Biological sex is assigned at birth and determines a large proportion of our future lives – we are expected to act, talk and even dress in a certain, predefined, way to please the stereotypes carefully crafted by our society. These and many other factors define gender identities and, more often than not, the identity people associate with is the same as their biological sex. But what happens when that is not the case?

Gender dysphoria, also referred to as transgenderism, is a condition where a person experiences discomfort or distress because there is a mismatch between their biological sex and gender identity.

Although not considered to be a mental illness in itself, gender dysphoria is often accompanied by depression and statistics have shown that trans people have a much higher rate of suicide – in 2010, 41% of trans people in America had attempted it, as compared to the national average of 1.6%.

Studies have shown that early access to hormone therapy or surgery, social support and reducing transphobia can significantly alleviate the suicidal thoughts and everyday struggles experienced by people living with this condition.

Sadly, early intervention is often not an option as a recent article published in the British Medical Journal (BMJ) reveals that one in five GPs in the UK refuse to prescribe hormone medication for transgender people.

General Practitioners are often the first port of call for people with gender dysphoria and, ideally, they would refer them to one of the 11 NHS gender identity clinics established around the country. There, following an assessment by a psychiatrist, a specific treatment plan can be established. However, GPs often delay access to treatment due to unnecessary referrals to a community psychiatry.

For adults, treatment often comes in the form of hormone therapy – trans men (female to male) will take testosterone (masculinising hormones), while trans women (male to female) will take oestrogen (feminising hormones). Hormones start the process of change for the body and often make trans individuals more comfortable with their physical appearance and the way they feel. Gender reassignment surgery is only possible after at least a year of living as their preferred gender.

This process is slightly different for children under 18 who are provided only with psychotherapy until they reach puberty. Although gender dysphoria disappears for the majority of children after that, the ones who still feel uncomfortable with their identity can be treated with gonadotrophin-releasing hormone (GnRH) analogues. GnRH analogues suppress the hormones naturally produced by the body and can delay physiological changes that usually occur throughout puberty, in order to prevent the child from becoming more like its biological gender.

As the effects of hormone replacement therapy are reversible, it has to be taken for life.

Currently, there is only 11 gender identity clinics around the country, so people would often travel over a long distance for consultations and prescriptions. A practical solution to this would be for GPs to prescribe hormone treatment, while gender identity clinics provide treatment advice and endorsement.

However, many specialists working in these clinics report that one in five GPs would refuse to prescribe transgender treatments, even following the NHS clinic’s advice.

In the BMJ, James Barrett of the British Association of Gender Identity Specialists says that the reasons often given for this refusal include that the treatment is too “dangerous, difficult, expensive”.
This conservatism expressed by medical professionals may also have religious roots, as Barrett continues: “I’ve also heard disturbingly frank admissions that it was against “deeply held Christian beliefs” or that “we are trained to treat illnesses, not to change nature”.

In response to such concerns, a recent report by The General Medical Council states that “ethical or principled objections are not acceptable in gender dysphoria and inexperience in the field should be remedied by prompt cooperation with a gender identity clinic”.

But this problem isn’t confined to the UK. A recent study conducted in America found that transgender individuals experience harassment, violence, and discrimination in a number of settings. Using national survey data, the authors found that 41.8% of the transgender participants reported verbal harassment, physical assault, or denial of equal treatment in a doctor’s office or hospital.

The issue of discrimination goes even deeper as a recent survey of over 7,000 transgender people reports that:
19% have been refused care due to their transgender or gender non-conforming status
28% were subjected to harassment in medical settings and 2% were victims of violence in doctor’s offices
50% reported having to teach their medical providers about transgender care

What is even more distressing is that a quarter of the participants report using alcohol and drugs as a way of coping with the discrimination they face, which would only reinforce the already underlying depression and distress that come with the condition.

The medical profession requires putting the interest and health of patients first, so where is this prejudice coming from and how can it be prevented? James Barrett says that many GPs he has spoken to report a lack of knowledge about the treatment to be one of the main factors that stop them from prescribing them.

In the UK, the Medicine curriculum does not include any modules on LGBTQ health. Similarly, only 33% of US medicine graduate programmes incorporate an element of the topic. This lack of education often leads medical professionals to direct trans people to mental health institutions instead, which often goes to indulge the problem rather than provide a solution.

But good news may be just on our doorstep. Following a recent Parliamentary inquiry into Transgender Equality in the UK, Brighton and Hove is launching an online guide for GPs that will help in treating and supporting transgender people.

The guide, which is the first of its kind in the country, was developed by the Brighton and Hove Clinical Commissioning Group (CCG) and with help from transgender individuals in the city.

Its launch could have been influenced by the council’s first ever trans needs assessment, which showed that out of the 2,760 transgender individuals living in the city only 1 in 5 said they were in good health as compared to 4 out of 5 in the wider population. Furthermore, 4 in 5 had experienced depression, while 1 in 3 said they have self-harmed.

CCG clinical lead for primary care and public health, Katie Stead, said to The Argus: “Although there are many good examples of excellent primary care for our trans population, there is also a lack of education and information for GPs available both nationally and locally.

“We hope it goes some way in plugging this gap locally and will give GPs the confidence to work with trans patients to provide great care.”

Rositsa Todorova

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