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There’s a big urban myth about transition regret. The myth is that ‘most people regret transitioning’, and it’s often used by medical professionals, particularly those who are inexperienced or ignorant regarding trans healthcare, to refuse trans people treatment. Loz Webb writes.

This myth is also exploited by the cis media in order to run shock stories about ‘sex changes’ and ‘reverse sex changes’, and to push a particular anti-trans agenda that asserts that trans people, whether or not they are happy with their medical interventions, are ‘spending the taxpayers money’, as though trans people aren’t worthy to use the NHS and should be exempt from the free healthcare that everyone is entitled to purely as a result of them being trans. This anti-trans rhetoric, so prevalent in our media, undoubtedly feeds into a culture in which trans people are treated ignorantly, or as #transdocfail showed, sometimes appallingly by medical professionals, as well as contributing to the frequency of hate crimes carried out against trans people.

Last week, academic Ruth Pearce, was contacted by Sundog Pictures via the following unsolicited email:

 “I’m currently working on an idea alongside Channel 4 following transgender individuals who have come to regret their sex changes and are keen to undergo further treatment / operations to reverse the change. The doc will be insightful and sensitive and will look at the way in which transgender individuals are treated in society and whether the process before someone is permitted an operation is robust enough.

I’m currently looking for real life cases to include in my pitch document and was wondering whether you might be able to recommend people I could speak to, or places I could contact to find individuals who are currently thinking about a reverse sex change. Any help would be really appreciated.”

At Action for Trans Health, we are incredibly concerned about the motives of such a documentary, and the effect it could have on the lives and health of trans people. Despite the disproportionate representation that people who regret transitioning receive in the press, the recent Trans Mental Health Study, the largest study of its kind ever undertaken in Europe, with almost 900 respondents, asked specifically about individuals’ feelings of regret following social and/or medical transition. These are the results:

  •  In terms of social changes made during transition (coming out to friends and family, changing name, living full or part time in a gender not assigned at birth), 34% of respondents had minimal regrets and 9% had significant regrets. A small majority, 53% had no regrets.
  •  Specific regrets given included: not having the body they had wanted from birth, not transitioning earlier, losing friends and family, and the impact of transition on others.
  •  In terms of physical changes made during transition (resulting from hormone therapy and surgical interventions), the vast majority, 86%, had no regrets. Of the remainder, 10% had minor regrets and 2% had major regrets.
  •  The specific regrets given include complications relating to surgery (especially loss of sensitivity), and the choice of surgeon (if surgery resulted in complications or required revisions and repairs).

In other words, the findings indicated that transition regret tends to be related to social stigma, poor surgical quality and results, and loss of family and peer support, rather than regret around ever having transitioned in the first place. It demonstrates that while someone’s dysphoria may be relieved by transitioning, the pressures of living in a transphobic society are not. This is important, as it indicates that regret is related to the same stigmatisation, othering, and ignorance that is perpetuated by the disproportionate and negative media focus on those who detransition – it indicates that documentaries such as this have an ill effect on the health and wellbeing of trans people.

Juliet Jaques writing on transition regret for The Guardian, writes:

 ‘Personally, I’ve not known anyone to detransition: this is not to deny that there are people who genuinely regret transition and particularly surgery purely because they’ve ended up with a body that wasn’t right for them, but instances do seem rare – partly because the pathway allows people to opt out at any point, and some remain on hormones before surgery for much longer than strictly necessary whilst they consider their options.’

Juliet makes a good point. Gender Identity Clinics require you to undergo at least one year of RLE, or Real Life Experience, during which you live full time as the gender you identify as before they will even consider HRT or medical treatment of any kind. Many trans people find themselves forced to undergo two years of RLE, just in case, and this can stretch out a lot longer if the person in question is non-binary, or is not suitably gender-conforming, or has a disability, or mental illness, or does not conform to the white western imperialist model of the gender binary. RLE itself is the topic of a future blog post, but it ensures that the process before any treatment of dysphoria can take place is long and drawn out, often to the detriment of the health and physical safety of trans people trying to access healthcare.

