Monday, 11 September 2017

The #ComeOutForLGBT Stonewall campaign matters. Here's why:

Last week, Stonewall published a new report into reported and unreported hate crime against the LGBT+ community. The "LGBT in Britain-Hate Crime and Discrimination" report was put together after Stonewall created an online survey that was disseminated by YouGov, to respondents in England, Scotland and Wales. 5,375 people responded to the survey. Being trans non-binary, I wanted to look at the report primarily from that perspective. Therefore it is important to note that out of the 5,375 respondents, 14% identified as trans, 4% said they "were unsure of whether they are trans or are questioning their gender identity", 8% identified their gender in "a different way" (including non-binary, genderfluid and genderqueer). 35% of all respondents to the report were disabled and 6% of respondents are from a British black, Asian or minority ethnic (BAME) background.  I'd argue that this high percentage of LGBT+ disabled participants means that particular attention should be paid to statistics relating to LGBT+ disabled people, including those who are non-binary (and genderfluid, genderqueer and agender).

Here are some of the overall key statistics from the report that you should be aware of:
  1. 21% of LGBT+ people have experienced a hate crime or incident in the last year because of their sexual orientation and/or gender identity
  2. 81% of anti-LGBT+ hate crime and incidents go UNREPORTED and there are an increasing number of young LGBT+ people who state that they are reluctant to go to the police because they believe that the hate crime or incident will not be thoroughly investigated (only 12% of LGBT people aged between 18 to 24 reported a hate crime or incident to the police)
  3. 10% of LGBT+ people who were looking to rent or buy a home in the past year were discriminated against
  4. 10% of LGBT+ people have experienced homophobic, biphobic or transphobic abuse online that was targeted at them IN THE PAST MONTH. 
  5. 17% of LGBT+ people who have visited a cafe, restaurant, bar or nightclub in the past 12 months were discriminated against because of their sexual orientation and/or gender identity
  6. 24% of black, Asian and minority ethnic (BAME) LGBT+ people were discriminated against by social services on the basis of their sexual orientation and/or gender identity
  7. 28% of LGBT+ people who visited a place of worship have faced discrimination in the last year
  8. 10% of LGBT+ people who attended a live sporting event (football match, tennis match etc) experienced discrimination in the last year based on their sexual orientation and/or gender identity.
In terms of trans, non-binary, genderfluid, genderqueer and agender people:
  1. 40% of trans people have experienced a hate crime or incident in the past year because of their gender identity 
  2. 18% of trans people have experienced a hate crime or incident in the past year because of their actual or perceived sexual orientation 
  3. 39% of non-binary people have experienced a hate crime or incident in the past year because of their sexual orientation and/or gender identity, compared with 19% of LGBT who define as male or female
  4. 26% of trans people online directly experienced transphobic abuse IN THE PAST MONTH
  5. 26% of non-binary people online directly experienced personal online abuse IN THE PAST MONTH
  6. 25% of trans people were discriminated against when looking to rent or buy a home in the last year
  7. 33% of trans people who have visited a cafe, restaurant, bar or nightclub in the past 12 months were discriminated against on the basis of their gender identity
  8. 35% of trans people who have visited a department store or shop were discriminated against on the basis of their gender identity 
  9. 29% of trans people were discriminated against when accessing social services
  10. 25% of trans people contacting the emergency services (through call centres) were discriminated against
  11. 38% of trans people who visited a place of worship in the past year have been discriminated against 
  12. 38% of trans people avoid going to the gym or take part in grassroots sport because they fear being discriminated against. 
In terms of LGBT+ disabled people such as myself (I'm dyspraxic):
  1. 27% of LGBT+ disabled people have experienced a hate crime or incident based on their sexual orientation and/or gender identity in the last year and they are 10% more likely to experience such hate crime or incidents than non disabled LGBT+ people.
  2. 13% of LGBT+ disabled people feel unsafe in their ward
  3. 21% of LGBT+ disabled people have been discriminated against when visiting a cafe, restaurant, bar or nightclub in the last year
  4. 10% of LGBT+ disabled people have been discriminated against when accessing bank services or visiting an insurance company in the past year
  5. 18% of LGBT+ disabled people have experienced discrimination when accessing social services in the last year
  6. 17% of LGBT+ disabled people avoid going to the gym or participating in grassroots sporting activities because they fear being discriminated against
  7. 16% of LGBT+ disabled people going to the gym or participating in grassroots activities have faced discrimination. 
These statistics are shocking and demonstrate the need, in my view, to argue strongly against those who believe that "enough" LGBT+ equality has been achieved in the UK. People like Steve H who tweeted: "They (LGBT+ people) have equal rights now. They have single sex (he means same-sex or equal) marriage. Enough is enough. This tiny minority should just shut up and be happy". So much is wrong with Steve's tweet. For starters, non-binary, genderfluid, genderqueer and agender people like me cannot get married without having to put a binary gender marker on a marriage certificate. Then non-binary people like me cannot get our gender identity recognised on official legal documentation such as passports. Then we face indirect discrimination in recruitment as some employers refuse to recognise the validity of  different gender identities (or lack thereof) and then find another reason not to hire you so they do not fall foul of employment legislation and the Employment Tribunal system. Then there is the issue with access to NHS Gender Identity Services services because such access isn't guaranteed;some GPs are indirectly discriminating against non-binary patients by refusing to carry out a referral although this may change with the introduction of new specifications for Adult Gender Identity Services. We are far from achieving real equality of opportunity in the UK.

Anti-LGBT Hate Crime:

Figures revealed in this new Stonewall report demonstrate quite markedly that trans people and non binary people remain targets for hate crime, with young trans and non-binary people (aged between 18 and 24) being at greatest risk. 56% of trans young people have experienced a hate crime or incident in the past year. At a time when society is meant to be more open-minded and tolerant of different gender identities, the fact that young people are most likely to be targeted is uncomfortable. Even worse for me is reading that 27% of LGBT+ disabled people have experienced hate crime or incidents that were because of their sexual orientation or gender identity in the past year. I am dyspraxic and I have been openly insulted by people in the street based on my walking (I've been called a waddling penguin, "Collywobbles" and a clumsy oaf) as well as being insulted and harassed based on my gender identity and presentation (the usual slurs that do not need to be repeated here). Trans, disabled people from BAME backgrounds are discriminated against on multiple levels in daily life and are far more likely to face hate crime and incidents on the basis of gender identity, their disability and their race than someone like myself. A holistic, intersectional approach should be adopted by the police, local authorities and businesses and organisations in the private sector so that racism, xenophobia, ableism and transphobia are all tackled head on from an early age to help debunk stereotypes and fight prejudice if we are going to reduce hate crime and incidents overall.

The report states that the most common type of hate crime experienced by LGBT+ people are ones where victims were insulted, pestered, intimidated or harassed (87%). Attitudes towards stereotyping of LGBT+ people, especially trans, non-binary, genderfluid, genderqueer and agender people needs to continue to be challenged head-on. Unacceptable homophobic, biphobic and transphobic language needs to be called out, any insults being excused as just "banter" should be condemned by LGBT+ people and their allies in offices, gyms, sports clubs, religious buildings, shops, restaurants, bars and banks across the UK. Street harassment against LGBT+ people should be reported to the police whenever and wherever it occurs.

More disturbingly, the YouGov polling revealed that 26% of LGBT+ people polled had experienced unwanted sexual contact, 21% had been threatened with violence and 11% had been physically assaulted (with or without a weapon). No LGBT+ person should accept being touched in their genital area by a person without consent. No LGBT+ person should accept being slapped on the bottom.
No LGBT+ person should face being threatened with violence or be physically assaulted by malicious bigots.  And yet, 81% of LGBT+ people have not reported hate crime and incidents such as these to the police. Trust in the ability of the police to thoroughly investigate hate crime seems to have been eroded, especially with young people. Polls and research I conducted myself on hate crime last year on this blog backs up such a sentiment. The Lincolnshire Hate Crime Strategy (discussed further in the next section) refers to a variety of research on transphobic hate crime, including a study into "the underreporting of transphobic hate crime and police interactions with the Trans community" by Greater Manchester police between 2013-15. The report found that 38.8% of trans people didn't believe the incident was serious enough to report, 35.8% thought the police officer at the station would perceive them as time wasting, 28.4% didn't want to inform police officers about their status and 22.4% feared being outed by police. However, the report did find that 65.9% of trans respondents to the report would have reported the transphobic hate crime through a third party organisation. Recommendations from the report included creating inclusive and engaging targeted campaigns to inform trans people about how to report hate crime and for frontline officers to demonstrate more empathy when dealing with victims of transphobic hate crime. Pretty much the same recommendations that are still being made by Stonewall in this latest report!

What else can be done to increase reporting rates and improve trust with the police? I agree with Stonewall's key suggestion that HR staff in local police forces need to ensure that training for frontline staff is robust so they have clear and concise instructions to follow when they need to make a report of LGBT +hate crime and incidents. Bias and stereotypes need to be debunked, so that all frontline staff are aware of the importance of recording all information received in an impartial manner so there is more of a chance of perpetrators being prosecuted. All police forces should sign up to a diversity programme such as Stonewall's Diversity Champion Programme (25 are currently members) so that training can be designed and delivered effectively with the input of local LGBT+ members. There should be a commitment in the police forces' mission statement or organisational strategy to tackle anti-LGBT+ hate crime in their force area and raise awareness of third party reporting centres that can be approached if the LGBT+ victim is afraid of reporting the crime directly. More importantly, data relating to LGBT+ hate crime should be analysed on an annual basis with reports being made public (released on the police force website) wherever possible and any recommendations to improve the organisational strategy clearly stated in the report.

