The public discussion of trans people’s rights in the UK is often bad-tempered, sometimes extremely so. The failure to improve rights for trans people in recent years has contributed to the UK falling to 14th in the European rankings on LGBTI rights (it was top as recently as 2015). For many in the NHS this wider societal discourse may seem like ‘somebody else’s business’, a thought possibly reinforced by the fear of getting caught up in such an aggressive space. However, as the Health and Care Act 2022 has again confirmed, the core purpose of the NHS is to provide good-quality health care to all and to reduce inequalities. If it wants to live up to that vision, the NHS cannot ignore the poor health outcomes and poor access to services that the available evidence suggests many trans people experience.
It is true that there is a general lack of data on the health and access to services of trans people, as highlighted by a 2016 National Institute of Economic and Social Research review. However, the existing evidence – from a wide range of sources including surveys (including the GP Patient Survey), Healthwatch, the Care Quality Commission and academic research – points towards poorer outcomes and poorer access. A lack of evidence shouldn’t be taken as an excuse for doing nothing while waiting for `more research’. What does the available evidence show?
'The existing evidence – from a wide range of sources including surveys (including the GP Patient Survey), Healthwatch, the Care Quality Commission and academic research – points towards poorer outcomes and poorer access [for trans people].'
On outcomes, it shows more trans people experience problems with their mental health, including depression and thoughts of suicide. Unsurprisingly, this is linked to higher use of mental health services. The evidence of poorer health outcomes is not limited to ental health. From the GP Patient Survey we also see, for example, younger trans and non-binary patients (aged 16 to 44) more likely to report a long-term condition, disability (including physical mobility) or illness compared with other patients of the same age.
Perhaps because data on service use is easier to collect than that on outcomes, it is in poorer access to services that the evidence really accumulates. This includes witnessing discriminatory or negative remarks and experiencing inappropriate curiosity when trans people do access services. And perhaps predictably, this experience leads many trans people to avoid services or treatment and to give lower satisfaction ratings when they do get access. Many organisations aim to be inclusive to the LGBT community as a whole and it is worth noting that where we have the data, inequality of experience seen for lesbian, gay and bisexual people is also seen for trans people, but often to a greater degree. These experiences occur not just in terms of trans-specific services but includes access to, and experience of, general health care and these differences can be dramatic: survey results show 30 per cent of trans and non-binary parents reported that they avoided perinatal care during pregnancy. We don’t have directly comparable data for the general population but as the Office for National Statistics reports that just 2.1 per cent of all births took place at home (and many of these will have included support from a health care professional), this is a dramatic difference. Finally, as respecting people’s chosen name (and pronouns) is itself linked to better health and wellbeing for younger people, the very experience of care can do damage when this is ignored or overlooked.
'Engagement with the trans community can also help identify where the local issues are, as well as co-produce solutions.'
How can the NHS do better? There are a number of things: there are pilots already looking at different ways of providing trans-specific care (for example, the East of England Gender Service) looking to provide more local services that are easier to access. Working with staff to make sure both that trans staff have a positive experience at work, and also that trans patients are met with respect and a focus on their health needs. Engagement with the trans community can also help identify where the local issues are, as well as co-produce solutions. Finally, ensuring that IT systems can capture better information will, overtime, help fill in some of the gaps in the data. Some of this is not rocket science given the NHS does have experience of trying to overcome prejudice and inequalities experienced by other groups when accessing care.
The challenge is only partly the understanding of what can be done to provide fairer, better access and through that, to improve the health of trans people. What is needed first is some confidence and resilience among leaders to tackle poor care given the toxic nature of the public ‘debate’. But if the NHS doesn’t face up to this challenge, then it has implicitly accepted it will fail a community that already experiences both poor care and poor outcomes. Whatever one’s personal beliefs, this was not what the NHS was created for.