The idea of detransition and regret also ignores the reality that for many people detransitioning is instead retransitioning – a person may discover that their gender identity changes over time, or a person who assumed that they were a trans man or a trans woman may discover that they are non-binary and wish to have a body that reflects this, or someone’s gender identity may not change at all, but they may wish to undergo further HRT or surgery to alleviate subsequent dysphoria, and all of these things are fine. The reduction of the infinite ways to be trans down to ‘sex changes’ and ‘reverse sex changes’ obscures the fact that actually, all trans people are entitled to all the treatment they need, all the time. Just like everybody else.

In her excellent open letter responding to Sundog, Ruth draws attention to the fact that Sundog use the terms ‘sex change’ and ‘reverse sex change’, which, as well as being loaded terms rarely seen in use outside the right wing press, are inaccurate, meaningless and othering. Furthermore, she points out that projects such as Trans Media Watch and All About Trans, which exist to improve the media representation of trans people, both offer clear guidance on how to respectfully talk about trans people, which Sundog could have discovered with a five minute google search.

There are a lot of important stories to tell about trans healthcare. The majority of them revolve around outdated, pathologising medical practices, unnecessary gatekeeping, ableism, racism, sexism, and transphobia. Some of them are about detransitioning or retransitioning, and yes, those stories are important, and the people who live them have experiences that are important and valid. But seeking to weaponise those stories, to ‘look at the way in which transgender individuals are treated in society and whether the process before someone is permitted an operation is robust enough’, is an act that is harmful to trans people and could be, nay, will be used to make healthcare even more difficult for us to access. And regardless of how ‘respectful and sensitive’ Sundog claim they want their documentary to be, courting a cheap bit of controversy for Channel 4 at the expense of trans people’s right to healthcare is neither respectful, nor sensitive. It’s dangerous.

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Yesterday Jess Bradley from Action for Trans Health attended “The future of LGBT ageing: Rethinking research directions” at The University of Manchester, and helped run a session on trans ageing. This article briefly discusses some of the issues that older trans people face and suggests some area for future research which has been identified by Action for Trans Health alongside suggestions which arose from discussion at the event.

Trans people face discrimination across all areas of life, which means that when compared to our cis peers, we often have less robust support networks, higher instances of mental and physical health problems, and may experience loneliness.  This is particularly a problem for older people, who may feel excluded from youth orientated LGBT spaces as well excluded from cisnormative older people’s groups . Beyond these more general issues, we have identified three main areas of interest; being trans in a care environment, healthcare issues in later life, and transition whilst being older.

Accessing care:

  • Trans people often delay seeking care due to a general distrust of the medical establishment and a perception of the institutional environment as being transphobic. This is compounded when considering that trans people in general have less financial access to high-quality care due to discrimination in employment and the costs of transition related care (when not NHS funded). However, delaying accessing care can have a negative impact on mental and physical health as well as a strain on social relations.
  • Few care providers have the necessary training to be able to cater to trans specific needs in a non-discriminatory environment. As such, trans people are often forced to educate care providers or clinicians themselves on basic trans etiquette such as not asking intrusive/irrelevant questions, not getting flustered when peoples’ bodies don’t necessarily match with gendered assumptions, and keeping patients confidentiality.
  • Trans people face higher level of domestic and personal abuse than their cis peers. This abuse can come from family, friends, or from staff in a care / clinical environment. Care workers may need to navigate very complex social situations where abusive situations may appear.

Healthcare in later life:

  •  It is now possible for trans people to change their gender markers on their NHS records when they get legal recognition of their gender. However, this means that trans people are often not automatically invited to attend some screenings (eg. prostate, cervical, and breast cancer screens) in later life which may be medically relevant to them.
  • Very little is known about the long term effect of hormone therapy on trans patients. Particular areas of concern include how hormone therapy might alter bone density or may result in blood problems later in life.
  • Very little research has been done into how hormone doses should change as patients get older, and how hormone treatments interact with various other drugs (which may be increasingly important as a person ages as they are likely to take more medications).
  • Trans people have an increased likelihood of experiencing particular health complaints depending on what medical interventions they have had. A trans-feminine person who has had bottom surgery is at increased risk of rectovaginal fistula and urinary tract infections, and a trans-masculine person on hormone therapy has increased risk of liver problems and diabetes.

Transitioning in later life

  • Many trans people may choose to wait until later in life, after family and work commitments are less pressing, to undergo any transition related healthcare. However, often older people often have more entrenched social roles and so making these changes can sometimes be more complex at this time.
  • Older people may have increased health issues, ie. heart disease or high blood pressure, which can make transition related medical interventions riskier.

