Think Tanks
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The King's Fund - Trans people and the NHS: the heat of the debate needs the light of evidence
2024 was a year in which trans health care was under the spotlight. We saw a flurry of announcements regarding and impacting the provision of gender-affirming health care for the trans community1, particularly for children and young people.
In April, Dr Hilary Cass published her independent review of gender identity services for children and young people. One of a number of recommendations was a ban on prescribing puberty blockers to new patients under the age of 18 experiencing gender dysphoria. The report cited a lack of evidence of safety and clinical effectiveness of the treatment. This prompted NHS England to temporarily ban puberty blockers for new patients. In November, the government announced an indefinite ban on puberty blockers and subsequently have committed to implementing all the recommendations the review proposed.
This ban highlights a broader systemic issue within the NHS: where there is a lack of evidence, there is caution, but rarely an increase in research. The uncertainty persists, the caution persists, and potential improvements to health are not realised. This is not an issue exclusive to the trans community. Parallels can be drawn among other marginalised groups of people who are often ignored and unseen in health and care data and research, including, but not limited to, Gypsy, Roma and Traveller people, sex workers, refugees and asylum seekers and rough sleepers. The issues each group experience may differ, but the fundamental issue remains the same: a lack of data leads to poorer health outcomes.
“What else happens when there’s a lack of evidence? Unfortunately, in the absence of informed knowledge, the void is too often filled with emotion, anger and anxiety. ”
Author:
What else happens when there’s a lack of evidence? Unfortunately, in the absence of informed knowledge, the void is too often filled with emotion, anger and anxiety. The public ‘debate’ on trans people’s rights is toxic, fear mongering, and ever-increasingly hostile. Indeed, since 2022, the UK has fallen from 14th to 15th in the European rankings on LGBTI rights, yet a decade ago the UK was leading in 1st place.
Back in 2022, former chief executive of The King’s Fund, Richard Murray, blogged about the available evidence of trans people’s experience of health and care. My original aim for this blog was to cut through some of the recent noisy public debate by building on Richard’s blog and examining what the latest data shows. Sadly, what I found is that there has been very little new evidence published since then. A topic that is much discussed seems to be little researched. Let’s take a look at what data there is.
Firstly, the health of trans people. In Richard’s 2022 blog, he outlined that more trans people are likely to experience issues with their mental health, including depression, anxiety and thoughts of suicide. More recent research, including the Cass Review itself, shows no improvement. The figures are sobering. According to LGBT Foundation, 45% of trans young people (aged 11–19) have tried to take their own life. We also know that trans people are more likely to report a long-term health condition.
Second, let’s look at trans people’s experience of accessing care. The King’s Fund podcast on LGBTQ+ health inequalities published in 2021 showed that trans people navigating the health system are more likely to have a poor experience. According to data collected in 2018 reviewing the previous 12 months, 40% of trans people had reported at least one negative experience when accessing public health care services. What might this look like in practice? It could include inappropriate curiosity or (un)intentional misgendering of patients by staff. This 40% doesn’t even consider the countless trans individuals who are avoiding care entirely for fear of a negative experience. This data is now seven years old and there is little new evidence to show whether there has been any change.
Thirdly, let’s look at the specific services for those seeking gender-affirming healthcare via the NHS. The waiting list for NHS gender identity clinics has been disproportionately long. NHS guidelines say you're meant to expect to be seen for routine operations like a knee or a hip replacement within 18 weeks, and the government has set out its plan to make sure 9 in 10 procedures happen in that time. However, in 2018, someone who was seeking gender-affirming health care was likely to wait an average of 18 months.
Seven years later do we find ourselves in a better situation? Well, no more official numbers have been published. The best we can do is look to independent surveys and according to TransActual, an adult might have to wait as long as 22 months for a referral to a gender identity clinic.
“waiting times have real consequences, often worsening clinical outcomes for people with pre-existing mental health or long-term conditions. ”
Author:
We all know waiting times matter. Many of us will have experienced the stress of being on an NHS waiting list, whether that’s to access mental health talking therapies, or waiting for an important scan. Timely access to gender-affirming health care is no different. As Siva Anandaciva highlights in his recent blog, waiting times have real consequences, often worsening clinical outcomes for people with pre-existing mental health or long-term conditions. But where people have timely access, it can improve people’s mental health, as has been shown with access to gender-affirming health care.
In his speech announcing the ban on puberty blockers, Wes Streeting said, ‘we need less heat and more light’ on trans healthcare. I agree. While we might not have all the evidence, let me lower the heat and shed some more light by finishing with a personal story.
A friend of mine recently had privately funded top surgery. In the days after their operation, they sent updates of their journey to a WhatsApp group full of friends and loved ones – their excitement and optimism, their joy. But also their despair. Their despair at just how long it had taken, the emotional, physical and financial resources it has required, and the difficulty to just exist as a trans person in the UK.
“Beyond pointing out gaps in the evidence, I’d like to see more action to fill the gaps in evidence with data and patient stories”
Author:
These sorts of experiences can act as a lesson to listen to patients' voices. Beyond pointing out gaps in the evidence, I’d like to see more action to fill the gaps in evidence with data and patient stories. It would help achieve a health and care system that treats trans people with the dignity and respect we all deserve, in line with the founding principles of the NHS itself, to make the same, high level of service available to all, according to need.