Equity in Healthcare for Trans and Gender Diverse People

Another trans activist/gender identity doctor gives training to student doctors. There are loads of these things.

About the event

We hope you’ll join us for this exciting talk discussing providing healthcare to trans and gender diverse people.

This month we have a very interesting talk from Dr. Kate Nambiar. Dr Nambiar is the co-founder of Clinic-T, a sexual health service for trans and gender diverse people based in Brighton. She has worked in sexual health since 2003 and specifically in trans healthcare since 2012. Currently she also works as a gender clinician for the Welsh Gender Service in Cardiff and she is the chair of the BASHH gender and sexual minorities special interest group.

Dr Nambiar will be discussing setting up a transgender sexual health service, as well as her experience providing healthcare to gender diverse people.

From the Eventbrite blurb

The organiser of the meeting was the Student & Trainee Association for Sexual Health & HIV (STASHH) so most of the attendees were medical students/junior doctors.

Equality and equity

Dr Nambiar began by telling us that he did not have any competing interests and welcomed any emails from junior doctors after the talk. The difference between equality and equity, was that with the former everyone gets a shoe, and the latter a shoe that actually fits (like Cinderella). Hence Dr Nambiar believes that trans people require their own special sexual health service. On the one hand, one can quite agree with this, especially if the patients are on exogenous hormones, you need a clinical team which understand the implications of this. On the other, if it is creating an environment where vulnerable adults end up being around trans activist medical staff, being presented only an affirmative approach to treatment, it might not be such a good idea.

Waiting lists

Access to ‘gender health care’ was the most pressing issue. This had gotten worse over time with most people having to wait over 40 months for their first appointment with a Gender Identity Clinic (GIC). Interestingly the GIC in Inverness only had a 7 month waiting time because it was geographically ring-fenced. Clinics in England, I believe, have no such ring-fence and I wondered how many people had been double or triple-referred to different clinics, creating a false impression of rising need.

It was waiting times which had a profound impact on the mental health of trans people. The WHO had removed gender dysphoria from the ICD-11 as a mental health disorder and it was now a sexual health issue (gender incongruence). Now that it was no longer classified as a mental disorder this should reduce stigma and improve healthcare.

Poor mental health

Despite this change in definition, studies were showing that trans people did have much higher levels of anxiety, depression and substance misuse (not defined, but presumably could include buying hormones from the internet). Fifty-three percent had self-harmed in the past, with a current figure of 11 percent continuing to do so (again, I wonder how ‘self harm’ was defined). About one-third had attempted suicide.

Minority stress

So, what was the reason for all this? ‘Minority stress,’ said Dr Nambiar and we were shown a cartoon graphic of a figure facing two toilet doors, one with a ladies sign saying ‘get yelled at’, the other the gents sign and ‘get beat up’. Life was fraught with a huge amount of stress. Dr Nambiar transitioned as a medical student in the 1990s and recalled the time he visited a sexual health centre prior to transition. There had been a women’s waiting room and a men’s waiting room. He chose the women’s waiting room and sat down. Most people didn’t have the confidence to take up space so early in their transition, not Dr Kate Nambiar though!

The minority stress effect has a negative effect on mental health and this had been proved time and time again with research. I suppose then, that women can argue that the increasing possibility they might meet a man in the toilets or on a hospital ward, genuinely ‘trans’ or otherwise, is having a profound effect on our mental health? Nope, thought not.

Increased mortality

Dr Nambiar quoted from a study taken from the Lancet, a diabetes and endocrinology paper, which I found post lecture, and which you can see here. The paper title is Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. Dr Nambiar confidently told us the reasons for increased mortality in transgender people were HIV/AIDS (it was a retrospective study starting from 1972 to 2018), illicit drug use, suicide, and lung cancer (due to higher smoking rates). Dr Nambiar said that the worries about the side effects of hormone use were just that and issues like cardiovascular risk were not the main causes for people dying, it was the ‘stuff which was much easier to prevent’ which were causing deaths.

The interpretation paragraph from the study though comes to a different conclusion:

This observational study showed an increased mortality risk in transgender people using hormone treatment, regardless of treatment type. This increased mortality risk did not decrease over time. The cause-specific mortality risk because of lung cancer, cardiovascular disease, HIV-related disease, and suicide gives no indication to a specific effect of hormone treatment, but indicates that monitoring, optimising, and, if necessary, treating medical morbidities and lifestyle factors remain important in transgender health care.

https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00185-6/fulltext

Fair-dos to Dr Nambiar for giving any citations in the first place though, most trans activists simply don’t bother.

