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In our continuing drive to improve healthcare for trans and non-binary people, GenderGP has been gathering information via Freedom of Information (FOI) requests from NHS CCGs, medical schools, and deaneries across the country. We wanted to try to get a clearer picture of who is responsible for providing guidance and education to primary care providers and students. The answers painted a picture of inconsistency and uncertainty, but there were also highlights. Some CCGs have guidelines in place that, if applied and understood consistently, could revolutionise trans healthcare in the UK.
Right now, gender identity services in the UK are commissioned by NHS England Specialised Commissioning in the form of Gender Identity Clinics. These clinics are few and far between, and as the number of people seeking support has risen bottlenecks have formed, with wait times running into years. One of the worst hit GICs is The Laurels in Exeter, which saw just two new patients in 2020 and has over 2,700 patients on its waiting list.
This means that there are thousands – if not tens of thousands – of trans and non-binary people waiting for specialist services, and relying on primary care in the meanwhile.
This leads to two important questions:
- What kind of policies are CCGs implementing to guide primary care, and ensure that patients are supported locally?
- What kind of education is being provided to the next generation of care providers to ensure that they are prepared for the increasing demand for gender-affirming care in the UK?
We found that almost all CCGs – about 90% – maintained some kind of equality and diversity policy. But despite this, only a fifth had any guidelines or policies specific to the care of transgender people. This difference is mirrored in medical education, where 81% of medical schools and deaneries have some kind of health inequalities curriculum, but less than half have content specifically relating to transgender healthcare. For instance, many medical schools report that they provide curriculum content on LGBTQ+ issues or sexual health, but do not support content specifically relating to transgender healthcare.
CCGs – Equality and Diversity Policy vs Trans Guidelines
Medical Schools Health Inequalities vs Trans-Specific Content
So why is there such a disparity? Why are these organisations capable of making CCG-wide commitments to protecting marginalised people, but not providing guidelines for supporting the health of trans and non-binary people?
54% of CCGs reported no policies relating to trans healthcare provision at all, while 29% referred back to NHS England Specialised Commissioning. That means that over 80% of CCGs have no policies in place or services commissioned to support trans and non-binary people waiting for specialist services. However, among the few who do, there are some promising glimpses of what locally commissioned services for trans and non-binary people could look like.
In Barnsley and Rotherham, for instance, CCG-wide prescribing guidelines for trans men and women are provided. These guidelines can be referred to by GPs treating trans patients who have been discharged from a GIC with a recurring prescription, or help GPs to support trans patients who are pursuing private alternatives (when it comes to working with private care providers, 20% of CCGs had a policy in place, 37% referred to NHSE guidance, and 43% had no policy at all).
In other cases, CCGs have independently commissioned third-party services to provide support for transgender communities. CCG Knowsley supports Cheshire Merseyside Gender Identity Collaborative (CMAGIC), which provides gender identity services for adults in the Cheshire and Merseyside area. CCG Liverpool commissions the Young Persons Advisory Service for transgender support as well as specialist support via Alder Hey FRESH CAMHS. These are services which are not under the remit of NHSE Specialised Commissioning, and are designed to support trans people in the community without the protracted wait for a GIC.
That some CCGs are providing these services but not others shows a striking inconsistency across service provision. It shows that, despite the 54% of CCGs who say this kind of service provision belongs exclusively to NHSE Specialised Commissioning, devolved gender identity services at a primary care level are possible. It also shows that there is clearly a problem with the current system that is not being properly recognised and addressed. It is encouraging to see some CCGs responding to these problems and taking steps to commission services, but less than a quarter is not enough. If NHSE provided official guidelines for every CCG to commission community gender identity services, how much stress could be taken off specialist clinics, and how many more people could be supported?
There is a huge opportunity for improving the treatment of trans and non-binary people with the introduction of consistent guidelines and services. Research shows that 40% of trans and non-binary people have had a negative experience of accessing health care as a result of their gender identity, and around half of those have avoided necessary treatment for fear of a negative reaction. At present only 12% of medical schools and deaneries involve the trans community in educational provision. By bringing healthcare provision into the community, and the community into the development of healthcare, both healthcare outcomes and trust could be improved. It would be easy to look at this information and use it to criticise the state of trans healthcare in the UK – but it’s also possible to look at it and see clear opportunities for development, and the potential for a better system of gender-affirming care.
If you have been denied gender-affirming care by your GP because of a lack of knowledge, or because there are not sufficient guidelines in place, we’d love to hear from you. Please get in touch with us on Twitter, Facebook, or Instagram, or via our Care Centre. You can also write to your CCG asking what their guidelines are, and encouraging them to implement them clearly.
We want to work together with the NHS and the community to develop guidelines for primary carers that can be used anywhere in the UK, and your experiences and voices can be an important part of that. If you’re a healthcare professional who wants to improve transgender healthcare in your area, get in touch via our Care Centre and we’ll be more than happy to work with you. You can also find resources and support in our online guide for healthcare professionals.