28 Britain The Economist February 19th 2022
GendermedicineTrans action
I
n 2020,before thepandemicslowed
treatment further, the nhs set up three
new pilot gender clinics with the aim of
cutting a long backlog by moving much
treatment into primary care. A fourth was
added in 2021. The idea was to make it easi
er for gps to prescribe hormones to trans
identifying adults and refer them for sur
gery. Previously, all adults who wished to
pursue a medical transition would be re
ferred to one of several specialist Gender
Identity Clinics (gics) attached to major
hospitals. The gics are a bottleneck, with
13,500 people on waiting lists in 2020 and
some people having to wait three years for
an appointment.
Until relatively recently, the gics had
robust assessment systems. Only the most
severe cases of gender dysphoria—discom
fort with one’s sexed body—were referred
for medical transition, since crosssex hor
mones and gender surgery can cause steril
ity, sexual dysfunction and other compli
cations. But increasingly, specialist clinics
follow an “affirmative” care model import
ed from America, which eschews most as
sessment and takes each person’s identity
claims at face value. The gics do, however,
still employ psychologists and psychia
trists for complex cases.
The pilot clinics aim to bring this affir
mative approach to gps. The Indigo clinic
in Manchester, for example, will be staffed
by gps who will train others to prescribe
hormones without detailed psychological
evaluation. It describes itself as “a service
designed by and for trans and nonbinary
people” that takes a “flexible view of transition”.Itwillinitiallysupportpeopleon the
waiting list for gics, but then accept refer
rals from gps and directly from patients. It
expects to see 900 people per year by 2026.
“If you are interested in taking hormones,”
says its website, the service “can help from
as early as your second appointment.” It
can make referrals for mastectomies and
connect people with the gic in Notting
ham for genital surgery.
Currently, gps may choose to give a
shortterm “bridging prescription” to a
transidentified person who is already tak
ing sex hormones bought online or whose
life appears to be in danger. Indigo is send
ing gps on a parttime “credentialling pro
gramme” run by the Royal College of Phys
icians (rcp), which aims to give them the
confidence to go beyond such interim
measures. Supporters point to nhs specifi
cations on treatment for genderidentity
issues published just before the pandemic,
which are being used to guide care at the
pilot clinics.
But the specifications raise troubling
questions. Initial consultations should be
with a “regulated health professional” (ie,
not necessarily a doctor). A second consul
tation should be with a “medical practi
tioner or clinical or counselling psycholo
gist (or by a supervised trainee)”. Buried in
the appendices is the statement: “Psycho
logical interventions will not be offered
routinely or considered mandatory.”
“The danger is that [this approach] will
sideline mentalhealth expertise and
thereby not address coexisting mental
health problems that might be worseningthe gender dysphoria,” says Lucy Griffin, a
psychiatrist in Bristol. The Economist’s re
quests for interviews with senior nhs fig
ures about the pilots were declined. An
nhs spokesman said: “Hormone treat
ment is only prescribed by a gp if, follow
ing a patient’s assessment appointments at
a clinic, a specialist doctor diagnoses gen
der dysphoria. Anyone undergoing hor
mone treatment must have thorough tests
and checks before and during treatment.”
As for the credentialling course, four
current or past members of the rcp’s ethics
committee have expressed concerns to The
Economistabout it. They say they raised
questions and were ignored, a claim de
nied by the head of the committee. Alas
dair Coles, a professor of neurology at
Cambridge University, was on the commit
tee until 2019, when it discussed the
course, and he heard a presentation from
its organisers. “We did not get the sense
that gender medicine was open to scrutiny
or selfcriticism on standard medical crite
ria, such as sideeffects and longterm out
comes,” he says. A spokesman for the rcp
says the course is about “exploring the
complexities of this subject”, and “sup
porting healthcare professionals to sup
port their patients in making choices”.
Many doctors are already uncomfort
able with the direction of travel, let alone
the idea that it should speed up. The new
clinics “are following an ideologydriven—
not an evidencedriven—agenda,” says Ju
lie Maxwell, a paediatrician in Hampshire.
“If I refer someone to a cardiologist, and
they outline a particular treatment that I
haven’t heard of, I take on trust that this
cardiologist is practising sound evidence
based medicine,” says Louise Irvine, a gp in
south London. “We make the assumption
that the gender clinics have a similar ap
proach. But actually, they don’t.” Many of
the bodies representing and regulating cli
nicians do not seem to recognise the con
cerns on these issues or give adequate
guidance, says Dr Irvine. The result is “an
atmosphere of ignorance and fear”.
Another gp, who declined to give her
name, says that doctors are now expected
to talk about gender dysphoria as a sexual
health problem, rather than a mental
health one. That, she says, “is pretty ironic
since, in treating it with crosssex hor
mones and surgery, you are messing up a
person’s entire sexual health”. She used to
refer patients to gender clinics, but
stopped. A third gptells of a patient with
serious mentalhealth issues who selfre
ferred to a pilot clinic. It wrote to the gp
saying that gender dysphoria had been di
agnosed after one meeting, in which the
patient requested orchiectomy (removal of
testicles). It asked the gpto refer the pa
tient for surgery at the local hospital.The
doctor declined. “I suspect there is likelyto
be pushback from many gps,” he says.nActivist doctors are pressing for more gps to prescribe cross-sex hormones