The reality of being transgender in medicine
Jai NicAllen describes what it is like for patients who are transgender in the NHS and what life is like as a transgender medical student
Starting medical school is scary. Students are thrown into the deep end: confronted with reams of hard facts, a new social scene, and a set of professional values we must uphold. But, for me, none of those were my biggest concerns when I started medical school. I am transgender, and the questions facing me were more about how should I come out, how to feel about lecturers who teach as if trans people do not exist, and how to deal with ignorance around transgender issues.
What does it mean to be transgender?
Most people go through life being comfortable with the legal gender they’re assigned at birth. Transgender people, however, realise at some point in their life that this assigned gender does not accurately reflect their experience of gender. They may feel that they are another gender—for example, someone who was assigned male gender may realise that she is a woman. Alternatively, they may realise that they are neither completely a woman nor completely a man, and this diverse group of identities is collectively known as non-binary. About one in 200 people, according to a US study, are transgender and ignorance of transgender issues is widespread, in general society and within medicine.
NHS transgender care
The Trans Mental Health Study (TMHS), which surveyed almost 1000 trans people in the United Kingdom, found that 61% think that they have to go out of their way to educate health professionals about trans health issues. This can put trans people in a difficult situation because the professionals they are turning to for help often know less about trans issues than they do.
Although the role of the expert patient is on the rise, nobody would expect somebody with a health condition like diabetes or cancer to have to teach their doctor about their treatment. Relying on patients for education can lead to unprofessional and invasive behaviour from healthcare professionals. In the study, 16% of trans people said that they have been asked inappropriate questions about their genitals by a health professional and 7% had a health professional ask to see or examine their genitals unnecessarily. One mother told me that her transgender son knew more about his health needs than their paediatrician: “At seven years old, trail blazing is a heavy duty when you’re only trying to be happy.”
This ignorance is a major concern because trans people are likely to access a variety of healthcare services. Trans-specific healthcare is a complex, multidisciplinary process, and trans people still have the same health concerns that everybody else has. Although trans-specific health needs are primarily handled by gender identity clinics (GIC), the initial referral often comes through primary care, and the lifelong management of hormone therapy ought to be managed in primary care. Yet, a lack of awareness of trans issues means that there are still many trans people who have to travel hundreds of miles just to see a clinician who understands trans healthcare.
Trans people are entitled to NHS counselling to help work out their best treatment path. Many trans people feel unable to speak openly to counsellors at GICs, because they worry that expressing doubts about their gender transition may result in them being denied medical interventions. This fear is not unfounded—some trans people have had their GIC care stopped because of their transgender history, or the way they expressed their transgender identity. The GIC ought to be a safe, welcoming place that supports patients in exploring their gender identity; instead many people find it feels like an ordeal they have to get through to access treatment.
Some trans people have experienced outright prejudice. The TMHS found that a quarter (24%) of respondents have heard a health professional use hurtful or insulting language about trans people, and 12% have had a general health professional refuse to treat them because they are transgender.
The NHS acknowledged that “many [transgender and non-binary] people continue to experience health inequalities born out of a lack of awareness of their needs and/or stigma among health professionals, and problems in accessing mainstream NHS services which are appropriate and personalised to suit the individual.”
Stigma within the medical profession
If the experience of trans people as patients can be negative, how does it feel to be a transgender doctor in the NHS? Pippa, a transgender doctor not yet out at work because she fears professional or physical injury, explains the stigma she faces.
“I still fear people’s prejudice. I have seen too many doors closed to people for being of any ‘non-heteronormative persuasion.’ In one post, I was ridiculed for knowing how to put tights on a patient neatly, with snide comments about “wonder what you get up to at the weekend?” she said.
The TMHS shows that 84% of respondents have thought about ending their life at some point, and 35% have attempted suicide. More than half have a history of self harm, and many directly link this self harm to their experience as patients within the NHS.
One trans healthcare professional who wanted to remain anonymous said: “When I was a student, occupational health told me I wouldn’t be able to graduate if I was self harming—but they didn’t give me any help with my dysphoria. I just lied and said I’d recovered because the health screening appointments were harder to pass than my exams. But these are the people who are meant to be giving you support.”
