TRans rights in the uk, pt.2

- Episode 15- Transcript

Georgie Williams, voiceover: Trigger warnings for this episode include many aspects of gender dysphoria including body hair, electrolysis and surgery as well as blood and medical conditions including Type 1 and 2 diabetes- please proceed with caution.

Between Part One and Part Two of this two-part exploration of transgender rights in the United Kingdom, the outcome of a major legal case rocked the British transgender community. If you are not familiar with the name Maya Forstater, allow me to summarise the case she originally raised in court. In 2019, Ms Forstater’s employment contract was not renewed at a British think tank, the Centre for Global Development,, as a consequence of her posting a series of tweets on Twitter questioning government plans - which were later scrapped - to let British citizens declare their own gender. In her original case she claimed she was discriminated against because of her beliefs, which include that, and I quote, "sex is immutable and not to be conflated with gender identity".

In the initial tribunal, employment judge James Tayler stated that Ms Forstater was not entitled to ignore the rights of transgender individuals and the "enormous pain that can be caused by misgendering". However, in her High Court appeal on June 10th, 2021, the judge ruled that her so-called "gender-critical" beliefs fell under the 2010 Equality Act. 

If you are still here with us on our fifteenth episode, you may now know how dearly this will have impacted the transgender community- but if not, join us today as we unpack what it is that has to change to establish a safe and secure community for the transgender citizens of the United Kingdom. Welcome to Episode 15 of /Queer. You’re here with me, your host, Georgie Williams.

In part one of this two-parter we had been conversing with Cat Burton, Chair of the Gender Identity Research and Education Society here in the United Kingdom. Cat unpacked misconceptions surrounding the transgender lived experience as well as the impact of transphobic media in the UK and the fallout of an ineffective national healthcare service on the wellbeing of the trans* community. Cat had much to say not only on these issues but also on how societal expectations upon the appearance of transgender bodies adversely impacted one’s wellbeing and welfare. At the root of much transphobic rhetoric is a fixation on who ‘passes’ and what constitutes ‘passing’- that is, to appear as the cisgender equivalent of your gender identity if you are transgender.

Cat Burton, in interview (00:00:00): You know, I’ve got friends who have ultimate, passing privilege, so they are absolutely invisible in the community. Most people take them for cis gender, and that’s absolutely fine with me. It’s not me, I don’t have that level of privilege, I’m ‘too big’, ‘too tall’, and I make no pretences- having transitioned in my late 50’s I’ve got some things that testosterone is never going to let me forget. You know, my voice isn’t perfect by any stretch of the imagination and the only reason why it sounds as feminine as it does is that I’m putting in a huge amount of hard work to make it sound more feminine. But you know testosterone damage is such that you can’t reverse it, even with surgery, your voice. There are some surgeries which are being tried, cricothyroid approximation is one of the better ones. But most of them don’t produce long-term, good results. Some of them produce a very high pitched, squeaky voice which still doesn’t sound feminine, and some of them just revert back – the vocal chords simply stretch back again over the space of a few weeks. And very often what that does is leave you with the original pitch of voice that you had but with much less power in your voice. So you know, it’s just hard work that does that. I had 147 hours of electrolysis to get rid of my facial hair and you know, that was, I did it over in the States, at $100 an hour, because they did it in complete face-clearance sessions, so, my first visit, I had 34 hours of electrolysis over 3-days. That was actually 17 hours in a chair because there were two girls working, one on either side of my face. But, 34 hours over 3 days. It was excruciating. My body hair, it responded to hormones by slowing down, but it still needed to be waxed, you know, it’s all very well slowing it down but it’s not going to take it away. And I remember going to the girl that did my waxing for me, and plonked myself down on her table and we were at it from about 9 in the morning to about 4 in the afternoon. Yeah it was literally one of the most painful experiences of my life. When she did my pubic hair, she lifted me off the couch with a strip of wax and there was blood. And of course it’s these things that you know we can talk about that prove that nobody would do this for the fun of it, nobody would do it trivially. It’s taken me years of hard work and pain and effort to present as well as I can, which I understand doesn’t give me ultimate passing privilege, but it’s as well as I can and it’s enough to make me comfortable in my own skin.

