Subscribe to Salvage and receive two print issues per year, plus digital access including audio and back issue PDFs
Gender Identity Communism: A Gay Utopian Examination of Trans Healthcare in Britain
The following piece first appeared in print in Salvage #7: Towards the Proletarocene, our relaunch issue. Subscriptions to our twice-yearly print issue can be set up here. Issues are also available to buy individually here. Our poetry, fiction and art remains exclusive to the print edition, and our subscribers have exclusive access to some online content, including all audio content.
We are two trans people who have managed not to be defeated by the process of being clinicalised by the Gender Identity Clinic (GIC) system, which oversees trans healthcare in Britain and occupied Ireland.
One of us, through a combination of patience and self-medication, faced down a GIC which, despite being among the swiftest in the country, still had an average waiting time of 51 weeks prior to treatment in 2018. For the other, avoiding processing through a GIC was a major factor in deciding to remain a migrant from Britain. Instead she accessed Hormone Replacement Therapy in Europe, where it was more swiftly and humanely available, taking less than four months from initial phone call to estradiol gel prescription.
Both of us are sick of worrying about our friends. Inspired by twentieth-century utopian communist thinkers and the pioneering healthcare practices of today’s trans communities, we write not only to bring the dire social conditions of trans people to light, but also to explore the autonomous means with which we have achieved survival despite the state.
Part 1: The clinics have failed
We are not too ill, too disabled, too anxious, too depressed, too psychotic, too Mad, too foreign, too young, too old, too fat, too thin, too poor, or too queer to make decisions about our bodies and our futures. We are all self-medicating. Our agency will be recognised. We each labour far harder for the health of ourselves and those around us than any doctor ever has, and we will continue [to] build supportive communities on principles of mutual aid.
—A4TH Edinburgh Manifesto
The clinics have failed. The current British system for trans healthcare provision combines unsustainable centralisation with chronic underprovision. Increasing demand for trans healthcare has coincided with the stripping of resources due to austerity. With only fifteen GICs in England, Scotland and Northern Ireland, lags of two to three years before accessing hormones are a new norm.
This leaves trans people facing down years of anxiety, depression and suicidal tendencies in the fact of pervasive transphobia and harassment, unaided. Such postponements are sentences to an unlivable life. To quote the title of Sylvia McCheyne’s incisive criticism of British healthcare, itself taken from a banner at an Irish protest: We are sick of losing people to these waiting lists.
This is a fabricated crisis.
The gratuitous inefficiency of the UK system contrasts with the ‘informed consent model’ of other healthcare systems, including that of the United States, wherein focus is placed on ensuring that a patient is clear on the potential risks and realistic scope of treatment – that testosterone or estrogen treatment, for example, will ultimately render them infertile. They are given realistic expectations for treatment outcomes: that HRT, for example, will not entirely transform their genitals. While mental health is assessed, this is usually a brief process to confirm the patient is of sound mind – for example, to exclude those undergoing a psychotic episode, or in some such way currently impaired from long-term thinking.
Where informed-consent models are oriented towards providing a treatment, the GICs are focused on first verifying the status of the patient – to establish that the trans person seeking treatment is trans at all. Trans people often approach official medical channels only as a last resort, having spent years in ‘exploration’, repression, ineffective therapies and circular conversations. The GIC system then extends this process – often by years.
Finding a sympathetic GP who will refer to a GIC can be an initial challenge. Once registered, the GIC becomes the primary service responsible for trans healthcare. This does not mean direct access to hormones or surgery, but more assessments by nurses, doctors and endocrinologists – scrutinisers inscrutable in their standards. The process demands trans people live for months and years at the beck and call of this gatekeeping bureaucracy, while straining to prove an identity that society would obviously rather did not exist.
