Tristan, a trans man who lives in West Yorkshire, was referred to an NHS gender clinic seven years ago, aged 18.
“It felt like I was going to have to put my life on hold,” Tristan recalls, of the astronomical wait time. “There were things that I wanted to do that I couldn’t do. It was worse in my early twenties, seeing things I would not get back. I [will never] […] have graduation photos where I’m comfortable with my face.”
The dire state of British healthcare means that in a sense all trans and non-binary people who choose to medically transition now have to pay for it. Be it through years spent on an NHS waiting list or a small fortune on private healthcare, there is a cost to everybody in either time or money. And the situation is only getting worse.
More than 26,000 people are currently waiting for their first appointment at an NHS gender clinic. Those who go to that appointment this year will have waited on average four years; those referred now could wait decades. It takes two appointments, often years apart, to receive the gender dysphoria diagnosis that permits a trans patient to access gender-affirming healthcare.
Tristan anticipated starting hormones and having had top surgery by the time he graduated from university – a long but “doable” four-year timeframe. But while he started testosterone at 20, he’s now nearly 25 and still waiting for top surgery.
Despite being on testosterone for three years, Tristan’s face hasn’t changed shape at all because of an unrelated orthodontic surgery he had when he was 17. This means he is almost never gendered correctly, doesn’t feel safe to use public bathrooms and isn’t comfortable dating.
Tristan wants facial masculinisation surgery, but it’s not available through the NHS. He works full-time and freelances on top of that, but there’s still “no way” he could afford the £3,200 necessary for a chin implant – so he’s fundraising to pay for this surgery privately.
Tristan’s case isn’t unusual. As a result of barriers to public healthcare, more people are medically transitioning privately. While the NHS system takes years, appointments with private gender doctors are booked in months. The number of private trans healthcare providers is increasing as demand grows – but so are their prices.
Trans people in the UK are more likely than cis queers (let alone straights) to experience homelessness, unemployment, violence and discrimination – it’s not a demographic naturally destined for private healthcare. As a result, trans healthcare crowdfunders have proliferated in recent years: in Scotland alone, there was a 65% increase in trans people fundraising to cover medical costs between 2021 and 2022.
But the trans community has dwindling resources to support these fundraisers, meaning that those able to access healthcare this way are likely to be those with a bigger online platform, or richer family and friends. That these factors influence someone’s access to medical transition is deeply unjust.
“We have seen a situation emerge over the past 10 years where barriers have started to appear and become more severe at every stage of the medical transition process,” explains Cleo Madeleine of national trans charity Gendered Intelligence. “Everyone you speak to now is waiting years for treatment. NHS wait times have driven a mental-health crisis.”
In 2021, advocacy group TransActual surveyed more than a thousand people about their experience of accessing transition in the UK. The report found 87% of those waiting for hormones said it was having a negative mental-health impact, while 83% said the same of waiting for surgery.
Zainab, 20, launched their fundraiser for top surgery in January after being “really shocked” by “disgraceful” NHS waiting lists. They expect it to cost between £7,000 and £10,500.
“It’s ridiculous, they [NHS gender clinics] are seeing people from four years ago. I’m not waiting around for that,” Zainab explains. “I set up a fundraiser because I’m literally a uni student – no way I can pay myself.”
They wanted top surgery as soon as they learned it existed. “The only barrier is money,” Zainab says. But they’ve only received one donation. “I have no idea when I’m going to raise that amount of money,” Zainab says. “I’m not very online. I have no timeline. I’ve been reposting and donating to other people’s top surgeries in the meantime.”
The oldest and biggest NHS gender clinic in the UK is London’s Charing Cross, established in 1966. Since 2018, the average time people wait before attending their first appointment has increased from 11 months to five years and one month.
Increased wait times are often blamed on a lack of money, but NHS England funding for adult gender clinics increased from £10m in 2015/16 to £19.2m in 2022/23. Last year, £8.9m was spent on four new pilot gender clinics. But the waiting lists continue to grow faster than patients are seen.
Madeleine says there are “lots of structural reasons why wait times are as bad as they are.”
“Probably the biggest culprits are NHS England specialist commissioning failures to fund and support services in line with demand, under political pressure,” she says. “It’s hard to get services running with so much venomous anti-trans sentiment in recent years. Throwing money at it earlier wouldn’t have solved the problem overnight, but it wouldn’t have got this bad.”
Ten private gender services are listed on UK website Gender Construction Kit – up from four in 2017. The oldest of those listed is GenderCare, established in 2010. It began with Dr Stuart Lorimer, Dr Leighton Seal and Christella Antoni, and has since expanded into a network of 11 specialist gender clinicians.
“Private healthcare providers like GenderCare have come to fulfil an important role in a healthcare system that is failing trans people,” Madeleine says. “If they didn’t exist, fewer trans people would access the care they need. It is also true that they are a profit-driven enterprise.”
GenderCare’s prices have increased over time: the average cost of the two appointments needed to start on hormones with Lorimer or Seal was £330 in 2011, it’s now £565. Overall, the average cost of a first appointment with a GenderCare clinician increased by 57% between 2011 and 2023, while the cost of a follow-up appointment increased by 69%.
Lorimer says GenderCare’s price increases are “broadly consistent with the average cost of private medical insurance”, and that “gender clinicians are as affected as everyone else by the ongoing energy and cost of living crises.”
“The current state of NHS gender services – and consequent time/money trade-off for anyone planning transition in the UK – is abhorrent,” Lorimer continued, adding that private sector services “provide a safety net of sorts for those with the means to access them”.
Emily*, a trans woman who asked that we didn’t use her real name, travelled to Spain earlier this year for facial feminisation surgery (FFS). She says the fact the NHS doesn’t offer facial surgeries for trans people demonstrates “a misunderstanding of the trans experience”.
“Cis people think some things are necessary for trans people, like bottom surgery,” Emily says, “but they think other things are cosmetic, like FFS. The fact FFS is not available on the NHS really shows the one thing that cis doctors think is important.”
Facial feminisation isn’t the only gender-affirming surgery Emily wants, but it was her highest priority. It cost £30,000.
“I wanted to blend in,” Emily explains. “With the [anti-trans] atmosphere and public discourse getting worse, I wanted to not have to worry. I don’t get looks in the street anymore, I don’t get clocked anymore. It’s really good.”
“I’m lucky I could afford it,” she says. But Emily will be waiting on the NHS for the rest of her medical transition.
Medical transition can be affirming, joyous or necessary; it is also, for many, about being able to move through the world more safely. Waiting for it not only has a deleterious effect on mental health, it can also force trans people to live with a higher risk of violence.
Currently, trans people can either languish for years on an NHS waiting list, be rich, or hope that a crowdfunder will amass enough money to pay for private healthcare. Faced with this choice, the sad truth is that some trans and non-binary people who need to medically transition can’t pay the price.