CW: References to sexual assault, transphobia, conversion therapy
From the beginning, healthcare provided to Trans+ people in the UK through the NHS gender clinic system has been about control and dominance. This system is currently in crisis and failing trans people. But it isn’t broken – it’s working exactly as it was designed to.
Our current Trans+ healthcare was not built to help trans people, but to limit the number who can medically transition, and to give power over this to cis people.
Medical developments, from the ability to make synthetic hormones in the 1920s, to surgeries developed in the 1940s that changed a person’s genitals and sexual characteristics, pathologised people who wanted to transition gender. Many of these developments are still standard practice at NHS gender clinics.
So is the diagnosis of ‘gender dysphoria’, which evolved to control who can transition and perpetuates the notion, still prevalent today, that Trans+ people can be “fixed” using medical procedures.
The first NHS gender clinic was established in 1966 to ‘treat’ trans people. A network of NHS gender clinics has grown since then, to 15 operational ‘gender dysphoria clinics’ today.
It’s well-documented that trying to transition on the NHS is a multifaceted nightmare. Right now, the estimated waits are up to 224 years for some patients. To understand the problems people face in the UK’s Trans+ healthcare system, we need to understand how and why it was established, who made it that way, and, critically, who it was built for.
The NHS, formed in 1948, established its first gender clinic in 1966 at Charing Cross Hospital. Social and political attitudes towards labour, class, gender and race at this time heavily influenced the UK’s fledgling Trans+ healthcare system. So did psychiatry’s emergence as a scientific discipline from the asylums that spread across Europe over the course of the 19th century. From the 1960s to the 1990s, Western psychiatrists were fascinated by people who wanted to transition. They were determined to fix the borders of gender, and police those who wanted to cross.
But the UK’s Trans+ healthcare system didn’t spring into existence from nowhere in the 1960s. For over a century, theories and ideas about gender, bodies and sex had been circulating around Europe. These theories, and the men who propounded them, would have a great influence on how Trans+ people in the UK were treated by medical professionals.
The importance of N
The roots of Britain’s Trans+ healthcare system go as far back as 1865, to the ideas of a German psychiatrist called Richard von Krafft-Ebing.
That year, a 23-year-old pianist named only as ‘N’ was taken to the Illenau asylum in south-west Germany. Around 400 people were incarcerated in the purpose-built asylum, sleeping together in single-sex dormitories of up to 20 people.
N was kept at the Illenau for nine years and died there, of tuberculosis, at the age of 32. Her dead body was cut into pieces, which were measured and examined under a microscope: a “normal” skull, “anaemic brain” with “atrophic” frontal lobes and “shrunken” ganglion cells, “very large” genitals and “small, lax” testicles.
N was one of hundreds of thousands of people who died in Europe’s asylums as they expanded throughout the 18th and 19th centuries. Unlike most of those people, we still have some actual information about N.
That’s because in 1886, Krafft-Ebing published Psychopathia Sexualis, a text containing some of the earliest Western medical descriptions of people with what was then termed “the delusion of sexual transformation”. N was one of Krafft-Ebing’s case studies, who he diagnosed as being at the “final possible stage in this disease-process”. From what we know of N, she might today be diagnosed with gender dysphoria.
Krafft-Ebing wrote that N was sent to the asylum because of “typical paranoid delusions” with “sexual symptoms”. She’s described by him as “weakly and dull” as a child, “always of abnormal character; silent, retiring, unsocial, and sullen. [She] practiced masturbation after fifteen… During the last year [she] had worked with great difficulty.”
These judgments of N’s childhood, character, masturbation practices and ability to work are telling, because psychiatrists still use them to decide whether a person is transgender, and whether they should be allowed to medically transition.
Trans+ people attending UK gender clinics today are asked about their work, family, friends, childhood and character. The psychiatrist’s letter confirming my diagnosis of gender dysphoria referenced that I was in full-time work and supported by family and friends to transition.
And like mine, N’s gender apparently fluctuated between masculine and feminine during her time locked in Illenau. But towards the end, from December 1872, Krafft-Ebing writes that “[her] personality became completely feminine” and “from that time [she] remained a woman”. N’s “delusion” that she was a woman “could no longer be corrected”. We don’t know how the asylum tried to “correct” N’s gender.
Another German psychiatrist, Emil Kraepelin, had his own ideas that came to interact with Krafft-Ebing’s thinking. In Mad World: The Politics of Mental Health, Micha Frazer-Carroll explains how Kraepelin promoted the idea that disorders of the mind could be categorised like physical diseases.