Georgie Williams, voiceover: Social perspectives on trans validity, even within more accepting communities, are still reductive. Some trans individuals who ‘pass’ as cisgender experience what Cat describes as passing privilege. Although these individuals may not want what is sometimes also called ‘cisgender assuming privilege’, where people incorrectly read their appearance as cisgender, it can be of benefit if an individual lives within a community where being visibly transgender will put them at risk. It is a misconception that all transgender individuals wish to ‘pass’- a misconception often grounded in the belief that nobody would want to look visibly transgender, which is in itself innately tied to cisnormative and even Eurocentric beauty standards. This occurs when what is visually feminine and masculine within a society is defined by European features, particularly facial features, such as a small nose on women- and the size of one’s nose does loosely correlate with one’s physical sex as well as other factors such as ethnicity. In a study investigating the impact cisnormative beauty standards, University of Indianapolis academics Monteiro & Poulakis highlight the perception that transgender women have that assimilatory expectations are placed upon them- that in order to fit in, they should look like and therefore be able to pass as cisgender women.

With this in mind, we must address how the transgender individuals who are platformed to talk on trans issues even within the queer community are those who ‘pass’, who are considered physically attractive and are thus perceived to be assimilating into cisnormative society, whether or not they actually wish to. This practice not only has a detrimental effect on the welfare of trans individuals who do not pass but may encourage unconscious bias that leads to the voices of nonbinary transgender people being overlooked too.

For those who are less familiar, nonbinary transgender individuals are those who do not identify with their assigned gender at birth but do not identify with either gender within the social concept of a gender binary- male or female. At this stage it is crucial that we address that being nonbinary is not directly correlated with one’s appearance- and that aesthetics do not equate identity. I speak, of course, as a nonbinary transgender person who passes as a cisgender woman regularly for various reasons- my appreciation of make up, fashion, my desire to stay safe in public places and my anxieties about how hormone replacement therapy would impact my body in ways I may not be able to predict- although my persistent gender dysphoria encourages me to pursue this treatment. This is, of course, a great deal of personal information to disclose in order for someone to respect my transness despite my appearance. So going forward, it is important that we consciously disentangle gender identity from how an individual looks.

That said, many nonbinary transgender individuals may appear outwardly androgynous or be hard to ‘read’ as being either male or female- which is often the intent. However, this inability to read a person can often cause discomfort in an audience and as beauty standards are inherently cisnormative and often operate within a gender binary, nonbinary individuals may be overlooked as voices of their community due to not being considered assimilatory in their appearance. We are encouraged from an early age to associate maturity, professionalism and even psychological stability with binary gendered appearances- although, in the case of women, often an appearance which is female but not hyperfeminine is considered more respectable. This can lead to individuals considering androgynous or ‘genderfuck’ appearances to be signs of immaturity, instability or a lack of professionalism. So at the core of trans-inclusive social reform, both inside and outside of the queer community, is a need to platform voices of trans individuals who do not meet cisnormative, Eurocentric beauty standards- whose transness is visible, whether they are binary transgender or nonbinary transgender.

My next question for Cat was taking on the beast at the heart of transgender welfare reform- healthcare- and it turns out Cat had more than a comprehensive response for what an effective healthcare model should look like.

Georgie Williams, in interview: I think it’s interesting that you mentioned going to the US for electrolysis because one of the questions I was going to bring up is obviously the subject of trans healthcare services in the UK is both controversial and a site of a great deal of misinformation. Particularly, as you mentioned, within the realms of mainstream British media. So, I was going to ask, in your opinion, based on your lived experience in particular, what steps do we need to take in the UK to reform and transform our health care system for the sake of trans and gender diverse individuals?

Cat Burton, in interview: So, I’m fortunate, I live in Wales, and we’ve got something that would probably still be called a ‘pilot scheme’ by England. They set up 3 pilot schemes in England, which pretty closely reflect what we’ve been doing in Wales. In Wales, we identified that the solution to huge waiting lists was not to throw money at the small number of very limited, very local, very understaffed clinics, which is the English model of GIC.