I also agree with Stonewall's recommendation to the Home Office that they should make anti-LGBT+ hate crime aggravated offences. This recommendation was also made in the Trans Enquiry Report, published by the Women and Equalities Select Committee last year, which also notes that "there are no offences relating to "stirring up hatred against trans people, as there are for race, religion or sexual orientation under the Public Order Act 1986" (https://publications.parliament.uk/pa/cm201516/cmselect/cmwomeq/390/390.pdf p.59). Currently, CPS guidance (updated August 2017) states that the prosecution have to rely on applying section 146 of the Criminal Justice Act 2003 uplifts. Section 146 makes it clear that judges have a "duty to increase the sentence for any offence that involves the offender demonstrating hostility based on the sexual orientation or transgender identity (should be gender identity) of the victim (or presumed sexual orientation or transgender identity) or the offence being motivated by hostility towards persons who are of a particular sexual orientation or transgender identity" (http://www.cps.gov.uk/legal/h_to_k/homophobic_and_transphobic_hate_crime/). Hostility may be defined as "ill will, ill-feeling, spite, prejudice, unfriendliness, antagonism, resentment and dislike" but evidence of this hostility must be provided in order to gain a successful conviction.

The report has also highlighted the fact that there are many LGBT+ people do not feel safe when walking on Britain's streets. 44% of trans people avoid certain streets so they do not become victims of targeted harassment. 14% of trans people do not feel safe in the area they live in. 40% of trans people have said they have changed the way they dress to avoid street harassment. Police officers and Police Community Support officers should engage directly with trans people in their local area and try and find out why they feel unsafe and come up with action plans or "specific interventions" to try and reduce the level of harassment.

The issue of online abuse has received significant attention over the past year and the figures from this latest report continue to demonstrate the need for social media platforms to take decisive action to help protect trans social media users from transphobic behaviour. Non-binary LGBT+ people face more targeted discrimination than binary LGBT+ people (26% of non-binary people experienced online personal abuse compared to 10% of men and 8% of women). 23% of young people have been subjected to homophobic, biphobic and transphobic online abuse, with young trans people most affected (34%). Young LGBT+ people are also more likely to witness online personal abuse targeted towards others in the LGBT+ community; 72% witnessed online abuse in the last month. Nobody deserves to be confronted with misgendering, threats of physical violence or death threats when using social media platforms. Stonewall has recommended that social media platforms take "swift action", keeping  tweeters informed of the progress and letting them know what actions will be taken following the outcome of the case. Blocking and muting functions available on accounts are usually effective until a tweeter decides to make up another account to troll you with and then keeps doing it on a regular basis...i.e. targeted harassment. This is why I wholeheartedly agree with Stonewall's recommendation that social media platforms "work with the police and with the Crown Prosecution Service to develop more effective responses to anti-LGBT+ hate online, in consultation with LGBT+ people and organisations". Strengthening of IT education in schools to include lessons on internet safety should help empower young LGBT+ people to report cyberbullying on social media platforms more regularly but LGBT+ people and allies online should be prepared to call out and report targeted cyberbullying and harassment whenever they see it occurring. This will send a strong message to social media platforms that they should continue to address targeted cyberbullying and harassment, especially against trans, non-binary, genderfluid, genderqueer and agender people.

Anti-LGBT+ Hate Crime in Lincolnshire: 

The report has revealed that 19% of LGBT+ people based in the East Midlands have experienced a hate crime or incident due to their gender identity or sexual orientation in the past year. A Boston Standard article from February 2017 highlighted an increase in reported hate crime, with LGBT+ people and disabled people reporting more hate crime and incidents (http://www.bostonstandard.co.uk/news/lincolnshire-force-sees-rise-in-recorded-hate-crime-but-not-in-the-aftermath-of-brexit-1-7822438). In Lincolnshire, there is a Hate Crime Strategy which has been in place since 2015, with agencies working together to tackle underreporting rates. The strategy, put together by the Lincolnshire Community Safety Partnership, highlights that there were 37 hate crimes recorded as hate crime against LGB people on the basis of their sexual orientation and 24 hate incidents recorded against LGB on the basis of their sexual orientation and 11 hate crimes recorded as hate crime against trans people in 2015/16 and 6 hate incidents recorded in 2015/16 (file:///C:/Users/User/Downloads/Lincolnshire%20Hate%20Crime%20Strategy%202016-18.pdf).

There are several elements to the Hate Crime Strategy. The first relates to available reporting routes.
If you are a victim of anti-LGBT+ hate crime or incident in Lincs, you can report the hate crime or incident directly to Lincs Police if you want, or you can report the hate crime or incident through a number of third party organisations who have agreed to support Lincs' Hate Crime Strategy. These include Lincoln Catch 22, Lincs YMCA, Total Voice, Lincoln Central Volunteering Services, Boston College and Boston Centrepoint. Individuals within those organisations have been specially trained to report hate crimes and incidents to Stop Hate UK, an independent charity which "offers service users immediate practical and emotional support" and operates a 24/7 service, which can be accessed through phone, email, web-chat, online form on their website or through post. Referrals to Stop Hate UK can be made anonymously but Stop Hate UK can also pass on details to Lincs Police with the consent of the victim. Just Lincolnshire, the "single equality organisation" that aims to champion equality and tackle discrimination across the county can also help with reporting hate crime and incidents. If you fill in their online form (http://justlincolnshire.org.uk/assets/downloads/Interactive_reporting_form.pdf) or call in and make an appointment with the wonderfully helpful team (who can help you compile the report), the report can then be passed on to Stop Hate UK and/or Lincs Police. Lincs police's website makes it clear that they will investigate all cases thoroughly and gives advice as to the types of evidence needed to help build the case, including providing a diary format for victims to use to record ongoing incidents of stalking, harassment and anti-social behaviour (https://www.lincs.police.uk/reporting-advice/hate-crime/). The victim may be also asked to "provide a statement to account for what has occurred" whether in written or video-recorded form. Even if the case investigation is then closed, it doesn't mean it will be closed permanently; if more evidence comes to light, Lincs Police pledge to review the case and carry out further investigations. Victims may also get support through Victims Lincs, including "access to a dedicated Complex Case Worker".  The City of Lincoln Council website makes it clear that anyone can report a hate crime, including visitors to Lincolnshire and still encourage hate crime and incidents to be reported, even if there were no witnesses to the crime or incident.

The Hate Crime Strategy also states that the "Home Office has supported the development of a website to encourage the development of a website to engage greater reporting of transphobic hate crime and incidents (http://www.tcrime.net/)". I'm sure that Lincs police are making use of this reporting tool and will continue to do so in the future.

It's important therefore that all Lincs residents are aware of what the definition of hate crime entails, how they can report the hate crime and what actions will be taken by the police force to pursue the perpetrators and bring them to justice. I believe this includes talking about hate crime as part of key Equality and Diversity training in public, private and third sector organisations across Lincolnshire and talking to secondary school children, college and university students about hate crime as part of pastoral care. I believe the more knowledge a person has of hate crime and the reporting system, the more likely they will be to report the hate crime and incident. Education, as is so often the case, is key.

Direct and indirect discrimination in daily life: 

Much of the hate crime and incidents in the UK are taking place in public spaces. 33% of trans people have faced discrimination whilst visiting a cafe, restaurant, bar or nightclub. 47% of young trans people (aged 18-24) have faced such discrimination. 51% of trans people avoid venues because they fear being discriminated against. 35% of trans people have faced discrimination when in a department store or shop. 26% of trans people were discriminated against when visiting a bank or insurance company. 48%, nearly 1 in 2 trans people feel uncomfortable using public toilet facilities. These statistics make it clear that trans people face routine discrimination when trying to carry out day-to-day activities. The testimony from trans people in the survey makes grim reading: 21 year old Flynn has had people asking about their sex and genitals in inappropriate situations and he was sexually assaulted in the street in public with people grabbing their crotch and 28 year old Dylan was being barred from both male and female changing rooms because they "were not perceived as male or female enough to use them". Such behaviour exhibited by customers and staff needs to be combatted and every customer-facing organisation should have an Equality and Diversity policy which makes it clear that the organisation will not tolerate anti-LGBT+ hate crime and incidents being committed on their premises. I agree with Stonewall's recommendation that staff should learn how to treat LGBT+ customers, especially trans, non-binary, genderfluid, genderqueer and agender ones with respect. At the very least, all employees should be aware of the need to use a person's correct pronouns (especially if a trans, non-binary, genderfluid, genderqueer or agender person mentions the pronoun at the beginning of the conversation) and avoid asking any unnecessary or inappropriate questions. Any insults or inappropriate language uttered by employees should be investigated and disciplinary procedures followed stringently, including the use of formal written warnings, suspension and dismissal for repeat offenders.  More organisations in Lincolnshire are beefing up their organisational policies and procedures but anti trans, non-binary, genderfluid, genderqueer and agender attitudes within the team need to be addressed head on and employees and customers alike should not be allowed to air their views during business opening hours. There are organisations in Lincoln who will support Lincoln Pride, including Siemens, Bond Housing Group and Lindum Fire Services (http://www.lincolnpride.co.uk/about) but it'd be good to see even more local organisations getting involved and showing solidarity with LGBT+ customers and employees.

