This is one in a series of needs assessments regarding protected characteristic groups to support compliance with the public sector Equality Duty (The Equality Act 2010).
The document is intended to raise awareness of the key public health, and health and social care considerations relevant to people with disabilities; and to provide a starting point to inform the development of Equality Impact Needs Assessments (EINAs).
Gender reassignment is a protected characteristic under the Equality Act 2010.
A person has the protected characteristic of gender reassignment if the person is proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex[i].
This needs assessment provides information on key health needs of individuals in this protected characteristic group in the London Borough of Richmond upon Thames.
Individuals who are proposing to undergo, are undergoing or have undergone a process to change their gender included in the definition of the protected characteristic group, often referred to as Transsexual, are a subset of the much wider Transgender or ‘Trans’ population. This is considered to include anyone who crosses contemporary cultural boundaries of gender identity, including Transvestites[ii], many of whom do not wish to go through a transition process.
While wider Trans groups are not covered by the legislation, organisations and especially public bodies, are strongly encouraged to apply legislation inclusively, to ensure that, as far as possible, all Trans groups are considered[iii].
Given that this report is intended as a needs assessment, it necessarily focuses primarily on Transsexual people, but its principles should be reflected in work across the spectrum of Trans groups.
The following medical terms provide some insight into the personal experiences of Trans people and how their needs are perceived by health professionals:
- Gender dysphoria; a rare condition in which a person suffers discomfort or distress that is caused by a mismatch between the person’s gender identity and their biological sex assigned at birth[iv]. Some people with gender dysphoria have a desire to live according to their gender identity rather than their biological sex, and this may involve treatment for gender reassignment so that their physical appearance is more consistent with their gender identity.
- Transsexualism; a medical term for the desire to live and be accepted as a member of the opposite gender, usually accompanied by the desire to make one’s body as congruent as possible with the preferred sex through surgery and hormone treatment.
Individuals often report feelings of gender discomfort from early childhood and may present at any age. However, the average age of presentation to health services for gender dysphoria is currently 42 years old[v].
Young Trans people face particular health issues, especially within the education system, including amongst others: the provision of gender-based vaccinations in schools; access to physical education/recreation; and appropriate sexual health and relationships education.
In recent prevalence studies in the UK the majority (80%) of those presenting to gender services have been those born as male[vi]. However, some Gender Identity Clinics report a recent increase in the proportion of those born as female attending their service. Across Europe, the gender balance is more equal.
3 Local picture
Estimates of the prevalence and incidence of gender dysphoria and Transsexualism are difficult to quantify due to the lack of robust national data. Commissioning of health services for gender dysphoria has historically been based on the results of a Scottish primary care study published in 1999 which estimated a prevalence of 8.18 per 100,000 population aged over 15 years[vii].
In other research, estimated prevalence was 20 per 100,000, and estimated incidence was 3 per 100,000 aged 15 and over per year presenting for treatment in the UK[viii]. These figures were estimated from numbers of those seeking treatment for gender dysphoria at Gender Identity Clinics in the UK, so are thought to be underestimates due to the number of individuals who do not seek medical help in the UK.
Importantly, estimations of prevalence and incidence of gender dysphoria do not include individuals from the wider Trans community who may experience gender discomfort but do not wish to reassign their gender. A recent GIRES publication estimates that 1% of the UK population experience some level of gender discomfort. In Richmond this translates to an estimate of 1,940 individuals who may be in need of health and other services.
There is significant geographical variation in the prevalence of Transsexualism which is not due to statistical variance[ix]. Factors such as local tolerance and service provision appear to affect where those with gender dysphoria present to local services for treatment. Thus the prevalence and incidence figures estimated above for the borough may not be representative of the true picture due to this geographical variance.