The Clinic system justifies this delay using the spectre of the mentally unstable trans person, who fails to appreciate the ramifications of their decisions. For decades, clinics have sought to distinguish between ‘true transsexuals’, and those merely confused gender deviants who must be prevented from making a calamitous decision. In this patrician approach, medical professionals are kindly guides to gendered experience, and authoritative arbitrators of its permissible limits without whom trans people’s mental health would be gravely endangered.
The reality is the reverse: strain is caused by medical gatekeeping’s indignities. The Gender Identity Clinic at once alienates us from our treatment, and imposes agonising waiting times between sessions. Postponing surgeries can be devastating for those undergoing ‘social transition’. Trans people who need timely treatment and informed support instead face a rigid structure that Action For Trans Health Edinburgh’s manifesto calls a ‘war of bureaucratic attrition’.
Since the 1966 foundation of the first clinic, in London, conformity to old-fashioned gender norms, or at least the pretence of such, has conditioned access to treatment. There was little place for non-binary identification, or even non-heterosexual orientation, for earlier generations of trans people navigating the GICs of the mid-twentieth century. While now partially reformed after decades of lobbying, the GIC has not abandoned such gatekeeping.
The GICs vary considerably in size, funding, staffing and practice. Like many other NHS bodies, the GICs have been left crumbling after cuts, and advancing privatisation. A new clinic in Cardiff was supposed to start taking referrals from March 2018, but nationwide coverage has not materialised. Most Welsh trans people still rely on the discretion of their GPs for hormone prescriptions, and rely on expensive travel to London for a full assessment (travel funding is nominally available but limited).
The clinic at Sheffield’s Porterbrook Medical Care Centre works to develop a shared culture of respect for patients, but is understaffed, underfunded and oversubscribed. Larger institutions such as Charing Cross GIC have suffered particularly badly from rising waiting lists, a situation hardly conducive to the development of shared values and accountability processes throughout assessment and treatment.
Closeted trans youth living at home and far from clinics are obliged to fabricate excuses for regular trips across the country. Often, appointments are at short notice, requiring patients to hurriedly organise logistics and finances. Failure to attend a single appointment can be met with threats to drop patients from the service.
Those who weather waiting lists and travel expenses need a clinical system sensitive to the desires and understanding of trans people ourselves, but treatment is often dire and approaches outdated.
GIC practitioners have much to learn about the options and subtleties of practice when it comes to HRT. For instance, anti-androgens are routinely prescribed to trans women to block the reception and action of testosterone, according to a medical regime based on boosting estrogen levels and suppressing testosterone at all costs. However, trans women prescribed anti-androgens frequently experience depression and other disabling side effects such as brain fogs and fatigue. Anti-androgens also tend to ‘oversuppress’ testosterone, often reducing it to undetectable levels, which can inhibit desired outcomes in the long term, leaving trans women wishing to get off them risking permanent damage to hormonal regulation. GIC doctors seem resistant to patients use of increasingly popular ‘monotherapeutic’ hormones regimes, which uses estradiol as the primary medication, waiting for elevated estrogen levels to trigger an automatic drop in testosterone. This reflex, the aromotose reaction, allows for dramatic rebalancing of circulating sex hormones without anti-andorgens. Despite increasing numbers of trans people reporting good results from this protocol, NHS medics still treat higher levels of estradiol as intrinsically dangerous, based on outdated clinical data.
This stubborn attachment to outmoded paradigms characterises GIC clinical practice. There is mounting evidence that hormones delivered transdermally – through the skin via patches and gel – bypass the liver’s first-pass metabolism, and are thus more efficient and safer. But NHS endocrinologists still exclusively offer oral medication, while often failing even to give full instructions on its effective administration through sublingual dissolving. Testosterone treatment is typically more efficiently delivered, but masculinising HRT is outmoded in other ways. Patients are rarely offered dihydrotestosterone (DHT), an androgen produced by the metabolization of testosterone, which can promote genital growth to the point where many find the results so satisfying they no longer feel the need for surgeries.