Direct and indirect discrimination against LGBT+ in the housing market is equally unacceptable. Flatshare ads are being disseminated with statements such as "No Gay People" or "Preferred Housemate:Straight" (Marlow, 31 years old states that such ads are "quite common" in London). Estates agents are getting away with misgendering trans people and landlords are making completely inappropriate sexual remarks. Estates agents, as with any other customer-facing businesses definately have to ensure that internal Equality and Diversity training is delivered, with managers or team leaders undertaking a specific course such as the NCFE Level 2 in Equality and Diversity (a formal qualification which is nationally recognised and could count towards the Continuing Professional Development annual requirement). This will help boost the reputation of the estate/lettings agency as LGBT+ friendly as clients may recommend the agency online through review websites or social media and this could then lead to more LGBT+ clients choosing to go with the agency in the future. Housing associations must remind all residents of the need to treat fellow residents with respect and dignity and that includes refraining from using homophobic, biphobic and transphobic (HBT) language. Targeted HBT bullying and harassment must be dealt with quickly, with perpetrators losing their right to continue the tenancy if they refuse to moderate their behaviour and encouraging victims of hate crime or incidents to report the perpetrators to the police as soon as possible so the case can be investigated meticulously.

The fact that LGBT+ social service users, especially from a British BAME background are being discriminated against is quite frankly unacceptable. Every person in the UK has the right to access social services free from being negatively stereotyped and judged and I am wholeheartedly behind Stonewall's recommendation that "mandatory training should be delivered to all social services staff to tackle anti LGBT+ discrimination and meet the specific needs of LGBT+ service users". The aim of the training should be to debunk stereotypes is essential and LGBT+ people should be involved in the creation of training materials and where possible, delivery of the course. Policies and procedures need to be updated by each local authority so that employees understand how to treat trans service users with respect and dignity. Employees who refuse to follow the new policies and procedures should be disciplined and offered the opportunity to undertake targeted training and if they refuse to take that training up, their position should be considered as it is not acceptable for public service members to continue discriminating against service users on the basis of their gender identity or expression/presentation. I also agree with the recommendation for local authorities to design and put up posters or disseminate leaflets that demonstrate to all service users that they are treating LGBT+ service users with respect and dignity. Such activities do not take much time but effective learning materials can really communicate a positive message, especially if LGBT+ social workers and other local authority employees have been involved in the production process.

From a personal point of view as a trans, non-binary Lutheran Christian, I am disappointed to see that LGBT+ people still face discrimination when attending a place of worship in the UK. Drilling down into the report figures, you find that 45% of BAME LGBT+ people have faced discrimination in places of worship compared to 26% of white LGBT+ people of faith. 38% of trans people who attend places of worship also stated they had faced direct discrimination. 27% of LGBT people believe that their religious community doesn't make them feel welcome and lesbians are less likely to feel welcomed than gay men (37% of lesbian respondents and 24% of gay respondents in the YouGov poll said this). These findings demonstrate the need for local faith leaders to play their part in welcoming LGBT+ people and calling out homophobic, biphobic and transphobic (HBT) language and bullying, especially if they are aware of bullying taking place in their youth and community groups. Christian vicars, pastors, priests, churchwardens, deacons, rectors, sextons, vergers, vestrymen, elders and lay leaders for example should help to debunk stereotypes and support young and old LGBT+ parishioners alike. Giving sermons on Jesus' acts of compassion and reminding parishioners of His message of unconditional love for everyone (Matthew 5:12, Matthew 22:37-39). Unfortunately there are faith leaders and representatives who believe it is their right to make disgusting comments. I'm reminded of David Robertson, the former leader of the Free Church of Scotland who believes that LGBT+ inclusive Sex and Relationships Education  at primary school age would lead to "state sponsored child abuse" because children would be taught age-appropriately about gender identity (http://www.pinknews.co.uk/2017/01/19/church-leader-claims-lgbt-inclusive-sex-ed-is-a-trojan-horse-for-child-abuse/comments/#disqus_thread). His views are vile and aim to spread fear and division rather than a message of love and compassion. He's not a role model to be followed. Instead, LGBT+ faith leaders should encourage the teaching of LGBT+ inclusive SRE as a way of reducing instances of HBT bullying in school and thus reduce the likelihood of those school students becoming perpetrators of anti LGBT+ hate crime in the future. Equally, if any HBT bullying happens during a Sunday School group session, the teacher should call it out straight away and reprimand the bully for not following Jesus' compassionate example. LGBT+ Christians should be aware that there are a number of faith organisations out there they can approach regardless of their denomination, including:

  • One Body, One Faith, the Lesbian and Gay Christian movement founded in 1976 and whose aim is that "human sexuality in all its richness" be accepted as a "gift from God gladly to be accepted, enjoyed and honoured as a way of expressing and growing in love". One Body, One Faith (a quote from 1 Corinthians 12:12) advocates for trans, non-binary, genderfluid, genderqueer and agender Christians too, with Christians embracing the diversity of sexual orientation and gender identity "present within the body of Christ to enrich that mission to be agents of transformation for all (http://www.onebodyonefaith.org.uk/). 
  • The Evangelical Fellowship for Lesbian and Gay Christians (EFLGC) set up in 1979 whose aims are to make LGBT+ Evangelical Christians and their allies welcome, valued as people and aware of God's presence and blessing. EFLGC welcomes Christians of any sexual orientation and any gender identity. EFLGC organises regional weekend conferences every spring and autumn and there are regional groups in some areas of the UK. EFLGC members also get two existing members who can provide information and advice (https://www.eflgc.org.uk/). 
  • Diverse Church (DC), set up by Reverend Sally Hitchiner, an Anglican priest in 2013 after meeting many young LGBT+ Christians who had experienced conversion therapy in an attempt to "cure" them of their homosexuality and others who had become depressed because  they had experienced rejection and ridicule. DC won the 2016 award for "Most Innovative Youth Work" at the Christian Youth Work Awards. There are now "over 350 members between the ages of 18 and 30 in the UK and the Republic of Ireland" and they communicate over social media platforms and organise local and national meetings (http://diversechurch.website/)

Christian denominations across the UK are slowly becoming more welcoming towards LGBT+ people, with the Church of England General Synod recently voting to affirm, not just welcome trans people. According to Tina Beardsley, the fact that the Synod vote was so decisive "signals that this church, as an institution, is ready to align itself with the evidence base that endorses trans people's reality and their right to self-determination" (https://www.theguardian.com/commentisfree/2017/jul/11/church-of-england-trans-gay-clergy-parishioners?CMP=share_btn_tw). However, Beardsley did recognise that non-binary people still face discrimination because we dare to challenge the gender-binary norm openly but she hopes that that non-binary people will eventually be accepted as well as trans binary ones.

Discrimination against LGBT+ people in sports participation and viewing has been highlighted in several reports over the last decade. The YouGov polling only adds to that existing body of evidence. 22% of trans people have experienced discrimination when attending a live sporting event and 51% of non-binary people said that they do not feel welcome attending sporting events. 38% of trans people avoid the gym or participating in grassroots sports groups and of those that do attend, 28% were discriminated against. Stonewall's recommendations include gyms and sports organisations making sure they have in place anti-bullying and harassment policies that are LGBT+ inclusive and look into potentially providing gender neutral changing facilities and(or at least) toilets so that trans, non-binary, genderfluid, genderqueer and agender people can change without fearing being insulted, harassed or physically/sexually assaulted. I agree with Stonewall that local sports venues need to do more to promote local and national LGBT+ sporting role models to encourage more LGBT+ people to consider joining their club and/or attend matches.

Conclusion:
As this new Stonewall report has highlighted, there is still a long way to go before we truly achieve equality of opportunity and acceptance of differing sexual orientations and gender identities in the UK. It's incumbent on LGBTQIA+ (I prefer LGBTQIA+ to just writing LGBT+ myself) people such as myself and those who consider themselves allies to speak up against those who believe it's OK to commit hate crimes and incidents in the name of "free speech" or "freedom of expression". Insults should be call out, harassers and bullies reported to the police through third reporting channels or directly, employees should stand up for their colleagues and customers and report HBT language to their line manager so appropriate disciplinary action and faith leaders should continue standing up for their LGBTQIA+ parishioners by preaching a message of love and compassion and empowering them to become active members of their faith community. The #ComeOutForLGBT campaign, launched by Stonewall after they analysed the YouGov polling, shows that the LGBTQIA+ community has plenty of celebrity allies but also allies from all walks of life and from all social backgrounds. Let's continue working together to reduce rates of anti LGBTQIA+ hate crime in the UK and empower more individuals to feel free to truly be themselves in their public as well as private lives.

