Month: October 2025

Trans health waiting lists are a political choice

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I’m just back from an awesome trans healthcare conference in Norway (blog on that to follow). Here I wanted to share information from a presentation by the founder of the transit trans healthcare service in Catalonia (Barcelona region), Spain. Transit is respected across the world for being a service that is leading the field in informed consent depathologised healthcare. Here I will share information on the approach, the history, how it works today and reflections on trans health waiting lists. First a quick spoiler for why you should read on: their waiting list for new referrals is 3 weeks.


The approach
The transit service was set up with a strongly trans affirming philosophy of care, building from principles including 1) a firm commitment to depathplogisation, that trans people have a right to affirmative healthcare without being under psychological or psychiatric control and without requirement for psychological assessment or diagnosis.2) commitment to Informed consent,that trans people of all ages have a right make their own decisions about their own healthcare 3) commitment to avoid diagnosis, recognising that a doctor or psychologist can never know someone’s gender identity.


The history
The transit service ran from 2012-2016 as a service running outside of state management and state funding. It ran in parallel to a state run gender clinic that was pathologising and gatekeeping. Transit was very popular amongst trans communities. The state run gatekeeper service was widely disliked. Three things happened. One, trans communities across the state united behind one clear demand and goal, to demand the closure of the state run gatekeeper service and the transfer of funding to the popular informed consent service. Two, communities organised and did activism growing support and unity behind their goal. Three, they managed to gain the support of a state politician who had the authority in a devolved spanish system to make a change. In 2016 state funding was shifted to the transit informed consent service and the gatekeeping psychology and psychiatry dominated service closed.


How it works today
Trans people always have a first appointment with a medical doctor able to prescribe hormones and never have a first appointment with a psychologist, psychiatrist or psychoanalyst. Fifty percent of patients receive hormones on that first appointment. The waiting list for the service is three weeks, meaning half of patients wait three weeks from referral to hrt.

The service does not deny hrt at first appointment for those who ask for it. For those who come to the appointment asking for hrt, they are usually well informed about her, and hrt discussions take up a very small part of the appointment, instead defining the appointment as a safe space where they can talk about any parts of their life that are difficult, with this discussion having no impact on them getting hrt which is guaranteed as it is their decision to make.  The reason people do not take hrt at first appointment is that they have not yet decided what they want and the patient themselves asks for more time, more support or other support.

The first appointment is 45 mins to one hour. There are zero required questions and no assessment of diagnosis. Doctors state that their job is not to assess or diagnose but to support their patient take decisions. The service operates what it describes as a multidisciplinary team but this means something completely different to what this term means in NHS children’s services. In transit it means that in addition to the medical doctor who takes the first appointment there are other professionals who the patient can request to see for additional support. A patient can ask to see a therapist to talk through their worries, history or mental health. A younger patient can ask to see a family support worker to get advice on getting support at school. They can choose to see a voice therapist. All of these additional professionals are offered and not required. The MDT offers value to service users,and does not operate as an abusive multi professional assessment, approval and gatekeeping gauntlet as happens in the UK. This same informed consent approach is followed for under 18s, with parents and legal guardians also involved in decision making for under 16s.

The transit service, with its three week waiting list, covers a population of 8 million, equivalent to the population of Scotland and Wales combined, or one seventh of the population of England, like one of our major regions. It has a total of 43 staff, a majority of whom are very part-time, working 6-7 hours per week for the transit service and working in other areas of healthcare the rest of the week. It has very high patient satisfaction rates. The key areas of complaint the service receives relates to the unavailability of particular formulations like injectable oestrogen, and complaints from parents who would prefer their child had gatekeeping in a slow psychological assessment and diagnosis model. The service has health provision in 8 locations across Catalonia, meaning people don’t have to travel far for an appointment.


Waiting
Last week UK trans healthcare advocates and journalists produced important work on the waiting lists for UK services. Those numbers are appalling. Whilst critiquing these ridiculous waiting lists I also hope we can do three other things:

1) Recognise the political and institutional choices that cause this waiting list: The NHS and our government choose to demand a gatekeeping psychology-led service that is the number one cause of our harmful waiting list. This is about the model of care, not about the amount of funding. In children’s care an increase in funding has led to an increase in the resources allocated to gatekeeping, not to any improvement in access to care. We should be long past arguing that increased funding is an form of solution without systemic reform

2) Recognise how easy it is to make better choices. Harmful gatekeeping services can be closed down and defunded. Respectful informed consent services can be funded and quickly expanded, delivering improved care at a smaller price. Importantly, a demand for informed consent care can and should be made for trans people of all ages, including trans children and adolescents. We need to stand together.

3. Recognise that the way in which we measure our waiting list matters. I hope we can move away from centring the metrics that our NHS and government think matter, and focus more on the metrics that actually matter. I would argue, that the key metric we should be counting, is a metric of the minimum expected time from referral to first getting a prescription for endocrine care, broken down by different characteristics including age and neurodivergence. Measuring a waiting list for access to a first appointment is entirely without merit in a service where the gap between first appointment and endocrine care is measured in years.

