You Shall Not Pass: Barriers to Accessing Gender-Affirming Healthcare in the UK

Written By Antonia Beevor Martinez

The principle of autonomy is a core tenet of medical ethics, but the NHS’ current system for gender-affirming care seems to fly in the face of this. It is a system that prioritises the opinion of clinicians over patients in matters of identity, leading to unnecessary waiting times for vitally important treatment. 

Transgender adults can access gender-affirming care, free of cost, on the NHS. After being referred by a GP to a gender identity clinic (GIC) where they can be assessed and diagnosed with gender dysphoria, they are able to access individualised gender-affirming care, such as hormones, surgeries and mental health services. ¹ Gender dysphoria is the term used to describe the distress someone may feel if their gender identity does not match their sex assigned at birth. Another term that is used by the NHS in this treatment pathway is gender incongruence - the discrepancy between gender identity as sex assigned at birth, but not including any feelings of dysphoria. 

“Gender dysphoria services” only made up £78.17 million of planned expenditure in 2023/24 ² as part of the NHS’ £171 billion budget ³, that is to say only 0.05%; however, the cost to the patient is far higher. This is most strikingly seen in the staggering waiting lists to receive care. At the Tavistock and Portman GIC – located in London, and the largest in the UK – first appointments are now being offered to those referred in March of 2020. ⁴ However in other areas, such as the West of England GIC, this stretches back even further, to June 2017. This far exceeds the maximum NHS waiting time of 18 weeks, often leaving patients on this list without any access to GIC services and support for years at a time. Moreover, patients are often required to wait months between their first and second appointments. ⁵ Those who can afford it can choose to seek private care, whilst most are forced to endure this wait untreated - a wait that leads to extremely poor mental health outcomes, self-harm and suicide. ⁶ This also prevents transgender people from obtaining a Gender Recognition Certificate (GRC) which allows them to live as their preferred gender in the eyes of the UK government. 

Dysphoria can have profound effects on someone’s wellbeing. The current NHS model requires a diagnosis of dysphoria at a GIC before a patient can access the clinic’s other services. 

One of the frequent arguments in favour of the current dysphoria-based system is that it prevents regret. Many gender-affirming treatments have irreversible effects, such as a deeper voice after taking testosterone, and visible physical changes after surgeries. It stands to reason that the NHS would want to ensure patients only received this care if they were ‘sure’ they would not regret doing so. This dysphoria-centric model centralises care within a GIC, providing patients with easy access to a multi-disciplinary team, ensuring their mental and physical health can be cared for without needing access to multiple clinics to do so. 

However, in allowing a patient to have autonomy over their own care, we must accept the possibility that they might regret their decision later on- and therein lies the glaring issue with the dysphoria-centric model. The NHS utilises a patient-centred and informed consent model of healthcare; it is the patient who has the final say over their treatment after being given the information to do so. But as Walter Bouman et al. (2014) write in their paper on consent in gender-affirming surgeries, “in the broader field of medicine aside from trans services, there are very few cases in which [multiple] opinions for physiological interventions are required”, citing these exceptions as involving patients who lack capacity to consent. ⁷ The authors argue that due to gender dysphoria historically being considered a psychiatric diagnosis, there is concern that these “‘psychiatric’ patients may be having their delusions colluded with…that an irreversible decision may be made which is later regretted”. ⁷ In most cases, an adult patient who is deemed to have capacity is allowed to give informed consent, but transgender patients are forced over and over again to prove this capacity, due to the lingering belief that their identities are “delusions”, and sometimes in very invasive ways. Eleanor Cummins, a journalist and adjunct professor at NYU, remarked that when regret is used to deny healthcare, especially to marginalised communities, it is often “not about the medical danger… this is about someone saying, ‘I have the power to stop you from doing something I think is morally terrible’”. ⁸ This is not to say that the system was set up deliberately to propagate transphobic views. But if you consider that gender-affirming care does not follow the broader NHS model of informed consent, then it is undeniably unjust to place the fate of someone’s health in the hands of everyone in the healthcare system but themselves. 

Furthermore, if the NHS considers potential regret so strongly, then why can other emotions not factor into the diagnostic criteria? They state that gender incongruence is “not universally accompanied by the symptom of gender dysphoria” ¹ but their service specification for gender-affirming care hinges on the ability to diagnose dysphoria. Why should emotions like joy and relief not factor into this decision? Why should gender euphoria not hold equal weight in the clinic? The system in place is slow, sending patients through complicated avenues to obtain a diagnosis whose clinical value is debatable. It denies transgender patients’ agency and autonomy over their healthcare. Even if this model was to remain, would it be possible to diagnose some as transgender without having to pathologise their existence into a disorder? 