Wednesday, 23 August 2017

Thoughts on the NHS England Gender Identity Services For Adults Consultation 2017

Gender Identity Services (GIS) in England are currently inadequately funded and staffed to meet the needs of trans and non-binary patients. Trans healthcare was one of the key areas of concern highlighted in the Trans Inquiry findings published by the Women and Equalities Committee last year (you should read the evidence submitted to the Trans Inquiry if you haven't already because it lays out the extent of current issues facing trans, non-binary, genderfluid and genderqueer patients when trying to access and when accessing GIS: https://publications.parliament.uk/pa/cm201516/cmselect/cmwomeq/390/39008.htm). It was clearly stated in the final Trans Inquiry report that the Women and Equalities Committee believed that the NHS was "letting trans people down" and failing to adhere to the Public Sector Equality Duty that they are mandated to follow under the terms of the Equality Act 2010. This is backed up by the findings of the Unhealthy Attitudes Survey carried out by Stonewall in 2015 (http://www.stonewall.org.uk/sites/default/files/unhealthy_attitudes.pdf) which was completed by 3,001 health and social care professionals. 28% of respondents to the survey stated that they did not feel that doctors were confident enough to respond to the specific care needs of trans patients, 9% were aware of colleagues experiencing discrimination or poor treatment because they are trans and 7% of respondents openly stated that they would "not feel comfortable" working alongside a trans employee.  Transphobic attitudes held by some GPs, nurses and other healthcare professionals needs to be stamped out, through the beefing up of HR led equality and diversity training. With regards to training, the Unhealthy Attitudes Survey found that 72% of respondents had not received any training on the specific healthcare needs of LGBT+ people; only 23% of respondents had received training on the legal rights of trans service-users. Also, only 27% of respondents said they'd received training on the legal rights of trans colleagues. There's definitely room for improvement.

The overall recommendation made by the Women and Equalities Committee was for the NHS to conduct, complete and publish a review of trans healthcare generally. There is also a  specific need to improve GIS, recommending that GIS be separated from mental health services and review their"treatment protocols", including the "Real-Life Experience" requirement to have access to surgery. However the Women and Equalities Committee refused to advocate for "on demand services" which made me think that there is still a general reluctance to accept that trans and non-binary people know their own mind and should have a larger stake in talking through procedures necessary to help them to lead their own lives.

NHS England have realised that GIS provision for adults needs to be improved and so have come up with a plan that they believe will make GIS more accessible and efficient. They have put these plans out to consultation and are encouraging trans (and non-binary) patients along with organisations such as Stonewall and GIRES to respond to their plans directly. So I'll offer a few of my own thoughts in this blogpost and encourage readers to consider responding to the proposals whether through YouTube videos, podcasts, blog posts or via NHS England's webpage (https://www.engage.england.nhs.uk/survey/gender-identity-services-for-adults/). It must be noted that this consultation is designed to bring in measures to replace the interim set of rules that were created in 2013 and that there have been 2 attempts to replace these rules which have not managed to progress. The 90 day consultation period (ending on the 30th September 2017) should allow for a range of voices to contribute their opinions about the proposed specifications and hopefully NHS England shall listen and make any necessary changes suggested in feedback.

The Consultation Document: 

Firstly, the Consultation Guidance from NHS England admits openly and honestly that GIS for adults need to improve. That includes looking at data collection, creating "quality and outcome measures", increasing capacity within GIS so that more patients can have access to treatment, addressing workforce constraint issues (the lack of specialist nurses, sexologists etc which is apparently primarily the concern of Health Education England), equalising "access to specialised interventions", addressing "infrequency and number of appointments" and revising administrative procedures. I'm glad that NHS England have identified these specific service improvements to focus on but as with everything NHS related these days, I wonder how much it will cost to implement these suggested improvements in England and whether NHS England are truly brave enough to ask for a specific increase in funding to allow these improvements to GIS to happen. No budgetary breakdown is offered in the consultation document itself but I am aware that an additional £4.4m had been invested in 2015/16 specifically for GRS in England. I'd like to know how much is estimated to be invested in GICs generally during the 2017/18 financial year with a breakdown of how much money has been allocated to each GIC for the 2017/18 financial year.

I am delighted to read that the consultation document makes it crystal clear that NHS England will not fund or allow providers of GIS to engage in the promotion of reparative therapy (aka conversion therapy) in any way. The non-surgical specification states that "the practice of conversion therapy is unethical and potentially harmful" and that "conversion therapy" is an umbrella term that includes any "therapeutic approach, or any model or any individual viewpoint that demonstrates an assumption that any gender identity is inherently preferable to another which then aims to get a patient to change their gender identity or suppress it". I hope that all NHS professionals working in GIS can agree with this declaration and that those working in the NHS more generally can regardless of their own private views.

As I've noticed with other recent NHS Consultation documents, there is a desire for NHS services to use advanced technological tools to help in the provision of advice and guidance for patients. I can see that for some trans and non-binary patients, Skype consultations with specialists could be appropriate, especially to discuss the effectiveness of current treatment plans. However, patients who are less comfortable with remote based conversations must still have access to face-to-face discussion appointments.

Referrals for gender reassignment surgery (GRS) on the NHS should on the whole be made through the GIS, provided that the multi-disciplinary teams at the GIS are in agreement that the individual is physically fit to go through GRS. Risk assessment should be the same as for any major form of surgery and should not over-focus on a trans person's "social issues" (those issues shouldn't matter anyways!) The GIS team must listen carefully to the needs of the patient and allow them to trust their own judgement (i.e. on an informed consent basis).

I understand that other NHS professionals who are not specialists (e.g. GPs) may feel reluctant about referring a patient directly for treatment, whether non-surgical or surgical. Training should be provided through Continuing Professional Development schemes to equip GPs with the knowledge they need to support a trans or non-binary patient throughout the initial referral process. My local GP was extremely proactive in finding out about access to my local GIC in Nottingham, ensured that they carried out all of the baseline tests within a fortnight of having had an initial meeting with them and then made the referral to Nottingham only a few days after the results of those baseline tests. My GP treated me with respect, non-judgement and listened to what I had to say, the same attitude that they would have had with any other patient. My GP may have only had a half-hour time slot to see me in (which was pre-planned by the surgery after I made the phone call to discuss GIC access; the receptionist on the phone was courteous and made no judgement). The nurses were equally empathetic; I remember during one baseline test I had to take off my vest and I was very nervous about doing this (I've never undressed in front of someone to that level since before secondary school) but the nurse carrying out the test put my mind at ease and never once referred to me by incorrect pronouns or tried to insinuate I was an "attention seeker" or "misguided" words you read on social media (luckily for me it's a rare occurrence). The service my local GP surgery provided was exemplary.

There is an increasing belief amongst LGBTQIA+ equality groups such as UK Trans Info that self-referral for GIS should be the norm because there is no real need for a GP to be involved in the initial referral process because it may be the case that GPs who have a bias against non-binary patients in particular may not carry out the referral to a local GIS despite an expressed wish by the patient on several occasions. There needs to be reassurances made by organisations such as the General Medical Council, British Medical Association General Practitioners Committee and The Royal College of General Practitioners that any unwarranted obstruction in access to service would lead to a GP facing disciplinary action as it may contravene the Public Sector Equality Duty placed on GP services by the Equality Act 2010. This should satisfy most concerns regarding the referral process.

I wonder whether private clinics should be necessarily ruled out from providing GIS on the NHS, especially if those private clinics have experienced professionals who deliver GIS on a regular basis. That being said I have concerns about increasing outsourcing of services to private sector organisations; Labour voters would not be happy to see more NHS funding being used to fund private sector treatments on a regular basis. What is important to remember here is that NHS Clinical Commissioning Groups (CCGs) should decide what happens in cases where a patient who has been able to afford private surgical treatment then loses their job and can no longer afford to pay for further treatment. Should those patients be automatically ruled out from consideration? I would argue that private patients should be allowed to access a NHS pathway of surgical treatment provided funding is in place from local CCGs to fund it. No patient should be turned away because they started their transition privately.

I agree with the proposal put forward to allow 17 year olds to access adult GIS in England and for the Gender Identity Development Service for Children and Young People (GIDS) to only accept referrals in future up to the age of 16, provided there is capacity in the system to allow 17 year olds to be seen swiftly. 17 year olds have reached past the age of consent (which is 16) and should have access to medical treatment (e.g. hormone replacement therapy) without facing unnecessary delays. I am concerned by the proposal that GIDS should remain responsible for the care of young people who may have "complex or psychosocial conditions" (it's not clear which conditions are included under NHS England's definition in the proposed specifications but it includes conditions such as schizophrenia, obsessive compulsive disorder and anorexia) which are thought to currently prevent them from pursuing physical interventions. I disagree that all psychosocial conditions must be included within this provision- for example, I am not necessarily convinced that a young trans person with ADHD or anorexia should be prevented from considering surgical treatment unless it could be proved beyond reasonable doubt that such treatment would exacerbate the problem. I think that these young trans and non-binary patients should take part in the decision making process when it is clear they have the mental capacity to be able to engage in the process.

Family members should only attend appointments when a trans or non-binary patient has specifically requested they attend with them; clinicians should not be allowed to demand a family member attend an appointment, even if they attempt to justify this on "emotional" grounds. A family member should never be asked to consent on behalf of the patient; a patient who has reached the age of consent (16) should be trusted to make their own decision. Never pressurise a trans or non-binary patient to bring someone with them; they may not have talked about their change in gender identity with family or friends before attending the GIC.