As mentioned, the number of people presenting to health services and Gender Identity Clinics for gender dysphoria is growing rapidly – an estimated 15-20% increase per annum.[x],[xi] This is thought to be due to a number of factors including increased public awareness and knowledge, NHS provision of services, legislative changes, mutual support within the growing Trans community and more respectful press coverage.[xii] Using the 2009 GIRES incidence estimate and this predicted growth, incidence in 2013 would be roughly 6 per 100,000 aged 15 and over per year. Recent estimates from GIRES are that 18,000 Trans individuals will have sought treatment by the end of 2013.[xiii]
Using these data, and assuming uniform distribution of individuals geographically, there may be between 16 and 39 people with gender dysphoria in Richmond Borough, and the potential for 12 presentations for treatment in 2013 in those over 15 years old.
In 2012/13, six individuals in Richmond were referred for support to the West London Mental Health Trust Gender Identity Clinic.
3.1. Health and wellbeing
It is accepted that gender dysphoria, if not treated, can severely affect a person’s quality of life and health status. High levels of depression are reported within Trans communities.[xiv] The majority of individuals have considered suicide, with an estimated 35% reporting an attempted suicide at least once in their lifetime. Roughly half of Trans individuals have self-harmed at some point.[xv]
The Trans community experiences disproportionate levels of discrimination, harassment and abuse. Survey research has shown that almost two thirds of Trans people have experienced some form of harassment in public, ranging from comments to physical violence[xvi]. Four out of five (80%) have experienced emotional, physical or sexual abuse from a partner[xvii] and roughly half experienced harassment or bullying at school from both fellow pupils and school staff including teachers.[xviii]
Difficulty with employment is also a major issue – both in finding work and in retaining it. Workplace harassment and abuse from fellow employees can have a damaging effect on an individual’s health and wellbeing, and may lead to their leaving their employment rather than continuing in that environment.
Housing is a key concern for the Trans community as roughly 30% of Trans individuals report being thrown out of their home as a result of their status.[xix] As well as the emotional and financial pressure this brings, hostels are often single sex which creates problems if an individual is transitioning.
Another problem that may impact on health and wellbeing includes barriers to participation in facilitated or venue-based physical activity, due to open changing areas and/or gender-specific facilities.
Physical transition of gender may also have an impact on health. As well as possible risks from multiple surgical procedures, there is evidence of increased incidence of metabolic syndrome in male to female Trans individuals using hormones.[xx]
3.2. Harmful behaviours
Alcohol abuse is a major problem within the Trans community – 62% of surveyed individuals in 2012 were assessed as being dependent on alcohol or engaging in alcohol abuse.[xxi] This has major implications for health, both in the short term due to the increased probability of injuries, violence and risky sexual behaviour, and from the development of chronic conditions such as cancer and liver disease in the long term.
In the same survey in 2012, 24% of individuals reported using drugs in the last year, whilst a 2012 Northern Irish survey found approximately half of Trans individuals displayed a sign of drug abuse within the last year, and 10% indicated severe drug abuse.[xxii] As previously mentioned, some individuals self-medicate with hormones purchased on the internet, which can have serious health implications.
Estimates for smoking prevalence vary from 19-32% of the Trans community.[xxiii],[xxiv]
4 Service Provision
It is important that health and social care services make provision to secure the equitability of both general and specialist health care services to individuals in this protected characteristic group. Numerous data confirms that Trans individuals have had negative experiences accessing general health services. Almost 20% of Trans people surveyed for the Equalities Review[xxv] reported that their healthcare was either affected or refused altogether by GPs who knew they were Trans.[xxvi]
In addition, there is a particular difficulty in accessing gender-restricted or targeted services for individuals who describe their identity as other than male or female, or are transitioning from one gender to the other.[xxvii] Furthermore, a recent study reported that 29% of Trans individuals who accessed mental health services felt that their Trans status was regarded as a symptom of mental illness[xxviii].
From April 2013 Gender Identity Services have been commissioned by NHS England (NHSE). NHSE will continue to work with the Transgendered community and stakeholders through the Clinical Reference Group for Gender Identity Services, to produce a single and consistent policy for the whole of England. A fully consulted policy document and service specification is planned for completion in 2014.
