A Trans Medical Student’s Experience of A Gender Identity Clinic
Lance Millar, University College
The waiting room is pastel yellow. Posters and noticeboards crowd the walls. The reception desk is opposite the door I came in by. Strip-lights rebound off the heavy-duty pyrex screen.
I walk forwards, hyperaware of the sensation in my legs, my feet against the ridged nursery-school carpet, describing it to myself by rote. Paraesthesia. L2/L3 dermatomes. I pace my steps, count each one against my breaths. I make it to the desk. Behind my head, a TV blares.
I smile a wonky smile at the receptionist. She asks for my ‘gender autobiography’. I hand over a sheaf of papers including a copy of my essay, 1,000 words exactly as specified. My deed poll falls out. I bend down to pick it up. Panic. I have not researched or rehearsed a gender-neutral bending motion. The receptionist tells me she can’t find my appointment in the system. She sighs. I give her my deadname. I feel the presence of the other people in the waiting room like that old fallacy of the Oxford interview where everyone from the friendly finalist to the buttery cook is assessing you. I try to listen to the TV, but the presenter’s words slip past me. The receptionist makes a phone call. She gestures for me to take a seat.
Sitting in a chair is something I’ve rehearsed. My shoulders are tense, my left calf visibly trembling. I tell myself I look normal. I’m passing. I’m good at exams. In my peripheral vision, I watch the person three chairs down, a slim person, heavily tattooed. I hope they will look up at me, so I can calibrate myself against unspoken feedback from their glance. But they get up and walk through the left-hand door to the drug and alcohol service. I try to listen to the TV. I have an urge to study my essay. It’s an appointment with a psychiatrist, a doctor.
I tell myself, I have no need to be anxious. I speak their language, I am one of them.
* * *
Initial GIC Assessment
All adults referred to a GIC currently receive two independent assessments from a specialist psychiatrist, usually 6 months apart, before being offered gender-affirming hormones1. Specialist psychological support can be offered after the first assessment, although surgery can rarely be accessed without 12 months social and hormonal transition.
Best practice guidelines on this initial assessment were issued by The Royal College of Psychiatrists in 20132. These have not been updated since, despite being marked as due for review in 2018, the year I was first seen at an NHS GIC. The one page outline of the assessment explicitly references “psychosexual history”, “childhood-gender-typed behaviours”, and “adolescent cross-dressing with possible erotic accompaniment”. Details of the service user’s social transition, or related plans, and support network come after. These are the tools from which majority cis-gender psychiatrists are expected to work.
I personally sympathise with clinicians overseeing people who use gender-affirming hormones or surgical interventions. I am just disappointed that, as medics, we’re not doing better for trans service users.
Any support group, online forum, or autobiography featuring trans experience will confirm the limited, heteronormative question bank used in GIC initial assessment appointments. It seems trivial to state that excessive focus on clothing and genitals undermines trans people’s complex and prolonged exploration of gender, and stifles non-conformist experiences. Peer-reviewed evidence, although less widespread and mostly limited to qualitative ethnography, conveys similar themes. UK studies interviewing over 400 people referred to GICs documented dissatisfaction in around half of service users3, with three-quarters of non-binary service users feeling unable to disclose aspects of their gender identity4. Publications in this area are still predominantly written by cis-gendered researchers, which makes the work of trans academics such as Ruth Pearce5 an invaluable inside perspective on barriers to healthcare access.
The Road to GIC Referral
There is recognition, particularly among general practitioners (GPs)6, that current medical support for trans service users is insufficient. The majority of GIC referrals are made via GPs, who are often the first medical contact for trans health issues.
A recent report from the Royal College of GPs (RCGP)7 enumerated areas where active education is needed. With GIC waiting times now over 2 years on average, the lack of formal training in transgender health aimed at doctors is concerning. In particular, GPs highlighted guidance was needed around: prescription of ‘bridging hormones’ in those who may turn to unlicensed self-medication while waiting to be assessed by a GIC; management of co-presentation of dysphoria and autism spectrum disorder (ASD); and safe prescription and monitoring of gonadotrophin-releasing hormone (GnRH) agonist puberty blockers in trans youth. Even IT systems in general practice need updating, it is currently not possible to refer a trans man for cervical cancer screening unless his gender is recorded as ‘female’. This report was informed by a survey of trans service users that named lack of communication between GPs and GICs as one of the major barriers to satisfactory healthcare8.
Demand for GP education is gaining momentum, with a manifesto-like editorial published in the BMJ earlier this year9. Contemporaneously, the RCGP made available its first online learning module covering LGBTQIA+ healthcare10. Even here, transgender identity is at times used interchangeably with dysphoria as if the two are synonymous, highlighting the need for nuanced external input.
Medical Student Experience
Exposure to many of the social and cultural factors affecting access to healthcare begins in medical school. Could our future GPs and psychiatrists be better equipped long before entering their chosen specialty training programme?
Despite the national requirement for cultural education through structured communication skills teaching11, formal training in trans health issues is not included in the majority of university courses. A survey of over 100 UK medical students12 reported low confidence in approaching trans and broader LGBTQIA+ health issues. Most students would prefer not to ask about gender or sexuality in any context due to lack of knowledge and, concerningly, more that 60% did not know where to look for more information. Uncertainty extended to decisions with potential consequences for patient safety, psychological wellbeing, and long-term trust in the health service, such as placement of trans patients in gendered wards. In the US and Canada, larger cohorts of medical students13 reported a total of less than 5 hours of teaching time allocated to LGBTQIA+ themes across their entire degree.