I am sympathetic to the proposal to reduce the number of clinical opinions needed to approve GRS to 1. I understand NHS England's concerns that a Registered Medical Practitioner should be the main clinical opinion sought during the process because they will have access to the patient's current and past hormone therapy data and be able to give their opinion regarding suitability for surgery. However I am also interested in hearing more about the proposal put forward to by the Clinical Reference Group for Gender Identity Services which states that no Registered Medical Practitioner opinion is necessarily needed because the specialist surgery team would examine patient history once they have been admitted into the unit.

I am extremely pleased to note that there is a firm commitment to ensure that all GIS will be available to non-binary and gender-fluid patients should they wish to have access to them, including surgical interventions.  Patients definitely have the right to self-expression ("personal autonomy") of their gender identity and presentation/ expression and also be referred to by the correct pronouns and names throughout the process. Regardless of these positive changes, it must be recognised that not every non-binary or gender-fluid person wants to have hormone treatment or surgery and should still have the right to self-identify and legally gain a Gender Identity Certificate without having to go through GIS or to "prove their identity" by going through a panel. Those legal changes are going to be discussed once the results of the national LGBT survey commissioned by the Secretary For Women and Equalities, Justine Greening, have been collected, collated, analysed and evaluated. I think we will all be interested in those findings when they are published (I am presuming this will be early 2018 at the latest).

The 12 month "Lived In Experience" requirement for GRS does seem rather an outdated concept to me personally. Most trans patients will have spent more than 12 months in their acquired gender before they even get to the GRS consultation stage and any consequences that come about as a result of GRS would only occur once the GRS has been undertaken. There is also no way of determining an objective assessment of  what the typical "Lived in Experience" is for a non-binary person so non-binary patients who wish to undertake GRS may be barred from accessing GRS based on not fulfilling the current requirement; this contradicts NHS England's stated aim of making GIS equitable for non-binary patients.

It's great to read that there has been a call for applications for more research on GIS from the National Institute for Health Research (June 2017). Improving the objective evidence base may mean that GIS will be commissioned that better meet the needs of patients and if some of the final reports are then made available in the public domain, we will all have a better understanding of how to provide the best level of care and support to trans, non-binary, gender-fluid, genderqueer and agender patients as well as helping to promote self-care where appropriate. That can only be a good thing.

As of yet I am undecided regarding the best prescribing arrangements for hormone replacement therapy for trans, non-binary genderfluid and genderqueer patients. At the moment, the specialist team based at the GIC will assess a patient's needs on an individual basis and then pass on the information to the patient's GP who then take full responsibility "for prescribing and administering the medicine (and to perform standard pre-treatment physical monitoring and laboratory investigations)". There are 3 alternative models that have been suggested regarding the prescribing arrangements for trans, non-binary, genderfluid and genderqueer patients. These are:
  • "A specialist team based at the GIC being responsible for issuing the first prescription" with the data relayed to the patient's GP who takes on responsibility for prescribing then onwards (Option B)
  • A specialist team based at the GIC issuing prescriptions for 1 year "or until the patient's endocrine treatment has been stabilised" with the GP prescribes from then onwards (Option C)
  • A specialist role being developed for GPs at a Clinical Commissioning Group level (or Sustainability and Transformation Plan level in the future if they get approved) with that dedicated GP issuing prescriptions "for all relevant patients in the area on the recommendation of the specialist team" (Option D). 
UK Trans Info (who have far more collective experience of advocating for better trans, non-binary, genderfluid and genderqueer healthcare than myself) have argued that the best model for providing HRT would be Option D because it "allows for the most efficient treatment of trans people in an area without requiring excessive amounts of travel" (http://uktrans.info/nhsconsultation2017). The consultation document does flag up the concern that some trans, non-binary, genderfluid and genderqueer patients may be asked to travel to a different GP practice than their own for the HRT, which may be difficult because they may not have the money available to allow them to travel, especially if they are unemployed. I cannot see a situation where the NHS would be able to routinely help with the costs of travel incurred, especially under the current funding constraints.
However, it must be pointed out that travelling to the local specialist GP's surgery would probably be cheaper and less time-consuming than constantly travelling to the GIC for a year (Option C). The consultation document does also point out that there may be issues trying to attract local GPs to consider taking up the specialist role, which "risks an inconsistent and inequitable approach to care"; will there be enough specialist GPs in rural counties such as Lincolnshire? Lincolnshire would need more than one specialist GP with it being the second largest county in England; one would need to be based in Lincoln to cover North and Central Lincolnshire with another based in Grantham or Boston to cover South Lincolnshire. There may be an issue with succession planning in the future too; what would happen if a specialist GP decided to relocate or retire and there aren't any qualified specialist GPs to take their place to allow for a seamless transition in prescription care? Patients would not accept a lengthy delay in receiving their HRT. 

That being said, Option D could be a blueprint for helping to develop local expertise and GPs in the local area may learn "experientially" about trans healthcare and endocrine management, which would be very beneficial in the long term; in fact, as specialist GPs become more experienced, they may be able to "take on more of the clinical services currently provided by GICs" but it is acknowledged that more funding would be needed to facilitate this decentralisation of services. 

UK Trans Info has pointed out that there may be long waiting times for patients and have argued that GPs should be able to give out bridging prescriptions if it takes more than 18 weeks for that specialist to issue the first prescription; the General Medical Council guidance issued last year recommending that GPs offer bridging prescriptions in exceptional circumstances (if they have been self-medicating or to reduce the risk of self-harm or suicide). UK Trans Info agrees with the GMC guidance and believes that any trans, non-binary, genderfluid, genderqueer or agender patient that has been self-medicating when they approach their GP should not be told to stop as is currently the case; instead there should be a bridging prescription made available, with regular monitoring of those trans and non-binary patients who have self-medicated in the past. Not ever GP will feel comfortable with the idea of offering bridging prescriptions without seeking specialist advice and guidance. Zara Aziz, a GP partner in a practice based in north-east Bristol wrote a recent article in The Guardian where she argued that whilst GPs are specialists "in prescribing and monitoring in many clinical areas that ...(they) commonly encounter or that...(they)...have developed an interest in", they do not have such awareness with regards to giving holistic care to patients and it could lead to an increased risk in the number of "complaints and litigation against family doctors", pointed out in guidance provided by the British Medical Association's General Practitioner Committee. Dr Azis argues that handing over most of the responsibility for specialised care to GPs in regards to GIS could lead to other specialised care responsibilities being given to GPs, stretching their time and money further. Dr Aziz wants to see the NHS "commission a robust and accessible GIC locally that can support patients and GPs alike" which would have a multi-disciplinary team in place to provide a holistic service.

I think it is important that specialists make it crystal clear to patients that they may experience a loss of fertility and that they may be able to freeze sperm or eggs but only if their local CCG agrees funding for this; patients cannot demand this service at the moment and it is unlikely that funding will made available in every CCG any time soon.

It's pleasing to see a requirement in the specifications that surgeons must perform a minimum of 20 procedures a year that have been commissioned from the provider and that surgeons are required to demonstrate evidence of Continuing Professional Development and engage at least once a year with their fellow surgeons to share best practice. This group of surgeons will then publish an annual report with data on caseload, outcomes and any complications that have resulted from surgery.

If a trans or non-binary patient requires treatment for complications that have arised as a result of surgery will be able to have treatment provided for up to 18 months after the surgery has taken place; the original surgeon will perform the new surgery.
If a patient does not want to continue treatment with a particular surgeon, they will be referred by the surgeon directly to another surgeon working in a NHS England commissioned surgical unit. The choice of surgeon will be discussed and agreed with the patient.

The Equality and Inequalities Impact Assessment: 

