In order to receive gender-affirming healthcare through the NHS, trans patients in the UK must surpass a series of checkpoints in which their gender identity is externally verified. The implication is that trans people are not capable of providing informed consent because people with non-conforming gender identities are by default mentally ill: this is transphobic.

Transgender healthcare

Trans healthcare includes hormone replacement therapy and a variety of gender-affirming surgeries, but can also involve speech therapy, laser hair removal, and navigating gendered healthcare spaces (such as trans men seeking gynecological care; see Robert Eads, a trans man who died of untreated ovarian cancer).

The process for gaining access to trans healthcare through the NHS is long, frustrating, and invalidating:

1. Patient makes appointment with their general practitioner (GP), several days or weeks in advance. Trans patient asks their GP for a referral to a Gender Identity Clinic (GIC). GP verifies that the patient is trans and not just “confused”—though the GP is likely confused.
2. GP refers patient to a mental health professional.
3. Appointment is scheduled with the mental health professional on behalf of the patient, several weeks in advance. Mental health professional administers a psychological evaluation and diagnoses the patient with Gender Identity Disorder, a mental health disorder.
4. Mental health professional refers patient to their local Gender Identity Clinic (GIC).
5. The GIC schedules an appointment with the patient, several months in advance. The first GIC appointment is short and verifies that the trans patient is indeed trans.
6. Subsequent GIC appointments are scheduled (weeks or months later), in which the trans patient may be given medication, hormones, or surgical consultancies.

This process involves unnecessary bureaucracy, and—speaking from personal experience—frustrating demonstrations of insensitivity, incompetency, and a complete lack of basic understanding of trans issues. Most importantly, it requires at least three external parties to verify and certify that the trans patient’s identity is what they claim, and that identity is then treated like a mental disorder.

Gender Identity Disorder

Non-conforming gender identities which require/would benefit from medical treatment are treated not as identities which are self-selecting, self-defining, deeply personal, and inarguable, but as disorders, diseases, or dysphoria which require external diagnosis and therefore undermine the sense of identity and invalidate the person staking claim to that identity.

Transgender people are treated as if their trans identities infringe on their ability to give informed consent or otherwise indicate that they are of sound mind and judgement (see Chelsea Manning). They cannot simply assert that they are the gender they claim and should therefore have the correct gender marker on IDs and access to trans healthcare—their identities must be signed off as valid by a series of (usually under-informed) doctors.

“It’s just a phase.”

The process of repeated external verification is rooted in transphobic notions of deceit or confusion on behalf of the trans person. The so-called “real life test” is another barrier to access for trans people in the UK: it is a mandated period of time (1 or 2 years) of “living as your preferred gender” (implying that your gender is changing and that it is a preference, both problematic) as an intentional hurdle to prove that the patient is serious, that their gender identity is not a phase, and that they are who they say they are. This system fails to consider that gender-affirming processes (everything from changing one’s name on documents to phalloplasty) are extremely difficult and time-consuming, and can be stressful, invalidating, and traumatic, not to mention potentially physically painful in the case of surgery or electrolysis. The decisions to take hormones or get surgery are not made lightly and the processes take so long that there is a lot of time to reflect on those choices; yet the myth of “transitioning back” is pervasive.

Not only do most healthcare professionals lack training, empathy, and a basic understanding of trans issues and are therefore liable to undermine or invalidate trans patients with questions like “are you sure you’re really a woman?” and use problematic language like “changing your gender” or “biologically fe/male”, but that trans patients need their identities externally verified at all is inherently invalidating.

Gender markers on identification documents

Some trans people do not want or need medical treatment or mental healthcare, but even people who only want to change their names and/or gender markers on IDs must be diagnosed with GID and present an official letter from a therapist to a judge for approval. In some cases (e.g. US passports) accompanying letters from physicians are required, certifying that the citizen has undergone gender-affirming surgery. This suggests that non-cis gender identities are only legitimate when accompanied by surgery—problematic on its own, but even worse considering the barriers of access to trans healthcare.

Argentina is the only state in the world that allows citizens to change their gender markers without external certification of their gender identity, simply allowing citizens to change their ID markers at their request.

Consequences of inaccessible healthcare

These barriers mean that many trans people are unable to access trans healthcare, which may not only compound their gender dysphoria but is also likely to undermine their trans identity in society (“they’re not really a wo/man because they don’t have breasts/don’t sound female/don’t conform to rigid and outdated gender norms”).

Because oppression is intersectional, trans people with additional marginalized identities have even more difficulty gaining access to healthcare: especially trans women, trans people of color, disabled trans people, and trans people who are not rich. Trans youth are particularly vulnerable because they are presumed unable to give informed consent until they are 18, and are therefore liable to take hormones purchased illegally.

The implication that trans people cannot give informed consent regarding their own healthcare on the basis of their trans identity is infantilizing, victimizing, and insulting. It strips trans people of their agency and delays them in claiming and affirming their gender identity. For a start, the NHS should axe the psychiatric evaluation currently required for referral to GICs; following Argentina’s example in allowing people to change their gender markers at will wouldn’t be remiss either.