People who wanted to change their gender were considered to have a mental disorder, as were those who heard sounds and voices that others don’t (auditory hallucinations), and those who desired people of the same sex – homosexuality was classed as a psychiatric disorder until 1968.
Kraepelin was influenced by the founder of eugenics, Francis Dalton (Charles Darwin's cousin), who said there was such a thing as a “biologically ‘normal mind’.” Any overlap between different mental disorders in one person was treated suspiciously; something we still see today when, for example, autistic Trans+ people seeking gender-affirming healthcare face disbelief that they can ‘really know’ their gender.
Krafft-Ebing was busy categorising the abnormalities of those he called ‘sexual deviants’, and Psychopathia Sexualis was widely read by European psychiatrists. His theories influenced how Trans+ and queer people were treated by Western medicine – in both European countries and the countries they colonised.
Today, many of those countries still criminalise being gay or Trans+ – a hangover of colonial laws that originate from the same era when Western medical ideas about how to treat Trans+ people formed. And like those colonial laws, Western ideas about what transness looks like still proliferate through the contemporary gender clinic system.
Class, race and gender in early Trans+ healthcare
When I decided to get a diagnosis of gender dysphoria in order to access the surgery I wanted, I was anxious about the process. But I wasn’t especially worried about whether or not the gender clinic would believe me. As a white, middle class and able-bodied person, I could be fairly confident that my account of my gender history would not be treated with suspicion.
This confidence is, in part, a result of the way that British healthcare first started seeing Trans+ patients: it began by treating white, wealthy people who wanted to medically transition. And, contrary to the transphobic line that Trans+ identities are a new “fad”, British doctors began treating Trans+ people nearly 100 years ago – before the NHS was even created.
One of the first Trans+ men to medically transition was Michael Dillon, a minor member of the Irish aristocracy, who began taking testosterone pills in the early 1930s and had top surgery and phalloplasty in the 1940s. Dillon found a plastic surgeon, Sir Harold Gillies, who specialised in reconstructing the penises of injured war veterans and was willing to use these techniques on Dillon.
Dillon then became a surgeon himself, going on to secretly perform an orchiectomy on Roberta Cowell, the daughter of Sir Ernest Cowell and one of the first British Trans+ women known to have gender reassignment surgery. After the removal of her testicles – an operation that was illegal in the UK at the time – Cowell went to a private Harley Street gynaecologist and obtained a document stating she was intersex, which allowed her to get her birth certificate reissued as female, and helped persuade Gillies to perform a vaginoplasty on her in 1951.
Cowell and Dillon accessed surgeries and hormones before NHS gender clinics existed, but the processes of gender transition have changed very little – early photos of trans men with top surgery show startlingly similar results to those of today’s surgeons. Back then, this healthcare was not easy to obtain, or even available at all to many people. While access has certainly improved, it is still difficult for the vast majority.
In the 1950s, endocrinologists and surgeons began developing treatment protocols for their transsexual patients, while people who learned about HRT and gender reassignment surgeries from the media’s sensationalised outing of famous Trans+ women pushed their doctors to provide them with medical transition.
But within the NHS, transition was restricted to people who psychiatrists thought would be able to ‘pass’ and live ‘successfully’ as their ‘new’ gender. This gatekeeping went on to create a very narrow category of what academic Chris Hendrie calls “legible and legitimate transness”, which only included people who fit into other normative groups: white, wealthy, able-bodied, heterosexual, binary. Often, those who fit into this category also had easier access to healthcare.
As a Trans+ person’s class, race and gender determined if they would access medical transition, so doctors were learning that people who medically transitioned fit into certain class, race and gender categories. In this way, these factors self-perpetuated as the NHS Trans+ healthcare system began to form, and a certain white, wealthy, heternormative image of transness developed alongside the advances of Trans+ medical care.
Treatment or cure
In the UK today, the state is dissuading children from being openly Trans+. Puberty blockers are banned by the NHS, schools are being encouraged not to let children socially transition, and the very fact of their existence is treated with hostility and heavy scepticism. Trans+ children with parents who want to support them face high costs and other barriers to care and support.
This echoes the historical treatment of Trans+ children by the NHS. In the early years of gender clinics, many of the doctors approached by parents with Trans+ children tried to stop them being trans. Some Trans+ children, particularly Black Trans+ children, were criminalised as gay – ‘homosexuality’ itself wasn’t partially decriminalised until 1967, and remained a medical diagnosis that wasn’t removed from the international classification of diseases until 1990.
