. And not being able to do that causes such anguish and distress. And it’s chicken and egg; what came first, the gender issue, or the mental health issue? Our experience by far says without a doubt that if you treat the gender issues, the mental health issues get better. People can live and breathe again, which is tremendously important. It goes back to the fear and the fact that the doctor never wants to make a mistake. And doctors never want to make mistakes. If we make a mistake, sometimes the mistake is just talked about and we discuss it and learn from it, sometimes there is a complaint from whoever the mistake happened to, sometimes the complaint is escalated and your whole career and life are put through enormous paces to see what happened in that mistake. So doctors are terrified of making mistakes, and none of us want to do that. We don’t want to take an appendix out when actually the tummy ache wasn’t appendicitis. We don’t want to make a mistake while doing an operation on someone’s bowels, and make a hole in the bowel when you shouldn’t have done. You don’t want to give somebody the wrong drug which brings them out in a reaction that might cause some harm. We don’t want to make mistakes. But what we can’t live in a world of, a medical world of, of making mistakes where we’re so scared of doing a mistake for one patient, that the rest of the patients needing that medication or treatment or operation suffer. That’s the situation that we have at the moment. Doctors are too scared to help trans patients off their back and make decision. So they either say to trans patients that they are not doing it, or that they are not going to make that decision for them. That they have to wait in line to see someone who is brave enough to take that decision. And the problem in the UK is that we don’t have enough doctors who are brave enough to make that decision. What those doctors really need to do is all about education. Just thinking about what this patient is asking us to do. This patient is saying, “I know my own gender, I’ve got no problem with that. I just need some medical help to switch my hormones. Can you help me?” The medication we are using is so safe and so simple; we use it in other conditions every day without even thinking about it. When you put it like that, you know, what we need is more doctors to come forward and say, “I am brave enough to do this. My patent is my priority. This patient needs my help today. Not until 3 or 4 years’ time.” What we then need is for our regulators and people who govern us as doctors to back us up and say that we did the right thing for that patient there. Which is what doctors are supposed to do.

You used the keyword for me there. You said safe. And, you know, when we are talking about trans care, usually we talk about side effects of medication. Even in my own family, people come back from the doctor’s and they’re googling side effects of medication. We’re talking about hormones, though. A lot of the potential side effects are actually the effects that we want, that we crave. And I’ve not heard of any evidence to suggest – I know there are health risks with everything – that somebody’s overall health has been compromised because they’ve been given HRT.

You’re quite right. When we talk about testosterone, side effects of testosterone are exactly what trans men, or trans masculine people, want. That is exactly what they want. Risks are very – there aren’t any. All medicine has risks. But the risks are minimal. The risks are what that person wants. When we talk about estrogen, it’s a different matter, because estrogen has been associated with risks, such as blood clots, breast cancer, heart disease and strokes. So estrogen does have those risks. But the way that I explain it to my patients is that those risks are the risks that every woman has. By switching your hormones, for someone who was assigned male at birth, switching from testosterone – actually, we’ll protect them from prostate cancer and other testosterone-related problems. And we give them estrogen, which gives them the same risk factors that other women have. Because you’re having the same hormones as half the population. So you’ll have a risk of breast cancer, you’ll have a risk of blood clots in the leg, heart attacks, strokes – but women have, because they have estrogen. So yes, there are side effects to everything we do, but what we’re doing is just switching you to the other risk profile than the one you were assigned at birth, if that makes sense.

Yes, I think if I understand what you’re saying is that the risks are you’re going to have the health risks of a woman if you take estrogen. That’s basically who we are. If we see ourselves as women, you can’t cherry pick the benefits. We take the risks as well as the benefits, if that makes sense.

Absolutely. And also, thinking about the protective bits. Trans men won’t get breast cancer. Trans women have a lower incidence of prostate cancer. So, you know, it swings round and round both ways, really. Fundamentally, transgender medical care is extraordinarily safe. It is very encouraging, I feel. That feeling should give GPs empowerment to say I can do this, there is no reason why I can’t do this. And actually, we are seeing a lot of trans people, unfortunately self-medicating. Which means, going onto the internet and buying stuff they think is medicine because they’re so desperate to try and do it themselves. And actually, GPs can say don’t do that. I will prescribe this for you. Let’s talk about this. Let’s talk about what I as a doctor see the risks that you might get if you do this. What you as a trans person feel are the benefits and risks might be to you if you do this. And let’s make a decision together after we decide if that risk is worth it, and the benefits are worth it. Let’s make that decision together as a patient who is an expert on themselves, and as a doctor who is an expert in medicine.

What would be the cost implications on a GP practice to be helping a trans person in this way?

Cost implications is a very emotive subject. It’s cheap. It’s cheap as chips. The testosterone for a trans man is absolutely cheap as chips. And so it estrogen. The injections are a little bit more expensive. But then what you have to do is balance that with what you were saying earlier about empowering people back into society, back into jobs, back into the world as a thriving and cohesive community, taken off the benefit system and into employment. So when you talk about the wider remit of funding, it’s more beneficial to give trans people the care that they need so that they can go back into society. In the same way that you compare it to antismoking treatment. Some people think why ever would we be prescribing nicotine patches to stop people smoking when it is a social problem? Why don’t they give up smoking like anyone else could? But what we see with the NHS is that it’s beneficial for the NHS funds to help people stop smoking, because there will be less heart disease, lung disease, brain disease, and other cancers in the future. If we put that money in now to help people stop smoking, it saves money for the future. And that’s the same vision that we need for transgender care. Put a little bit more money in the pot now, and we help someone to live and breathe and have a successful contributory life.

I think bringing it back to what’s the state of play in this country regarding transgender healthcare. And I think what you’re saying is that the medications that we use are really safe, that they’re not dangerous drugs, that the adverse effects of the medications are not going to have long term effects on the NHS. That what we’re really looking at is education within the NHS, certainly within GP practices, that could definitely start at primary care. Maybe there are going to be more serious procedures further down the line, and then maybe they could move into the more specialised care. Would that be fair to say?

I absolutely agree. The fundamental thing that we need to move towards is bringing trans healthcare into general practice, into everyday general practice, because your GP is the person who knows you best. They may have helped you be conceived, they may have helped you through your mother’s pregnancy, they may have helped you through your childhood. They know you best, and they are the person to understand how you fit into your current state in your home and society; they’re the best person to help you, with a very safe medication and treatment regime. And then if you need surgery in the future, they can refer you to the local centre that does the operations the best for you. Because that is what your GP will want for you, they will want the best for you. And that’s what I’m hoping for. And just as a little side note, in case this feels like blue sky thinking, I remember twenty years ago when I was looking at sexual health services in Worcester, it was at a time when chlamydia infection was getting to raise heads, and people were understanding that there was this kind of hidden infection called chlamydia that was causing women to be infertile, and we did an education campaign where we went into GP surgeries, and said the GPs, when your young girls come in for a pill check, could you ask would they like a chlamydia swab? And everyone was like, “We can’t do that, we are not specialised enough to do that. What if they come back with a sexually transmitted infection positive result? What do I do about that? Goodness gracious me!” And actually now, if you go for a pill check or if you go for a smear test at your local GP surgery, then very commonly the nurse will say, “Do you want to do a chlamydia test while you’re here?” So, we can make that change, and I’ve seen changes like this happen in my time as a doctor. And I am hoping that in the next 20 years, we will see trans healthcare coming into GP level on an everyday basis, because patients know their own bodies, they know their identities, and they just need a little bit of medical help to switch the hormones and feel happy.