It’s a mixed up, muddled up, shook up world, except for Lola’: transforming health and social care for trans people

Julie Fish PhD*

Reader in Social Work and Health Inequalities, De Montfort University, Leicester, UK

*Corresponding Author:
Dr Julie Fish, Reader in Social Work and Health Inequalities, Faculty of Health and Life Sciences, Hawthorn Building, The Gateway, Leicester LE1 9BH, UK. Tel: +44 (0)116 257 7714; email: [email protected]
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Deconstructing sex and gender

Sex is one of the defining characteristics of an individual. The first question posed to a parent about their newborn baby is usually whether it is a boy or a girl. Sex is usually considered to be unambiguous and determined at birth by the baby’s genitals: being a boy depends upon the possession of a penis, and being a girl is determined by the presence of a vagina. When these physical characteristics are signalled, for example, by sex-appropriate clothing, such as blue for boys and pink for girls, this is a cultural preference.

Gender is the term used to describe the cultural significance of sex, and refers to the social roles associated with being male or female. Traditionally, gender has been clearly demarcated. Masculine characteristics have historically comprised social roles (such as being the breadwinner), leadership, or capability in mathematics. Commonly ascribed feminine qualities have included caring for children, responsibility for the home and proficiency in language. Distinct personality traits are attributed to each gender. Males are aggressive, independent and unemotional, whereas females are passive, empathic and emotional. Being a man means not only having a body with certain physical attributes, but also behaving in ways that have come to symbolise masculinity. Sex and gender are believed to coincide: the biological ability to bear children is associated with the cultural role of and responsibility for bringing up children.

The genitals are the most significant marker of sex, but in most cases we make decisions about a person’s sex without having seen the person naked. In the film The Crying Game, Fergus falls in love with Dil, the beautiful girlfriend of a dead British soldier. Fergus is about to make love with Dil, who as she undresses reveals that she has a penis. Until this point in the film, Fergus has accepted Dil as a woman. The ability to ‘pass’ as a woman is one of the criteria, known as the ‘real-life test’, used to determine whether an individual can have gender reassignment surgery. Despite the high profile of trans characters in filmand theatre (e.g. Transamerica, Priscilla Queen of the Desert and Boys Don’t Cry), trans people’s health and social care needs are poorly understood.

Who are trans people?

Trans is the terminology used in the UK to describe people who are gender variant in their identities, expressions or behaviours. They do not conform to traditional gender norms of society by the clothes they wear or the way they present themselves. The three categories widely used to describe people who live cross-gender, namely transvestite, transgender and transsexual people, often reflect overlapping identities on a continuumwhere gender identity does not match the sex assigned at birth. In the mid-1990s, trans emerged as a social and political movement seeking equal rights and anti-discrimination legislation. New theoretical understandings have enabled a conceptual shift from pathology (the notion that trans people have a disease or disorder) to gender non-conformity (the view that trans people do not conformto society’s narrow views about gender; Fish, 2007).

Some trans people have described feeling as if they are trapped inside the wrong body. Many become aware, sometimes fromthe age of 10 years or younger, that the sense of their own gender, and their emotional and psychological traits, do not match their body or physical appearance (Xavier et al, 2007). They have strong and ongoing cross-gender identification, and the desire to live and be accepted as a member of the opposite sex. In order to achieve this, some trans people seek gender reassignment surgery. Medical professionals in gender identity clinics require a high degree of conformity to traditional gender roles in order to distinguish ‘real’ candidates (those who will subsequently receive surgery) from others. These assessments evaluate whether candidates are ‘true women’ or ‘true men’ in such areas as relationships, interests, family responsibilities and occupations (Fish, 2006).

Trans encompasses a diverse and inclusive community ranging from people who cross dress parttime to those who are seeking hormonal, surgical or other procedures to reassign their bodies to their preferred gender role. The process of changing gender is known as transitioning, and can extend over a number of years. Individuals who are transitioning from female to male (FTM) are often known as trans men, whereas male to female (MTF) transsexual people are known as trans women. After successfully transitioning to live permanently in their preferred gender role, many prefer to be considered simply as men or women. In the past, trans people would seek to blend into their community, sometimes known as living in stealth. Trans people can be heterosexual, lesbian, gay or bisexual.