So what we’ve got in Wales is learn from another health condition which experienced a similar explosion in numbers, and that was type 2 diabetes. Now type 2 diabetes, when it became prevalent, and it became prevalent through the 50’s, 60’s, and 70’s because of an unhealthy diet. But it was nevertheless a genuine health condition. Type 1 diabetics had always been referred to specialists, but there were too many people who were developing type 2 diabetes for that specialist centralised model to work. So it became the purview of your GP, it devolved to primary healthcare. Looking at that we came up with an idea that what we should do, is to encourage GPs to take a little bit of extra training, and it’s not much because prescribing hormones and the like isn’t rocket science, it’s about 2-days extra training in fact. We encouraged GPs to do that and the object of the exercise initially was to have one GP in what’s called a ‘cluster’, so that’s not one in each GP practice, it’s within groups of- perhaps a town of GP practices. So there are 71- I think- clusters in the whole of Wales. So the initial plan was to have 71 GPs, each of whom had a little bit of extra training, and they would be the primary provider of healthcare for transgender people. What we recognised was that it was a very linear process in the industry GIC’s, it was all pointed at the outcome of surgery, and not every trans person needs surgery. It was all focused on psychological evaluation and then prescription of hormones. And then a recommendation of surgery from at least two senior psychiatric clinicians, and then onto a surgical waiting list. And an awful lot of people don’t need all that, all that most trans people need initially is to be able to talk to someone. Talk through their processes, talk through their thoughts, potentially to transition socially. The GP can provide that virtually in-house. If it’s a really complex case with underlying pathologies, they’ve got access to the Welsh Gender Centre which, at the moment, there’s only one in Cardiff, but there’s plans to open another 3 in other areas of Wales. They have a staff of much more expert doctors. So they’ve got endocrinologists, they’ve got psychiatrists and psychologists, they’ve got speech therapists, they’ve got… we’re probably not going to be able to afford going down the electrolysis route because it takes so long, but we’re certainly hoping they’ll provide laser hair clearance  which works for people with strong contrasts between their hair and their skin. You know, all these things will be available centrally, but the service isn’t looking to treat people centrally. Some cases which are more complicated than the cluster GPs wish to treat, will be referred to the centre. But the centre is also there to act as an advice centre for those GPs. It trains the GPs, and it’s also there for advice when something is a little bit beyond their training. So the idea is that more and more GPs are going to take that training. And I go along and I talk a couple of times a year to what’s called ‘GPSG3’ which is the very last bit of GP training. These are already qualified doctors, who are training in the specialty of general practise and they work under the supervision of other GPs within group practises for about 3 years. And SG3 is right at the end of that process, they’re about to be signed off so they can go off and start their own practise all on their own, somewhere in their own little village in North Wales, and we go in and give them transgender awareness talks myself and often an academic from Swansea university. One of the biggest questions we get asked at the end of our awareness talk is ‘how do I get the extra training to be a cluster GP’. So, particularly young GPs, are multiplying so fast in our service now that it’s not going to be long before pretty much every practise has got at least 1 person who’s got this training. And that’s where we need to be, we need to be in a position where every GP is competent to prescribe hormones. It really isn’t rocket science, to be honest with all of the waiting lists an awful lot of transgender people self-prescribe, I must admit I did, myself.

I went along to see my GP and I said ‘look, I know you’re going to tell me that this is dangerous and I shouldn’t do it, but I am self-prescribing and I want you to just carry out your primary healthcare function of just monitoring my basic health. So, send me along for a blood test, ask for all the hormone readouts, but most importantly from your point of view, monitor my kidney and liver function, make sure I’m not damaging my organs. I will look at the blood tests and set my own doses of the hormones I am taking’. And I was taking testosterone blockers and oestrogen, as a gel – I had the Sandrena gel which is a very common choice for HRT for peri-menopausal women. And I’d been referred to the GP, to the NHS gender clinic in Charing Cross at this stage because that was the Welsh model at the time, and 15 months later even the person who’s referred me, the local psychiatrist, hadn’t heard back and I had taken in my head that I was now going to go and see someone privately and see a private clinic in London, took along all my blood tests, all the way right at the beginning when I started taking hormones, up to the latest one. And he looked at them and said ‘well we aren’t going to have to change any of these doses are we, Cat?’ because most trans people are so well versed in everything to do with being transgender, that we can self-prescribe quite happily and get the levels right. What we can’t do is make sure we aren’t killing ourselves in the process. So it would be really nice to have a GP, locally trained, who is at least as competent as me at prescribing hormones, and getting it right. Like I say, it’s just not rocket science. 

I told the committee today that that’s the model they should be looking at for healthcare in England. Because throwing money at GIC does not work. It will never get rid of 5 year waiting lists. Whereas telling the GPs saying ‘why don’t you just do this guys?’… we had to overcome some problems as GPs were very sceptical at first in Wales. But we found out that their main point of scepticism was that they would be asked to prescribe off-licence medications.

 Now, medications are only put on licence because the developing drug companies want to pay to put it on licence. And the perfect example is two very similar drugs called Finasteride and Dutasteride both of them prevent the production of dihydrotestosterone which is a breakdown product of testosterone and is actually the agent that causes male pattern baldness. But it also does other things like causing the prostate to swell and that’s called [benign-prostatic-hyperplasia]. And the treatment for that is either Finasteride or Dutasteride. Finasteride is a much older drug it’s about 75% effective in preventing DHT production. Dutasteride is a newer drug and is at least 90% effective. So needless to say the doctor would almost always chose Dutasteride cause it’s a better drug. However, finasteride is on licence to prevent male pattern baldness. Dutasteride is not because the developing drug company never paid to have that use put on licence. But it’s definitely the better choice, if you want to prevent male pattern baldness. But some doctors are reluctant to prescribe it because it’s not on licence.

