Life as a trans person in the United States is not easy, but the grass isn’t always greener on the other side. The United Kingdom has set a low bar for quality of life when it comes to trans citizens, and powerful voices there are trying to lower it further. The United States is currently a better place for trans individuals in some ways, but vocal lobbyists are working hard to drive down the quality of life and get that bar even lower than the UK’s.
I was born and raised in the United Kingdom, but when I was 23 I immigrated to the United States of America. In the summer of 2016, I married my spouse and became a permanent resident (green card holder.) That’s how I came to be living near Atlanta, Georgia when I finally fully came out as nonbinary.
The Trump presidency was a stressful time to be “other” on two counts in a Southern state: living as both an immigrant and as a trans person. I came out at work in 2018 and began a medical transition in early 2020. By the time the 2020 election rolled around, my spouse and I were beginning to question whether it would be safe for us to remain in the US if Trump claimed another term, whether by vote or by other means. We’d watched the increase in violence against minorities, the aggressive response to protests, and the continued proposition and enaction of legislation targeting both the safety and the quality of life of the LGBTQ+ community. Through the fall of 2020, we had serious conversations about what we would do based on certain outcomes, which included the bleak possibility of fleeing the country with what we could carry and figuring things out from there.
Through the fall of 2020, we had serious conversations about what we would do based on certain outcomes, which included the bleak possibility of fleeing the country with what we could carry.
My experience as an out member of the queer community was all based in the United States. Listening to the rhetoric and watching the anti-trans bills that were being brought forward, I was sure that the American South was the most inhospitable place I could choose to live as a Trans or Gender Non-Conforming (TGNC) individual. As I researched and spoke to friends and family, however, it was with some dismay that I realized that the UK was actually in a worse situation on most fronts, and that to return there would most likely mean halting my transition. The only silver lining I could find was that with lower gun ownership over there, it was less likely that I would be shot for being trans. It was a shock of cognitive dissonance to realize that, despite the famed inhospitable nature of the United States South for TGNC people, I had easier access to affirming healthcare and was in a country largely heading in a better direction here than I would be in my homeland.
Trans Healthcare: As It Stands
While not every trans person seeks a medical transition, access to healthcare for trans people can mean survival in many different ways. This can be in the form of affirmation, a medical transition, or simply not being declined treatment for unrelated issues because of “ideological” issues or ignorance (as with trans broken arm syndrome.)
The trans healthcare provided by the United States is far from ideal. Getting access to the proper resources requires finding a primary care provider (PCP) who is knowledgeable and open to providing affirming and appropriate treatment for trans clients. Some of these providers still gatekeep access to hormones or surgeries with requirements for letters from therapists that prove that you are “trans enough”–a requirement that necessitates finding an accepting therapist and being able to afford the fee to have them write such a letter. Finally, you rely on having access to vast funds and/or a health insurance plan that covers trans issues, as many insurance plans will refuse to cover gender-affirming surgeries outright or require excessive “proof of necessity” before covering it.
I’m aware that my own experience is not in any way universal, but I was stunned at how easy it has been to pursue hormonal treatment once I got over my own mental blocks. After sifting through a lot of therapist profiles, I began seeing a therapist in January of 2020 who was accepting and knowledgeable of trans identities. In February, I decided that pursuing low-dose HRT was right for me. I was able to find a PCP who was well-versed in non-binary identities (a benefit of living near a large metro area and conducting extensive internet research) who did not require gatekeeping letters and was happy to accept that I knew my gender experiences best. By March of 2020, I had my first prescription in hand and was scheduled for regular follow-ups.
I probably represent close to the best-case scenario, and others within the United States obviously face more challenges. When dealing with medical professionals who are not as well-versed with the queer community I have faced consistent misgendering even from the well-intentioned (non-binary identities are still confusing to too many people). However, while a few people were dismissive, no one was openly hostile (and yes, the bar really is that low sometimes). Treatment can be harder to access depending on an individual’s exact location, how accepting their family is, whether they have health insurance, etc., but online healthcare options such as Folx, Plume, and QueerDoc are making it easier. While none of these situations are ideal, they exist in stark contrast to experiences fellow trans individuals have had in the United Kingdom.