The Equality and Inequalities Impact Assessment identifies a number of areas that have been addressed by NHS England in order to improve trans and non-binary patient care:
  • Front-line staff need training to be able to treat trans and non-binary patients with respect, including making sure that trans patients are not placed on the wrong sex ward in hospitals and are not excluded from screening programmes. NHS England have decided to "undertake an initial scoping and feasibility study" to address concerns, focussing on "non-specialised services such as gynecology and voice and communication services" that form part of the NHS pathway of care within NHS England's service specification. The data and recommendations made as a result of carrying out this project will then be used to assess how changes can made "across NHS services more generally".
  • The proposed specifications do not have an upper age limit for non-surgical and surgical inventions which means that any patient who wishes to be referred to a GIC should be able to receive treatment when the specialist team prescribes it.
  • Patients with communication difficulties as a result of co-existing complex physical or mental health conditions or as a result of a learning difficulty (I prefer the term difference) will require additional support from GICs and from their GP. The EIA makes it clear that in both specifications, a tailored individual treatment plan will be provided and allow for "additional assessment consultations" and "additional support services" when appropriate.
  • The EIA confirms that patients with a Body Mass Index (BMI) of more than 30 (for genital surgery) will be required to lose weight unless a surgeon has approved surgical invention once a risk assessment has been carried out.
  • Trans patients with HIV would have "consistent access to the range of available interventions" which would lead to "more timely assessment, diagnosis and treatment".
  • A patient's history of substance misuse would be a factor in determining access to treatment; those with a current addiction to non-prescribed drugs and alcohol it would seem would find it more difficult to access treatment but it's not clear from the consultation document how long a patient would need to be "clean" before being allowed to access non-surgical and surgical treatments.
  • There is an under-representation of BAME trans and non-binary people attending GICs and I agree with the EIA conclusion that GIS must be delivered in a culturally appropriate way. I hope that NHS England will take the time to consult with patients and organisations representing the trans and non-binary BAME community to come up with specific recommendations as to how GIS can be made more accessible, including designing training for frontline healthcare professionals to follow. It is good to see NHS England make a specific commitment to improving their data collection procedures to ensure full compliance with the Equality Act Public Sector Duty.
  • It's interesting to note from the consultation document that the Trans Mental Health Study (2012) found that most trans patients have no religious affiliation (62%) but out of the remaining 38%, 20% of trans patients identified as Christian. Data Collection carried out by NHS England from GICs in 2016 had the number of patients who had no religious affiliation at 61% and those who were Christian at 21%. Only 35% of patients filled in the "Religion and Belief" field. Despite this, there must be Chaplaincy services available to those trans and non-binary patients who require "pastoral or spiritual care" regardless of their religious belief.
  • The proposed specifications should not discriminate on the basis of sexual orientation and frontline healthcare professionals must not pry into a patient's sexual history because it is irrelevant for non-surgical and surgical treatment processes. Where a patient actively chooses to disclose their sexual orientation, this information must be kept strictly confidential.
  • GIS must be inclusive and accessible to patients who may not be registered with a GP. It can be difficult for certain patient groups to register with a GP; e.g. a homeless patient has no fixed address and a sex worker may have no proof of address or identity and may be excluded from registering with a GP based on this. NHS England believes that patients must be registered with a local GP because they are currently best placed to "offer healthcare support", prescribe drugs and monitor treatment, especially once "contact with specialist teams has reduced or come to an end". They reiterate that GP surgeries cannot refuse to register a patient because they do not have personal information to hand (there is no statutory requirement to request this). Therefore, patients currently not registered with a GP should be encouraged to register if they wish to access GIS.
The consultation document also identifies other areas NHS England needs to take into consideration. Many trans and non-binary GIS patients have stated publicly that waiting times for initial appointments are far too long. For an initial appointment with Nottingham GIC for example, I was told that 18 months was the standard waiting time and since I was referred in April 2016, I will probably not receive an appointment letter until early 2018 at the earliest. These waiting times are in breach of the NHS Constitution but NHS England insists that the proposals made in this specifications will go some way towards addressing the waiting time issue and that they will focus on recruiting more specialist staff in the future to relieve pressures. James Palmer, in his first blog as the Senior Responsible Officer for GIS (https://www.england.nhs.uk/blog/we-are-meeting-concerns-on-gender-services/) states openly that the 18 Week Referral to Treatment standard will be monitored "throughout the entire trans pathway" with "regular consistent reporting" beginning from 2018 which will allow for "absolute transparency about waiting times".

NHS  England also noted in February 2016 that they had a "shortage of suitably qualified staff" (http://www.bbc.co.uk/news/uk-england-35605956) but recruitment and retention of talent is flagged
up as a continuing issue at the beginning of the consultation document. Unless NHS trusts find a way of encouraging more qualified staff to join English GIS, waiting times may remain stubbornly high.

The consultation document doesn't specifically address access to services for trans and non-binary patients who are in the criminal justice system. Current evidence states that trans and non-binary prisoners are "routinely segregated" on secure prison wards and denied gender-affirming products whilst in prison which means they are less likely to fulfill the current "Lived In Experience" requirement for surgery. The Department for Justice released guidance (Prison Service Instruction) to prisons on the issue of access to healthcare for trans, non-binary and intersex prisoners which was issued in November 2016 and which came into force on 1st January 2017 (https://www.justice.gov.uk/downloads/offenders/psipso/psi-2016/PSI-17-2016-PI-16-2016-AI-13-2016-The-Care-and-Management-of-Transgender-Offenders.docx). The policy specifically states: "Establishments must ensure that prisoners who have been diagnosed with gender dysphoria have access to the same quality of care (including counselling, preoperative and post-operative care and continued access to hormone treatment) that they would expect to receive from the NHS if they had not been sent to prison." If a prisoner has attended a GIC and has been receiving non-surgical treatment and signals their desire to carry on with their treatment, "it should be continued until the prisoner's gender specialist has been consulted on the appropriate way to manage the prisoner's treatment unless the doctor working in the prison has reasonable clinical grounds for not doing so."

The policy also states that access to private health clinics for prisoners is restricted: "there must be sound and demonstrable clinical reasons for allowing access to private health services. There must be evidence that this will improve the health of the individual and is not based on uninformed personal choice".

When a trans, non-binary or intersex prisoner signals an intention to begin hormone replacement therapy for gender dysphoria, the prison health care team have a responsibility to inform the relevant Clinical Commissioning Group and "request a point of contact for liaison". When a prisoner wishes to undergo GRS, the prison GP must liaise with a consultant directly to accept advice from them. The Governor may also "prepare a report to the consultant as to the practical impact within a prison context" of the prisoner recovering from GRS. The consultation document and specifications do not give guidance on how the referral process for trans and non-binary prisoners may differ as a result of a prison Governor's report intervention, for example. 

What's been made clear in the consultation document is that NHS England will not provide surgical and non-surgical treatment to patients whose presentation "primarily relates to intersex conditions" (aka disorders of sexual development) who have expressed a desire to have surgery through the future GIS. This may be because NHS England believes that a standard treatment pathway may not fully take into account specific needs of intersex patients. UK Trans Info have argued that intersex patients should have full access to non-surgical and surgical treatment when they have expressed a wish to undertake such treatment but that they should not feel forced or coerced into undertaking any treatment correctively. They also point out that whilst not most intersex patients will not identify as trans, there are some intersex patients who do publicly identify as trans or non-binary; are they going to be denied access to non-surgical and surgical treatment entirely? If such services are not going to be provided through GIS, where are trans and non-binary intersex patients going to have access to non-surgical and/or surgical treatments? When will NHS England unveil this alternative pathway? How much longer would trans and non-binary intersex patients have to wait to be seen by specialists?Would specialists in the alternative pathway  have the contextual knowledge to treat trans and non-binary intersex patients with true respect and dignity? These questions need to be answered and I think a review of intersex patient healthcare is timely and necessary so that healthcare professionals and the public alike understand clearly what will happen.

An interesting response to the NHS Consultation : 
Not every organisation is in favour of engaging with the NHS consultation; the main reason being that they do not believe that the current GIS system is acceptable in any way whatsoever. The Edinburgh Chapter of the Action On Trans Health organisation have released their own "Trans Health Manifesto" (https://edinburghath.tumblr.com/) designed to revolutionise the way that trans and non-binary healthcare is delivered: "we demand nothing less than the total abolition of the (Gender Identity) clinic, of psychiatry and of the medical-industrial complex". Instead, there would be:
  • universal access to hormones and blockers through free prescriptions so that trans and non-binary patients can self-medicate
  • access to therapy at drop-in clinics or through self-referral
  • anonymous blood tests with equipment being delivered through "post or at drop-in endocrinology clinics"
  • an end to surgical prerequisites with access to tailored surgery, including access to reversal surgery on demand
  • resources for hair removal of any kind 
  • voice coaching that doesn't "coerce us to alter our voices in ways we do not express a need for"; such coaching should respect accents 
  • medical training so that self-medicating trans and non-binary patients can carry out research in order to "improve the quality of medications" and "reduce negative side-effects in the long term"
  • create research centres and libraries which are organised for and by trans patients with "full funding" being made available for any projects carried out
The initial concern here again would be with funding; how much would it cost to fund the surgeries required, the research collectives and the medical training. Even with the money saved from shutting down GIS (which I am concerned about), I suspect there will be not enough funding available to meet such demands. There are other aspects of the vision document which do not sit well with me, including revoking the medical licences of GIS staff, who are on the whole extremely hard working and passionate and whose knowledge and skills would be needed to help direct training to aid research anyways. There are other elements of the vision statement that I agree with, including the mandatory education about trans and non-binary issues that should at least involve trans people and organisations and the demand for accessible, high quality housing  for trans and non-binary people who find themselves unemployed or on in-work benefits. Anyways read the document for yourself; it's thought provoking! 