Research Directions

Key areas for action may include:

  •  Longitudinal / cohort studies on the long term effects of hormone treatment on trans patients.
  • Research into the interaction between hormone therapy treatments and other medications.
  • Studies to identify effective training on the needs of trans patients for carers and clinicians.
  • Research into the effect of dementia and similar conditions on gender identity.
  • Studies on how best clinicians can best support lay carers of older trans people
  • Investigating the inclusion of a question of trans identity on large surveys conducted by the Office of National Statistics so that researchers are better placed to utilise large studies to in their work. How would this question(s) be worded, and how can people encourage accurate self-reporting?

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Action for Trans Health trustee Loz Webb talks about #transdocfail and how we are helping GIRES with developing a non-binary protocol for GICs. The first step for this is collecting data on non-binary experiences. You can help us out by completing this short survey.

I wish I could tell you that my initial feeling upon reading the transdocfail hashtag was surprise. But I can’t. As a young trans person, a non-binary trans person, as a trans person who has accessed (or sometimes tried and failed to access) mental health services, I can’t lie to you; I was not surprised. I think what I felt most overwhelmingly, was relief.

Now, that might sound like a strange thing to feel. But in the transdocfail hashtag, I saw more than a legacy of failure and of brutal injustice. I saw a glimmer of hope. Finally, this conversation was happening. And it wasn’t happening in a dimly lit bedroom, or in someone’s living room after dark, when we could be sure that the prying ears of the medical institution and the cis people who support it were far away while we were locked in safe. For so long, these conversations have happened in secret because we are afraid. Because we rely on these doctors for the lifesaving treatment that we need, and we rely on them because in a world where we are stuck between the rock of pathologising, fetishizing and sometimes outright violent doctors, and the hard place of mass unemployment, family estrangement and structural poverty, we have no other option. And crucially, they know it.

This means that it becomes incredibly difficult to be an active participant in your own treatment, as suggestions, queries or criticisms are often met with the removal of treatment as punishment:  

  • Charing Cross GIC told my psych that I was suicidal as revenge, after they discovered a negative blog post I wrote about them.#TransDocFail 
  • I am terrified of talking about my experiences because I am afraid of having treatment withdrawn by the GIC.#TransDocFail

Despite the fact that it is clear that the majority of psychiatrists understand very little about trans people and gender dysphoria:

  • My psychiatrist initially refused to refer me cos “most people regret transitioning” #TransDocFail

Or perhaps they simply enjoy torturing us, safe in the knowledge that they can bully us as much as they like, because we still need them on-side:

  •  NHS Psych told me I wanted to transition to male cos I was too ugly to live as a woman. Also told me I’d never pass as male #TransDocFail
  • Psych invented name to call me because I wouldn’t tell him my birth assigned name #TransDocFail

Most GPs have no idea what to do when presented with a trans patient, and instead of listening to the patient or spending time researching, they decide to make things up based on their own values and moral judgements:

  • The first GP I told later told me he could no longer treat me because I was trans; he later shredded my notes #TransDocFail       
  •  GP thought depression was ‘normal’ given my being trans & thus ADs pointless. Even though they alleviate the depression.#TransDocFail

GPs also have a history of deciding simply not to refer their patients to a GIC for no apparent reason:

  •  My GP repeatedly told me she’d referred me when she hadn’t. Took 11 months from asking to be referred to being referred.#TransDocFail 
  • First GIC appointment next week, first went to GP for help 44 months ago.#TransDocFail

Emergency services seem to regard trans people’s lives as lives not worth saving:

  •  Denied care for a heart condition because “I have all this gender stuff going on so it was probably in my head”#TransDocFail
  •  I rang NHS Direct to get help for partner. NHS Direct doctor spoke to them and told them to leave me as I was an “abomination” #TransDocFail

And trans people have a history of being refused treatment by experts in the field simply for not conforming to outdated, sexist stereotypes:

  •  Was refused transition treatment for being lesbian, riding motorcycles, and not wearing skirts and heels to appointments.#TransDocFail

 I will not detail any examples here, but it is important to make mention of the fact that many people reported sexual assault, including non-consensual and unnecessary genital examinations and groping of the chest or breasts, at the hands of GPs and GIC doctors.

