Psychiatric assessments for trans patients need completely overhauling in the UK - because long waiting lists could be contributing to patient deaths.
Many people with gender dysphoria seek body-altering hormone therapy as part of their transition.
But, according to international guidelines, a patient must first have their mental health assessed before hormones are allowed to be issued.
That, says trans surgeon Christopher Inglefield, is creating enormous waiting lists that drive desperate individuals to buy potentially-dangerous hormone drugs online.
Mr Inglefield, medical director at The London Transgender Clinic, says: “The majority of trans individuals do not need mental health assessment prior to starting medical transition.
“Yes, a small number of people do need support for mental health issues - the same as any individual who requires medical supervision, for example, high blood pressure or asthma would need medical input to ensure that the most appropriate care is provided.
“However, individuals are being made to wait years to be ‘assessed’, before then being referred for hormone treatment - which is then another long waiting list up to 12 months.
“Many will lose faith, or not want to subject themselves to the assessment, and are then buying hormones online, typically from clinics in India.
“Without a proper prescription, patients don’t really know what they’re taking and they often end up paying over the odds - hundreds of pounds per month - for the privilege.
“Many trans patients also struggle with anxiety and depression, with a high rate of attempted suicide. These long delays to access care only to be refused shared care by their GP is often enough to destabilise them and trigger their suicidal ideation into action.”
Those seeking hormone therapy have two options - the NHS route and the private route.
The NHS will typically refer patients to a Gender Identity Clinic (GIC), which offers mental health assessments and support, as well as cross-sex hormone treatment, speech and language therapy, hair removal treatments, surgery and peer support groups.
If a patient wants to have genital reconstructive surgery, they’ll usually first need to live in their preferred gender identity full time for at least a year. Only then will they be considered for surgery.
But Mr Inglefield says many patients endure a two year wait just to have an initial mental health consultation at a GIC, before being referred and in some cases having to wait another year for hormone therapy.
Mr Inglefield, and other private trans clinics, are bound by the Standards of Care by the World Professional Association for Transgender Health (WPATH), which state a patient needs a referral from a psychologist trained in trans issues before hormones can be dispensed.
But he says: “Even privately, away from the NHS and GICs, there can be long waits.
“You’ll have to find a psychologist, then wait around three months for an appointment, and a further wait then for hormone therapy.
“It’s a long and convoluted process which needs to be streamlined.
“Once a patient begins hormone therapy, it could then be another six months to a year before any changes become apparent.
“But just having the hormones in place makes a patient feel like they’re on the road to where they need to be and it eases some of the anxieties.”
There are just eight GICs in England - two centres in London, as well as Sheffield, Leeds, Newcastle, Daventry, Nottingham and Exeter.
Just two of those clinics assess children.
Hormone therapy for adults means taking the hormones of your preferred gender.
The NHS says a trans man - female to male - will take masculinising testosterone, while a trans woman will take oestrogen.
And Mr Inglefield is not alone in calling for change. Earlier this month experts from McGill University, Canada, also called for the mental assessments to be dropped for both adults and teens.
Bioethicist Florence Ashley wrote in the Journal of Medical Ethics: “The fundamental ethos is that people know what they want regarding their body.
“Whether they want hormones or whether they want to be pregnant and keep a child to term — they should have the power to bring about the desired situation.”
However, the trans community appears divided on the subject.
Journalist and author David Thomas found ‘comfort and support’ from speaking with psychological experts - and says the assessment is ‘necessary, especially for young people.’
He adds: “I can easily imagine kids ascribing feelings to being transgender that might actually be due to being gay, or just going through a developmental phase.
“Of course, for actual trans kids it's not a phase and they won't get over it ... but you need to make damn sure before you start prescribing life-changing treatments.
“I'm also very wary about making any definitive decisions too soon, because even if a teenager is transgender, full gender transition may very well not be the only appropriate course of action.
“He or she may actually be OK at a different point on the spectrum, living with a gender-queer, androgynous presentation and they may not settle on the way of life that works best for them until they are fully adult themselves.
“Plus, I have to say that speaking personally, it has been a huge comfort and support to me to have had the chance to speak to lots of people who are experts in the field and receive the reassurance that I am what I think I am.
“That knowledge that I have been properly assessed gives me great strength when faced with sceptical transphobic bigots who act as though we're all sick, or delusional or just faking it.”
“When I say I approve of assessment, I do so on the condition that kids - and adults too - are believed, supported, taken seriously, respected and empowered by the system that is assessing them.
“I am not seeking to prevent anyone from transitioning who wants to do so. I certainly don't want to make the lives of trans children and teenagers any harder - I was one, after all!
“I just want to make sure that they are given every resource to find the right path for themselves .. and that includes a full understanding that transition may not be the best thing for every trans person.”
Shock figures reveal 40 per cent of transgender people have attempted to take their own lives at some point, according to a study by the National Centre for Transgender Equality.
"The majority of trans individuals do not need mental health assessment prior to starting medical transition."
Christopher Inglefield, trans surgeon
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