A comprehensive range of public health programmes[xxix], and health and social care services are designed, planned and delivered to meet the needs of Richmond’s population.
The following mechanisms are in place to ensure that consideration is given to the diverse population and individual needs of residents, including those of protected characteristic groups.
- Development of needs assessments to research local population health and wellbeing needs.
- Liaison with a range of local community organisations, including the Richmond Lesbian, Gay, Bisexual and Transgender (LGBT) Forum.
- Tailoring of the design and delivery of services to maximise their appropriateness and accessibility to all residents, including the targeting of services and initiatives at populations with diverse needs, including protected characteristic groups.
- Audits, reviews, and evaluations of existing services including consideration of equality and diversity issues.
- Equality Impact Needs Assessments (EINAs) of new services and changes to existing services.
- Monitoring of service use by key population characteristics, including some protected characteristic groups.
- Adoption of equality requirements in service specifications and monitoring processes as part of contracting requirements for services and their providers.
- Annual reviews of compliance with the Public Sector Equality Duties.
- Implementation of the NHS Equality Diversity System by local NHS commissioners and providers.
The council has undertaken an audit of provisions for protected characteristic groups in public health programmes, and the findings are under consideration
A number of further actions are underway or being considered by Richmond Borough Council, including:
- Development of a detailed equalities profile for the Borough based on the results of the 2011 Census. This will further support general consideration of protected characteristic group equality issues across council responsibilities and beyond.
- Work to support Richmond CCG in their planned update of their Public Sector Equality Statement and implementation of the NHS Equality Diversity System.
- Consideration of the extension of routine consistent equality monitoring of all protected characteristic groups, including use by Trans people, across public health programmes, in addition to those groups most frequently and routinely covered by standard data collection systems (i.e. age, sex/gender, ethnicity).
- Review of service specifications for the commissioned services included in public health programmes, to ensure an adequate and consistent approach to equality issues relating to the protected characteristic groups.
- Review of access to data essential to undertake adequate equality monitoring of key public health services, particularly immunisation and screening.
[i] HM Government Equality Act (2010): Chapter 15, Part 2, Chapter 1 Protected Characteristics. http://www.legislation.gov.uk/ukpga/2010/15/part/2/chapter/1 Accessed 19.09.13
[ii] Department of Health (2008): Trans: A practical guide for the NHS. http://www.gires.org.uk/assets/DOH-Assets/pdf/doh-trans-practical-guide.pdf
[iii] The Lesbian, Gay, Bisexual and Trans Public Health Outcomes Framework Companion Document (2013). http://www.lgf.org.uk/phof
[iv] The World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version, September 2011 (page 5). http://www.wpath.org/
[v] Gender Identity & Research Education Society (GIRES) (2009). Gender Variance in the UK: Prevalence, incidence, growth and geographic distribution. http://www.gires.org.uk/assets/Medpro-Assets/GenderVarianceUK-report.pdf
[vi] Gender Identity & Research Education Society (GIRES) (2009). Gender Variance in the UK: Prevalence, incidence, growth and geographic distribution. http://www.gires.org.uk/assets/Medpro-Assets/GenderVarianceUK-report.pdf
[vii] Wilson, P., Sharp, C., and Carr, S. (1999). The prevalence of gender dysphoria in Scotland: a primary care study. British Journal of General Practice 49 (449):991-992.