Not surprising then, that we are incredibly reticent to make complaint when we receive any kind of medical care at all; the consequences are all too clear and incredibly frightening.

But #TransDocFail gave us the opportunity to have this conversation in public. Suddenly all these stories were being told, and more importantly, being heard. After one came another and another, no power on this earth could have stopped the flood. Years of frustration at mistreatment, assault and administrative violence came pouring out and as time passed it became clear that these stories were not ‘one offs’ which could be shrugged off as an individual doctors ignorance or misinformation. What was being revealed was a legacy of structural violence.

As a non-binary trans person, I’ve had to make the decision between getting the lifesaving treatment that I need and being open about the person I am. That is a conflict in me that has not settled, and perhaps will never settle, because I spent 24 years trying to be someone I wasn’t and running away from the person I am, and it is difficult now to sit down in a room and lie, and omit, and tell the story I know that I’m meant to tell when I can’t help but feel in my soul that I’m not being fair to myself, that I’m selling myself out, that I’ve gone through so much to know myself better than this. I have to remind myself over and over that I don’t owe authenticity to those who would weaponise it, and that I don’t need a panel of people to meet in order to know what to do with my own body. But it’s hard, because in the last few years I’ve grown accustomed to being honest with myself and it’s not something that I relish giving up. I feel like I’m sacrificing my history to buy myself a future, and I don’t think that’s right. I don’t think that’s good enough.

The Equality Network in Scotland commissioned research into how the process of transitioning impacts on the mental health and wellbeing of trans people, in which they found (I would suggest unsurprisingly) that 70% of respondents were more satisfied with their lives after transitioning, while 2% were less satisfied. Somewhat at odds with the claim that ‘most people regret transitioning’. NUS LGBT recently commissioned research into the experiences of LGBT university students, and found that 1 in 3 trans students have experienced bullying or harassment on campus, and that half of trans students have seriously considered dropping out of university. Of those who had considered dropping out, around two thirds mentioned health problems and ‘not fitting in’. The report discusses the psychological consequences of harassment, indicating that trans and homophobic bullying and harassment have long-term consequences for LGBT people. In other words, trans students are more likely to need to access mental health services as a result of the harassment they face in academic institutions. But paradoxically, these services are clearly shown to replicate the exact same bullying and harassment that trans students face at university.

The fact of the matter is, trans healthcare is in crisis, and it has been for a long time. The intervention of banks exorcising their morality in the recent furore around inhousepharmacy, seven year NHS waiting lists, mistreatment by doctors, and the refusal to treat non-binary people is forcing trans people to go private and to choose medical treatment over the weekly shop. I want to rephrase that. Trans people are being forced to choose between their right to medical care and their right to eat.

This is not acceptable.

Action for Trans Health have teamed up with GIRES to research the experiences of non-binary people who have tried to access transition related healthcare. This research will be used to develop a non-binary protocol that will be used by gender identity clinics to enable them to provide life saving treatment to non-binary trans people. The more responses we get, the more we can improve transitioning for non-binary people, and the closer we get to putting trans healthcare back where it belongs: in the hands of trans people.

So please, help us share this survey far and wide, because medical care is our right and non-binary people need you to fight alongside us right now.

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An overworked, underpaid, and demoralised health sector cannot work best for all patients, including trans patients. The Coalition Government’s attacks on NHS workers are just one part of a wider plan to weaken and sell off parts of this service which, although not perfect, is an essential service. And as the recent film Pride has shown, it is through common struggle that the bonds of solidarity are forged; when doctors, nurses and other NHS workers see trans and queer people supporting their cause, they are going to be more amenable to supporting ours. For those reasons, Action for Trans Health are calling on trans and queer activists to support the public health sector strikes that are happening week commencing 13th October.

The strike: 

Nine unions representing NHS workers are out on strike for the first time in 32 years in protest over pay and conditions. For some unions, like the Royal College of Midwives, it will be their first strike in their 132 year history. There will be a 4 hour strike from 7am – 11am on Monday 13th October, followed by 4 days of action where NHS workers actually take the breaks that are legally entitled to them. The week of action will be rounded off with a TUC organised rally in London on the 18th October.