So the problem we had when setting up the Welsh Gender Service was doctors saying well I can’t prescribe that because it’s not on licence and I’m not insured to do it. And what the Welsh government said was ‘well, we’ll pick up the extra liability insurance that covers you for off licence prescriptions and other drugs that are in common use in the treatment of transgender people. Whether that be Dutasteride or Sandrena gel which is on licence for HRT for peri-menopausal women but not on licence for treating transgender women, it’s doing the same job in both of us. And for testosterone blockers, particularly GNRHs which are the most effective ways to do it, and of course these are the ones that have caused controversy in the courts recently. But they may not be on licence for us but they’re on licence for treatment of precocious puberty and in that case they may be given to a 3 year old kid who’s showing signs of puberty, to stop puberty from happening until they’re 12 or 13 when it’s appropriate. You know that’s a 10 year use of that blocker whereas most trans people will only ever be prescribed it at the onset of Tanner stage 2, which is the onset of visible signs of puberty so maybe erections or the first budding of breast growth, something like that. They will then be prescribed blockers for maybe 2 or 3 years as a pause button so they can be absolutely sure of what they want to do and which puberty they want to go through so you know, just let the kids have time to decide, treat them fairly, treat them in a really timely fashion and at the moment of course the waiting lists for young people’s transgender healthcare is so long that some arrive at Tanner stage 2 and are at Tanner stage 4 before they even get seen.

You know, that’s a tragedy because almost all of the things I’ve talked about having to change in myself, somebody who’s put on blockers at Tanner stage 2 will never have to go through that. Because they will have long enough to be absolutely sure of what they want to do and the phrases we use is persistent, consistent and insistent, that they are who they say they are, and if they continue with that and wish to carry on to hormonal- cross-gender hormones- or surgical intervention, none of that is going to take place until they’re competent. Sixteen for the hormones and eighteen for the surgery. And of course, that addresses competence, and there’s such a thing as Gillick competence and in that case undermines Gillick competence in its entirety. Why on earth would you single out one type of people, transgender people, and say well you’re not competent but a 12 year old girl who’s just started her periods is perfectly competent to go and decipher she wants to take a birth control pill without even consulting her parents. You know Gillick competencies are an absolutely fundamental principle and it’s one the courts shouldn’t be tinkering with.

Georgie Williams, voiceover: Gillick Competence is a term used in English and Welsh medical law and is used to decide whether or not a child- in this case, an individual below the age of medical consent, which is 16- is able to consent to their own medical treatment, without the need for parent or guardian permission or knowledge. Gillick competence is determined through the use of the ‘Gillick test’, which has no set of defined questions but assesses  the child's age, maturity and mental capacity, their understanding of the issue at hand- such as transitioning their gender and what it involves, their understanding of the risk and consequences, how well they understand any advice or information they have been given and their ability to explain a rationale around their reasoning and decision making. So to contextualise the issue Cat raises, her concern is that cisgender adolescent girls are allowed to access contraceptives based on their Gillick Competence but transgender healthcare isn’t assessed on the same criteria. Undoubtedly, both contraceptives and transitional therapies have long-term effects on the body- and yet trans youth are not considered to have the same decision-making capacities under UK law as their cisgender peers. Cat’s vision for transforming transgender healthcare extends beyond access to adult treatments to how the needs trans youth are addressed- with a need to address the dismissive and often shame-inducing perspective parents, carers and healthcare professionals impose on trans youth about their feelings and convictions surrounding their own identities. Where some popularised research has found high rates of detransitioning amongst trans youth, this research has been widely criticised for its methodology, as well as for including gender non-confirming children who may not have identified as transgender at all. More academically reputable and rigorous research by Boslaugh and James has found that standard rates of detransitioning are around 8%, with 62% of that 8% going on to transition away from their assigned gender at birth again at a later date. It’s important to note that many transgender individuals cite lack of social support and discrimination due to their trans identity as being one of their key motivations to detransition in the first place.

Georgie Williams, in interview: It sounds like once we’ve even gotten past the issue of ideologies surrounding the trans community and misinformation others experience, then there is this hurdle of like actually educating medical practitioners on how to prescribe, how to prescribe it, who its appropriate for, this idea of who has agency and autonomy over their bodies… feels like quite a hurdle still.

