Transgender Healthcare Is at Breaking Point In This Corner of Europe

Transgender people in Northern Ireland are currently unable to access lifechanging gender-affirming healthcare due to a lack of funding and extremely long waiting lists.

The Brackenburn Clinic, Northern Ireland’s only Gender Identity Clinic (GIC), did not take on any new patients for two years from 2018 to 2020, and while it is now resuming its service, it is refusing new referrals as it wades through its extensive backlog.

Freedom of Information (FOI) requests sent by VICE World News to Belfast Health and Social Care Trust, which manages the Brackenburn Clinic, show that the clinic currently has 493 people on its waiting list. It has also temporarily stopped its drop-in clinic due to “limited resources”.

Northern Ireland lags behind the rest of the UK in certain aspects of healthcare, in part due to entrenched social conservatism and a preponderance of conservative politicians. A law criminalising abortion was lifted in October 2019. But many women are still encountering difficulties accessing abortion over a year later, likening it to a “postcode lottery” due to limited resources at various health trusts “leaving many areas without access.” Amnesty International said it was a “failure to commission and fund [abortion] services,” much like with transgender healthcare. 

The FOI data shows that funding for Brackenburn Clinic dropped from £224,181 in 2015/6 to £147,700 in 2019/20, a stark decline of 34 percent in just four years, despite a continual increase in demand, with over 306 referrals made in the past three years.

According to the FOI data, average waiting times for those at the top of the waiting list in 2017 were 26 weeks for a first appointment, which then fell to 18 weeks in 2019, but some patients have been waiting up to four years on the waiting list for their appointment since their first referral to the clinic. In Northern Ireland, the target wait time is 13 weeks from their first GP referral to a first appointment.

There are no private GICs in Northern Ireland, and other private hospitals' do not list HRT treatment for transgender patients on their list of services. Trans people in Northern Ireland seeking treatment could travel to England, Wales or Scotland, but there are 13 clinics across the UK countries for the tentatively estimated 200,000 to 500,000 transgender people who live in the UK, all of which have long waiting lists – often even longer than the Brackenburn clinic. In any case, being treated abroad is far from ideal, as it makes it more difficult to access regular check ups that are needed.

The Institute of Conflict Research, a non-profit based in Belfast, found that of those who travelled to England, many “expressed a desire for surgical services to be provided in Northern Ireland,” eliminating the need to travel after a “painful, and to an extent, immobilising” surgery.

Ted, a trans man who asked to be referred to by a pseudonym, started transitioning when he was 38 and was referred to the Brackenburn Clinic in April 2017. Two weeks after his referral, his GP received a letter from the clinic stating “we’ve accepted this patient but we don’t know how many years it’s going to be until we see them.”

Ted was able to go through private healthcare. This involved attending a clinic in Brighton twice a year for the past three years, something he referred to as “taking the boat across”, while his GP in Northern Ireland maintained his blood levels and administered prescriptions to him. He believes that the NHS, and particularly the Brackenburn Clinic, is being “left out to dry” by those at the top. “It’s not the fault of the NHS, it’s a fault of the funding they get, and the people who decide how little is given to trans healthcare,” Ted said.

Nichola Mallon, a member of the legislative assembly (MLA) in North Belfast says, “The current system requires urgent overhaul. We have only one centre in Belfast providing healthcare for trans people, and the centre appears to have limited resources including staff numbers. The lengthy waiting list which has increased steadily over recent years should have been a wake-up call that the current system is not working.”

Ayra Morrighan, a 25-year-old trans woman based in Northern Ireland, was referred to Brackenburn Clinic in October 2018 by her GP. She has “had no official communication with the clinic since.”

“I believe on their records I’m 251 on the waiting list as of last month, but to get this information I have had to contact them myself,” she told VICE World News.

Some patients on the waitlist have been offered appointments in recent weeks, but the process is slow. It is likely that most patients further down the waitlist will continue to wait for months or years for their treatment.

“Brackenburn has a notorious reputation among the trans community due to lack of transparency and communication on how they treat and engage with patients,” Morrighan said.

