Imagine this: you’re the parent of a transgender 14-year-old. When they were born you thought your child was a girl, but it has been very clear for many years that they identify completely as a boy. He’s been known by a male name in your house for years and would be revolted if anyone used a female pronoun for him or referred to him as a girl.
You have been to see your GP, who has referred your son to the Tavistock clinic in London, the gender identity service for under-18s in England and Wales. But because of an unprecedented increase in the number of referrals over the past year, Tavistock has said it will be eight months before your child can be seen. He has just begun female puberty and is starting to panic about growing breasts, changing shape and getting a period. He is desperate not just to be put on hormone-blockers, which will prevent his female puberty, but also to be put on male hormones, so he can start male puberty, which the Tavistock clinic will not prescribe until he is 16 and has spent a year on hormone-blockers.
You’ve heard there are GPs who operate privately and prescribe hormones to children. But you’re not sure if this is legal: if there are age restrictions in NHS clinics, surely, you think, there are guidelines to restrict private practitioners as well. You read up and call around. But no one can give you a clear answer. Worse, no one even knows who you should talk to in order to get one.
Related: UK doctor prescribing cross-sex hormones to children as young as 12
Two weeks ago, the Guardian launched a series looking at some of the issues facing trans people. I spent weeks talking to trans people, their families, trans support charities, as well as doctors and psychiatrists. One issue that came up again and again was that there was an utter lack of clarity when it comes to some issues relating to transgender healthcare.
The issue of private prescriptions of hormones to teenagers is a good example. The NHS guidance says cross-sex hormones can’t be given to patients under 16 at its gender identity clinics, but after talking to a GP who prescribed cross-sex hormones to patients as young as 12, I tried to find out if there are similar guidelines or laws in place that applied to private gender specialists. It seems there aren’t, but the process of getting an answer to that question was beyond farcical.
I first put the question to NHS England, which told me it was a matter for the General Medical Council, which in turn referred me to the National Institute for Health and Care Excellence (Nice) and back to NHS England. Nice said it hadn’t been asked to write guidance on the subject and that this was a matter for the Department of Health. The department said that since private GPs were regulated by the Care Quality Commission (CQC) I should talk to them; the CQC said its job was to enforce guidance, not write it, but suggested speaking to the Royal College of General Practitioners and the Royal College of Physicians, both of whom couldn’t help.
I finally got a statement from the Royal Pharmaceutical Society, which said: “Doctors have to carefully consider each prescribing decision they take based on their own clinical judgment. Medicines can be prescribed off-licence as long there are sound clinical reasons for doing so.”
Trans people shouldn’t have to have some sort of NHS Rosetta Stone to work out what treatment they are entitled to
This is just one example of the muddy, bureaucratic waters that trans people have to swim in order to understand what healthcare is available to them, never mind trying to access it.
In Scotland, for instance, the current guidance says that people under the age of 16 can be prescribed cross-sex hormones if they are thought to “have enough intelligence, competence and understanding to fully appreciate what is involved in their treatment”.
But this is not the understanding of the only gender identity clinic that treats children and adolescents in Scotland, Sandyford in Glasgow, which has said that Scottish services don’t prescribe cross-sex hormones to under-16s and the reason the 2012 protocol says something to the contrary is that it “contains some inaccurate information and requires updating”.
And then there is the raging debate surrounding “bridging prescriptions”. Doctors at gender identity clinics (GICs) say “bridging” prescriptions are meant for patients who have been through an assessment at a GIC and have been prescribed hormones but who have, for example, moved away and need a prescription for hormones to tide them over while awaiting an appointment at a new clinic.
Talk to some trans charities and you hear a different story. They say bridging hormones can be issued to someone who has never been to a gender clinic, but who is on the waiting list to get in. They argue that since waiting times for treatment are so long, GPs are not only allowed to but are bound to issue hormone prescriptions to patients who ask for them in the name of harm reduction.
Related: Gender identity clinic for under-18s sees number of referrals double
I have read everything I can find on bridging prescriptions and I am still not confident as to what they are. The guidelines from the NHS (pdf) are unbelievably vague on the subject.
Trans people shouldn’t have to have some sort of NHS Rosetta Stone to be able to work out what treatment they are entitled to. They shouldn’t have to call nine separate health bodies to get a vague answer about whether a private GP can prescribe hormones to their child. And doctors – both within the NHS and operating privately – should have clear guidance about what treatments they can and can’t offer.
These questions aren’t for the sake of pedantry. If doctors aren’t confident of what’s legal or recommended when treating trans patients, then they will either err on the side of caution and not offer medical intervention when they should; or offer interventions when they shouldn’t, out of a desire to help.
It is only when there is clarity on trans healthcare that doctors who want to do the right thing will be confident of what that is, and that trans people will be able to get the treatment they need and to which they are entitled.
There needs to be more clarity in transgender healthcare
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