Cis people get gender-affirming healthcare over the counter. Why can’t trans folk have the same?

Gender-affirming healthcare is used by cis people, too

Gender-affirming healthcare for trans and non-binary people is being attacked, legally and politically, in the UK.

We’ve seen this with Keira Bell’s well-funded court case, which almost succeeded in making it so that trans kids needed court approval to get puberty blockers; we see it with the fact that the trans healthcare crisis means that a trans person in London going to their GP today for a referral to a gender clinic might wait as long as 26 years for a first appointment, going by the current rate of intake; and we see it every time a politician bleats about “only women having cervixes“, a lie that comes as many trans men and non-binary are struggling with access to timely cervical screenings and reproductive healthcare.

Transphobic rhetoric about how gender-affirming surgeries are “mutilation” and lies about how hormone replacement therapy leads to “sterility in 100% of cases” are widespread, shared by blue-tick “gender critical” activists, heterosexual newspaper columnists, and steadily creeping into parliamentary debates.

But why are cis people so bothered about gender-affirming healthcare for trans people, when they themselves get gender-affirming healthcare all the time?

Let me explain with a story. A couple of years ago, a housemate of mine was prescribed a testosterone-blocking medication called spironolactone by her GP. She has PCOS and the doctor said that spironolactone would help treat some of the symptoms she was experiencing, like increased hair growth on her body and face.

She left the appointment, prescription literally in hand, and picked up the medication from the chemist a few minutes later. After trying spironolactone she realised that she liked the side-effects of that even less, so she stopped taking it. And then, she asked me if I knew any trans women who might want the meds she had left over – because trans women, too, are prescribed spironolactone to block their testosterone.

But the vast majority of trans women in the UK can’t get spironolactone from their GP. If they wanted to block their testosterone, which many trans women do, they’d start with a GP appointment, which would lead to a referral to a gender clinic, then a wait of several years before a psychiatric assessment and a clinical diagnosis of gender dysphoria. Then, they could be prescribed a testosterone blocker – and, most likely, also the hormone oestrogen.

This inequality in access to hormones is not limited to spironolactone. When I wanted to try taking testosterone, I first had to go to my GP for a referral that meant I then spent several years on an NHS gender clinic waiting list. Finally I had two hours-long appointments, one with a social worker and one with a clinical psychologist, discussing everything from my childhood to my sex life to my mental health. I received the precious diagnosis of gender dysphoria, which permits me to obtain gender-affirming hormones and surgery. Then, finally, I was prescribed testosterone gel.

If I’d been a cis man, say in my forties, struggling with a low sex drive, depressed and feeling a bit moody, then I also might’ve gone to my GP as a first port of call. But there the similarity ends. As a cis man, my GP could order a blood test and, if my testosterone levels were low, send me to a specialist (after a wait of weeks, rather than years) who could prescribe me testosterone gel. Note: no several years spent waiting, and no need to obtain a clinical diagnosis to prove myself.

In both cases, testosterone gel is being used as a gender-affirming treatment. But the way the same medication is prescribed is hugely different.

Gender-affirming healthcare: Not just for trans people!

It’s not only hormones that cis and trans people alike use to affirm their genders.

Boob jobs? Gender-affirming surgery. Hormone replacement therapy for menopausal cis women? Gender-affirming healthcare. Hair transplants for balding men? Gender-affirming treatment. Viagra? Gender-affirming healthcare, definitely.

I would, and happily will, argue that in many cases a cis person who is going to the gym, getting tattoos, shaving their legs, wearing a bra, dying their hair or wearing make-up is acting in a way that, for them, affirms their gender – however unlikely they might be to recognise that that’s what they’re doing.

But there’s no crowdfunded £250,000 court case saying that cis men shouldn’t have access to Viagra. Perhaps it would’ve been money better spent.

And that’s because when cis people affirm their genders – be it through the clothes they wear, their haircuts, their jewellery or, yes, the surgical operations they undergo to better assert their gender – it’s not a big deal. It’s commonplace. So commonplace, in fact, that we don’t even see it that way.

Yet when trans people affirm our genders through the way we dress, our haircuts, our jewellery or, sometimes, through medical interventions like taking hormones or having surgery, it’s a very big deal to cis people. It is perceived not just as healthcare, like what they have, but trans healthcare. And as such, they feel the need not only to tightly control it, but to argue against it and to make it harder for us to have it.

And for those of us who talk publicly about aspects of our own personal medical transitions, they feel it’s OK to tell us exactly why they think what we’ve chosen to do with our bodies is disgusting – in language that would rightly be lambasted if it was aimed at cis people. It’s expected that trans people will accept a certain level of abuse if we talk publicly about the gender-affirming healthcare we’re accessing, in a way that a cis woman taking hormonal contraception or a man dying his greying hair might be surprised to experience.

The answer is not to restrict cis people’s access to gender-affirming healthcare, but to make it easier for trans people to get hold of. Hormones should, as trans civil rights activists have long argued, be available at GP’s and sexual-health clinics under the model of informed consent – in other words, the same way in which the same hormones are already available to cis people. And why is it that some medication is available at big supermarkets, while other medication is not? Codeine and anti-histamines at Tesco, but not testosterone? Why?

The earlier examples of testosterone and spironolactone are not the only hormones where we see this health inequality between trans and cis people play out. We see the same thing with oestrogen: readily available to cis women as a hormonal contraceptive at their GP, yet extremely hard to get hold of for trans women, who must go through a specialist gender clinic and psychiatric assessment to access the same drug.

In fact, most trans healthcare is actually cis healthcare, if you think about it – very few of the speech and language therapists, laser hair-removal specialists, or surgeons constructing penises for trans men, originally trained to offer their services to trans people. Their services were for cis people first, and then adapted for trans people.

And the fact that cis people are happy to have these different forms of healthcare for themselves yet so vehemently against it when trans people want it takes us back to the question: Why are cis people so bothered about gender-affirming healthcare for trans and non-binary people? Perhaps it’s not the healthcare that they have a problem with, after all.