My Doctor Emailed Me Back
Abigail Thorn
Mon 23 December 2024 16:56, UK
Updated Mon 23 December 2024 20:36, UK
In 2022 I made a video about my attempt to get gender-affirming care from the NHS entitled “
I Emailed My Doctor 133 Times.” I showed that Britain operates a discriminatory healthcare system in which trans people have to beg permission to transition whilst the same medicine is available to cis people much easier. This results in years-long delays that have contributed to the deaths of multiple patients. I compared my odyssey through the system to the Joseph Heller novel Catch-22.
Recently I was contacted by someone very senior at NHS England. I’ll call him Colonel Korn. He told me he and his colleagues enjoyed my video, which surprised me given how critical it was, but he wasn’t just writing as a fan. Korn knows the British trans community doesn’t trust the NHS. He knows that panic, misinformation, exploitation, and risky behaviours are common. But there are changes coming and it’s part of his job to communicate those changes to the public.
He asked if I would be willing to work with NHS England and its “stakeholder organisations” to present a series of short videos explaining the changes. His vision was for bare-bones factual content: e.g. “Here’s how you get referred to a Gender Identity Clinic.” He thought if I were to bring my experience as a communicator and my standing in the community to the project, the trust issue could be addressed.
Before going any further I’d like to make clear that I hold no personal ill-will towards Colonel Korn, who struck me as a sympathetic man doing his best. But I declined his offer, and during our meeting I tried to explain why.
A Clash of Ideologies
There is a clash going on in Britain between two fundamentally irreconcilable ideologies.
The NHS, DHSC, and many other official institutions like courts view transition as a response to a medical problem they call ‘gender dysphoria’ or ‘gender incongruence.’ From this starting point it seems appropriate that trans people have to get permission to transition: transness is a medical matter with inherent risks that ought to be controlled by “specialists.” Sometimes those specialists delay or deny permission, but that’s just part of the job. It also makes sense to ask which treatments are “most effective at treating dysphoria” and explore alternative treatments through trials, reviews, consultations, etc. I call this view ‘Pathologization.’
According to Pathologization, past treatments like electric shocks simply failed to alleviate patients’ dysphoria. These days we have more effective methods, and one day we might discover a cheap way of treating it without transition- a silver bullet conversion therapy. Doctors and managers will determine when and whether adjustments to the system are needed. Ideally they’ll engage with trans people in “stakeholder groups” but if those groups don’t get what they want that’s not a dealbreaker. Patients who suffer or die waiting are unfortunate but hey, the NHS can’t save everyone.
On the other hand, the view of an increasing number- especially young people and trans people ourselves- is that transition is a bit like pregnancy. It’s a process that may require professional assistance to bring to the happiest possible conclusion (whether completion or termination), and for this reason it is appropriate and necessary that the NHS is involved. But whether, how, and when to do it should be up to you. From this starting point there should be as few obstacles as possible: the role of doctors and managers is to facilitate and advise but never delay or deny. Prompt, reliable access to transition is a civil rights matter. I call this view ‘
Freedom of Sex,’ a term borrowed from American writer Andrea Long Chu.
According to Freedom of Sex, it is wrong that we have to get permission to transition. It was always wrong. It’s wrong no matter how benevolent those “specialists” claim to be and it would still be wrong even if getting their permission were much quicker and easier than it currently is. What they call “care” is really control.
Pathologization exaggerates and in some cases wholly imagines the risks of transition to justify denying us the right to weigh those risks and choose for ourselves, and there is no place in medicine for that kind of paternalism. Attempts at “reform” only aggravate the situation. The people who have been harmed deserve justice. The people who died on the waiting lists are victims of social murder by institutional neglect and their killers must be held accountable. We do not consent to the power that doctors and managers have over us, and it is a dealbreaker: if they delay and deny, they must be deposed.
We need an informed consent system in which we control our own bodies without needing permission from anybody. This is the ideological struggle Colonel Korn finds himself in the middle of.