The UK children’s service has long had a waiting list of over 6 years for a first appointment. That statistic is likely to reduce. Trans under 18s are being forcibly discharged from the service for not attending identity exploration sessions, trans young people and families are ‘choosing’ to ask to be deregistered from a service that they find harmful and know won’t help them, trans young people and families are deregistering from the waiting list, and reforms to the referral system have made it increasingly impossible to get a new referral. But if that waiting list for the service goes down, does that matter? When those are the end of that wait have to wait for many year more, perhaps until they are 18 (or 25…) for approval for endocrine care.

For adults there has long been a minimum 1+ year delay from the end of the waiting list to getting endocrine care. That is part of the waiting. For many that wait is far longer than one year, and some people go years or never receive NHS approval for endocrine care. We need to focus less on the wait for a first appointment and more on the wait for endocrine care. This data could be collected, by the NHS or by ourselves.

Questions could be asked at the point of a first prescription including:
1. How long did you wait between referral and getting this prescription ?
2. How much of that wait was spent doing things that you found beneficial (counselling you chose to pursue before hormones, time for thinking, time for working through other issues including housing , employment and social transition that you chose to pursue before hormones, time to work through other mental health issues you chose to pursue before endocrine care, time to understand medical transition options). This can be defined as acceptable and patient-centred waiting for healthcare.
3. How much of that wait was not beneficial or harmful to you? (This can be defined as unacceptable waiting for care). Unacceptable and unwanted waiting for essential healthcare is a systemic inequality. Where this this number is counted in months or years rather than weeks, it is a form of state violence against trans people.

Huge waiting times for trans healthcare in the NHS, both in children’s and adult services, are there by design. Better political and institutional decisions in locations like Spain have removed this waiting list, delivering far better outcomes at a fraction of the cost. We demand better from our national healthcare.

Conversion therapy is harmful and shouldn’t inform NHS practice – new insights from clinical history.

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Conversion therapy is harmful and shouldn’t inform NHS practice. This shouldn’t be controversial, but sadly in the UK conversive approaches are now mainstream.

A new article just published today shines an important lived-experience perspective on some old clinical literature.

An autoethnographic critique of a past report of inpatient psychiatric treatment for gender diverse children

by Jayne McFadyen, Timothy W Jones, Rowena Koek, Fintan Harte, Brendan Jansen, Megan Galbally, Warren Kealy‐Bateman, Catherine Wall, Quinnehtukqut McLamore and Anja Ravine

In this short blog I will briefly discuss this new article, and its place in modern healthcare policy in the UK. First a bit of background.

Kosky (1987)

The new article published today presents a lived experience critique of an old 1987 article:

Kosky (1987) Gender disordered children: Does inpatient treatment help?

The abstract to that 1987 article states:

“Treatment guide-lines for gender-disturbed children currently are unclear. This clinical report describes eight children with cross-gender behaviour who were treated in an inpatient unit for children. The short-term outcome and long-term clinical observations are provided, which indicate a generally good outcome. The findings may have both practical and theoretical significance because they suggest that some gender disorders may be determined by intrafamilial interactions which are correctable“.

You might not be familiar with that article. But if you have been paying attention to discourse on trans youth healthcare you will be familiar with a 2016 literature review that included the Kosky article.

Ristori and Steensma (2016) Gender dysphoria in childhood

This literature review is an absolute favourite of transphobes, and has been the key citation to justify terrible healthcare policy that has harmed trans children for the past decade. It is the key citation used to legitimse the idea of ‘desistance’ or the concept that trans children will grow out of being trans, as long as they are rejected rather than affirmed or allowed to socially transition, as long as they are forced through an unwanted puberty rather than receiving affirmative healthcare. It is a key citation supporting policy recommendations against social transition. It is a key citation supporting the rejection of trans children’s identities at school. It is a key citation given to parents of trans children to encourage them to reject their children. It is a key citation underpinning the claim that puberty blockers are dangerous and should be banned due to their impact on changing the trajectory of sexual and gender identity development. It is a mainstay of anti-trans policy making, and a key citation of the Cass Review.

The Cass Review utilises a 2016 literature review as a key citation, to avoid citing the underpinning literature, the titles of which would raise concerns. The Commission on Human Medicine adopts the same tactic, citing an even more modern literature review by Michael Biggs, that does the exact same thing, using a modern ‘literature review’ to rebrand and present as modern a literature review of some really old and problematic studies. 

If we look at the studies upon which the 2016 Ristori and Steensma literature review is based, we see just how old those studies actually are:

Bakwin (1968) Lebovitz (1972) Money & Russo (1979) Zuger (1984) Davenport (1986) Green (1987) and Kosky (1987)

These studies are HUGELY unethical trash, that should have been in the bin decades ago, as I’ve written about before here, here and here. Even looking at their titles shows a pathologising view of difference.

The new study that has been published today focuses on the last of these, Kosky (1987) “Gender-disordered children: Does inpatient treatment help”.

Kosky (1987)

The study Kosky 1987 provides a clinical perspective on the treatment of gender non-conforming children in and around the year 1975.