This meant that, whatever their identity, people defined as gay were also defined as insane and locked up in prisons or psychiatric hospitals. Others were subjected to crude conversion therapy attempts.
In 1952, renowned mathematician and code-breaker Alan Turing was convicted for “gross indecency” for having sex with a man. Forced to choose between prison time or a form of conversion therapy – a hormone treatment intended to reduce his libido – Turing chose the latter. He died by suicide two years later, in June 1954, as a result of cyanide poisoning. It wasn’t until 2017 that the British government passed Turing’s law, which offered a pardon to all gay men who, like Turing, had historical convictions of gross indecency for being gay.
Three years before Turing was convicted, in 1949, seven-year-old Alice Sullivan told her mum she was a girl. As a result, she was taken to a hospital near where the family lived in Putney, south London, where a psychiatrist orchestrated two abusive attempts to coerce Alice out of being trans.
Alice describes being taken to a hot room where she was put into a skirt and overdone make-up – red lipstick smeared, clown-like, around her mouth – in front of a full-length mirror. She was made to drink a salty solution, which made her feel sick, and when she started throwing up her mum held her by her shoulders, forcing Alice to watch herself in the mirror while she vomited. Alice remembers she was then taken to another, much colder room, where she was stripped naked, held again by her shoulders and then hosed down with freezing cold water by a nurse.
Later, Alice’s parents told her that if she said she was a girl again, she’d be “put in a home” and would have to “live off bread and water” for the rest of her life. So, Alice said she was a boy. She hid herself for the rest of her childhood. In the psychiatrist's view, he had successfully cured Alice of her delusion that she was a girl.
The conversion attempts Alice underwent were practiced by the NHS for decades, with untold numbers of people suffering – there are no records of how many people underwent these treatments or died as a result. We don’t know how many more Trans+ children like Alice there were, made to keep their true selves a secret because of abusive medical practices and the threat or reality of family rejection, nor how many Trans+ adults tried and failed to get medical care from doctors.
Meanwhile, Psychopathia Sexualis continued to be a key influence on how doctors acted towards people wanting to medically transition in the late ‘40s and ‘50s. It crops up in the influential 1949 essay, Psychopathia Transexualis, by sexologist David Cauldwell, and in 1952 in the first Diagnostic and Statistical Manual of Mental Disorders (DSM). This is the handbook still used by Western doctors around the world today to diagnose mental disorders.
The very first edition of it included definitions of different categories of ‘sexual deviation’: “Homosexuality, transvestism, paedophilia, fetishism and sexual sadism (including rape, sexual assault, mutilation)”. Eighty years on from Krafft-Ebing’s landmark text, his categorisation of queer and Trans+ people as ‘sexual deviants’ not only persisted, but had become mainstream.
With the inclusion of Trans+ people in the DSM, our pathologisation was solidified. Wanting to move across and beyond binary, fixed sex and gender categories was now a globally recognised “mental disorder” that could, the gender doctors promised, be cured.
It could also be treated, some doctors began to theorise, by affirming Trans+ people’s gender and providing medical support for them to live in it. Whether a patient was ‘cured’ or treated depended on a combination of factors: when they went to the NHS for help, the doctor they saw, their mental-health history, age, race and class. The affirmative approach was still paternalistic, with doctors allowing someone to medically transition still guiding the process according to their own fixed ideas of what gender and transition ought to look like.
It was against this backdrop of the medical environment of the 1950s, where it was common practice to violently attempt to make people cisgender, heterosexual and sane, that the first official NHS gender clinic opened.
Charing Cross GIC was established in 1966
Psychiatrist Dr John Randell joined Charing Cross Hospital, which had become known for providing affirming trans-related healthcare, in 1950. He began working with Trans+ patients and controlling their access to surgeries and hormones. When Charing Cross GIC was formally established in 1966, Randell was its head.
Randell worked at Charing Cross GIC until his death in 1982 and is considered by many to be the single most influential person on the British Trans+ healthcare system. He had strict criteria for which patients were ‘true’ transsexuals, and the small proportion who were eligible for medical transition.
In 1969 he asked, in an essay evaluating whether people should be allowed sex reassignment surgery: “Are the surgical interventions justified by the results or should those who have ‘passed’ into the opposite gender role be persuaded – if that is possible in these compulsive and obsessed individuals – to be content with social acceptance in their ‘passed’ gender role without surgical intervention?”
The number of patients approved for surgery at Charing Cross GIC was small. Of the roughly 50 people Randell saw a year in the 1960s, 10% were approved by him for gender reassignment surgery. In the 1970s, Randell was seeing 200 patients a year, with just 15% going on to have surgery. These figures remained the same well into the 1990s, with one study finding that only 17 out of 106 people who went to Charing Cross GIC were referred for surgery – just 16%.