It is vital to realise that organisations can embody an ideology even if nobody working in them believes it. I think sometimes when people hear “Organisation X is institutionally discriminatory” they interpret that as “The leaders of Organisation X are bad people.” For example;
“The Metropolitan police are institutionally racist.”
“I’ve met some police officers and they’re lovely!”
This is a mistake. To say that an organisation is institutionally discriminatory makes no comment on the character of its employees, merely the pattern of its outputs. Not everyone who controls trans healthcare is a frothing bigot; again, I have no animosity towards Colonel Korn or his colleagues. My issue is with the outputs of the system they manage.
We are used to thinking of ‘ideology’ as a dirty word, but when I say Pathologization is an ‘ideology’ I mean it in the
technical sense. Ideologies help organisations decide what data to take on board, which to connect, and
which to ignore. They are, as the name suggests, ‘the logic of ideas.’ Ideologies are like arseholes: everyone’s got one, everyone needs one, but you rarely examine your own unless it goes wrong.
(And even then, you’d wait till it got really bad.)
If an organisation- be it a healthcare system, government, or a corporation- is ideologically set up in such a way that it cannot process critical information then it will fail despite the good intentions of the people working in it. This, I contend, is what has happened with the NHS trans healthcare pathway. Its outputs are discriminatory and harmful, contrary to the values and goals of many who work in it, because the system cannot process key information.
Here we reach the crux of the matter and the source of the distrust many trans people have for the NHS. We tell them we are trans, we want to transition. But that information about who we are and what we want counts for nothing unless we also have their permission. The system denies that we are reliable bearers of fundamental truths about ourselves. Our lack of trust in that system is just the equal and opposite reaction: they don’t listen to us, so we don’t listen to them.
As long as the system pathologizes us we are never going to trust it. We are going to keep protesting, occupying buildings, submitting complaints, homebrewing, smuggling, and stealing medicine, and fighting it every step of the way until it stops telling us what to do. It’s that simple.
Colonel Korn wanted to sidestep all that and just focus on “the facts” about the upcoming changes. However, as I tried to make clear to him, there are no neutral facts. I cannot communicate facts without attending to the context in which people interpret both their content and importance; nobody, no matter how good they are at communicating, could do this job and achieve the outcome he wants. If I made videos explaining the upcoming changes it would not make trans people trust the NHS more; it would make trans people trust
me less.
Colonel Korn’s Bind
The changes the NHS are preparing will maintain and reinforce Pathologization, as I predicted they would in my video. They want to conduct a clinical trial into the efficacy of puberty blockers on treating “dysphoria,” which is the
wrong question to be
asking and is only being asked now because of a moral panic and Labour’s ban.
They have no plans to offer apologies or restitution for the harm they’ve done. They have no plans to abolish “dysphoria” as a clinical diagnosis, or the invasive and humiliating assessments required to get it. They have no plans to address the
infiltration of the NHS by
conversion therapists rebranding as “
exploratory therapists.” They have no response to the
Cass Review being condemned by international medical authorities.
At best, they want to open a few more segregated clinics. Trans adults will remain firmly under their control. Trans children will be denied permission to medically transition entirely.
When I tried to explain all this Colonel Korn became frustrated and tried to interrupt me, which I did not allow. He said he did not feel able to enter an “ideological debate,” even though, as shown above, his job requires him to take an ideological position. He described my perspective as “political” when in fact the opposite is true: the function of critique is to open up new meanings and systems of valuation while the function of politics is to fix and
naturalise meanings, which, again, is exactly what his job requires. The fact that he seems not to realise this is probably why he’s good at it: if he was inclined to push back on the terms of value the system adopts he would not be able to play a senior role within it.
Colonel Korn attempted to push back slightly on Freedom of Sex, saying there are some trans patients in the current system who are “really very sick” and need “holistic care.” I took this to mean there are some who have other medical needs, including complex mental health needs. I have no doubt this is true, however it’s a non sequitur. Obviously I want those people to get the care they need but denying every trans person the right to control our bodies doesn’t seem to facilitate that.
In fact it makes the situation worse since, in addition to those complex needs, they’re also having to get help from a system that denies them basic autonomy. Many pregnant people also have complex needs but whether, how, and when to become pregnant is still rightly up to them. Disabled and neurodivergent trans people have been making this point for years and it was disappointing to hear this paternalism in the mouth of the man to whom they should be turning for help. So much for that.
Colonel Korn also said the low-trust environment makes our community vulnerable to panic, misinformation, and exploitation, and he’s absolutely correct. There are private companies out there who claim to provide healthcare but take our money and give the bare minimum. (We all know who I’m talking about.) It would be nice if we didn’t have to resort to such measures, or to buying hormones off the internet. I consider these practices analogous to backalley abortions: the inevitable response to paternalism. People will seek freedom where they can get it, risks be damned.
As for panic and misinformation, I think this too is the result of a system that routinely ignores trans perspectives. There is a brazen pattern stretching back years of the NHS doing wildly out of pocket things, getting called on it, then clamming up rather than apologising and holding themselves accountable.
Consider the following examples:
In 2021 NICE published a review into the use of puberty blockers. It was
condemned for asking the wrong questions, excluding trans people, and ignoring evidence. The NHS did not respond.
In 2022 clinicians wrote an
open letter condemning NHS England for failing trans patients. The NHS did not respond.
In 2022 NHS England issued a proposal saying trans children would need a doctor’s permission before even social transition- that is, getting a haircut or name change. They were
condemned in a joint statement by WPATH, ASIAPATH, USPATH, AUSPATH, and EPATH who called the proposal “unconscionable,” “unevidenced,” “ludicrous and dangerous.” The NHS did not respond.
The Cass Review was
internationally condemned for excluding trans people from its governing body, asking the wrong questions, and ignoring evidence. Tory minister Kemi Badenoch admitted that Cass was appointed to push “gender critical” (transphobic) ideology. Other countries’ reviews into trans youth care have come to opposing conclusions. The NHS did not respond.
In 2024, when the Chalmers GIC stopped referring trans adults under 25 for surgery they didn’t tell patients for
several months. They later said referrals were “paused” pending a “review” but wouldn’t say who commissioned the review, why, or how long it would take. The NHS did not respond.
In 2024, senior administrators in charge of trans children’s healthcare and the upcoming puberty blocker trial were caught attending a conference
hosted by an anti-trans hate group. The NHS did not respond. (Neither did Colonel Korn when I told him this directly to his face.)
In 2024 the RCGP hosted a conference of conversion therapists and anti-trans hate groups. Peaceful protestors outside were maced by police.
The NHS took no action and accepted no responsibility.
No public investigations have been held into these incidents and nobody in the NHS has resigned or been punished, and these are all from just the last few years!
There are even more serious charges. The coroners’ reports into the deaths of
Sophie Williams and
Alice Litman said lack of gender affirming care contributed to their deaths. That is to say, it is a matter of publicly recorded fact that the NHS’ failure to provide gender affirming care has contributed to the deaths of patients. Nobody at NHS England has resigned or faced consequences.
Of course panic, misinformation, and mistrust take hold in these conditions! Of course people come to believe the NHS are making secret plots behind closed doors! These conditions are entirely of the NHS’ own making. Slapping a famous trans person’s face on a new outreach program does nothing to address them. As I told Colonel Korn, if the NHS wants to increase trust they should start by apologising.
But the Colonel expressed his bind to me the same way every other NHS senior official I’ve spoken to has. The Department of Health and Social Care tells the NHS how they have to spend their money. The mandate they get from the Health Secretary tells them what services they have to commission: if it says “Ten more transplant wards,” they need ten more transplant wards, and that’s that. If it says “Spend £90m pathologizing trans people,” that’s what he has to do.
This point bears underlining: every single person I have spoken to in the NHS- from local GPs to the National bosses- told me they are powerless. There is nobody at any level of the organisation who takes responsibility for the state the service is in and the suffering it is causing. Every single person blames the person above them, even the man at the top.
Conclusions: Where Do We Go From Here?