Conclusion:
The two draft specifications that have been offered by NHS England are broadly speaking to be welcomed; there are proposals which will help to provide better standards of patient care for trans, non-binary, genderfluid and genderqueer patients. There is a commitment to reviewing waiting times, a commitment to treating non-binary, genderfluid and genderqueer patients with respect and dignity and for most 17 year olds to access adult GIS so they can begin HRT as soon as possible. There are issues with the specifications with regards access to treatment for patients who have a mental health condition (there needs to be clarity regarding what mental health conditions would necessarily preclude a trans, non-binary, genderfluid or genderqueer patient from being able to go through HRT or GRS). There needs to be much more clarity regarding intersex patients who also happen to be trans or non-binary and their access to GIS. There needs to be a review into surgical procedures that can be offered on the NHS, including the ability to access corrective surgery including when complications have arisen after the 18 month time-frame. The Lived-In Experience requirement needs to be reviewed for effectiveness; if it's impossible to quantify what constitutes what is a "normal" experience for a non-binary person, there's no way a non-binary patient can fulfill the requirement and can therefore not gain access to GRS should they require it. Equally, there is no real way to be socially a man or woman that isn't rooted in gender stereotypes; a trans man can still wear dresses occasionally if they choose even if this isn't typical of all men and this should not impact in any way the validity of that trans man.  As UK Trans Info have pointed out, the Lived-In Experience requirement may also be seen as patronising; do trans people need to be taught about the consequences of transitioning? Prescribing service provision needs to be agreed with the consent of all stakeholders involved; Option D may be the ideal but there may be pushback from CCGs in certain areas of the country who believe there can be no special GPs allocated to become specialists in prescribing and offering specialist care and support to patients. I look forward to seeing the results of the survey and conclusions and recommendations drawn and hope that NHS England will be proactive in reviewing and addressing areas of concern within the specifications. Then perhaps we will begin to see GIS that truly provides the highest standards of specialised and effective patient care across England. 

Monday, 14 August 2017

Thoughts on Charlottesville: Keep Standing Up To White Supremacists and Alt-Right Commentators

The horrific events that have occurred in Charlottesville on Saturday seem to have shocked people not just in the US but around the world. Such events should shock every person who believes that compassion towards others should never be rationed. Heather Heyer, a civil rights activist who was exercising her democratic right to peaceful protest lost her life and 19 people were injured as a result of a driver seemingly choosing to deliberately run over protesters just because they were counter-protesting an organised hate driven rally organised under the vague label of "Unite The Right". If an ISIS terrorist had done this on a Saturday afternoon in an American city, they'd have been immediately labelled as a terrorist; yet President Trump could only condemn the "egregious display of hatred, bigotry and violence on many sides"  in his first statement rather than call out the actions perpetrated by the driver straight away.
Alt-righters have already tried to excuse or condone the driver's actions, stating that the driver had been "scared" by the number of protestors in the road and swerved off. We shall find out in the next days, weeks and months what primarily motivated the driver (the young man from Ohio currently charged with second degree murder is the main suspect) to commit such a heinous act but nobody should be surprised if police find out he had accessed materials that had been created and disseminated by alt-right commentators. The suspect seems to have adopted a poisonous, nationalist, white supremacist Neo Nazi based ideology that should be condemned at every opportunity. The act was deliberate and if found guilty, people have every right to label him a domestic terrorist because his act was designed to terrorise innocent people inspired by his political ideology. That makes the driver no better than ISIS suicide bombers.

The "Unite The Right" rally at Emancipation Park was organised by the former Daily Caller writer Jason Kessler, with speakers such as Richard Spencer, President of the National Policy Institute (a white supremacist think-tank) who has openly called for "peaceful ethnic cleansing" of the US or a "white homeland" for "a dispossessed white race" as The Southern Poverty Law Center have highlighted (https://www.splcenter.org/fighting-hate/extremist-files/individual/richard-bertrand-spencer). Such views are ridiculous to a liberal like me but then Spencer idolises nihilistic Nietzsche:
(see more about Spencer here: http://www.dailywire.com/news/11089/5-things-know-about-alt-right-leader-richard-aaron-bandler). Alt-righters like Spencer love being allowed to vent
 their views full of hatred, bigotry and inspiring xenophobia, racism as well as not being ashamed of celebrating white supremacism. Urgh.

The event was planned after it was revealed in February that Charlottesville City Council had voted remove and sell a statue of General Robert E Lee, after a campaign run by a local high school student. There have been a number of campaigns across the American South dedicated towards removing monuments that celebrate the slave-owning Confederacy. I don't entirely understand why the divisive legacy of the Confederacy needs to be celebrated (after all the Union side won) and it's strange to see the level of negative emotion shown by white people who are upset that the confederate flags aren't being waved with pride on a daily basis anymore because they say that flag represents freedom and liberty. I thought the modern United States flag was meant to represent those values? Yet there are others who believe the confederate flag should still be celebrated because it honours the sacrifice of confederate soldiers (the flag itself is a battle flag and not a national flag so there is some sympathy with the honour element: http://www.bbc.co.uk/news/magazine-23705803). Anyways the Charlottesville rally was basically planned for months and was designed to be the largest gathering in decades of white supremacists (5,000-10,000 was the estimate given for attendance pre the event). There was an altercation on Friday night between white nationalists/supremacists/alt-right and counter-protestors on the University of Virginia campus, where counter-protestors were sprayed with pepper spray and lighter-fluid (you can read more about the build-up here: https://www.theguardian.com/us-news/2017/aug/12/nazi-white-nationalist-rallies-virginia-protests).

Alt-right white supremacist nationalist speakers (that's what the majority of the alt-right are really....white supremacists; Spencer admitted the alt-right was a movement "for white identity" and he coined the term so it's easy to see it as modern code for white supremacy even though he rejects the term white supremacy) stir up hatred, bigotry and fear in a provocative manner. It's what they specialise in. Division is their end goal. Most of them hate diversity and cannot abide the idea of coexistence. That's why it's important for those of us who believe in the values of tolerance, compassion and respect to speak up and actively condemn speakers like Richard Spenser and also continue to condemn traditional white supremacist group speakers, including the ex KKK grand wizard, shameful David Duke. Duke's brass neck is visible for all to see. He can't hide his delight in the fact that Trump's election has meant he's now empowered to speak out about his white supremacist agenda: "We are determined to take our country back....We are going to fulfill the promises of Donald Trump". Duke interprets the "take back our country" slogan as being one that follows white supremacist lines but Duke was more than a bit upset at Trump's (vague) rebuking tweet, stating openly that Trump's win was down to "White Americans....not radical leftists". Duke's tweet is racist and false; "radical leftists" include white Americans and there were also Americans from ethnic minority groups who did vote for Trump (wonder if some of them regret this now given his actions during the Presidency...). Still a shame that Duke's been allowed a Twitter account when alt-right commentators such as Milo Yiannopolous have been banned from the social media site; what makes Duke more acceptable than Yiannopolous?!

It's important to mention the fact that most of the white supremacists and alt-right protesters were men. As a trans non-binary person, I find it very difficult to accept that white guys are the "most oppressed" people in America (and equally in the UK). A Vox article "The Charlottesville protesters are white fragility in action" (https://www.vox.com/identities/2017/8/12/16138558/charlottesville-va-white-fragility) points out that men at the march were changing slogans such as  "you will not replace us"; given that the 2016 census data indicates that 76.9% of the US population are white as opposed to 13.3% of the US population who are black or African American (https://www.census.gov/quickfacts/fact/table/US/PST045216) demonstrates quite clearly that these white men have no reason to chant such a slogan and besides, racial diversity is certainly nothing to fear. Yet these men are evidently afraid of change; there's no doubt a large number were angry at President Barack Obama and want to dismantle his legacy and also at the Black Lives Matter protests that have been gaining momentum in the US and beyond.

In America, white supremacists have the right to protest (under the 1st Amendment). An article in Vox explains how even the American Civil Liberties Union defended the right of Kessler et al to protest in Emancipation Park (https://www.vox.com/policy-and-politics/2017/8/12/16138326/aclu-charlottesville-protests-racism).  I can and will never understand how someone can be so insecure about their own life that they end up blaming immigrants, African Americans, Asian Americans or Latin Americans for their own misfortune. There's no evidence to prove white people are being oppressed on the basis of their skin colour. It is worrying to see predominately young men turning to Neo-Nazi, white supremacist ideology for comfort. There's something quite frankly chilling about seeing young men marching with tiki torches, chanting Nazi-era slogans and threatening innocent students and protestors standing up for their fellow Americans with violence.  It seems we have to defend a person's right to protest, even if their views are abhorrent to us; that's the supposed hallmark of a democracy. But nobody should condone the right of protesters to resort to verbal abuse or physical violence, regardless of who those protestors happen to be. Violence is never the answer.White nationalists are far from the paragons of American virtues that they purport themselves to be. No gentility of character evident whatsoever.

A tepid false equivalence statement such as the one issued by Trump as his first response to Charlottesville was not acceptable. There was NOT blame "on many sides"; the blame firmly lies with the white supremacists. This group of individuals have oppressed African Americans, Asian Americans and Latin Americans for generations. They protest because they want to continue having a foothold in American politics, aided and abetted by alt-right commentators who have now spruced up the white supremacist ideology to suit the millennial (and younger) social media watching audience. They have used YouTube, Twitter, Facebook and even Instagram to their own advantage to push an odious ideology which has no place in a liberal, tolerant and open world. Most political commentators (and most Americans) wish Trump had openly condemned white supremacist and, alt-right groups on Saturday. Republican politicians lined up to criticise Trump's choice of words: Senator Cory Gardner urged Trump to "call evil by its name", stating that the act was committed by "white supremacists and this was domestic terrorism". Utah Senator Orrin Hatch tweeted that white supremacist protesters' "tiki torches may be fuelled by citronella but their ideas are fuelled by hate & have no place in civil society". Instead, Trump couldn't help but lay part of the blame for the events at the door of those who bravely protested these groups, including Black Lives Matter activists. I'm not ashamed to say that if I'd lived in Charlottesville and I had heard that an alt-right and white supremacist rally was going to take place in my town or city, I'd have tried to get involved in peacefully protesting them. Any person who abhors white supremacist ideology would have done the same.The White House has issued a "clarification statement" where they state that Trump was referring to white supremacist groups in his statement; it's just sad that he couldn't condemn them by name in the first place. Trump has also spoken out and mentioned the KKK by name but why did it really take him so long? If I was President of the US or Prime Minister of the UK, I'd have called them out straight away. A dithering attitude doesn't inspire much confidence leadership wise.