HIV prevalence amongst trans-identified males

We were shown a map of the world and the statistic that men who identify as women were 49 times more likely to be infected with HIV. Dr Nambiar explained this was because they had reduced job options and were thus forced into sex work and even sometimes trafficked. Reduced access to healthcare also increased the risk of infection (very true for places outside Europe, so not particular to those who identify as trans).

A study Dr Nambiar had been involved in, had shown that trans people with HIV experienced a higher rate of verbal abuse/assault as well as familial and job exclusion (31 trans participants out of a total of 1,576) – see here.

A Public Health England study found that 36 percent of trans people living with HIV had difficulties with activities of daily living (e.g. washing hair) as compared to 13 percent, which strongly suggests that hormones have a very deleterious effect. Dr Nambiar said nothing about this disparity.

Counting trans people

Not counting trans people properly in statistics is ‘really, really serious,’ Dr Nambiar told us. Which must be why huge numbers of LGBT organisations have campaigned to ensure that the Census, and healthcare surveys generally, word questions in such a way that it is impossible to disaggregate sex and gender identity.

Instead of that analysis, we got this quote from Laverne Cox, which I think we can agree is a lot more brave and stunning.

It really is so, so important. If we’re not counted, then we don’t count, we are erased, we are rendered invisible.

Dr Nambiar

The world is against us

Dr Nambiar then told the students that the barriers trans people had to face included inadequate healthcare, inadequate commissioning of services, ‘cisnormativity’, and pathologizing of trans and gender diverse people. Moreover, in the UK there was ‘relentless transphobia’.

Dr Nambiar described this as ‘absolutely horrible’ but refrained from giving any examples, instead relying on a news report, which in turn quoted Stonewall, that more than one-third of trans people experienced a hate crime in 2017. If only people could recognise and embrace difference!

Cultural humility

This is a new one on me, taken from the essayist Anne Fadiman. Doctors know your place!

Dr Nambiar felt that the young doctors should embark on a lifelong learning about trans people and thinking about the ‘power imbalance’ between doctor and patient was key.

When you don’t pay attention to cultural humility, you end up with the ‘trans broken arm’, i.e. the trans activist notion that health problems should not be attributed to the shitload doses of exogenous hormones or repeated botched surgeries. Trans people are just normal people, with normal health concerns.

A cartoon from Jessica Udischas was used to demonstrate how silly this was (not shown below).

Udischas is no longer on Twitter and related website down – wonder what happened there?

We need to snap ourselves out of this type of mentality, the students were told by Nambiar.

Representation

Representation, however, was vital, cue a slide of Dr Kate Nambiar for some Terence Higgins Trust promotional material. Trans people need to see themselves in sexual health campaigns. CliniQ had provided two guides which were particularly good.

At time of writing, the ‘Hook-Up’ guide is missing, but the awful ‘Cruising’ still available

CliniQ and Dean Street were doing an invaluable service providing gender dysphoria sensitive cervical screenings and was a perfect example of equitable versus equal care.

Dr Nambiar also mentioned Brighton’s maternity services, and denied it was about erasing women, rather an opportunity to provide specialist services to women who identify as men (even though most women on testosterone are sterile and require hysterectomy). ‘Nothing about us, without us,’ chimed Nambiar. This had first been the rallying call of disability rights activists and had then been picked up by queer activists, Nambiar said. You cannot provide services for trans people without involving the community.

Personal journey

Dr Nambiar transitioned when he was a medical student in the 1990s, originally at the medical school in Oxford and then at St Mary’s Hospital, Paddington. ‘It was an incredibly hard time’ as he struggled to cope with his mental health. A lot of this was ‘down to transphobia’ and he had some ‘horrible reactions from other students, saying really nasty things about me, and gossiping about me behind my back,’ and Nambiar cast his eyes downward and looked a bit sad.

Dr Nambiar was given a personal tutor at St Mary’s who helped him through this difficult period and was available to chat with at any time. Without that support, Nambiar told us, he ‘probably wouldn’t be here today’.

Final word – taking a stand

Nambiar is inspired by the people who had come before him, including Elizabeth Garrett Anderson, and reminded us that political campaigning by doctors had always been a thing. His most recent role model was the female doctor who had spearheaded the campaign for Pre-Exposure Prophylaxis (PrEP) to be available free on the NHS. In this way, Nambiar wanted to make clear of his support for women activists.

Just a few days before the Governor of Texas had passed a directive making the prescribing of GnRH agonist hormone treatment AKA ‘puberty blockers’ as child cruelty. Nambiar described this as ‘horrific’ and encouraged the students to ‘take a stand’ against this and that it was ‘incumbent on health professionals’ to do so. (A few days before Russia had also invaded Ukraine, just saying.)