What you can do: 

Pop down to your local picket on Monday 13th 7am – 11am to join striking workers in solidarity. Bring baked goods and hot coffee, maybe signs saying something like “Trans people support the strike” or similar. Chat to striking workers and use this opportunity to talk about health sector pay and conditions, and to talk to them about Action for Trans Health or other trans healthcare activism. More information about where local pickets will be will be posted as that information becomes available.

Join the TUC rally in London on the 18th October. The TUC are arranging travel from all areas of the country, see their website and search for your local area for more details.

Change your profile pictures, avatars, etc. to a selfie of yourself with a sign saying “trans people support the strike” / or similar. Tweet, tumblr, and use facebook to raise awareness of the strike.

If you do show your support for striking NHS workers, please let us know how. Send us your photos of you on pickets, with signs, or at the rally to

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Have you had a bad experience with your GP? Do you want to check out whether anyone has made complaints to us about your GP in the past?

Action for Trans* Health are producing a “shitlist” of GPs to avoid for trans* people to avoid. If you have had a bad experience with your GP that compromised your ability to seek healthcare advice and treatment, please let us know through completing this short survey.

How will we use your information? 

The name and contact details of your GP, along with your description of what happened and the dates on which incidents occurred will be stored on our system. For legal reasons (we don’t want to get sued) these will not be published on the internet. If you want us to take further action regarding the incident (ie. offer training to the GP, support you in making a complaint, organising protests, etc.)  please provide us with your contact details and we will do our best to help you. We aim to check the list once a week for updates. All your contact details will be kept confidential.

How to find out if my GP / potential GP is on the list 

Unlike our list of member-recommended GPs, we cannot publish our GP shitlist on the internet for legal reasons. However, if you want to check to see if your GP or potential GP is on the list, and how they have responded to any interventions on our part, please email info[at]


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Interested in trans healthcare activism and want to find out more? 
Thinking about setting up a trans healthcare campaign? 
Want to meet other awesome trans activists? 

Come join Action for Trans Health for our activist training day in Brighton on Saturday 4th of October. 

The day will be split into two halves.

The first half will cover getting a group together and organising actions, information pills fundraising, pill and support, site and will be primarily aimed at people wanting to set up an Action for Trans Health chapter or their own healthcare campaign.

The second half will be a “train the trainers” session to empower trans people deliver training and advocacy services to healthcare professionals.

Places are limited. To reserve a place please email
If you have any access issues that we need to know about please let us know via email and we will try our best to accommodate them.

See facebook event for updates

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This statement has been written to formalise Action for Trans Health’s position, viagra aspirations, and commitments regarding problems of racism and cultural appropriation within the UK trans community. It will go on to form an integral part of a wider safer-spaces policy for the organisation.

Action for Trans Health seeks to be a safe space for all trans people to organise for our liberation. We recognise that the UK trans community has an ongoing problem with racism, cultural appropriation and a colonialist attitude towards trans liberation in the global south. Transmisogyny and binarism has its roots in colonialist violence and this structures the way that we talk about and experience gender. As such, we feel anti-racism and decolonialisation is key to gender liberation.  It is necessary for Action for Trans Health to commit to opposing racism by creating safer structures and spaces and by expecting our white members to recognise their white privilege and seek to reduce its impact on others. This will hopefully ensure that we can create spaces where all trans people feel safe and empowered to organise for trans healthcare.

Safer Spaces

Trans people of colour’s right to exist is not up for debate. As such, Action for Trans Health operates a safer spaces policy both online and offline regarding racist behaviour. We commit to moderating our online spaces so that racist comments are deleted and the commenters warned / banned. We commit to challenging racist behaviour at events we organise and events we attend, and reserve the right to require that people leave our events if they are being racist. We recognise that people with white privilege are sometimes blinded by that privilege when it comes to racism and so people of colour have a better understanding of what is racist and what isn’t. As such, we commit to trusting people of colour about their experiences of racism. Some examples of racist behaviour include:

– the use of racial slurs against marginalised groups;

– romanticising indigenous non-binary identities and the cultural appropriation of those identities;

– cultural appropriation including exhibiting dress, hairstyles, tattoos, that are considered racist by people of colour; and

– expecting people of colour to take on the role of educator. It is not the responsibility of people of colour to educate white people about their racism.

Spaces for People of Colour

We recognise that privileged voices often dominate conversations within our spaces. As such, we commit to creating a people of colour caucus at our gatherings. This caucus can then decide how it wants to operate within the structure of Action for Trans Health; whether it wants to elect representatives to committees, run autonomous campaigns, or simply provide a people of colour only space to discuss issues and events.

