Straight to the point

It’s never been easy to get gender reassignment surgery on the NHS. More than a decade ago, when I was living in Birmingham, I was referred by a psychiatrist to a Gender Identity Clinic in London. NHS England funded seven adult clinics: none of which were anywhere near me. I had to take six days off work just to attend a series of brief appointments at the Charing Cross GIC in Hammersmith. My first assessment came in May 2012, six months after that referral. Four years later, I was eventually discharged after my surgery.

One could hardly call that efficient. But for patients today, my experience is the stuff of dreams. Waiting lists have ballooned out of all recognition. My former GIC in London is candid: “We are currently offering first appointments to people who were referred in January 2018.” Those people have waited four and a half years, merely to get to the starting line. But dig a little deeper into the data and the forward projections look even worse. In May 2022, there were 11,407 people languishing on the waiting list; just 50 of them were offered a first appointment that same month. This figure seems typical: in April it was 56, and in March it was 33. At those rates it will take between 17 and 28 years to clear the backlog. Typically, the clinic receives around 300 referrals every month, so with each month that passes, those waiting lists get even longer.

Elsewhere, the story is much the same. A GIC in Sheffield is offering first appointments to those referred in March 2018, while one in Exeter has seen nobody referred after June 2016. Behind this data, there are people stuck on waiting lists: almost 4,000 at Exeter in a queue that has stopped moving. The message from the clinic is stark: “Please do not contact the clinic to enquire about waiting times as our staff are very busy and we cannot provide any more information than is provided here. Thank you.”

With NHS services grinding to a halt, it’s not surprising that private clinics have sprung up to provide a faster alternative. Some clinicians are moonlighting alongside their regular jobs for the NHS. Consultant psychiatrist Dr Stuart Lorimer was brutally honest about his reasons: “Doctors have mortgages too, and my partner was on the verge of retirement… I was looking for ways to generate more income.” A tidy income, it seems — Lorimer charges £300 per hour.

Meanwhile, the London Transgender Clinic, a private practice, was established by plastic surgeon Christopher Inglefield in 2015, “in response to a noticeable increase in enquires from transgender and non-binary patients. Many of these patients were unable to access quality and timely care from the overwhelmed NHS gender services.” But his fast-track pass comes at a cost. LTC’s guide price for the management of hormone therapy is £849 for the first year, and £468 per annum subsequently. And that doesn’t include the drugs: “LTC is not a licensed dispensary, therefore, we advise that you take your private prescription to your local pharmacy.” It’s a far cry from the NHS, where a prescription prepayment certificate costs just £108.10, and that covers all your medicines for the year.

While NHS surgery is free to the user, private patients pay the full cost themselves. LTC charges from £27,000 for male-to-female gender surgery, rising to at least £32,000 if a section of colon needs to be used. LTC is perhaps on the pricey side, but their fees are not off the scale. The Parkside Hospital in Wimbledon told me that, “it’s £23,000 for a vaginoplasty”. Alongside their private patients, Parkside has a contract to treat NHS patients — 132 of them in 2019. This suggests the NHS is paying north of £3 million per year to treat around a dozen patients each month.

 

This model is hardly sustainable, with the London GIC alone currently receiving more than 300 referrals per month. Even if the clinic somehow increased its capacity to assess those patients in a timely fashion, what happens next? While it is perhaps feasible for the world’s pharmaceutical industry to step up production of hormone therapy and blockers, surgery is a different matter. Vaginoplasty is a skilled job that few surgeons can do. In 2016, GRS surgeon Phil Thomas pointed out that “there are simply not enough people in Britain who know how to make a vagina”. His colleague Tina Rashid said, “attracting new surgeons into the speciality was extremely difficult… GRS is a very niche area.”

As a result, the NHS system of Gender Identity Clinics is not only failing to deliver at present; it’s hard to see how it could ever deliver in the future. Even if, say, £100 million could be found every year to fund around 5,000 surgeries, it is futile if there is nobody to do them. A totally new model is needed, and we do not need to look hard for it.

Last month, the Tavistock and Portman NHS Trust announced the closure of their Gender Identity Development Service for Children and Adolescents (GIDS), the clinic for children who think that they might be trans. It was perhaps inevitable after the Cass review criticised the clinic as: “Not a safe or viable long-term option in view of concerns about lack of peer review and the ability to respond to the increasing demand.” It will be replaced by regional centres offering more “holistic care” with “strong links to mental health services”.

Adults deserve no less. Patients who should be assessed, screened for comorbid psychological disorders, and perhaps offered counselling are instead being consigned to seemingly endless queues — and told not to bother the staff. Adult Gender Identity Clinics are another broken system in need of replacement.

There is a certain mystique surrounding NHS gender clinics, but they are NHS services like any other, where clinicians meet with their patients and discuss their treatment plans. At the GIC the options are limited, or at least they were for me. I spent less than four hours in that consulting room. After two one-hour initial assessments, the clinic wrote to my GP to recommend hormone therapy: oral estradiol valerate and an injectable GnRH agonist — a “blocker” — that desensitised my pituitary gland, which in turn shut down the production of testosterone in my testes. Whether this is safe or not, nobody really knows. The drugs are not licensed for these purposes.

I had four further half-hour consultations. During that time, I was referred 200 metres up the road to Charing Cross Hospital for gender reassignment surgery. And that was that. No psychotherapy, and no psychiatry of note. Less than two months after surgery, I was discharged to the care of my GP. If any long-term research is going on, I am not part of it. I’ve had no contact with the clinic since 2016.

If gender dysphoria needs to be treated — and I think it does — then psychotherapy should be the first approach. It seems madness to proceed otherwise. Surely, we need to explore the issues thoroughly with a counsellor before considering hormones and surgery. Therapy can be provided locally and close to home; it certainly shouldn’t need a whole day out in London. And if surgery is what’s needed, it shouldn’t require choosing whether to pay a year’s salary or sit on seemingly endless waiting lists, with no support from the staff. A rigorous, judicious and efficient service is what’s needed. At the moment, it’s failing on every front.

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