My personal experience of other medical students has been of acceptance and sensitivity. Students themselves, queer and ally alike, are some of the most vocal advocates for diversifying their medical school curriculum14. Since coming out, I have not found a space where more people refer to me unprompted with neutral pronouns and invite my contributions on LGBTQIA+ projects. And yet I remain concerned that empathy is not a substitute for trans-led specialist education. Particularly at a time when the combination of media furore and scientific evidence inaccessible to non-experts, for example surrounding provision of puberty blockers to adolescents, significantly diminishes the ability of compassionate doctors to act in the best interests of service users15.
* * *
Looking back now, reflecting on my own GIC specialist assessment, anxiety had made me egocentric. I have never been so enveloped in myself and how I was perceived. It makes me cringe.
But that was my defence. I have constructed my gender autobiography as an explosion of achievements. Packed with philosophy and neuroscience, it was my old pre-clinical habit of heaping reference after reference into an essay to mask my lack of self-belief that I deserved to be there. I am ready to discuss Judith Butler’s social construction of gender16, Cordelia Fine’s exposure of rampant systemic bias in gender sociology and psychology17,18, Joan Roughgarden’s zoological examples that dethrone the chromosome as king of binerised reproduction19.
I am asked: “Did you have short hair as a child?”
I stammer an abrupt response. Yes and no. It depends. Isn’t the interviewer supposed to encourage me, to allow me to show all I know? That question again. “Did you have short hair as a child?” In that moment, I don’t know. I feel every follicle on my head as if it is gouging into my skull. I appeal to the psychiatrist, the doctor, silently pleading. That flicker of camaraderie never comes. Four agonising minutes later I confess. I am a fraud. I didn’t have short hair as a child. The psychiatrist reviews my essay. When he asks me about Butler I can’t elaborate. I am monosyllabic.
This was 2018. After the “trans tipping point”, after Caitlyn Jenner, after Laverne Cox. I thought I spoke their language. Now I know that their language is too bare to accommodate or uplift either the physician or the trans service user.
Edition: 69 (2020-2021)
Correspondence to: firstname.lastname@example.org
1. NHS England, 2020. Gender Dysphoria: Treatment. https://www.nhs.uk/conditions/gender-dysphoria/treatment/, last accessed 05/09/2020.
2. Royal College of Psychiatrists, 2018. Good practice guidelines for the assessment and treatment of adults with gender dysphoria. https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/cr181-good-practice-guidelines-for-the-assessment-and-treatment-of-adults-with-gender-dysphoria.pdf, last accessed 05/09/2020.
3. Ellis, S., Bailey, L., McNeil, J., 2015. Trans people's experiences of mental health and gender identity services: A UK study. Journal of Gay & Lesbian Mental Health, 19(1), 1-17.
4. Scottish Trans and The Equality Network, 2015. Non-binary people’s experiences
of using UK gender identity clinics. https://www.scottishtrans.org/wp-content/uploads/2016/11/Non-binary-GIC-mini-report.pdf, last accessed 05/09/2020.
5. Pearce, R., 2018. Understanding trans health: Discourse, power and possibility. Policy Press, Bristol, UK.
6. Joseph, A., Cliffe, C., Hillyard, M., Majeed, A. 2017. Gender identity and the management of the transgender patient: a guide for non-specialists. Journal of the Royal Society of Medicine, 110(4), 144-52.
7. Royal College of General Practioners, 2019. The role of the GP in caring
for gender-questioning and transgender patients: RCGP Position Statement. https://www.rcgp.org.uk/-/media/Files/Policy/A-Z-policy/2019/RCGP-position-statement-providing-care-for-gender-transgender-patients-june-2019.ashx?la=en, last accessed 05/09/2020.
8. NHS England Specialised Commissioning, 2015. Experiences of people from, and working with, transgender communities within the NHS – A summary of findings, 2013/14. https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/11/gend-ident-clnc-exprnc-rep-nov15.pdf, last accessed 05/09/2020.
9. Howard S., 2020. The struggle for GPs to get the right care for patients with gender dysphoria. BMJ: British Medical Journal (Online). 368, m215.
10. Royal College of General Practitioners, 2020. LGBT health hub. https://elearning.rcgp.org.uk/mod/page/view.php?id=9380, last accessed 05/09/2020.
11. General Medical Council, 2018. Outcomes for Graduates. https://www.gmc-uk.org/-/media/documents/outcomes-for-graduates-a4-6_pdf-78952372.pdf, last accessed 05/09/2020.
12. Parameshwaran, V., Cockbain, B.C., Hillyard, M., Price, J.R. 2017. Is the lack of specific lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) health care education in medical school a cause for concern? Evidence from a survey of knowledge and practice among UK medical students. Journal of homosexuality, 64(3), 367-81.
13. Korpaisarn, S., and Safer, J.D. 2018. Gaps in transgender medical education among healthcare providers: a major barrier to care for transgender persons. Reviews in Endocrine and Metabolic Disorders, 19(3), 271-5.
14. James, S., Sylvester, H.C. 2018. Transgender health and its current omission from medical school curriculum: medical students’ perspective. Advances in medical education and practice, 9, 607.
15. Cohen, D., and Barnes, H. 2019. Gender dysphoria in children: puberty blockers study draws further criticism. BMJ, 366, l5647.
16. Butler, J. 1990. Gender trouble, feminist theory, and psychoanalytic discourse. Routledge Books, Abingdon, UK.