The events in Charlottesville demonstrate the need for real cultural change in America, including conservative attitudes towards peaceful protestors from the Left. Protestors are not paid shills for George Soros, no matter how hard the alt-right wants to push that false stereotype. People on the left care about freedom but they also care about (on the whole) equality and diversity and celebrating living in a multicultural society. It's important to mention that there are Republican lawmakers who want to make it legal for protesters to be hit by cars. In the UK this would be entirely unthinkable and contravenes Article 8 of the UK's Human Rights Act 1998. So to a British person like me, such a change in laws regarding protest in America are repulsive. So the lawmakers of North Carolina (who passed a bill with 67 people voting for it...https://www.usnews.com/news/articles/2017-04-28/north-carolina-house-votes-to-protect-drivers-who-hit-protesters) Texas, Florida, Tennessee and North Dakota really need to take a look in the mirror and question their prejudices; would they try and change the law if an alt-right or conservative protester was mowed down by a car? Hmm.

Education is going to be key if America is to deal with the issue of persistent white supremacist ideology being pushed by elements of the alt-right movement. From an early age, whether at church (community centre or any other religious building), in elementary schools or at youth camps, children should be taught that hating a person based on the colour of their skin is fundamentally wrong and at odds with any notion of freedom, liberty or equality. However, testimony from the driver's history teacher proves how much of a challenge it is to try and get some young men to steer away from being seduced by Neo-Nazi and white supremacist ideology; his comment about Dachau concentration camp is so chilling that I will not mention it here (read it for yourself: http://abcnews.go.com/US/charlottesville-murder-suspects-teacher-thought-nazis-pretty-cool/story?id=49193213).

More generally, frank conversations do need to be had over white privilege. This may be more difficult with those who have conservative  political views who may not wish to be told that their comments or actions have a negative impact on people from ethnic minority backgrounds and could be interpreted as casually racist; an interesting case is pointed out in the first Vox article where a young woman at an anti-racism training session couldn't accept that her views could be challenged so overtly by participants who were from ethnic minority backgrounds  to the point where she declared she "might be having a heart attack" to her white colleagues which then re focussed attention and sympathy on her and away from the comments she had made. Some white-supremacists and casual racists react in such a sensitive way so as to escape their responsibility for their hate speech. Others are blatantly proud to hold such views and they should be condemned openly for those views. I don't think there is any free-speech issue concerning  no-platforming of racists, white-supremacists who may define as alt-righters; social media sites should be diligent in policing their platforms and quick to remove videos, tweets and Facebook posts that contain white-supremacist or racist ideology whenever they are alerted to such content.

There are certainly white nationalist supremacists out there who appropriate Christianity for their own ends without seemingly recognising some vital basic facts about Christianity (Spencer describes himself as an atheist and a "cultural Christian", which is confusing enough!) Firstly, Jesus was from the Middle East (born in Judea which is now part of the Palestinian West Bank) and was a Jew; he was not white or evangelical. Secondly, Jesus believed that demonstrating acts of compassion were a vital part of leading a fulfilled and happy life. Thirdly, Jesus believed that those acts of compassion should be demonstrated to all, regardless of religion, nationality or race. Fourthly, Jesus taught us about the importance of loving your neighbour; alt-righters and white supremacists may love their immediate neighbour but show little respect or compassion towards those who lead different lives. James Martin, a New York based Jesuit Priest, points out in a Twitter post (https://twitter.com/JamesMartinSJ/status/896528129971281920) that "supremacy is absurd to Jesus": Mark 10 42:43 makes it clear that Jesus expects us not to "lord power over others" and be "each other's servants". The Parable of the Good Samaritan is one of the best examples of Jesus's acts of compassion to use to counter alt-right narratives but Father Martin also points to the example of the Roman centurion, whose servant he healed without passing judgement on either of them. Racism, Marks says, "goes against all that Jesus taught: It promotes hatred, not love, anger, not compassion, vengeance, not mercy. It is a sin". Religion can be a force of good in the world and it is a Christian duty to stand up to white nationalist supremacists. After all, we are all made equal in the image of God the Father, Son and Holy Spirit: (Galatians 3:28: "There is neither Jew nor Greek, there is neither slave nor free, there is no male or female, for you are all one in Christ Jesus). God does not show favouritism (Deuteronomy 10:17 declares that God "is not partial and takes no bribe").  Christians should also be prepared to forgive those who truly repent of their racism/ white supremacism: Ephesians 4:32 states: "Be kind and compassionate to one another, forgiving one another, just as in Christ God forgave you". That being said, Christians respect the legal system and the law must be allowed to take its course when racists have taken action designed to terrorise others.

It has to be pointed out clearly that problems faced by communities in rural America (also faced by deindustrialised communities in the North of England) are NOT the result of "diversity genocide" or completely the fault of "mass globalisation". White supremacists only look to the past and glorify every action taken by the ancestors. That's not going to help solve the issues faced by "angry white young men" today.  Instead, there needs to be policies enacted that help to address those issues. The Alt-right and traditional white supremacist groups like the KKK cannot offer solutions; they just contribute articles to their own groupthink websites like AltRight.com where they try and read fascism into the work of David Bowie: (http://forward.com/fast-forward/360401/richard-spencer-and-white-supremacists-aim-for-bigger-platform-with-altrigh/).

As I've said earlier, education is key. More young white American men from working class backgrounds should be encouraged to apply for higher education programmes (including night school) because they need to realise that they will probably not be able to walk into a job without a good standard of education -i.e. college degrees (see more here: https://www.fastcompany.com/3062321/why-are-there-so-many-white-young-american-men-without-college-degrees). Trump's more bothered about reviewing federal education policies (mainly K-12 education) than increasing access to college education and the fact that his administration has rolled back the protection for individuals who may default on their college loans signals a disregard for college students. In fact, Trump wants to reduce state grants for career and technical education (for those who do not want to go through traditional college, akin to the UK apprenticeship programmes) and cut the funding for the US federal work-study (for those who do attend college but might have ended up working to fund it) programme by 50% (https://www.theatlantic.com/education/archive/2017/05/trumps-education-budget-takes-aim-at-the-working-class/527718/).

Young people should also be empowered to look for a sense of self-worth that is not contingent on "membership" of a hate political movement. Getting them involved in community work, arts projects, the church can help in this respect.

Those who elected Trump who do not consider themselves in any way a part of or allied to the KKK or the Alt-right movement (including some independents) apparently did so in part because they believed that he could bring economic prosperity to the American rust belt. As of yet, Americans have heard very little about policies that would directly help working class Americans, including those who may have alt-right sympathies. Instead, there's an emphasis on tax reform that seems to predominantly benefit business owners, cutting the corporation tax from 35% to 15% (although Trump says he'll eliminate income tax for single people earning under $25,000 a year) with the "hope" that those business owners then expand and create jobs for young people including those involved in the alt-right movement. Will such trickle-down capitalist economics work? Doubt it.

Recently, Trump's administration have focussed on isolationist and protectionist policies, including trying to bring an immigration reduction bill (named the RAISE Act) to Congress; such an act would, according to a Penn Wharton study, lead to the US's Gross Domestic Product being 0.7% lower by 2027 and 2% by 2040. Whilst it may raise per capita GDP in the short term, the economy on a person-by-person basis would be smaller by 0.3% (https://www.vox.com/2017/8/11/16125578/raise-act-economic-impact) by 2040. The Penn Wharton study also found that such a policy may end up reducing the number of jobs in the US by 4.6 million. Trump's approach has been criticised by the Dean of Harvard Business School, Nitin Nohria who stated that the US needs to focus on the "ambitions and aspirations linked to globalisation" because they are part of "the American dream". The US must remain attractive to highly skilled migrants because they help drive economic growth: "more than 50% of Silicon Valley start-ups have an immigrant co-founder" and they help to employ US born citizens in well paid roles:  (http://www.independent.co.uk/news/world/americas/us-politics/donald-trump-economic-policy-us-risk-president-harvard-business-school-dean-name-a7870866.html). A more positive and progressive approach to immigration would be much better and there needs to be economic reforms that help young people get into work. But that doesn't seem to be coming any time soon.

My thoughts and prayers are with the family of the Ms Heyer and with the injured and their families who are in a critical or serious condition in hospital; having lost my Uncle on Sunday due to liver cancer I can only hope that they are all being well supported during the grieving process. Nobody should lose their life when exercising their right to protest peacefully. Nobody.

Thoughts are also with the two police officers who died when their helicopter crashed into a wooded area outside of Charlottesville. They died whilst carrying out their duty to "protect and serve".

Yet we must continue to protest white supremacists through countering the ideology that feeds their hatred, including through social media and engaging in a positive, practical way with those who would be susceptible to turning to the alt-right for advice and guidance. A pro-active approach is essential.  The words of Edmund Burke are more important now than ever: