Trans Mental Health, Transition and Gender Identity Clinics – By Dr Louis Bailey

The Trans Mental Health Study 2012)[1] is the largest survey of its kind within Europe and the first to explore mental health and well-being within the UK trans population.  The survey examined rates of life and body satisfaction within the trans population as well as trans people’s experiences of accessing a range of health and support services (including gender identity services and mental health services), current and past mental health issues, and experiences of daily life.  The full report can be found here.

Impact of Transition on Mental Health

The key finding to emerge from this study was the significance of gender transition in improving mental health and well-being.  74% of the respondents felt that their mental health had improved since transitioning.  85% were more satisfied with their bodies since undertaking hormone therapy, 87% were more satisfied after non-genital surgery and 90% after genital surgery.  Both social and physical changes of gender were shown to have a substantially positive impact on trans people’s self-esteem, happiness and quality of life.  Crucial here was the importance of being able to socially transition as their felt gender identity and having that identity recognised by others.  Alongside and interacting with this was the positive role played by hormonal and surgical interventions, which enabled necessary physical and psychosocial changes to be made.  Such changes reduced instances of Gender Dysphoria and negative body image and, in turn, served to increase confidence, satisfaction and overall well-being.

Rates of self-harming, suicidal thoughts and suicide attempts were high with 53% of respondents having self-harmed, 84% thinking about suicide and 35% attempting suicide at some point over the life course.  However, gender transition was shown to drastically reduce rates of self-harm and suicidal ideation within this group.  Of those that had completed transition, 63% reported having self-harmed, thought about or attempted suicide more prior to transition compared with 3% after transition.   Whilst transition has been shown to significantly reduce rates of self-harm and suicidal ideation, it consequently follows that those who would like to transition but who are unable to or who are experiencing significant delays or set-backs within the healthcare system will be at risk of increased self-harm and suicidal behaviour.

Impact of NHS Gender Identity Services on Mental Health

Whilst treatment for Gender Dysphoria was shown to have a beneficial impact on mental health, the process endured by respondents in order to gain access to that treatment was decidedly negative.  20% of respondents had wanted to harm themselves in relation to, or because of involvement with a NHS Gender Identity Clinic or health service.  The reasons listed included: Long waiting times and delays to treatment, restrictive protocols, inaccurate and unnecessary assessments, being denied treatment, being given the wrong information or advice, receiving negative or inappropriate treatment from psychiatrists, experiencing outmoded attitudes or questions/tests:

  • ‘…some things said to me at my last appointment (specifically that I should accept that my wife and daughters would be better off if I left them) upset me greatly. I left the Gender Identity Clinic on that day and sat in the car crying for over an hour. I decided there and then never to go back.’
  • ‘The Gender Identity Clinic…seemed to have very rigid ideas of masculinity and femininity and seemed to be adhering to a now outmoded medical model…with one my assessors asking me about sex positions, and how this ‘differed from heterosexual sex”‘
  • ‘The GIC expected me to be some stereotypical image of a woman rather than being myself’
  • ‘I experience the NHS GIC service as largely a paternalistic gatekeeping exercise where psychiatrists exercise inappropriate levels of control over the lives and choices of patients. They ensure compliance by withholding or threatening to withhold access to treatment… Having to negotiate the GIC system seriously hindered my transition. At many times, it has left me feeling angry, disappointed, manipulated, controlled and despairing. The system is deeply flawed.’

Summary of Findings

 Protective Factors:

–          Timely access to hormones and surgery

–          Social recognition of their gender

–          Professional understanding and support

 Risk Factors:

–          Untreated Gender Dysphoria (delays, refusals)

–          Minority stress (discrimination, harassment)

–          Unnecessary and intrusive questioning/tests

–          Prejudicial attitudes from service providers

–          Restrictive treatment pathways

Key Recommendations

Exploration of Alternative Health Care Models

There should be a shift towards models of trans healthcare incorporating informed consent and patient flexibility. This could be within the context of Gender Identity Clinics, however there are substantial issues within this system as it currently stands in terms of patient experience and outcomes. Many other models of trans healthcare are used globally and should be explored as alternatives. For example, the THInC model from Chicago (Trans Hormones Informed Consent) has very positive outcomes with the communities being fully engaged and involved in decisions around their healthcare. Informed Consent models are easily adapted to the UK health system (for example the T-PIC model; Traverse Research). These alternatives should be developed and researched to provide a valuable resource for informing true evidence-based practice focussed on enhancing outcomes, and in the process reducing costs.



[1] The Trans Mental Health Study 2012 – Jay McNeil, Louis Bailey, Sonja Ellis, James Morton and Maeve Regan (Equality Network; September 2012).