Trans people of whatever gender can rarely access opportunities to freeze their gametes, resulting in an ongoing lawsuit by the Equality and Human Rights Commission after their pre-action letter declaring the NHS clinical standards outdated was ignored. Though the NHS, unlike some other national systems, has never require trans people be sterilised, this remains the de facto norm.
Falling outside the familiar paradigms of ‘transsexualism’, non-binary trans people in particular have been denied access to the full scope of their potential options. Despite formal changes towards inclusivity since 2018, the very notion of non-binary identities is still excluded from the dominant imaginary of today’s GICs, which are notorious among non-binary people for retrograde treatment regimes, old fashioned concepts, and sometimes openly hostile attitudes. Non-binary people routinely encounter sceptical attitudes towards their desired outcomes, as reported for example in a number of accounts collated in 2014 by Action For Trans Health. Most NHS specialists display a dismissive attitude towards the possibility of securing non-binary physiological changes at all. These assumptions are not limited to highlighting specific limitations such as that certain levels of particular hormones are required for sustaining bone integrity, but often amount to tacit or explicit invalidation. Ignorant and insensitive comments are widespread: one patient was asked whether they were non-binary or ‘a regular female’. The mutual distrust is such that it’s common in non-binary circles, where people are not too discouraged to seek medical support altogether, to hear the advice simply not to mention this aspect of gender identity when approaching medical professionals.
Adding insult to all these injuries, we have lost track of the stories of basic bureaucratic errors in the GIC’s handling of – often sensitive – information, which often serves to extend waiting times still further. Incorrect names and pronouns are often used in letters and official reports, aggravating the very dysphoria the whole process is supposedly intended to treat, and eroding any remaining trust.
How have the GICs failed this way?
The late Douglas Crimp observed that US government-sanctioned healthcare advice on AIDS failed to stem the crisis by attempting to address queers and drug users solely in ‘a “universal” language that no one speaks and many do not understand’. We might find reference to an ‘intravenous drug user’, but never skin popping, a skag queen, or any other slang relevant to the lives of actual gays. Similarly, the GICs refuse engagement in the terms trans people use to understand ourselves on a daily basis. Interacting with a GIC can mean abandoning the language best-suited to make sense of a transgender life. Distinctions between ‘feminine’ and ‘effeminate’, ‘man’ and ‘boi’, ‘gay’ and ‘queer’, might be highly important to a trans person under scrutiny, but such nuances simply do not appear in the clipped vocabulary of medical professionals. Instead, trans people are expected to achieve fluency in the tongue of the bureaucrat, without reciprocation.
Even within their own terms, the approach taken by the GICs can be inscrutable. A doctor might deliberate as to whether to make a diagnosis of ‘transexualism’ or ‘gender dysphoria’, a distinction baffling in the traditional terms of the professional (persistent gender dysphoria is a diagnostic symptom of ‘transsexualism’), and alien to the lived experience of trans people. Nonetheless, we have seen the distinction used to sort binary-identified ‘full transexuals’ from dysphoric non-binary or gender-non-conforming individuals.
The Race Equality Foundation has found that trans people of colour remain largely invisible within current research and clinical practice, not least because many feel unable to disclose their identity fully in the face of pervasive transphobia and racism. The research also shows that current clinical practice is poorly equipped to address those who identify in non-Western or non-anglophone terms. Considering, for example, the recent election of Jair Bolsonaro in Brazil, this racist lacuna is a failing that will become increasingly apparent and dangerous as the twenty-first century continues, and LGBT and refugee struggles continue to interlock.
Our actual needs are relatively modest. That services and substances that could so easily be universally provided have been winnowed bespeaks structuring principles of the system: to restrict access, govern a minority population, and complicate transition as an experience. Not only does this mean a shortage of treatment that should be easily provisioned, without delay, but the loss of a wealth of clinical data, and a breakdown of language between patients and clinicians. This disconnect will likely be exacerbated as Generation Z comes of age in a context where transition has been culturally normalised, no longer an unusual pathology, nor even a radical political movement, but a mass phenomenon. Far from preparing for the health needs of femboys or NB testosterone micro-dosers, the Clinics are still wrapping their heads around trans women in trousers, or gay trans men who enjoy contouring before a night out.