When dealing with medical professionals who are not as well-versed with the queer community, I have faced consistent misgendering even from the well-intentioned.
The process in the UK has some additional steps that can drag out the process of simply getting access to the necessary healthcare, and the system has extensive gatekeeping built into it. The issues that exist with the system might be most succinctly summed up by the need for websites such as Trans Health UK that serve as guides for trans people on healthcare, including tips to ensure you get treated, lists of trans-friendly doctors alongside a “shitlist,” and instructions for DIY medical transitions. Through the National Health Service (NHS), rather than receiving treatment directly from your General Practitioner (GP, the UK equivalent of a PCP) you have to request a referral to a specialist gender identity clinic. These clinics have long waitlists and often have prescriptive ideas of gender that they use as part of gatekeeping treatment. If approved, the clinic will recommend you to a specialty doctor. This doctor will evaluate you further, and can then send a letter containing a recommended treatment plan to your GP who can then provide you with treatment.
While this might simply sound like tedious bureaucracy, Fiona, a trans woman in the UK, explained how tortuous and damaging this process can be. Having come to the conclusion that a medical transition was the right choice for her, she asked for a referral to The Laurels Exeter Specialist Gender Identity Clinic (GIC). Although it was not a convenient location to travel to, (a common problem as the UK has very few GICs and Wales has none at all) Fiona had heard that The Laurels had shorter waitlists and were less prescriptive regarding gender presentation or having to openly present your gender for an extended period of time before receiving treatment. This was in 2015.
Gender Identity Clinics have long waitlists and often traffic in prescriptive ideas of gender that they use as a way to gatekeep treatment access.
Fiona received her initial appointment with the clinic in 2017. Over two years later. During this time, the only information she could receive was that she was on the waitlist and would need to continue to wait. When she finally reached her initial appointment, she was subjected to extensive questions that included invasive questions about her presentation, her sex life, and her childhood. While Fiona had known her own identity for a long time and had needed to specifically request this treatment (it is not something that doctors will automatically suggest,) she still had to prove it to someone she had never met.
At this 2017 appointment, the gender clinic approved her and referred her to a specialty doctor. This second appointment came in March of 2020. Five years after her initial referral she was once again being asked many of the same invasive questions, as well as several new ones. She described the experience as feeling “very gatekeepery” and, while she didn’t need to herself, knows friends who have felt the need to fabricate stories from their childhood to ensure that they are seen as “trans enough” in the eyes of the doctor.
Fiona’s doctor decided that they needed another appointment with her before beginning treatment. The doctor then went out on sick leave, and it was March 2021 before Fiona saw them again, and was mostly asked the same questions one more time. At this point, her specialist finally sent a letter recommending a treatment plan to her GP, which led to her receiving a prescription for simple estradiol patches in April of 2021, over six years after her initial referral. When initial blood tests came back showing low estrogen levels, despite the letter recommending an increased dosage in that situation, the GP instead contacted the gender clinic again, the bureaucracy of which required another month of waiting to receive the increased dosage.
Rather than listening to the patient, Fiona’s GP contacted the gender clinic again. Jumping through its bureaucratic hoops required another month of waiting to receive the increased dosage.
What took me a matter of weeks in the US took Fiona over six years in the UK. She said of the estimated wait times that it seemed “the longer I waited for my second appointment, the longer it got […] six months became a year, became two years.” Six years is a long time when you know that a certain treatment course or surgery will help you live comfortably in your body on a daily basis. A wait that long can leave some fighting against changes that will be irreversible and require more aggressive treatment to combat. Of course, like many trans people, Fiona self-medicated in that time, acquiring hormones from friends, purchasing them from overseas, or from websites that slowly became unavailable to access in the United Kingdom (sites like Folx and Plume are not available there and one called GenderGP is currently the subject of a protracted legal battle.) The availability of these hormones being variable meant that her dosage was as well, and the start of her medical transition was done without medical guidance beyond Google and without blood tests to monitor her hormone levels.