Let’s just pause here, Dr Nambiar believes it is incumbent on health professionals to encourage the sterilisation of minors.

If you are neutral in situations of injustice, you have chosen the side of the oppressor. If an elephant has its foot on the tail of a mouse and you say that you are neutral, the mouse will not appreciate your neutrality.

Slide with Dr Desmond Tutu – in fact it is an attributed quote, made sometime before 1986, but no one knows where

Dr Nambiar said that when we fight for equity in healthcare for trans people, we are fighting against social injustice. Healthcare professionals should embrace cultural humility and representation and visibility was vital. Never be afraid to offer support or to take a stand.


And that was it. A 40 minute talk in which absolutely none of the relevant health issues affecting people who take cross sex hormones for cosmetic effect were mentioned, aside from one brief mention to say that heart attacks weren’t really a problem. This was to a group of junior doctors specialising in sexual health and HIV. Zero mention of surgeries gone wrong or worsening mental and physical health post full gonadectomy. Zero mention on how taking hormones might affect HIV or other sexually transmitted diseases.

The immediate feedback from the young doctor acting as host was that it had been a brilliant talk, and indeed Nambiar spoke in a calm measured voice throughout. Very soothing. He is very much the pillar-of-the-community trans activist that the establishment loves, with absolute confidence and conviction in the narrative he presented. That people change their mind about their identity or regret taking hormones, was never mentioned.

Question and Answer

The Q&A session, however, was a slightly different beast.

One student shared that they were currently enrolled on a course run by Future Learn called Transgender in Healthcare. At the time of writing, 536 people are enrolled on this course, which costs about £36 freestanding, or available for about £20 if you have an ongoing subscription with Future Learn. It is a six week module produced a team of trans-identified young doctors at
St George’s Hospital in London. This is the team.

Caspian looks a delight

Dr Nambiar recommended a book written by a friend, Ben ‘Batshit’ Vincent (sorry that’s just my nickname for him), called Transgender Health. Nambiar described it as ‘very accessible, not technical at all,’ which is just perfect for medical students, isn’t it? Wouldn’t want them to get all confused with technical terms, would we?

A person who trains GPs on ‘LGBTQ+ health’, reported that the most common question from GPs was how cross sex hormones would affect blood profiles and wanted to know if there were any specific resources on this. Nambiar knew of two papers which had that information, but didn’t have it to hand, and encouraged the person to email after the meeting. He also said that he didn’t want to focus on the technical aspect of hormones, and referred to testosterone as a ‘masculinising gender affirming hormone therapy’ and that reference ranges could sometimes be ‘tricky’.

Pelvic rehabilitation was also discussed. There was a young health professional on the call who wanted to specialise in this area. Dr Nambiar told us that he had worked with a ‘lot of trans masculine people’ who had struggled with pelvic pain as a side effect of testosterone, and said that the cramping pain was bought on by increasing muscle tone, vaginal atrophy and vaginal inflammation. He had seen people benefit significantly from pelvic floor physiotherapy and that it could sometimes avoid the need for hysterectomy.

Another student wanted to know if Nambiar supported GP prescriptions for cross sex hormones, comparing them to oral contraceptive pills (as far as I’m aware, the oestrogen dose in the OCP is about one-fifth of that prescribed in the gender identity setting). People should be supported to self-medicate confirmed Nambiar.

Someone had a question about what to do with doctors and health professionals who held ‘homophobic’ and ‘transphobic’ views. Dr Nambiar said that the GMC had a zero tolerance policy and it was also against the law.

A research scientist felt that LGBTQ+ training often fell short and bemoaned the fact that they had come across a lecturer who didn’t believe that ‘trans and non binary individuals can become pregnant’. What could be done about this? Nambiar managed to give a long waffly response to this without mentioning any specifics and asked the questioner to email after. Quite impressive.


Someone on the call posted a link to a survey currently being run by the British Medical Association for LGBTQ+ doctors. The survey is in association with an LGBTQ+ doctor association called GLADD (not to be confused with GLAAD – a sort of Stonewall for Americans). You can see the survey on the link.


We are now in a situation where whole new cohorts of medical students are being fed trans activism. It has become perfectly acceptable to cause serious medical problems and now it seems the NHS will happily pore further resources to try and stem the tide of iatrogenic complications, like physiotherapy for vaginal and uterine pain caused by testosterone use. Something has gone seriously wrong in medicine.


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