This power imbalance is present from the initial GP consultation (where patients’ referrals are delayed without reasonable cause) to the reductive diagnostic checklists once they have reached a GIC. Patients are left without adequate support or facing outright transphobia from the people who are meant to be helping them. ^{9, 10} Evelyn Callahan, a trans healthcare researcher at UCL, discusses the experience of one trans patient at her psychiatric assessment who thought it would be a “caring encounter”, but discovered it to be a tick-box exercise in proving her experiences fit the current medical understanding of transness. ¹⁰ 

Callahan themselves went prepared to their GP appointment having gone through the list of referral questions with answers prepared and mentioned “how unnecessary it all felt”. They found the GP asked the same questions that were posed in their first GIC appointment. The consultation showed how the NHS afforded the GP a sense of authority on their patient’s identity, one that was not given to the trans patient.¹⁰ Abigail Thorne, an actress and educator, describes how her GP failed to send her referral to a GIC on multiple occasions, first saying to come back for the referral in a month if she “was still trans then”, and later saying she’d just forgotten to send the letter. ⁹ These accounts show that the dysphoria-based system requires the approval of multiple doctors, whose opinions are given more credence than the patient themselves, no matter how well-informed on gender-affirming healthcare they are. Whether it stems from a lack of education or bigotry, trans patients face barriers not just from a badly designed system, but from the providers within the system itself. Under this treatment system, we can see the vestigial hold of paternalistic medicine in the NHS. 

If a patient must wait years to access a first appointment, it is not surprising that some choose to lie in order to fit the NHS’ narrow criteria to avoid further delays. And if patients lie to fit these criteria and still receive healthcare that improves their quality of life, then the utility of this system must be questioned. Gender-affirming healthcare has been proven to have low regret rates (possibly as low as 1% ¹¹), increase positive mental health outcomes, and greatly reduce the risk of suicide in a vulnerable population⁶. It seems irresponsible on the NHS’ behalf to make accessing this treatment difficult and traumatic. 

Walter Bouman et al. (2014) show the double standard present in this system, in the two wildly different diagnostic criteria for an orchidectomy (removal of the testes) for a cis and trans patient. A cisgender man seeking an orchidectomy for chronic scrotal pain - which is more prevalent than gender dysphoria and usually has “no identifiable cause to explain their discomfort” - mostly relies on patient testimony to be diagnosed” ⁷. The procedure doesn’t require psychiatric input, nor is there a minimum duration for which the pain has to have been present. A trans woman, however, must be subjected to multiple psychiatric consultations, which she must wait for multiple years to obtain due to GIC waiting lists, potentially facing ignorance and harassment on multiple occasions, to alleviate her discomfort. The choice to set up this separate treatment stream for trans patients is frustrating, not just because of how poorly it serves them, but also because of the administrative costs of running a separate pathway. Could those funds be utilised more efficiently in a different system? The NHS values state that patients will be treated fairly, yet it has created a two-tier system that routinely delays transgender patients the care they require.

A more equitable model could be one of informed consent. In contrast to the current system that is dependent on psychiatric evaluation, the informed consent model is one better aligned with NHS values. As in other clinical areas, options for gender-affirming treatment would be communicated to the patient, as well as the risks involved, and the patient allowed to make the decision that best suits them. As Cavanaugh et al. (2016) discuss, this model still allows the doctor to explore a patient’s possible dysphoria and provide mental health support whilst separating this treatment from gender-evaluating assessments.¹² They describe how this model “expresses respect for the patient’s capacity for self-knowledge” and allows the clinician to better understand a patient’s identity and goals, as the patient would no longer feel the need to conform to a stereotypical presentation of their identity.¹² As the informed consent model has not yet been widely adopted, few larger scale studies on patient satisfaction have been conducted. But, those that have suggest that this model could lead to higher levels of patient satisfaction, improved trust and communication between patient and provider, and reduced cost due to fewer appointments being required. ^{12, 13}

It is clear that the NHS has failed transgender patients – failing to consistently deliver care and failing to listen to the feedback of researchers and patients. The informed consent model presents an opportunity for the NHS - a chance to deliver faster and cheaper care, and to offer more effective mental health support to its users in addition to other services. By allowing mental health support to exist separately from the diagnostic pathway. Knowing that such a flaw in our healthcare system exists, it is the duty of healthcare providers to ensure that it is rectified, and that patients are treated fairly, not just in clinic, but by the systems they use.  

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