I do not believe this system can be reformed. It must be abolished. In practice, that means every GIC needs to be closed and inquiries held into the abuses that have gone on there; every conversion therapist needs to be kicked out of the NHS; apologies, resignations, and damages need to be given to all those who have needlessly suffered and their families; and a system-wide redesign of the entire pathway must take place with the following axiom at its core:
If someone wants to transition, that’s their business
The result would be an informed consent system that produces better healthcare outcomes, minimises downstream costs, maximises patient trust and buy-in, and- let’s not forget- saves tens of millions of pounds of taxpayer money.
My discussion with Colonel Korn confirmed something I already suspected: we cannot achieve this through the NHS. No amount of complaints, protests, or engagement with “stakeholder groups” will work: they really are required to do what DHSC tells them.
Accordingly, those of us who want trans liberation need to go to the top, to the DHSC. Right now it’s headed by Health Secretary Wes Streeting who shows no signs of embracing depathologization. Quite the opposite.
I have written to Wes and the DHSC eleven times offering to brief them on the trans health crisis, and though the offer still stands it has been ignored every time. Colonel Korn told me Wes has met with all the “stakeholder groups” on this issue and opined that he is better informed on the subject than previous health secretaries, which is of no comfort whatsoever to those of us
whose bodies he still controls. I agree with others who study this field that consultations and “stakeholder meetings” have become a form of abuse by the NHS and the government: we’re included
nonperformatively – given time to speak in order to legitimise the
process of ignoring us.
The Labour Party churn out maudlin statements about how trans people should be “treated with dignity” and “feel valued and respected” but it’s all bullshit so long as we need their permission to do what we want with our bodies. No engagement process that treats cis control over our bodies as legitimate is acceptable. We won’t “feel listened to” just because someone takes a 40 minute meeting with us; we’ll feel listened to when they give us what we’re asking for. The rest is timewasting.
I note with despair that peaceful protest, legal action, and contacting our political representatives have also, so far, failed. But I cannot accept that the situation is impossible. I refuse to believe trans people must always live in a world where someone else controls our bodies. We will not always be second-class citizens. We can start by refusing to internalise Pathologization and insisting on the abolition of systems that produce it. We can grasp the determination necessary to go around those systems.
If you want to medically transition (especially if you are under 18 ) I would advise you to engage with the NHS extremely cautiously. I would also advise that you look into safe and legal options for community care. Most people I know who DIY do it on a patchwork basis- a little bit of NHS care, a little bit of community care- to mitigate the risks, which are real. You do not need anyone else’s permission to transition. You do not need to explain yourself, or let a clinician “get to know you as a person” first, “lead you in exploring your feelings,” give you “holistic care,” or any of the other euphemisms they use for “Not Until I Say So.”
If you are a GP there is a great deal you can do. Currently, prescriptions for trans HRT and puberty blockers are “off-label,” meaning the individual prescriber takes full legal responsibility for the outcome. Some good GPs are happy to take on this responsibility and educate their peers. We salute them, as we salute the homebrewers and artful dodgers who find creative means of getting medicine into the hands of those that need it.
The road ahead is long, but we have never been stronger. For the first time ever we are seeing the emergence of a global collective trans subjectivity. We have always been here, but often isolated and in hiding. Now in the early years of the 21st Century we have made an astonishing discovery:
There are a lot more of us than anyone thought!
Trans people in the UK, France, Germany, Eastern Europe, North America, Brazil, Taiwan, India, Russia, Australia, North Africa, South Africa, New Zealand- more places every day- are thinking and talking about ourselves in similar terms, and making similar demands. This has never happened before. Moreover, cis people are slowly realising they are cis. We really have reached a “tipping point,” no doubt in part thanks to the internet. The bodily autonomy of trans people is bound up with the bodily autonomy of all people, particularly cis women who have also suffered for far too long under the paternalistic medicalising gaze. That’s why I think the Colonel Korns of this world are doomed to fail: they are trying to do medicine and management on a civil rights movement.
The writer of this piece has asked for her fee to be donated to Medical Aid For Palestinians, please also consider lending them your support if you can.