Cat Burton, in interview: Well, it’s definitely heading in the right direction. We’ve developed a service now from initially where it was going to be, um, anything complex was gonna get referred up to London and back onto the waiting list, to now, everything is pretty much dealt with in Wales and .. we have no waiting list in Wales, it’s as simple as that. There is no waiting list. I mean you’ll hear that there is a waiting list to see a specialist in Wales but that’s because most of us don’t go to see a specialist, we go to see a GP, you know, in the next village over or the next practice down the road and that is how we’re proceeding. Yes some people still think surgery are the be all or end all and may well be end up being referred for surgery, probably in London because that’s where the surgeon is, although we’re certainly looking at bringing that in-house in Wales as well, but you can get rid of a huge amount of the queue if you realise, not everybody wants surgery and not everybody wants hormones. Pretty much everybody wants to go and talk to their doctor about it, and the GPs are the perfect doctors to do that with.

Georgie Williams, voiceover: We opened this episode with a focus on the Maya Forstater case, whose beliefs have been protected under the 2010 Equality Act. This wasn’t only to highlight the state of trans rights in the UK at this point in time but also to convey the disparity between the rights of those considered eligible for protection under this act and the rights of those who are overlooked by it. The 2010 Equality Act states that, and I quote, "a person has the protected characteristic of gender reassignment if the person is proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning the person's sex by changing physiological or other attributes of sex” This definition does not provide protections for those not wishing to transition, medically unable to transition, or non-binary, or genderqueer individuals for whom this aspect of the trans experience may not be relevant. Cat is right- not every trans* person wants or requires hormones, surgeries or other medical transitional therapies- but there should still be legal coverage for the rights of those individuals against discrimination and social inequality. 

The key areas of necessary reform for transgender welfare in the UK form a trifecta- healthcare, legislation and social education. One informs the other. Social education occurs when a variety of transgender voices are platformed to dispel misconceptions about the trans community, facilitating more accurate representation of this social group and positively influencing wider social perspectives. This generates more effective and informed allyship which subsequently puts pressure on governments to address shortcomings within healthcare and legislation- and legislation ensures, or should ensure, that transgender healthcare meets a particular standard. Widespread implementation of transgender healthcare and legal protections further normalises trans experiences and integrates them further into social and cultural awareness. 

In order to generate this change, it has to start from the bottom-up. This pressure has to come from the majority- the general population. Allyship is a term which is misused and often associated with performativity or platitudes- but true allyship is what can generate measurable change within a society. This is our final episode in the United Kingdom- the second part of a two-parter that has explored the rights and freedoms of many of the members of our own /Queer team- but these rights and freedoms affect all of us on some level, no matter where we’re from or our gender identity. If you are a cisgender British citizen you likely have friends, colleagues or relatives, whether or not they are out to you, who are transgender. You may even have children whose rights are less than yours due to their gender identity. If you are not a British citizen, this episode may echo truths about transgender rights in your own home country- or serve as a cautionary tale for the direction that those rights could go in without active allyship and protection of those rights. In the UK, as with many countries around the world, we have an uphill struggle ahead of us- transgender rights and freedoms will be secured no more easily than gay rights or other civil rights. But the numbers are on our side- and every voice amplifying the plight of the transgender community is a success for the cause. 

This episode of the /Queer Podcast was edited by Sam Clay, transcribed by Bronya Smith, co-scripted and produced by myself and Matt Thompson and hosted as always by me, Georgie Williams. A very special thanks to Cat Burton from the Gender Identity Research and Education Society for her contributions to this episode and to our previous episode. Thanks as always to our Patreon subscribers- your support of our podcast, articles, social media content and fundraising projects has carried us so far- into the devices and the ears of fans across 121 countries. If you’re not a patron and want to support the podcast, you can find the /Queer Patreon at patreon.com/slashqueer. That’s S-L-A-S-H Queer. The link is also available on our Facebook, Instagram and Twitter pages. We have new merchandise being released this month as part of our Pride Month celebrations and are accepting donations via Ko-fi- and you can find the links to both in the description for this episode. For those of you who continue to like, share and listen to this podcast, I hope you know how much your support matters to us. We wouldn’t be where we are now, eighteen months since the genesis of this project, without every single one of you.

This episode was recorded on location in London, the United Kingdom. Music in this episode was composed by our resident audio king, Sam Clay. If you enjoyed this episode or have any feedback, please get in touch on Instagram or Twitter at @SlashQueer or email us at slashqueer@outlook.com. During pride month our mantra always feels extra special so, as usual- stay kind, stay radical and stay queer.