This post discusses mental illness.
I’ve asked the Gender Identity Service for Northern Ireland why they don’t provide expedited treatment to assertive patients plenty of times. Whereas I don’t believe you should have to be assertive to access timely access to trans healthcare, I do think that people who are assertive should not be held back from accessing that healthcare within the bounds of clinical responsibility.
The answer I’ve received multiple times about their refusal to expedite patients is that “every patient’s journey is individual”, and that providing a one-size-fits-all approach to treatment does not serve all patients well. The assertion here that removing the assessment period has to remove all counselling services prior to treatment for everyone. Whereas I understand, and fully agree with the idea that every patient is different, the GIC’s insistence on it as a defence of arbitrary timelines is really beginning to irritate me. Clearly, some patients will present to gender clinics being fully sure of who they are and what they want, and will have support networks and circumstances which will help them to transition. Others will present with difficulties in personal, family or professional life, or may not be sure about what, if any, medical pathway they wish to take. However, I don’t think the current system benefits all patients in the way an individualist system should.
The current system channels every patient through a 6-12 month assessment period before accessing any physical treatment, including safe and reversible services like hormone blockers and fertility treatment. After six or so months, some patients will be permitted to access HRT (Hormone Replacement Therapy) and other treatment, but some may be deferred to a longer assessment process due to concerns about their health (physical and/or mental), circumstances (family, work etc) and their consistency of identity. Treatment is also dependent on beginning social transition in many cases (a requirement specifically advised against in the new RCPsych guidelines).
What this means is that people who need mental health support and counselling get it, which is great. I think this is extremely important for those that need it, and an ongoing support service should continue to be offered. What it also means is that patients who have already socially transitioned and who have no other contraindications to treatment are required to present to the Clinic for at least six months before getting access to life-saving interventions. For those that struggle with discrimination and violence in society without access to HRT etc, this is a very real and immediate threat to mental and physical wellbeing, and frankly I think withholding treatment from these patients is walking a very dangerous path indeed.
Story time! I transitioned many months before first attending the Clinic, and as such I had already largely adjusted to presenting as female. What I struggled with was not passing to the general public, which caused me a lot of anxiety and distress on a daily basis. I presented to the Clinic as a binary trans woman who knew what healthcare she wanted and needed, and was already well underway with social transition. My mental health was good considering the circumstances, and I had a great support network around me and had plans in life beyond transition. Although much of this should not matter in terms of timely access to healthcare, HRT was postponed by six months because of arbitration within the system.
Six months is not a long time for a therapist who sees you for an hour a month. Six months, when you’re dealing with othering and ridicule from the general public, and the anxiety and depression that results from that, is an extremely long time. Balancing up the relative health risks of hormones versus the guaranteed mental health risks of withholding treatment is a fairly clear cut decision to me. Oestrogen especially, whose impacts are largely reversible for quite some time after beginning treatment, is an extremely safe thing to take. Comparatively, the mental health struggles, and they were struggles, caused by being denied access to HRT were very, very real, and elements of them still scare me at times when I reflect back on them. These struggles with mental health are a common experience through the trans community before being granted access to HRT, and they go under-reported to trans healthcare providers because many patients feel obliged to paint their mental health in a more positive light than it really is to hasten access to HRT and other treatment. Personally, I don’t think depression, anxiety or similar illnesses should delay a trans person medically transitioning, especially as it’s gender dysphoria which often causes a lot of this illness, but mental illness continues to hold patients back. Again, denying people access to things which would improve their mental health, just because they are mentally ill, seems like an odd stance to take. This extended assessment period is apparently to grow a working relationship between professionals and patients, and to ensure patients are stable and suitable for treatment. In reality, whereas it works for lots of people, it puts lots of others through at least six very difficult months, especially if they’ve just begun transitioning socially or have recently come out.
The Northern Ireland clinic, like others across the UK, uses a period of “Real Life Experience” concurrent with or prior to starting HRT and other treatments as part of the typical care pathway. This means that patients are asked to socially transition around the same time as they start medically transitioning, a request that isn’t too hard to unpick as problematic. Unlike requirements for surgery, there are no obligations for social transition in the current UK RCPsych guidelines for access to HRT and most other treatments. This brings into question the current requirement for social transition for HRT, although social transition shouldn’t be required for any medical treatment (in my opinion – your social presentation often has no correlation on your ideas about your body).
It looks like the current system is less designed for the individual needs of each patient and and is more rigidly enforcing arbitrary timelines, to the immediate detriment of patients for whom medical transition is a matter of urgency (which is a great many). As the average age of trans people medically transitioning continues to trend downwards, and as trans people are more and more informed about healthcare and medical transition, this will become more of an issue. People can currently arm themselves with almost as much (and often more) information about trans endocrinology than their healthcare providers – being told to wait half a year to make sure they’re trans is endlessly frustrating and needless.
I’d like to make a small suggestion. Although I’m all for truly accessible and open access to transition healthcare, a little step towards that would be to remove the arbitration and stick to the guidelines currently in place. Six months of assessment means nothing when patients can sculpt their answers to questions to expedite treatment (newsflash: this happens), and the requirement for social transition is based on sexist stereotypes and dodgy ideas of what it means to be trans, and it puts trans people into direct risk of violence from society, among other problems. Continue to offer support and counselling services to patients that want/need them, but let people who know who they are, know what they want and can otherwise transition to transition. It’ll cut down on self-medication (although our current endocrinology setup is something for another blog post), it’ll help people get out of GICs and on to live their lives more quickly, and it’ll start to recognise the agency of trans people, something which is all-too-often forgotten in healthcare.
It helps everyone in the end.