This is Randell’s legacy: a decade after his death in 1982, Charing Cross gender clinic was still allowing only a tiny fraction of the people who got an appointment to have surgery. One psychiatrist’s view about Trans+ people was dictating the healthcare that we could access; a scenario that, in many ways, continues to this day.
Work it with the Real Life Test
In addition to psychiatric opinions, there was another important factor at play in determining who would be allowed to access Trans+ healthcare: work. After years of exhaustive, humiliating assessment by psychiatrists at the gender clinic, Trans+ people had to pass the ‘Real Life Test’ before they could get hormone replacement therapy (HRT). This looked like socially transitioning and living full-time as their gender for one or two years, and documenting this to prove that they had done so successfully.
Crucially, this meant demonstrating employment. But it didn’t become illegal to fire someone for being Trans+ in the UK until 1996, so people faced getting sacked when they came out.
Successfully getting another job in this new gender required passing as that gender, which meant conforming to contemporary gender stereotypes: feminine women and masculine men. Still today, Trans+ women who don’t wear lipstick to gender clinic appointments risk being criticised by doctors.
The clinical judgement about Trans+ people’s ability to work goes all the way back to N, who Krafft-Ebing noted had worked “with great difficulty” in the year before she was sent to the Illenau asylum. Ever since, social and legal recognition of Trans+ identities has been bound up in Trans+ participation in the capitalist production process.
And through the ‘Real Life Test’ administered by NHS gender clinics, our ability to work became part of the criteria for being able to transition.
Fear and diagnosis
As the criteria for accessing Trans+ healthcare developed in the 1970s and 1980s, the borders of Trans+ as a category were being secured in two ways: by psychiatrists working in gender clinics who determined the location of the borders, and by Trans+ people who moulded their own histories of gender to fit themselves firmly within those borders.
Over time, a ‘typical patient narrative’ for transness came to be: distress at being the wrong gender, discomfort with having the body and sexual characteristics of the wrong gender, a strong desire to live in the ‘opposite’ gender, and a childhood history of playing with the toys of, making friends with children of and wearing the clothes of the ‘opposite’ gender.
This narrative persists today in phrases like “born in the wrong body”. And while that feeling is accurate for some Trans+ people, it’s not a universal experience.
In determining whether to diagnose people as ‘true’ transsexuals eligible for healthcare, psychiatrists looked at a patient’s gender history to see if they fit this typical patient narrative. Sandy Stone, in her seminal 1987 essay The Empire Strikes Back: A Posttranssexual Manifesto, describes this as a feedback loop: the development of diagnostic criteria for transsexualism meant transsexual people deliberately conformed to the criteria in order to be considered eligible for healthcare, leading doctors to believe that their criteria were an accurate way of identifying transsexuals.
As more people transitioned and understanding of transness in the NHS progressed from those early, deeply pathologised days, the chokehold that the diagnostic criteria had on people’s access to transition would come to loosen.
The NHS still heavily restricted which forms of medical transition people could access by refusing to pay for certain things – still today, for example, the NHS will not fund facial feminisation surgery (FFS) – but heading into the 2000s, things were about to change.
Reforming the UK's broken Trans+ healthcare system
A major turning point for British people gaining wider access to Trans+ healthcare arrived in 1999. Three women brought legal action against the North West Lancashire Health Authority for refusing to pay for their gender reassignment surgeries. In its legal arguments, the health authority said gender reassignment surgery for Trans+ women was cosmetic and unnecessary, and that the correct treatment, which was “appropriate” to fund, was psychotherapy “with a view ‘to the person accepting their biological gender’”.
The challenge against this policy was the first of its kind, and the women won their case – making it illegal for any health authority to flatly refuse to pay for Trans+ surgeries. From then on, certain Trans+ surgeries were automatically paid for, and the NHS was obliged to fund Trans+ healthcare in a way that it hadn’t been before.
By 2002, there were five gender clinics in England: Charing Cross, Leeds, Newcastle, Nottingham and Sheffield. People still had to prove their transness to the NHS in order to access healthcare, but the beginnings of depathologisation could be observed.
In 2004, the new Gender Recognition Act (GRA) allowed British Trans+ people to change their legal gender without the requirement for sterilisation or surgery. But the requirement for a gender dysphoria diagnosis remained, both for legal gender recognition and access to Trans+ healthcare, and NHS gender clinics also retained the ‘Real Life Test’ into the 2000s.
