What would it take to transition by 2027? The NHS is failing trans people.
Or, let’s run with a tabloid headline for a moment…
I saw a ridiculous new tabloid low on Twitter this morning: some nonsense satire about the UK’s Prince Harry having “had a sex change” in 2027 and is now going by Harriet, a little over seven years from now.
And someone I follow on Twitter pointed out that he’d probably have to come out tomorrow in order to get gender confirmation surgery on the NHS.
So I decided to do the math, because the number one thing that shocks cis people when I talk to them about this BS gatekeeping-based medical system is the unmatched wait times for all minor and major medical interventions.
Think of this as a to-do list for any royalty, time travellers, or uninformed members of the media who would like to try beating the clock. Let’s put aside the public figure they’re trying so hard to insult in any way they can, and follow our plucky hero and heroine, Harry and Harriet, as they start the process in November 2019.
(I chose to include both because trans men’s and trans women’s experiences can differ. I haven’t experienced this system personally as a trans woman, so I can speak to these experiences only from listening to those who have. Nonbinary people are often gatekept at every single stage for additional months or years, and therefore choose to present as a binary trans person to try to avoid this.)
Step one: talk to your GP.
Let’s assume that they have GPs. Not everyone in the UK does, of course. They’ll need to find one to get a referral to a GIC. The obstacles they face include:
- Getting an appointment, as many people have to wait weeks to see a doctor.
- The actual, terrifying process of coming out, for possibly the first time ever.
- The doctor’s reaction, which frequently ranges from “come back in a few months if you still feel this way”, to outright conversion therapy (“are you sure you’d be happy this way?” or “let me prescribe you the wrong hormones to see if that fixes you”), to mysteriously lost referrals and stalling. Harry may be told he’s just a confused lesbian; Harriet may be told she’s just a crossdresser and fetishist, regardless of either of their sexual orientations.
- The medical trauma from being disbelieved, gatekept, sent away — in some cases, repeatedly over the course of years — and feeling like one has no recourse is immense and will have lifelong impacts.
- The waiting time for this referral to actually be written, sent, and received. It can take several weeks for the GIC to receive it, best case scenario. Many trans people wait months only to find out that the GIC lost their referral, even when it was sent via signed delivery, and have to go through this process two or three times or more before the GIC finally actually receives the referral and acknowledges it.
Let’s assume they each have a GP who actually believe and listen to them, and don’t attempt conversion therapy. They get appointments quickly. Maybe their first referrals are lost, but their GPs are on the ball and spot it, and make sure they get through the system. It’s March 2020.
Step one (b): Better hope you’re in England or Scotland.
If our hero and heroine are in Northern Ireland, they have virtually no hope of making this timeline. The waiting list hasn’t moved at all in at least three years, which means there is effectively no GIC access for Northern Irish trans people.
If they’re in Wales, there are two possible paths. The old route means an extra 6+ months wait, as they’ll each have to get a mandatory psychiatric evaluation in order to get approval for funding to see an English GIC, which will take several more months. (This funding may “run out for the year” at any given time, leaving them stuck on the waitlist until it resumes.) Said psychiatrist may know nothing about trans people and retraumatize them again, and may or may not agree to make the onward referral, even though they have no specialist experience in trans matters. In the new path, they can only be referred to the Welsh GIC which was promised for many years and seems to finally be open. Chances are good this waitlist will grow rapidly.
Step two: wait for your GIC referral.
We’ll say Harriet and Harry are waiting for Charing Cross GIC, the largest and oldest gender clinic in the UK.
Scottish residents only may have a somewhat shorter wait, but this isn’t guaranteed. In England, it’s nearly impossible to find one with a shorter wait time these days. If you do, the wait time will usually sharply increase as everyone else requests a referral there for the same reason.
Charing Cross GIC had approximately a two-year waitlist at the time it stopped giving estimates of wait times to new patients. We can safely say, therefore, that our protagonists are going to be waiting at least two years for an initial appointment. Two and a half years is very reasonable, as some GICs have three-year-plus waitlists, so we’ll call it that.