In the face of this breakdown in provision and communication, an increasing number of trans people are opting for self-medication regimes. Others rely on private services, such as Gender GP (which styles itself the antithesis of the GIC system, with its slogan ‘Putting you in charge of your gender journey’). Such services are beyond the means of most trans people, but we’ve seen approaches ranging from crowdfunding to spending almost the entirety of a student loan to secure access to these swifter and less humiliating private services. The NHS has responded by doing its best to shutter these stopgap solutions.
For the neoliberal state, the case of trans healthcare is practically unique in that even the ideological principle of providing a ‘choice’ between nationalised and private healthcare is being abandoned. Even private practitioners are being placed under increasing scrutiny that extends to pressuring them out of practice. One private provider reported that NHS doctors issued third-party complaints to the General Medical Council concerning private practices for not conforming to the retrograde NHS policies. Four medics who provided these services have been suspendedL the most recent was a sole provider of hormones for over 1,600 patients. These interventions were clearly intended to drive the practices out of business, with their longer-term prospects left unclear. In an attempt to remain afloat, one practice readied patients with an offensive disclaimer clearly implicitly informed by the same ‘trans-trender’ paranoia that guides the GIC. Given the intensity of these efforts by the state, it seems inevitable that in future other medics will be discouraged from opening such services.
Internationally, campaigns against the psychopathologisation of trans people are making steady progress. In 2018, the Eleventh edition of the International Classification of Diseases removed the classification of trans-identification as an illness. Despite this momentous progress, the ICD-11 continues to use the ‘temporary and imperfect’ language ‘Gender Incongruence’ to describe trans, gender non-conforming, and dysphoric people, in the face of an international campaign, spearheaded by South African groups such as Iranti, to remove this vestige of stigmatising language.
Back in the British backwater, the clinical lens through which the NHS surveys trans culture remains a blinder. The traumatic imposition of ‘Real Life Experience’, when trans people were expected to live full-time as their true gender without either hormonal or surgical assistance to prove they were ‘for real’, has largely been formally abandoned. Yet the huge delays in treatment, and the widespread refusal of GPs to provide reprieve, have resulted in its de facto retention. Often, clinicians’ questions amount to the same intrusive and stereotyped adjudication of whether we are living openly in our chosen gender. Left waiting for years for treatment, we negotiate whatever opportunities to live as trans that we can, which means – as with Real Life Experience – exposing ourselves to social transphobia without medical or state recognition.
The GICs have proved remarkably resistant to change, even when administrative breakthroughs gave cause for hope, such as when national NHS best practice guidelines in the 2010s mandated that GPs should be expected to provide ‘bridging’ medication, and services such as epilation. Unfortunately, despite this official mandate such support has not materialised. Some GPs express reluctance to operate as stopgap sovereigns, given their lack of specialist training: one trans person navigating the system reported being refused by three such doctors, before a fourth would offer the (supposedly nationally mandated) bridging medication.
Allowing access to hormonal treatment on the basis of informed consent would alleviate the current crush with near immediate effect.
The GIC system was always a means of state discipline and managed deprivation, and replacing it has become increasingly urgent. After twenty years of determined campaigning by liberal trans activists, the reforming approach is reaching its limit. Breakthroughs by the trans movement in the cultural and legal spheres have come up against intransigence on the part of government, healthcare institutions, and transphobic press. Efforts to ‘reform’ the GICs have fallen well short of the overhaul that would allow them to weather austerity. Even the most persistent agitation and spirited fundraising seem unable to overcome the callous logic of this system. The salience of the few valuable reforms that have occurred seems unclear in the face of the current meltdown of provision.
Some trans people are able to buy their way out of dealing with the GIC; some make it through the ordeal of awaiting treatment with the support by friends and loved ones; others cross borders to escape it; others flout the law in one way or another; and others do not survive the medical neglect and structural incompetence in a transphobic society. The Clinic system can be seen as a ruthless stretching and testing of the social support each trans person who encounters can call upon. Those who suffer worst from it are those who were most vulnerable to begin with. The system has less to do with any universalist’s vision of a benevolent welfare state, and more to do with an interrogator’s stress position.
The system developed into its current state with no long-term plan for accessible, effective or reliable provision, and it should be replaced on a new foundation. Trans clinics should serve the newly out and empowered UK trans population wherever we are, taking into account the advances in hormonal, psychological and cultural understanding which have often been led by our political struggle.
We cannot rely on the political class. The new Tory government has kicked its long-touted (and already inadequate) plans to reform the Gender Recognition Act into the long grass.
The Clinic system’s historical role of verifying ‘valid’ transitions has become totally dysfunctional in the context of swingeing cuts, but its approach has also been surpassed by the realities of autonomous action by trans communities to provide for ourselves. Trans people facing myriad attempts to undermine our means of living have, out of desperation, developed capacities for collective survival. What’s more, our combined medical knowledge and political vision far surpasses that of government bodies on the matter.
Part 2: Beyond The GIC – DIY Liberation
There will be no clinics, and no authorities. We will conduct our own research, and experiment with our own bodies. We will heal and grow together. We will accumulate knowledge and share it freely and accessibly. We demand nothing less than the total abolition of the clinic, of psychiatry, and of the medical-industrial complex…We do not consider that our work will ever be complete, there will always be greater things on the horizon.
A4TH Edinburgh Manifesto
Our vision of twenty-first-century trans healthcare is not limited to a more ‘efficient’ version of the existing process of professionally administered transition, or to ameliorating the choked-up state of British trans healthcare. We demand something new, hatched from the emancipatory practices trans people have already developed for ourselves.
Trans healthcare in the twenty-first century provides many stories of hope, although few from conventional sources. Beyond official websites, Westminster lobbies and NGOs, a churn of social activity sustains and expands trans communities. Affinity circles freely share and discuss the latest scientific research into desired clinical outcomes. New explorations of non-binary transitions are attempted and collated. Social media rallying points such as #transdocfail persistently challenge and reassess the practice of healthcare professionals. Unlike the rigid and proceduralist approach of the GICs, this trans culture crosses borders, contexts, the variations of sensibility and sensitivity which define human experience. Sharing healthcare knowledge on our own terms, trans people across the world are securing the gender expression which we see fit, by whatever means are available.
An increasing number of trans people opt to bypass the GICs, and source our own sex hormones. This approach to transition is known as ‘self-medication’, and it has become commonplace. Restrictions on non-clinicalised access to such hormones vary. Primarily because of how coveted testosterone is by body builders, it’s treated as a restricted substance. By contrast, exogenous estrogen and progesterone are relatively easily available, to cis and trans women alike. This distinction is likely to account for the increasing numbers of young trans men and masculine people approaching the NHS for treatment, unlike the unknown number of trans teenagers relying on estrogen who can bypass the medical system through internet ordering. In turn, trans-masculine people often share NHS prescribed testosterone as an act of mutual aid.
In the face of the current media moral panic around youth transitions, it seems likely that the next stage of widespread medicalisation will be the government restricing access to estrogen. This would not only impact trans teens, and could greatly complicate existing self-medication practices. Any expansion of these legal prohibitions must be resisted. As activist group Action 4 Trans Health Edinburgh put it: ‘We are all self-medicating. Our agency will be recognised.’ It hardly falls to us to sketch the entirety of a new order: our community has been moving ahead of the state for some time.
Hormones issued by prescription still reach the hands of trans people who can ingest them at our own discretion. We can ignore the advice and chastisement of our doctors. Nonetheless, we still rely heavily on the state and market for their resources. We have to buy our hormones from somewhere. (At least for now – the ‘Open Source Gender Codes’ project is providing hope for ‘home-grown hormones’ and a new generation of DIY practices.) But ‘DIY’ practices exist everywhere. Resources include sizable online communities, but often the skills and encouragement needed to start medical transition are found in more intimate encounters. It may be a matter of knowing one or two fellow travellers in your own town and developing friendships for survival. Those medically qualified might offer vital information and encouragement. Reliable websites are shared. Such collaboration are often provisional: one elaborate operation ran in Austria saw a trans woman leave a stash of medications in an abandoned building, to be collected by a self-medder still awaiting full authorisation.
Much of the work done is exploration of options for hormonal treatments, and verification of the safety and efficacy of those formally prescribed. We educate ourselves through long hours on online medical databases such as PubMed. Many of those most immersed have professional medical or research training (although the nature of medical school makes it rare for trans people to attain full MDs). Others are autodidacts by necessity.
DIY trans healthcare practices are developments in the struggle for trans liberation that must be understood when considering a replacement for the Clinic. Such practices and communities have already achieved a direct impact on those facing otherwise substandard care. The ambition of DIYers is growing, openly challenging the typical hierarchical division of labour characterising medical treatment. Beverly Cosgrove of Modern Trans Hormones has described the approach formulated by her group as a ‘new best practice for trans healthcare’. Cosgrove oversees the MTF Trans HRT Hormone Forum, in which trans people undergoing HRT and medical care in various contexts have both pooled their own experiences, and collected empirical studies, and offer guidelines on HRT. The conclusions the group has developed have proven invaluable for many, and even those who disagree with the particular approach can reapply principles developed there.
In a Reddit DIY forum, one trans woman with apparently exhaustive knowledge of the literature, compiled a fully referenced guide for non-binary transitions for male-assigned trans people. Another thread flagged previously obscure research studying cis men with prostate cancer in Argentina, and extrapolated a new approach to using transdermal gels, immediately drawing responses from trans women sharing their blood levels, demonstrating its efficacy. Another forum runs its own wiki to collect advice and sources. These queer amateur practices often diverge from prescribed knowledge within British and American clinics, but seem to achieve many trans people’s desired outcomes.
There is a concrete utopianism at work in DIY trans healthcare, enabling survival in the present, and pushing forward our future understanding through new forms of knowledge and social relations. Such autonomy is typical for LGBT healthcare, at least when conditions are at their most dire. In the 1980s–90s, groups like ACT-UP and its predecessors pioneered efforts to understand and face down the transmission of the virus. More recently, the community-led campaign I Want PrEP Now led to a remarkable collapse in the HIV transmission rate. Founded by Greg Owen, a gay man who had seroconverted while attempting to access treatment, I Want PrEP Now provided an off-brand version of Truvada, making the drug affordable for most gay men. Owens ran the website out of his bedroom, supported by a number of LGBT people sharing his commitment. The website became a focal point for revitalised AIDS activism in the UK, at a time when the NHS still refused to provide the drug on a mass level, only sanctioning small-scale tests. Through community campaigning from groups such as the UK’s newly refounded ACT-UP, provision of PrEP was achieved on a much broader scale than the NHS authorised, through non-state means. Between 2015 and 2016, the Dean Street sexual health clinic reported a 42 per cent fall in seroconversions. Nationally between 2015 and 2017, transmission rates fell by 31 per cent: the PrEP provision campaign appears decisive in one of the largest declines in the virus’s spread since the start of the crisis. After these results, mass distribution of PrEP was finally permitted under the NHS.
It is in a similar fashion that trans people have bypassed the state, offering informal processes of skill-sharing to distribute technologies, information about trustworthy medics, and the means of navigating gatekeeping as swiftly as possible.
These practices may discomfort those more used to ‘professional standards’ regulating the most important features of life. Predictably, the British establishment has responded with scaremongering media stories characterising online pharmacies as ‘cowboy chemists’. But a certain queer amateurism – related though not identical to the ‘radical amateurism’ referred to in Helen Hester’s Xenofeminist Manifesto – has often prevailed in the face of systemic neglect, in Britain and elsewhere.
We do not see these communities as acting in pristine detachment from the established medical institutions. Rather, these ‘homebrew’ approaches to treatment practices are acts of resistance to a system that under-provides skilled treatment as a matter of course – drawing knowledge from that system through medical databases and medically qualified comrades.
DIY practices are not widely respected within the GICs. Most doctors display a combination of concern about and open hostility towards self-medication. One trans woman, for example had come to her own view of how to dose her estradiol subcutaneously. When she raised the fact she was DIYing at an early GIC meeting, her psychiatrist refused to prescribe bridging medication, and discouraged her continuing DIY treatment. When she subsequently asked how she could safely ‘taper off’ her current hormone regime, he refused advice, denying her choice altogether, and leaving her without the support to either continue or end treatment safely.
Certain medical professionals have come to respect the urgent need for access and autonomy in our healthcare, which in rare cases has led to a more collaborative approach. Dr. William Powers, for example, has produced documents written in dialogue with, rather than imposed on, us.’ I didn’t get all this knowledge because I’m a genius,’ he has said. ‘I got it because transgender women and men are experimenting on themselves … and it worked, better than anything else did.’
To avoid irrelevance, and to overcome its ignorance, the medical establishment must respect DIY practices and knowledge. Our capacity to make judgements with respect to our bodies, medication, psyche and lifestyle will be expressed with our without medics – who should now justify themselves to us. Today’s Gender Identity Clinics are framed around sorting the ‘authentic’ from ‘trans-trenders’ or ‘fakers’, and providing a single pathway to treatment. Their abolition could replace a meatgrinder of surveillance and pathologising, with the development of centres of shared experience and genuine expertise, to be led by trans people ourselves, with expert advice offered as part of a responsive dialogue. Breakthroughs would be produced continuously by transition as an emerging mass phenomenon.
At present, DIY resources exist in unreliably updated blogs, furtive subreddits, and local networks. While indispensable, these channels are ad hoc, and often challenging to those most in need (for instance due to learning disabilities, inability to access the web, or read and speak English fluently). For all their strengths, we should not mistake informal distribution channels for the finished article in utopian healthcare. As Helen Hester has it, ‘the “Y” in “DIY” never operates in isolation, but is enmeshed in a web of structural oppressions, networks of power, and technomaterial relationships’. The new trans clinic would make this ever-expanding body of practical wisdom truly accessible to the swelling number of trans people who require these resources for truly informed consent. We envision a synthesis between the vital knowledge produced by trans people through our practice, and the scale, accountability and resources of established medical institutions. In particular, a fixed centre to collect and compare clinical data, on a consensual, anonymised basis, would improve on the thriving informal hubs.
Encounters between clinics and GPs should be premised on the unconditional provision of desired medications and services. But we can go further, to consider what a trans healthcare system that is meaningfully integrated into society would look like, as part of a liberated healthcare for all people in our society – including at its margins, and across borders.
Different aspects of trans healthcare provide distinct challenges. Hair removal can be performed at any number of salons. Voice training could clearly be practiced more flexibly and widely than in the current system, which often restricts us to an affected, ‘standard’ British vocal register. By contrast, surgeries require trained surgeons in fitted operating theatres: in such a case, we call for more sympathetic professionals, including trained trans surgeons, as well as proper information on the full range of options, unquestioning access, full aftercare and paid leave for recovery. Due to the nature of the developing knowledge base, surgical expertise could be best expanded by transnational collaboration, and platforms for the rigorous discussion, comparison and improvement of the available procedures.
Trans-specific healthcare saturates our everyday life. An inadequate regime can expose us not only to symptoms such as cognitive impairment, spikes of dysphoria, continual hot flushes, but violence on the streets. Therapy and counselling can be valuable throughout transition, not as a means to assess our authenticity, but as a space in which we can articulate ourselves, in expectation of sympathy and insight. Vocal control, hair management, even fashion advice, can be important means of navigating our genders, or refusal thereof, every day. Our needs cannot be summarised in terms of a single, specialised procedure (‘the surgery’). Transition is a varying and continually navigated process.
An immediate mandate to make medication and relevant services available on a local level would alleviate the worst strain on the system. But beyond this, a Clinic system which only recognises our experiences within fixed geographic and diagnostic bounds can only oppressively restrict where and how we can live.
The degree to which individual trans people take our healthcare under personal control will vary, based on required treatments and material circumstances. Not all of us will be able to design and prescribe our own hormone regime. Not all of us are interested in growing testosterone in a herb garden. Our decisions will always be shaped to some extent by the care of professionals, family and others in times of medical need. We insist on deep sympathy and understanding from those who claim to care for us.
The pedagogic theory of Ivan Illich helps capture the efficacy of DIY practices, and how they could be extended. Illich was a dissident Catholic priest whose political work with poor Puerto Rican communities influenced the New Left. In Deschooling Society, Illich provides a vision for a liberated education system:
A good educational system should have three purposes: it should provide all who want it to learn with access to available resources at any time in their lives; empower all who want to share what they know to find those who want to learn it from them; and, finally, furnish all who want to present any issue to the public with an opportunity to make their knowledge known.
Illich envisioned the development of ‘learning webs’ using networked computers to make information on any topic available to all, valuing critical refinement but never held back by gatekeeping. These principles of accessibility and free discussion are being developed by DIY communities today.
Illich’s futurism preempted widespread internet usage which would cast his arguments in a new light. At the margins of society today, trans communities are doing such work. Online spaces are, for many, the first encounters with trans and queer culture. They facilitate community-building, self-exploration and a sense of subcultural belonging. Through expanding and struggling for such community webs, the forbidden knowledge of queer life has become pervasively available, against the injunctions of a cis- and heterosexist society.
We should begin with and expand the work of DIY communities. These minoritarian practices are incubating a radically new form of healthcare, and we believe a new emancipatory vision can be hatched through their work.
The movement which makes possible the trans clinic as we have described it here has yet to come. It will rely on further struggle, experimentation and democratic participation. Utopian visions are often dismissed as whimsical, impossible to realise. Our argument is that another form of trans healthcare already exists: the makeshift social reproduction that keeps trans life continuing in the present tense.
A new queer futurity could open still further the mutual participation that we already see across Britain and the world. Locally creative marginal politics could be expanded through trusted and democratic channels. The potential exists in the unsung labour of trans people today to reclaim transsexuality itself: from a divisive means of state categorisation, to a mutual field of personal self-fulfillment informed by a collaborative working.
What is called for is not piecemeal institutional reform, but a wholly new science of trans and queer life. In making this call, we echo the words of Mario Mieli in Towards a Homosexual Communism:
The movement of communists struggles for the determination of a free future, for that garden of intersubjective existence in which each plucks at will according to their needs the fruits of the tree of pleasure, of knowledge, and of that ‘science’ that will be a gay science.
We, too, yearn to seize the fruits of contemporary medical practice, and assign them according to our varied needs and desires. The seeds of this emancipated practice are already being cultivated in our own communities, sharing freely from collective knowledge and experience to survive and flourish. We call, now, for a garden fit for these emerging gay sciences.
Jules Joanne Gleeson is a communist from London. Her writing has featured in VICE, Hypocrite Reader, New Socialist, Blind Field, ‘Identities’, JSTOR Daily, Verso and Pluto Press’ blogs, and Viewpoint, Ritual, Commune and Tribune.
J. N. Hoad is a communist, DIY transsexual and femmes de lettres in the North West of the UK.