The state and its Trans+ healthcare system were changing their attitude towards Trans+ identities, but slowly – still viewing transness as a mental illness, remaining sceptical of whether or not people were really trans, and requiring us to prove it.
The number of gender clinics also grew slowly, up to seven in 2015. At the Women and Equalities Select Committee’s inquiry into transgender equality that year, John Dean, the chair of the Clinical Reference Group for Specialised Gender Identity Services at NHS England, explained how this network had grown: “There is quite considerable diversity of opinion between different clinicians and different clinics,” he noted. “All seven gender clinics in England arose out of the special interest of an individual a long time ago. There has not been a lot of planning of their development, and there certainly is no training pathway for medical practitioners or others who work in this field.” Because there is no formal training, the individual who founded each gender clinic has a big influence on the operation of it today.
Gender clinics have always been an arena of male egos and differing viewpoints and practices. Dr Ruth Pearce, author of Understanding Trans Health: Discourse, Power and Possibility, describes modern gender clinics as a “contested space”. While there is no longer one psychiatrist running the show, lots of different people with different intentions are crowded into the clinic: NHS commissioners, politicians, gender clinicians and patients.
When it comes to gender clinicians, some want to help. Pearce refers to those who do this paternalistically as “Daddy knows best” doctors. They operate on terms like “you can transition but only in the way I tell you”, she says. Others are more old school and “actively want to control people's presentation”.
And then there are “the people who genuinely want to help people by listening to people, and being like, what do you want? What do you need? I'll see if I can do my best to provide that,” Pearce explains. This model can be best seen at the newer gender services commissioned by NHS England, which, incidentally, have the shortest waiting times for care today.
At the end of its 2015 inquiry, the Women and Equalities Committee voiced several concerns about gender clinics, one of which was that they remained part of mental health services despite Trans+ identities no longer being broadly regarded as a disease of the mind. However, it would be another four years until the World Health Organization stopped classifying being Trans+ as a mental-health disorder, in 2019.
The MPs made several recommendations, including a sweeping “root-and-branch review” of the Trans+ healthcare system, and the NHS’s treatment of Trans+ people. The recommendations should have prompted a move away from a Trans+ healthcare system of gender clinics.
Instead, the government focused on reforming the GRA, creating room for the contemporary anti-Trans+ movement to flourish. But in 2020, three new pilot gender services were announced. These are TransPlus in London, Transcend in Merseyside and Indigo in Manchester, which are comparable to traditional gender clinics in that they can diagnose gender dysphoria, prescribe hormones and make surgical referrals.
These new style clinics offer a vastly improved service for people wanting to transition in the UK. But even with their introduction, the average wait for a first appointment at an NHS gender clinic stands at 25 years. It would take 83 new clinics like Indigo to clear the waiting list of more than 48,000 people, and there is no political will to do so. The gender clinic system is structurally flawed, working not for Trans+ people’s health and wellbeing but against Trans+ existence itself.
The clinics and the diagnosis don’t have to exist. They were invented within the lifetime of people living today, made by men who had complex motives for working with Trans+ people. The diagnosis was a way for them to protect themselves and legitimise their work, but it was not asked for by the people it was imposed on.
While the most brutal part of the history of British Trans+ healthcare has passed, the intent to control transition remains. The NHS Trans+ healthcare system is built on rotten foundations, still excluding many people from its criteria for transness. Its existence overlooks the fact that transitioning is a personal decision and a matter of bodily autonomy – like using contraception or having an abortion.
As long as healthcare for people who want to medically transition is gatekept by doctors, the right to bodily autonomy for Trans+ people in the UK has yet to be won.
Understand how we got here, so you can fight back
Milestones is a limited six-part newsletter that will unpack, explore and deliver you a critical understanding of how Trans+ rights in the UK have been shaped.
From the creation of NHS gender identity clinics, to the pivotal court cases that set precedents for rights that exist - but are under attack today.
This article is just a preview of what's to come in the series.
This special newsletter series has been written by some of the UK's most respected Trans+ journalists, Ludovic Parsons, Jess O'Thomson, Sasha Baker and Alexandra Diamond-Rivlin - with hours of research poured in.
Expect accessible, but comprehensive long reads on six themes:
- What court cases have shaped the rights of Trans+ people at work
- The history of the UK's Trans+ healthcare system
- How the media has shaped public understanding of Trans+ rights
- Legal gender recognition
- The way the criminal justice system is treating Trans+ people
- Different ways Trans+ communities have fought for rights