This waiting period assumes no further increases in waitlists, changes in funding, extra doctor training, etc. A switch to informed consent hormone treatment could reduce this waitlist to a few months in a matter of a few months, but is politically a gargantuation, risky move right now for whichever health minister supported it. Thanks, media.
The period between acknowledging to oneself the need for medical interventions and actually being given said interventions is the period when trans people are most vulnerable to mental health crises.
In this time, if they want to speed things up later, they’ll have trans friends who tell them to start living “in role” ASAP and change their names legally. If they do get this tip, they’ll likely get to experience the worst of societal transphobia — especially Harriet — without access to hormones to help them be read as cis. They will undergo tremendous stress, whether or not they’re victims of the rapid increase in hate crimes against visibly trans people. Their visible transness may cost friends and family relationships, housing, employment, and more.
Harriet may self-medicate and start hormones to help her grow more comfortable in her body, and to help her be read as cis and avoid hate crimes while waiting for NHS help. DIY medications come with risks, but waiting several years for medical treatment after you’ve acknowledged to yourself and others the need for it is also incredibly risky. Her GP may or may not support her in this.
For Harry, self-medication is extra dangerous, as testosterone is a controlled substance and importing it or buying it on the black market can carry criminal penalties. Luckily he’s a UK citizen, or this could lead to his deportation to his home country, whether or not it’s safe for trans people to live there. Still, it’s too difficult and risky, and black market steroids carry a high risk of unstable hormone levels, contamination, and other serious problems.
With two and a half years waiting, they’re nearly ready for their first GIC appointment. It’s September 2022.
Let’s say neither of them have self-medicated, because they were afraid of punishment by doctors. They also didn’t change their names or live “in role” for this time, because they didn’t want the public tearing apart every aspect of their bodies and medical choices (or lack of choice).
Step three: first GIC appointment.
At some GICs, the initial appointment is just a nurse evaluation of one’s physical health with no medical help offered whatsoever. At others, it’s a psychiatric evaluation with no medical help offered whatsoever.
The experience here will vary wildly depending on which clinician they see. Harriet and Harry may have to talk about irrelevant details of their childhood, inappropriate details of their sex life, and answer many such invasive questions to prove a history of gender dysphoria.
They may find out here that the GIC will require them to be “in-role” and to prove this with payslips, legal documents evidencing a change of name — even if they like their birth names and don’t want to change it — and so on. The GIC would also strongly prefer they’ve already come out to friends and family, employer, etc, before they can start hormones.
Hopefully Harriet didn’t wear jeans and a t-shirt to this appointment, or some clinicians will try to discharge her on the basis of clearly not wanting to be a woman badly enough. Let’s assume she was warned, and dutifully wore a dress and heels for that terrifying bus ride through Hammersmith while people stared at her, even though she doesn’t think womanhood has anything to do with stereotypical makeup, dresses, and so on. She’s bi, but she doesn’t her mention attraction to women, because she knows that in debunked and outdated medical theories, trans women with any attraction to women were perceived as straight men with a fetish. Her clinician doesn’t disapprove, which is the best outcome she can hope for.
Harry, meanwhile, is a gay trans man, so he’s relieved that he doesn’t get held back or discharged for “just being a confused lesbian”. He does get treated as a bit of a freak and curiosity and his clinician interrogated him on his history of relationships to see if he’s ever been attracted to women. He also gets told he’ll have to have a smear test and physical exam to check his reproductive system before hormone treatment. This is incredibly traumatic, and rarely necessary. The sexual element of his medical abuse leaves him ashamed and he doesn’t speak about it to anyone.
But otherwise, they both got good clinicians and followed the rules: present as binary, dress “in-role” for the appointment, talk about the crippling history of dysphoria starting as a young child, don’t be too desperate but don’t be too cool, don’t be a smoker, and so on.
They each get to wait another year (update: apparently it’s currently 18 months) for an appointment now, and are told to go away and start presenting in-role, with the exact same consequences and risks as above.