Of course, all of this is based on experiences with the National Health Service (NHS,) which has been chronically underfunded and has remained disinterested in improving the quality of their trans healthcare despite the increasing need. One alternative is a private clinic, such as GenderCare. A trans man I spoke with, Endeavour, chose this route, and while it circumvents some of the issues with the traditional NHS GIC path, it is significantly more expensive and is still plagued by many of the same problems.
“The longer I waited for my second appointment, the longer it got. Six months became a year, became two years.”
When Endeavour first contacted GenderCare, it was necessary for him to also ask for an NHS referral at the same time, as private gender clinics are intended as a stop-gap solution with the intention of eventually discharging patients into the NHS. He was fortunate to be able to get an appointment with a doctor who had recently joined the practice, meaning that his wait time was only three months, and was able to receive a hormone prescription via his GP only a short time after that. Since then, the increased visibility of trans identities and the continued overloading of this aspect of the NHS system has meant that many private wait times have also become exceedingly long. Endeavour is still waiting to receive an appointment with his NHS GIC.
Endeavour only needed one visit to be able to be properly referred to receive treatment, and the questions asked were significantly less invasive than the ones that Fiona experienced. Just as with the NHS GIC, GenderCare can only provide recommendations to others and not provide direct treatment themselves. However, they are able to give advice on how to ensure that the system functions more effectively, such as how and when to chase GP offices and how best to form a complaint letter regarding a GP continuing to misgender the patient.
When it came to surgery, GenderCare was able to refer Endeavour directly to a surgeon of his choosing, with the biggest hurdle being having to fund the operation himself. However, as treatment has continued he has found it necessary to pursue a hysterectomy, a surgery that requires the NHS GIC to recommend it. The first gynecologist available to him had no understanding of trans healthcare and made tone-deaf suggestions about trying to “gee up” the GIC. A second gynecologist informed him that he was wrong about his own experiences and symptoms, instead. It seems unlikely that he will be able to be seen by the NHS GIC and get the medical attention he needs anytime soon as he recently reached out to them and learned that they are “currently booking first appointments for referrals made in October 2017.”
Consensus in medical science has shown that there is a definitive benefit to providing trans people various hormones and surgeries to help them complete their medical transition if they want them. However, there is an ignorance in the UK among the practitioners who are able to actually sign off on those treatments, and both Fiona and Endeavour referenced more than once having to provide links to online resources and medical journals to persuade doctors to read up on trans healthcare, with mixed success. The treatments are known to help, and the reticence to move on these treatments harms trans people, but that, of course, is part of a larger problem.
Trans Politics: Where It’s Heading
The political situation in the United States when it comes to trans people can feel bleak. While an optimistic view might foresee an upcoming passage of the Equality Act, largely the focus is less on passing progressive legislation and focusing on damage control against regressive bills.
Despite Trump leaving office, 2021 has seen a record number of anti-trans bills introduced across the United States. Conservative legislatures have largely abandoned their previous attempts at “bathroom bills” after they were ultimately unsuccessful. However, one particularly egregious holdover appeared in Tennessee with a bill that would have required businesses to put up a sign to warn customers if they let trans people use the correct restrooms. Their renewed focus has been on laws that overwhelmingly target trans youth, preventing them from participating in school sports or accessing basic healthcare such as puberty blockers, a treatment that has long been safely, successfully, and uncontroversially used to delay precocious or early-onset puberty in cis children.
Ultimately, transphobic bills in the U.S. have regularly been rebuffed before they could be signed into law, or have been struck down by higher courts. The United Kingdom has not always been so lucky.
These bills often come pre-written to state legislatures across the country by ambiguously named hate groups such as the Alliance Defending Freedom (famous for supporting the Masterpiece Cakeshop and Hobby Lobby) and The Heritage Group. Fortunately, these bills do not go unchallenged, with organizations like the ACLU working overtime to combat them. Ultimately these bills have regularly been rebuffed before they could be signed into law, or have been struck down by higher courts. The United Kingdom has not always been so lucky.