Experiences of discrimination

Trans people meet with discrimination and prejudice in their everyday lives. This places limits on their employment opportunities (despite legislation prohibiting discrimination), their personal relationships, their access to goods, services and housing, their health status, and their access to health and social care. Harassment in public places is common. A Europe-wide study found that 79% of survey respondents had experienced some form of harassment, ranging from transphobic comments to physical or sexual abuse (Turner et al, 2009). Ordinary activities, such as the use of leisure facilities, may not be accessible to trans people because they fear discrimination in changing rooms or single sex sports provision (Whittle et al, 2007). Many, regardless of social position, experience isolation and face limited understanding of their lives. These experiences place many trans people at risk of alcohol abuse, depression, suicide and self-harm, violence and substance abuse (Kenagy, 2005).

Changing social and legislative context

Recent legislation has implemented key safeguards for trans people. The Gender Recognition Act (GRA) 2004 gives legal protection for the trans person’s acquired gender. The Act enables them to apply to a Gender Recognition Panel. In order to qualify for this, they need to have lived in their acquired gender for two years and intend to do so for the rest of their life. If their application is successful, they will be issued with a gender recognition certificate, their acquired gender will be given full legal status, and they can obtain a new birth certificate. The legislation introduces new responsibilities to maintain client confidentiality. Section 22 of theGRA 2004 makes it unlawful for anyone who has obtained information in an official capacity, such as health or social care providers, to reveal that a person has a gender recognition certificate. An exception allows health and social care professionals to make a disclosure if they believe that consent has been given or if the disclosure is made formedical purposes (Whittle, 2005).

With the introduction of the Equality Act 2006, legislation has afforded protection from discrimination on the grounds of gender reassignment in the provision of goods and services. The Sex Discrimination (Amendment of Legislation) Regulations 2008 prohibit discrimination against trans people and outlaw harassment on the grounds of intention to undergo, currently receiving, or having completed gender reassignment. It is best practice to treat service users and patients equally and with respect, and not to make assumptions based on their appearance or possible gender ambiguity.

Relevance for health and social care professionals

Increasing numbers of people are seeking gender reassignment treatments following the growing acceptance of gender diversity. It is estimated that approximately 300 genital reconstructions are performed each year, and there is a greater likelihood that health and social care professionals will provide care for this emerging community (Hartley andWhittle, 2003). Little research has been conducted in the UK to inform service providers about meeting the needs of trans people. Many health professionals lack appropriate information about trans people’s general health needs. Gaps in social care provision, in particular, have been filled by self-help groups (Hines, 2007).Moreover, there are concerns that the lack of an evidence base may result in poor practice. Professionals have sometimes been insensitive to the needs of trans patients, partly due to a failure to accept the person’s acquired gender and also through breaches of client confidentiality (Whittle et al, 2007; 42):

‘I was put in a side room on the women’s surgical ward. I was told that before I had even arrived on the ward that the word had gone out that a man was being put on the ward. My stay was made a living hell by one staff nurse which all the others seemed to follow.’

(Male-to-female trans woman)

In healthcare, discrimination against trans people has included the refusal of care (e.g. smear tests), disrespectful treatment (e.g. professionals behaving as if the person is wasting their time), and the practice of placing trans women who have completed gender reassignment surgery on male wards (Laird and Aston, 2003).


A first step in transforming public services for trans people is to change the culture and dispel the myths about them by providing access to information, training and support. It is also important to know what constitutes good quality health and social care. The Equality and Human Rights Commission (2007) has produced guidance to enhance service provision for trans people. It contains examples of best practice in relation to patient privacy, patient dignity, autonomy and care for a trans man undergoing a hysterectomy operation, care planning for older and disabled trans people, support for trans survivors of rape and sexual assault, and emergency accommodation for a homeless trans man. The Department of Health has also produced a series of resources to support health and social care professionals in providing the best possible care, including DVDs and training materials (e.g. Burns, 2008). These developments can underpin the transformation of health and social care provision and ensure the basic rights and freedoms for trans people in the UK.


Lola is the title of a song first performed by The Kinks in 1970. The lyrics describe an invitation to dance by a trans woman in a Soho Club in London, and suggest that it is the rest of the world that is confused, rather than Lola.


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