Last year, a review of how the Brakceburn Clinic can better meet demand was commissioned, but during the review process, the service “completely broke down,” according to Alexa Moore, director of Belfast-based transgender resource centre TransgenderNI, as no provisions were made for those already waiting while they looked at the clinic’s issues.

Moore has seen a significant number of people seeking support from TransgenderNI because they cannot access the Brackenburn Clinic. The clinic has seen ongoing staff and funding shortages for the last two years, which the review was looking at but they have not yet reached a solution. According to the clinic’s Freedom of Information Request response, “The service is currently funded for 1 WTE [whole time equivalent] consultant and 1.7 WTE therapist posts” – implying one full-time role and a part-time role. The salary of a full-time consultant ranges from £82,096 to £110,683.

Moore believes the clinic places too much emphasis on putting transgender healthcare into a mental health framework. She believes that this has led to extensive questioning and gatekeeping of those wanting to transition, forcing them to wait longer than necessary for their treatment. 

She has found that many of TransgenderNI’s clients have started self-medicating with testosterone and oestrogen by ordering it online instead. “The reality is that if you want to access any kind of gender affirming care in Northern Ireland, it is a choice between self-medicating or paying extortionate amounts for private care, which many folks can’t afford.” 

Morrighan was subjected to intense questioning about her sex life, particuarly in regards to who her “previous and current partners are.” She was also given antidepressants, which she viewed as an attempt to “dissuade” her from a referral to the clinic.

Morrighan has turned to self-medication while she waits for the Brackenburn clinic to see her. She turned to online websites to purchase oestrogen, which she administered herself, without medical oversight. She says, “I was forced into self-medicating as harm prevention,” due to the severe gender dysphoria she felt as she waited to begin her transition.

Finley, a 25-year-old trans woman from Portadown who only wanted to give her first name, has been waiting nearly two years for her appointment with Brackenburn.

She has never been to Brackenburn, nor has she spoken to anyone from the clinic since she was first referred. “Part of the problem is that there’s no transparency with them, they never email you and say, ‘Hey, this is why we’re closed right now, this is why we’re not taking new patients,’” she says.

Not being able to access healthcare with the clinic has affected her poorly: “I have a few moments where I’m hit by gender dysphoria, thinking about how it could be. Who knows how many years it could be before I get healthcare?”

While Brackenburn has been struggling with its waiting list for years, the coronavirus epidemic this year meant access to care was pushed back even further to allow the NHS to focus on treating COVID patients. There is currently extensive pressure on the NHS in Northern Ireland, on an “over-stretched health service”, due to the pandemic, making it all the more difficult for Brackenburn and their patients to access healthcare.

A letter from the Department of Health, seen by VICE World News, said that “a review into the functioning of the clinic was due in June 2020 but has been delayed due to COVID-19.” The ongoing review of the clinic was also paused in March, and only resumed in September of this year. The review group found that “the Trust has faced challenges in successfully recruiting new staff” for the GIC because of the specialised nature of the services provided.

In order to resume service, “Belfast Trust have managed to secure a small resource from Lothian Gender Clinic, Edinburgh, to support ongoing management of people who have started their gender journey.” They have “offered 44 new patient appointments since October 2020.”

In a statement, the Department of Health said, "We continue to work closely with the Belfast Health and Social Care Trust, the Health and Social Care Board and a range of other key stakeholders… in undertaking a review of the Gender Identity Service in Northern Ireland. One of the key considerations… will be its capacity to offer timely access to assessment and treatment in accordance with waiting time targets.

“Every effort is being made to progress the review in a timely manner with a view to the group reporting its findings and recommendations to the Department by summer 2021 although this is predicated on the availability of staff during the ongoing pandemic."

Belfast Health and Social Care Trust, commenting on behalf of the Brackenburn Clinic said: “Similar to other gender clinics across the UK and indeed other health services in Northern Ireland, there is a rising demand for the Gender Identity Clinic, thus waiting times are greater than we would wish for. The Trust is currently working in partnership with the Health and Social Care Board to undertake a review of gender services in Northern Ireland.”