The crisis in the NHS’s adult gender clinics

Hilary Cass’s review of children’s gender services revealed how young people are being badly let down by the NHS. The picture for adults awaiting treatment in NHS gender clinics is similarly bleak: the current system is broken – and thousands of people are stuck in limbo.

he waiting list at my old clinic – I am an alumnus of what used to be known as the ‘Charing Cross’ Gender Identity Clinic in London – has ballooned to 15,448 people. In March, just 35 first appointments were held at the Gender Identity Clinic. At that rate, it could take decades to clear the backlog, even as the referrals continue to flood in: that same month, over 250 referrals came through; in February, there were another 406. These are catastrophically large numbers for what is essentially a cottage industry made for different times.

It’s clear that the NHS is struggling to cope with the demand on its gender services. People are left languishing on waiting lists for too long, with their lives on pause. These patients might wait months, or even years, to be seen by a doctor who is a specialist in the field.

The current situation is in no one’s interests; it’s surely time for something radical to change. Perhaps the NHS should admit defeat and say gender identity clinics are not something it should fund. Medicine is, after all, about keeping healthy people fit and making sick people better. If, as some activists claim, that in the case of gender patients there is no mental health disorder to treat, then the work of the gender clinics sounds more like cosmetic treatment: it’s something we do to change the way other people perceive us. There is nothing wrong with that, but, perhaps, neither is there any need for the NHS to get involved where the focus is not so much on health as self-image.

This is a debate that NHS bosses – and indeed the government – will shy away from. It’s a pity: someone needs to speak up for those who are in limbo. As NHS waiting lists grow, private providers have, of course, spotted an opportunity but they don’t come cheap. One clinic charges £360 for a 60-minute appointment. Other patients resort to buying hormones over the internet from overseas suppliers, perhaps with no medical oversight whatsoever. It’s a mess.

The situation in gender clinics hasn’t always been this dire, but even when I went through the system back in 2012-2016, the outlook for patients was fairly gloomy. My experience of adult gender services was distinctly underwhelming. I wanted two things from them. Firstly, a letter to my GP recommending the prescription of cross-sex hormones. That was secured after my second appointment. The second was a referral for gender reassignment surgery, which came at the fourth. But then I was one of the lucky ones: I knew what those who had gone before me had said, and I read from the same script. Three more half-hour appointments followed while I waited for that surgery, but there was little to talk about beyond anecdotes from work and perhaps the upcoming Test Match at Lords.

Then, as now, the difficult part was getting in front of the right doctor in the first place. In 2012, I had to first navigate the local mental health services. Back then, gender clinics did not take referrals directly from GPs, and certainly not self-referrals by patients.

If you made it through the obstacles, as I eventually did, there was one other issue to overcome: the knotty problem of who was going to foot the bill. Until 2013, gender medicine was commissioned to varying degrees by Specialised Commissioning Groups and Primary Care Trusts. With no central budget, getting the right treatment was something of a postcode lottery.

I was typical of the cohort who could navigate the local health services and say the right things to secure funding. I was middle-aged, well educated and established in life. Arguably the gatekeeping was unfair, but it limited numbers and – perhaps crucially – skewed the clientele to those who were able to take responsibility for what they were doing to their bodies and their lives.

During one appointment I asked my clinician why he had chosen to work in gender medicine. He explained that psychiatry generally concerned with managing ongoing conditions and patients could be on the books for life. Gender patients, on the other hand, were treated, discharged, and never seen again. The assumption was that this was one field in which psychiatrists could actually deliver a cure.

My contact – or indeed lack of it – since I underwent treatment certainly suggests that the NHS is focusing on delivering a ‘cure’ for trans people rather than their long-term post-op care. Charing Cross gender clinic discharged me in April 2016, two months after gender reassignment surgery. Since then, my ongoing care was largely left in the hands of my GP – a family doctor who knew me personally but was no gender expert. We pondered the results of blood tests together using a densely-worded 14-page booklet, Information about hormonal treatment for trans women. The aim, we read, was to ‘prevent osteoporosis (brittle bones), increase general well being and have a healthy heart’. The hormone dose should be adjusted so that blood oestradiol was in the range 400 to 600 picomoles per litre. What did that mean? At times, it is hard not to feel like a guinea pig.

As my years advanced beyond 50, my GP asked me about menopause – was this something that should happen to transwomen? I didn’t know, so she wrote to Charing Cross. The reply suggested that she just keep prescribing the hormones indefinitely; I’m still on them today. Is that wise? According to a more recent research paper, ‘given a lack of research on the management of gender affirming hormone therapy with aging, a shared decision-making approach is recommended to ensure individual goals are attained whilst minimising potential medical risks’. (My emphasis.) I’ll keep taking the pills, but only time will tell whether this is the right decision.

One of the things Cass’s review uncovered was questions over evidence for various treatments when it comes to children and young people. There’s clearly a problem too in the way that adult trans patients like me are treated. Without evidence, and in the absence of specialist knowledge, maybe we are merely sharing our ignorance. Since that reply from the clinic, I’ve heard nothing else from them. Unless they follow my columns in The Spectator and elsewhere, I could well be dead for all they know. Perhaps their silence is understandable: their waiting list is, after all, only growing longer.

Following a house move, I have a new GP, but my latest practice shares the concerns of the previous one and, worse, they have to catch up on my medical history. At a recent annual review, a clinician expressed their concern about managing my seemingly life-long hormone treatment: ‘We don’t know anything about this,’ I was told. It was suggested that I was referred back to the gender clinic. I laughed and pointed out that the odds were against me lasting another 37 years to get to the front of the queue. The practice I’m at is continuing to prescribe for now, but I worry about the future.

In many ways, I am fortunate: I am not stuck on a waiting list to finally be seen by a doctor. But plenty of people in the position I was in only a few years ago are not so lucky: they face a long wait to get to the front of the queue. Even then, their future looks far from certain.

So what should happen to the NHS’s adult gender clinics? Doctors working in them are clearly swamped and struggling to cope with demand. No one wins from this situation: perhaps it is time to ask the question as to whether the health service should be involved at all.

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Debbie Hayton is a teacher and journalist.

Her book, Transsexual Apostate – My Journey Back to Reality is published by Forum

* This article was first published by The Spectator on 26 May 2024: The crisis in the NHS’s adult gender clinics.