The UK LGBTQ+ community suffered two recent major setbacks. In 2020, the UK government delivered its decision on reforming the Gender Recognition Act of 2004 (GRA.) The primary hope for this reform was that TGNC people would be able to self-identify their gender for correcting their birth certificates. While the reform reduced the fee for the process and required fewer documents, it still required that a panel of strangers decide whether an individual qualified as the gender that they identified as. The GRA reform falling short of the original hopes is largely credited to the fact that TERFs (Trans Exclusionary Radical Feminists) dominated the consultation and misrepresented what the GRA would do, claiming that it would allow anyone to enter single-sex spaces such as restrooms and changing rooms. This was not the case, and trans people were already given the right to enter the appropriate spaces for their gender identity in the UK by the 2010 Equality Act.
Seeing people riled up by the misleading lies of vocal minorities like TERFs leave trans people questioning whether they are safe in public spaces.
Similarly, 2020 saw the Bell v. Tavistock case, which brought a ruling that people under 16 were not able to consent to being prescribed puberty blockers and would need to obtain a court order before being able to receive treatment. This is yet another impediment to healthcare for trans people, and puberty blockers are of course of most use to people under 16. As with the GRA, the case saw gross misrepresentation of the facts with a narrative being spun that these treatments were irreversible actions and not the stop-gap that they actually are: one designed to allow TGNC people to get to a point in their lives where they can make more permanent decisions safely, and a treatment commonly dispensed to postpone early puberty in cis children. In May of 2021, a judgment allowed parents to give consent on behalf of their children to receive puberty blockers without seeking court approval first, but this relied on trans individuals having supportive parents, which is sadly not always the case. In September 2021, an appeal led to the original ruling being overturned, meaning that the net result was almost a year of pain and suffering to trans youth in the UK only for the legal situation to return to where it began.
Just as the US has Alliance Defending Freedom, The Heritage Group, and conservative and religious pundits, the UK has groups such as WPUK, the LGB Alliance, and outspoken public figures like JK Rowling. In the UK, their arguments regularly center around the idea that trans rights will somehow detract from women’s rights through arguments lodged in transphobic mindsets.
Trans Quality of Life: What It All Means
With both countries working to one-up each other on their latest anti-trans legislation, it can feel like a depressing race to the bottom. Anti-trans youth bills in the US have left families of trans loved ones questioning whether they will need to uproot their lives to move to a more accepting state. Whether these laws get enacted or not, the conversation around them gives a large amount of airtime to people who are espousing hypocritical and false narratives about trans people in the media.
All of this causes tension in the community that has a negative effect on the mental health of trans people: denial of access to support and trans healthcare has been linked to higher incidents of self-harm and suicide in the community. Additionally, the rhetoric surrounding these conversations puts trans people at risk of physical harm. Seeing people riled up by the misleading lies of vocal minorities leave trans people questioning whether they are safe in public spaces or at risk of being assaulted or worse, a fear supported by the trans community’s low life expectancies and a high proportion of hate crimes. More than 30 transgender and gender non-conforming people have been killed in the United States in 2021 alone, despite making up a relatively small proportion of the population. In England and Wales, trans people are twice as likely to be the victims of crime as their cis peers. And in both countries, the risks are even higher for trans people of color.
I am tired of questioning my safety in public. I am tired of wondering whether I will have healthcare six months from now. And I am exhausted from feeling privileged for having access to the most basic healthcare.
The silver lining here is that these actions from right-wing politicians and hate groups are a pushback on the positive progress that is happening for trans rights. Wider public acceptance of TGNC people both in opinion polls and in popular media is helping to drive larger progress. The United States has seen a huge increase in TGNC people running for, and winning, elected offices, a fact that has helped to quell some of the anti-trans bills moving through legislatures. It is important that small victories against larger losses are not taken as a chance to rest on laurels, and that both nations continue to fight against the lowering of the bar and instead fight for acceptance of all.♦