Charing Cross Gender Identity Clinic (GIC) is legendary. It has a 47-year history of care for people who are transgender in the United Kingdom.
This is 46 years longer than many health systems in the United States, which made me excited to come here to learn. It was a highlight of my sustainability tour of the UK.
GIC has been led by Dr. James Barrett, a consulting psychiatrist, for 12 years (but has practiced in it for 25), who sat with me, walked with me, supported me in sitting in on patient consults (with their explicit consent, of course).
You arrive at Charing Cross Hospital through Margravine Cemetery which apparently is a normal morning commute route. Really centers you. The clinic itself is situated on a non-descript side street near the hospital, where it has been since 2003, in a custom configuration.
My photos of the walk and of the interior are below, click to enlarge.
I had so many questions based on my experience to date, that James and team helped me with.
What’s the history of Charing Cross Gender Identity Clinic?
- At one time, Charing Cross was actually at the famed Charing Cross
- The service started in 1966 as an informal referral service, and eventually became institutionalized within the NHS
- The service is now connected Charing Cross Hospital, which was built in 1973 in the Hammersmith neighborhood
- It’s current home was created to specification and opened in 2003
The NHS appears be less conflicted than the US health system about whether to cover medically necessary care to this population – why?
- R v North West Lancashire Health Authority in 1999, which made it all the way to the European Commission on Human Rights, quashed a UK Department of Health policy of non-coverage for people who are transgender. It’s a fascinating read with a final “Appeals dismissed. Permission to appeal to House of Lords refused.” at the bottom to seal it forever. Is now illegal to refuse to cover this care in the UK.
- James pointed out that this makes coverage for medical care for persons who are trans the only legally mandated treatment in the NHS Everything else, from strep tests to cardiac bypasses are not legally mandated to occur in any group of people.
- As I explained back, this is quite ironic, since in the United States, the overhwelming majority of health plans today only explicitly exclude coverage for medically necessary care for people who are transgender. This is beginning to change (see: Anthem Blue Cross Releases Transgender Health Plan Benefits), however.
How is this care service structured?
- This is an interdisciplinary clinic that includes psychiatrists, therapists, nurses, an endocrinologist and surgeons (see photos)
- There is fluid understanding among all the team members about surgical, behavioral health, hormonal, approaches to supporting the health of this population that cross their specialties. 47 years is a long time to build this understanding.
- They receive about 1500 referrals per year from General Practitioners. The rate has been doubling every 5 years. Charing Cross is one of 7 such clinics in the NHS, which together receive about 1500 referrals, so there are about 3,000 total/year.
- The GIC maintains continuity with patients as they undergo their transition process, which is guided according to a shared decision-making model developed over many years, which I observed in practice (more on that below)
- James indicated that the GIC may be moving away from WPATH standards in the near future. He has written a book, (Transsexual and Other Disorders of Gender Identity: A Practical Guide to Management: Amazon.co.uk: James Barrett: Books) which details what he calls a very practical approach to treating this population. He indicated that there are groups of patients in the UK who might see Charing Cross GIC’ approach as conservative (and might comment so on this blog, I said we would learn that together).
- The reality of cost/benefit of treatment is much different than the potential non-reality expressed by people who have never delivered this care. The most complex surgeries are often not pursued, not because they aren’t covered, because of life circumstances. As a reminder, this is a far more permissive health system than in the US – all you need to be covered is to be a human being – there are no out of pocket costs.
- The clinic operates on paper. I was informed about the Gender Recognition Act of 2004, which provides protections for this population, based on another lost appeal to the European Human Rights Commission in Christine Goodwin v United Kingdom. Specifically, one’s gender status is legally protected information and it is a criminal act to disclose it. This has the ramification of starting a new medical record from scratch when a person’s gender changes.
What about use of language – do you refer to procedures as “cosmetic” or “aesthetic”?
- “Cosmetic” and “Aesthetic” are not used to describe surgical procedures here. James cautioned against using these terms. “Aesthetic,” he says, is an arts/crafts type term that means that something that’s functional is being made more beautiful. That’s not what these procedures are for. Instead, they don’t label the procedures at all using these terms – they just call them what they are: “genital surgery”
- Same goes for “Sex Reassignment Surgery” or “Gender Reassignment Surgery” – as he noted, “gender” is a person’s sense of their identity, it is not being changed or reassigned.
- A view of NHS’ patient-education site shows a more modern use of terminology than I see used in the United States, and reflects their experience: Transgender health and wellbeing – Live Well – NHS Choices
What does the environment at Charing Cross GIC reveal?
- What I saw was normalcy, respect, compassion, interest in supporting achievement of life goals.
- All of the cues here, from the photographs on the wall, to our conversations, to the patient visits I witnessed show a normalcy of this medical care with any of the other medical care I observed while I was here, or anywhere.
- Patients are exit surveyed electronically and sampled via paper surveys as well, with an astonishing 99% return rate, James says. They are analyzing the latest data now.
- As it says under the photo of Beth on the wall: “Life is for living, now I can!”
- As James tells me, concern that the care of this population is costly must be outweighed by the overall reduction in cost to society, the health system, and improved productivity to society when patients receive necessary medical care. To quote, “They go off and thrive and send a photo from their wedding.”
Why would a surgeon, psychiatrist, endocrinologist choose to practice this medicine?
- Quote from James:
“This is a patient population who are engaging, do well, and are grateful. It is a privilege and a pleasure to work for them.”
Seems quite similar to what Toby Meltzer told us in April, 2013
- A surgeon who decides to train to do the necessary procedures does it over a period of 18 months. In the UK, because all human beings are cared for in this system, surgeons become experienced and maintain skill with a very diverse population.
“Bittersweet”, by Ciaran Russell, a gift to Charing Cross GIC View on Flickr.com
Art and medicine present themselves here, too.
Several of the GIC’s patients are artists, and as James explained to me, an artists’ reputation and ability to show their work is based on a record of public showings of their art. To assist them, the GIC makes itself a place where an artist can say their work has been shown publicly.
James showed me a beautiful piece of art produced by one of his patients, Ciaran Russell, who gave it as a gift to the GIC. It’s called “Bittersweet” and it bears in its description one of my favorite phrases: “love conquers all”
It turns out that James and I bumped into Ciaran on the stairwell on the way to lunch, which I found out when I asked for permission to post the art here:
Thanks for your email,and the photo of James with my artwork really made me laugh,its a great picture. Yes you have my permission to repost the photo’s on your blog,and it’d be a positive thought for me to know my artwork is being shown in that way. I did very briefly see you yesterday with James,i bumped into him on the stairs and he was chatting to me about the heating in the building and the NHS,remember? I agree that art and medicine combined together can be beneficial in any healing process, as the art side is therapeutic and calming. I wish you well in your career.
The approach as I saw it made sense to me, and I have always believed that what health is to a patient is defined by them, and at the same time, a medical diagnosis is something that a patient and a physician arrive at together. That’s why we’re here. Speaking of being here, what I see is that:
- the world is learning to love better
- our generation does the power to change everything, and
- our generation of physicians in partnership with (not for) patients, will make it happen faster, through experiences like this.
I would like the well wishes for my career to cause more people like Ciaran being able to laugh and have great careers. Again, what is health care here for if not for this?
I am happy I made the request, happy the team at Charing Cross GIC invited me to come. A health system and society that maintains and supports its diversity is one that is sustainable to be sure. Thank you for your time, patients, staff, clinicians, and NHS for allowing me to learn.