Step four: second GIC appointment.
It’s now March 2024 and they get to come back for another appointment. Yay! They’ve endured a hell of a year and a half living in-role without hormones to help smooth their relationship with their own bodies, and others’ perceptions of them.
After another set of questions and blood tests, Harry gets a recommendation for testosterone. And he has a good clinician again, who recommends top surgery, but he can’t get that until he’s been on hormones for at least a year, so “come back in a year”, they say.
He’ll have to go to his GP practice after the referral is sent and received (June 2024) and convince them to prescribe under a shared care agreement. He’s lucky again, for the sake of argument, and the GP agrees to do so. Many GPs still resist prescribing at this stage. From then on, he needs to visit his practice every month or two, depending on his hormone regimen, for injections.
Harriet, meanwhile, has started self-medicating to help this waiting period. In the four years since she came out to herself, she’s finally feeling more like herself every month. This decision is scrutinized and the clinician finally decides that she’s really trans. After telling her off for self-medication, they agree to recommend prescribing to her, too. She faces a similar wait and resistance as Harry. They disagree with the stable hormone regimen that has been working for her and try to taper her dose, slowing or halting her transition. She’s lucky that she manages to persuade them to continue on the combination and dosage that has worked for her so far. No top surgery for her, either, because surgeons want to see what growth will happen with more time on hormones.
Step five for Harry: third GIC appointment and beyond
It’s September 2025. By this point, since we’ve established they’re lucky ducks, they’ve each been on hormones for over a year, and have each experienced many of the main effects.
For many trans people, it can take years of back and forth with specialists to find a regimen that works well for them. Trans men are recommended to start hormone injections at four-week intervals, for example, which can result in a “low energy and mood” week every month. (Sound familiar? But phew — unlike many trans guys, Harry’s periods stopped on this dose, removing one of his big dysphoria triggers.)
Harry gets a referral to a top surgeon! Yippee! He prefers a specific surgeon who leaves an aesthetically pleasing chest that won’t attract attention for the rest of his life when at the beach, in locker rooms, etc. This is treated as a strange, demanding request. He gets to wait several months for a consultation and eight more months for top surgery (it could be a year, but we’re going to assume he got lucky with the waitlist). It’s August 2026 by the time he gets to have surgery, and he has no complications.
At his next GIC appointment, which is in March 2027, the clinicians are pleased with his progress and happy to recommend him for lower surgery. It takes until May 2027 for that referral to be received. He has his consult in July 2027, and finds out that the waitlist for each of the three stages in his lower surgery is over a year long.
He continues to be lucky at every stage not to experience complications or need additional healing time, and the NHS is actually still alive and funded properly, so waitlists aren’t continuing to increase. (They used to be 3 months or so per stage, after all.) Harry’s first stage of surgery is July 2028, and then his second stage happens in September 2029 and his third stage in October 2030. This third stage often results in infections that stop the process, requiring him to wait a year between attempts to complete it, but he got lucky, so he finally feels like he’s done with his transition and can move on with his life. (For now — depending on the lower surgery option, he may require this third stage again, every 3–10 years.)
It takes a few months to heal, and then —he’s done! He’s successfully been rushed into transition by The Trans Lobby!
He only had to endure medical trauma, disbelieving professionals, public torment, media headlines that mocked his existence, and a nice short eleven-plus-year wait between 2019 and 2030.
Step five for Harriet: third GIC appointment and beyond
It’s September 2025 again. For Harriet, at her third GIC appointment, the doctors were happy with her living in-role. They wanted to see her happier than when she started this process, and she either was, or was able to gloss over her realistic human reactions to the trauma they’d inflicted upon her.
Having experienced breast development in taking estrogen, she was happy with this and didn’t feel top surgery was necessary. Therefore, with over a year of hormone experience, they agreed to refer her for lower surgery too.
She waited several months for the referral to be sent and received, and her consultation happened in January 2026. But wait… hair removal time! In order to experience the best results, she has to undergo electrolysis.