Yet some have more positive stories. Anne Grey, a trans nurse at Royal Preston Hospital in Lancashire, described her experience transitioning at her NHS trust, and told me of the inclusive trans policy her employers and peers have adopted. “I am so impressed how hard my colleagues worked on getting pronouns right, asking very good questions and supporting me as a trans woman,” she said.
Being a trans medical student
So what’s it like being a trans medical student in this climate? So far, it is proving incredibly hard. It isn’t that most of the people I meet are transphobic—they’re not. It’s more that everyone is undereducated about trans issues. Despite good intentions, this ignorance is evident in how I am treated by my peers, in my interactions with lecturers and support staff, and even the content of our classes. Being transgender is probably more common in the UK than having HIV, cystic fibrosis, or chronic hepatitis C. All of the latter have been mentioned multiple times as part of my medical education, and I would not be allowed to graduate without knowledge of these conditions. Yet I am not expected to demonstrate any knowledge of how to provide either specific or general healthcare to trans people appropriately and sensitively.
At medical school, I have been taught things that are factually incorrect, such as uterine cancer only affects women. In reality, trans men have a slightly elevated risk of uterine cancer owing to long term administration of high dose testosterone. Health professionals need to be aware that trans men can indeed experience uterine cancer, and to understand the different approach required to treat uterine cancer in trans men. Trans awareness and inclusivity are essential to comprehensive healthcare provision—and they are sorely lacking.
Looking to the future
With regard to my future as a doctor, I am concerned about the impact being trans might have on my career progression. Transitioning is a public process. It can be difficult for a trans person to get a job without being “outed” as trans, usually because their references or documentation reference a former name. Although there are no specific studies looking at trans employment in the NHS, studies looking at trans employment do not present a positive picture. More than half of all the participants in a 2007 Home Office research paper said they had experienced discrimination and harassment at work, with one in four moving jobs as a result. Combine that with the above information on treatment of trans people in the NHS and it is no surprise that most people interviewed for this article wanted to remain anonymous.
The only way to improve this situation is to work towards equality. As Pippa pointed out, much has changed since she graduated from medical school: “The internet brought together disparate groups like the trans community in a way not possible before. Furthermore, in 2004, there was the Gender Recognition Act and a whole lot of other legislation protecting trans rights,” she says.
NHS England and NHS Scotland have clinical networks that are working to improve trans healthcare, in consultation with trans communities. I am also working with the Scottish Transgender Alliance to develop training resources for healthcare professionals. The Gender Identity Research and Education Society (GIRES) and the Royal College of GPs have released an e-learning module to train GPs about gender variance, and a motion was passed at the BMA’s annual representatives meeting by medical students calling for more trans awareness and training, at undergraduate and postgraduate level.
Progress is being made, and I hope that in 20 years’ time I will be able to return to Student BMJ and talk about successfully working as an openly transgender doctor, thanks to improved LGBT+ (lesbian, gay, bisexual, transgender and other marginalised sexualities and gender identities, such as asexuality) equality. The trans part of the LGBT+ community may still be in the early phases of the struggle towards equality, but if the rapid improvement in LGB acceptance is anything to go by, the necessary improvements may well be put in place during my medical career.Jai NicAllen, first year medical student
1University of Dundee
Correspondence to: email@example.com
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
- Conron K, Gunner S, Stowell G, et al. Transgender health in Massachusetts: results from a household probability survey of adults. Am J Public Health 2012;102:118-22.
- McNeil J, Bailey L, Ellis S, et al. Trans Mental Health Study 2012. Edinburgh: Scottish Transgender Alliance, 2012.
- National Health Service England. NHS drive for action to tackle trans inequalities. 2015. www.england.nhs.uk/2015/06/26/drive-for-action/.
- Curtis RJ. Should trans men have a hysterectomy? Gender Identity Research and Education Society. 2015. www.gires.org.uk/health/should-trans-men-have-a-hysterectomy.
- a:gender. Gender identity and employment monitoring: transsexual/transgender/intersex perspective. Home Office, 2007.
- Gender Recognition Act 2004, c.7 (England).
Cite this as: Student BMJ 2015;23:h6648