Working with other organisations

Action for Trans Health commits to not working with, sharing a platform with, or accepting money from, any far right, fascist, or racist organisations. This commitment extends to not working with, sharing a platform with, or accepting money from the police (including the National Trans Police Association).

Allocation of Grants

Action for Trans Health fundraises to give individual trans people grants in order to facilitate their access to healthcare. As trans healthcare is currently in crisis, it is expected that for the foreseeable future demand for grants will always outweigh our capacity to fundraise. As such, we commit to prioritising grant allocations towards members of marginalised groups. We also commit to ensuring that our 3-person grant allocations committee will always have at least one person of colour on it, or it will not be able to operate.

Further Reading

6 reasons why we need safe spaces

On cultural exchange and cultural appropriation

Binarism: myths and reality

Why No Platform is still relevant and the trouble with liberal ‘anti-fascism’


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As many people in the trans-o-sphere are aware, store today Stonewall met with a group of trans professionals, discount campaigners and activists to discuss the possibilities of trans-inclusion within Stonewall.

Historically, Stonewall England have been very firm about not wanting to allow trans people a voice within their organisation. They have also actively excluded trans people who are L, G and/or B, and released training material that included uncontested transphobic slurs. Rather than simply ignoring trans people, Stonewall have actively harmed trans people.

This has not been well received by the trans community, especially given that Stonewall take their name from a riot started and fought by trans women of colour, a fight that is often credited as the catalyst for the beginning of the LGBT rights movement as we know it today.

Action for Trans Health are glad that Stonewall seem to want to put that behind them and we hope that, regardless of how relations between the trans community and Stonewall develop, this will be a turning point for Stonewall that indicates an end to their transphobic behaviour of years past.

We are also concerned that it might be that the trans community can do more for Stonewall than they can do for us: with trans people becoming increasingly visible, thanks to the work of out trans journalists, actors and presenters, such as Laverne Cox and Paris Lees, it seems that transphobia is going out of style, and that paying lip service to trans-inclusion might be a way for more conservative organisations to hike their popularity, especially among younger LGB people.

The attendees of today’s meeting are overwhelmingly white, binary-identified, middle-class, and adult. We believe that there can be no real trans-inclusion that does not listen to the voices of those most marginalised within our community, the voices of disabled trans people, trans people of colour, non-binary trans people, working class trans people, and young trans people. We believe that if Stonewall are truly committed to putting transphobia behind them, these will be the people they prioritise meeting with next.

We’d also like to see Stonewall review their diversity awards policy and stop giving diversity champion awards to organisations that actively harm LGBT people, and have policy to continue actively harming LGBT people, such as the Home Office and the DWP.

We hope that today’s discussions were fruitful and that future consultations are successful, and that Stonewall are really as committed to listening to trans voices as they claim to be. If so, they may yet become a useful and powerful ally in the fight for trans liberation.

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Action for Trans* Health wholeheartedly condemns recent attempts to harass, cialis 40mg intimidate, purchase and misgender trans activists.

This includes attempts to distribute personal information (doxxing) and deliberately interfering with their economic security through sabotaging their employment. Action for Trans* Health was founded on the principles of mutual aid and as such we are deeply shocked and disappointed that these attacks have come from both cis and trans* individuals.

We would also like to clarify that Action for Trans* Health does not officially take any position on issues that are not trans healthcare related, unless otherwise stated in our website or constitution

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Healthwatch England included a request for information on any difficulties people were having accessing gender identify services. If you are willing to share your experiences (anonymously is fine) please get in touch with them and they will use these experiences help inform the national discussion.

The call out is as follows:

“Have you come across problems with Gender Identity Services?

We want to know if you have found out about difficulties for anyone in accessing gender identity services. This will inform our feedback to NHS England.  Healthwatch Telford and Wrekin and Healthwatch Torbay have raised concerns around waiting times and funding for gender reassignment surgery. If you have any evidence you would like us to include, check please email us”

The email address to send your comments to Healthwatch is enquiries[@] Please put Gender Identity Services responses in the subject line.

If you want Action for Trans* Health to support you in making a complaint about the service, hospital please copy in info[@] and we will be in touch.