In 1975, Jayne McFadyen (a key author of the new article published today) was ten years old. She had known she was a girl since the age of 8, but lived in a time and a place where affirmation or being supported to be a trans girl was not considered an option by the professionals around her. Clinicians blamed her parents for causing her gender non-conformity, and took her away from them, putting her into an institution where she would be treated to convert her into a gender confirming boy.

Within the 1987 article, the clinicians in charge of ‘conversion therapy’ outline the success of their approach.   

Many decades later, Jayne recognised her experience, the location and dates of her own experience as lining up with the 1987 article. But she did not recognise the article’s central claim that the therapy had been beneficial and successful. She felt very strongly the opposite.

Now in her 60s, Jayne shared with a team of researchers her own perspective on her conversion therapy treatment at the age of 10, as well as sharing her own clinical file and notes that she was able to access. She recalls being shamed, abused and traumatised in attempts to wipe out her gender non-conformity.

According to the Kosky study, the institutionalisation, separation from parents, and abusive treatment was a success, removing gender non-conformity. The Kosky study has been used for decades, and continues to be cited today, to justify several claims:

  • It is used to evidence a claim that a majority of gender non-conforming children, if unsupported/rejected, will not be gender non-conforming or trans as adults.
  • It is used to evidence a claim that parental influence can cause a child to be gender non-conforming, and that separation from parental influence can remove gender non-conformity or transness.
  • It is used to evidence a claim that that therapy can remove a child’s transness, gender non-conformity or gender confusion. 

The new article examines this woman’s memories and her clinical records, comparing these with the claims within the published study. Important differences are noted. Substantial ethical failings are noted, both in terms of clinical practice and in terms of research. The woman shares her life experience – the impact of the ‘treatment’ in creating and reinforcing shame and self-hate. The ‘treatment’ forced her, through fear, into repression and hiding. She reflects on how it took her decades to process the impact of the childhood abuse that she received at the age of ten – abuse that is claimed as a success in the Kosky study. She shares how in mid adulthood she finally transitioned. Now in her 60s, half a century on from her institutionalisation at the age of 10 in 1975, she reflects on the harms done to her as a child. She shares her perspective, how her identity as a girl and woman has not wavered since she recalled feeling that way at the age of 8. 

The new article argues that this 1987 publication “should not be considered reputable evidence in any debate over transgender policies — either by direct or indirect citation”.

It notes, however, that this article is indeed being used as evidence upon which healthcare policy is based in 2025. It notes it being used indirectly, via the 2016 literature review, by the Cass Review. It notes it being used by anti-trans parent organisations like Bayswater, by those advocating for conversion practices, and by those who accuse parents of ‘transing’ their children.

This article continues to be used, directly or indirectly, by actors including the NHS to justify plainly bad policy positions including:

  • To justify restrictions on, or criminalisation of puberty blockers, on the basis that gender non-conforming kids naturally grew out of their gender non-conformity, before puberty blockers changed the outcome, unnaturally keeping kids on a trans pathway.
  • To justify restrictions on social transition, including in schools, on the basis that unsupported children grew out of gender non-conformity
  • To justify advising parents against supporting a trans child, on the basis that unsupported children grew out of gender non-conformity
  • To justify safeguarding investigations into supportive parents of trans kids, on the assumption that parental action can cause a child to be mistakenly trans
  • To justify in-depth questioning of trans kids without their parent present, on the assumption that parental action can cause a child to be mistakenly trans
  • To justify denying the existence of trans children, replacing that group as a whole with the term ‘gender questioning children’, on the assumption that childhood gender variance is temporary, unstable and will be grown out of as long as it is not affirmed.
  • To justify prolonged non-affirmation or rejection of a trans child’s identity, on the assumption that affirmation puts children on a lifelong medicalised pathway who would otherwise grow out of it.

The seven bullet points listed above are having a huge impact on trans children across the UK in 2025. Each one of them is so absurd to almost be laughable. Each one of them is having a cruel and abusive negative impact on trans children’s lives.

This abusive 1987 study was considered a terrible study on which to base modern healthcare policy even before this new lived-experience critique. This lived-experience critique adds further weight to a long-stated argument that these old abusive studies should have no influence over healthcare policy in 2025. Studies like the 2024 Cass Review, like the 2024 Commission on Human Medicine report that enabled the continued criminalisation of puberty blockers, continue to rely on literature reviews of very old and abusive research to justify harmful trans-hostile policy positions, while ignoring modern research that overwhelmingly supports affirmative care. This decision to ignore modern literature and rely on trans hostile literature summaries of old and abusive literature is entirely political and ideological.

The new article summarises its key finding thus:

“Contrary to ongoing representations of efficacy, “therapy” that aimed to change or suppress a gender diverse child served to delay self-acceptance for two decades and caused long term harm”.

The NHS already know this.

Those opposed to or ideologically in denial of trans children’s existence will continue to apply conversive approaches to trans children regardless.

The Cass Review, and UK NHS policy remains rigidly committed to doing everything it can to harm trans children. For more on this, I strongly recommend reading another article, also out today.

“Cass Review does not guide care for trans young people“