This takes a year and a great deal of money, because after waiting six months to get the hair removal funding she’s promised, she realizes it’s not coming through and pays privately. It’s July 2027 and she sees the surgeon again.
Yes, the doctor is happy with the results! Now, time to go back on the waitlist… it’s only ten weeks long for her, though.
It’s October 2027, and Harriet gets lower surgery. For her, it’s just one stage, and she doesn’t experience complications.
So much of her journey happened long, long, long ago: over ten years ago when she first realized she was trans, over seven years ago when she talked to her GP, over five years ago when she had to begin presenting “in-role”… you get the idea.
(I could speculate on the possibilities and be entirely within the realm of common experiences. Maybe she got fired for showing up to work in a dress, or harassed out of the job by women complaining about her using their bathroom. Maybe the poverty that resulted from her unemployment left her homeless or drove her to sex work. Maybe so-called feminists online used her survival sex work as evidence that she’s fetishizing her own gender.
There are dark possibilities, but I choose to hope that she was one of the lucky ones. She was surrounded by supportive, kind people like you who believed and helped her along the way.)
And then a time traveller comes and ogles her before running back in time to declare that she’s undergone a sudden, shocking transformation in a single stage!
And she smiles and flips him the bird, because she’s gone through a kind of hell he’ll never even begin to grasp, and this entire time has been an epic journey to beat the clock of this arbitrary timeline.
What it’s really like for trans people to transition…
These are only a couple of potential transition paths, and these are only two binary trans characters I made up. Harry and Harriet got lucky at a lot of points in my fictionalized timeline.
Many, many people experience obstacles that aren’t accounted for here — from being held back until they “fix” their mental health after crises caused by these very wait times, to being “lost in the system” repeatedly, to being discharged for spurious reasons. People of colour, gender nonconforming trans people, trans lesbians, trans men perceived as confused lesbians, those too young to be believed at their word about their experiences, transfeminine people, those from other countries and cultures, disabled people, autistic people… many groups tend to struggle more than “average”, too. All this to say there is no real average!
Some people also have different goals: not all trans people want the same transition path, hormones, or surgeries. GICs and some surgeons are reluctant to allow people who want surgeries without hormones to proceed, so this tends to add waiting time or force people to choose between elements of their bodily autonomy. This also doesn’t touch on facial feminisation surgery, hair removal, vocal training, and other transition steps which some trans women find much more important to them and their sense of wellbeing and/or safety than anything else. This is because the NHS does a poor or nonexistent job of funding these transition steps. Similarly, hysterectomies can be (or quickly become) necessary for trans men and still require several years of fighting the NHS bureaucracy to actually access.
I’ve referenced recent accounts for wait times, because it’s impossible to extrapolate and say they’ll rise or fall in the future (without a time machine — we should all be so lucky), but they have increased in the past decade.
All this to say — there are tons of variables here, and this may not at all reflect other trans people’s experiences. I’ve chosen to be slightly conservative in my estimates and my accounts of things that may well happen to our fictional hero and heroine, Harry and Harriet.
But above all, it should shock and sadden you that the premise above holds true: in order to have had the lower surgery most people mean when they say “the sex-change surgery” on the NHS by 2027, Harry or Harriet would have to come out tomorrow.
We’ll be waiting to offer our support, share advice and economic resources, and accept them exactly as they are while helping them affirm their gender in every way they need to.
And we’ll be fighting like hell to make sure the above reads like an outdated dystopian fiction by 2027.
(Special note to trans people: I know the above may feel totally hopeless. I don’t want to encourage that bleakness that I know can settle in when dysphoria tells you there is no way of waiting that long. You may be able to bypass steps, and clinicians are growing more educated. There are other paths, and I only touched on a few of them here. And I believe that we are making progress on changing the system so that if you come out tomorrow, you won’t go through what we have to get here. Solidarity. ❤)
Ed Davies (they/he) is a trans activist by virtue of wanting to remain alive and happy in society. They’re also an author living in London, usually found seeking bees to pet and flowers to boop.