[viii] Gender Identity & Research Education Society (GIRES) (2009). Gender Variance in the UK: Prevalence, incidence, growth and geographic distribution. http://www.gires.org.uk/assets/Medpro-Assets/GenderVarianceUK-report.pdf
[ix] Gender Identity & Research Education Society (GIRES) (2009). Gender Variance in the UK: Prevalence, incidence, growth and geographic distribution. http://www.gires.org.uk/assets/Medpro-Assets/GenderVarianceUK-report.pdf
[x] Gender Identity & Research Education Society (GIRES) (2009). Gender Variance in the UK: Prevalence, incidence, growth and geographic distribution. http://www.gires.org.uk/assets/Medpro-Assets/GenderVarianceUK-report.pdf
[xi] Gender Identity & Research Education Society (GIRES). Transgender awareness e-learning for local authorities. http://www.gires.org.uk/elearning/new/player.html
[xii] Gender Variance in the UK: Prevalence, incidence, growth and geographic distribution (2009). http://www.gires.org.uk/assets/Medpro-Assets/GenderVarianceUK-report.pdf
[xiii] Gender Identity & Research Education Society (GIRES). Transgender awareness e-learning for local authorities. http://www.gires.org.uk/elearning/new/player.html
[xiv] The Lesbian, Gay, Bisexual and Trans Public Health Outcomes Framework Companion Document (2013). http://www.lgf.org.uk/phof
[xv] The Lesbian, Gay, Bisexual and Trans Public Health Outcomes Framework Companion Document (2013). http://www.lgf.org.uk/phof
[xvi] Whittle, S., Turner, L., and Al-Alami, M., (2007). Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality &Discrimination. The Equalities Review. http://www.pfc.org.uk/pdf/EngenderedPenalties.pdf
[xvii] Whittle, S., Turner, L., and Al-Alami, M., (2007). Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality & Discrimination. The Equalities Review. http://www.pfc.org.uk/pdf/EngenderedPenalties.pdf
[xviii] The Lesbian, Gay, Bisexual and Trans Public Health Outcomes Framework Companion Document (2013) http://www.lgf.org.uk/phof
[xix] Personal communication – Alistair Hill, 2013
[xx] Vidales, A. et al. (2011). Cross sex hormone treatment and metabolic syndrome incidence in a transgender Spanish population: A three years follow-up. Basic and Clinical Pharmacology and Toxicology 109:54
[xxi] Scottish Transgender Alliance (2012). Trans Mental Health Study. http://www.scottishtrans.org/wp-content/uploads/2013/03/trans_mh_study.pdf
[xxii] The Rainbow Project (2012). All Partied Out? Substance use in Northern Ireland’s Lesbian, Gay, Bisexual and Transgender Community. http://www.rainbow-project.org/assets/publications/All%20Partied%20Out.pdf
[xxiii] Scottish Transgender Alliance (2012). Trans Mental Health Study. http://www.scottishtrans.org/wp-content/uploads/2013/03/trans_mh_study.pdf
[xxiv] The Rainbow Project (2012). All Partied Out? Substance use in Northern Ireland’s Lesbian, Gay, Bisexual and Transgender Community. http://www.rainbow-project.org/assets/publications/All%20Partied%20Out.pdf
[xxv] The Equalities Review was set up by the government to provide an understanding of the long-term, underlying causes of disadvantage, make practical recommendations on key policy priorities and inform the modernisation of equality legislation and the development of the Commission for Equality and Human Rights (CEHR). The Equalities Review final report was published in 2007.
[xxvi] Department of Health (2008) Trans: A practical guide for the NHS. http://www.gires.org.uk/assets/DOH-Assets/pdf/doh-trans-practical-guide.pdf
[xxvii] The Lesbian, Gay, Bisexual and Trans Public Health Outcomes Framework Companion Document (2013) http://www.lgf.org.uk/phof
[xxviii] Scottish Transgender Alliance (2012). Trans Mental Health Study. http://www.scottishtrans.org/wp-content/uploads/2013/03/trans_mh_study.pdf
[xxix] NHS Health Checks, LiveWell Richmond health lifestyle service, Kick It stop smoking service, School nursing and the National Child Measurement Programme, Sexual health and contraception services, Substance misuse services, Screening programmes, Immunisation programmes.
The Equality and Diversity pages of DataRich provide further data and analysis on each of the protected characteristics under the Equality Act 2010.
Published: July 2014
For review: July 2017
Topic lead: Jane Bailey, Public Health Lead