The Slow Violence of Transgender Healthcare Public Consultations
'I have a trans friend', false equivalences and external adjudication
On 7 August 2024 the NHS announced, in line with the Cass Review Final Report (2024) Recommendation 24, a Review of the NHS Adult Gender Clinics would be undertaken by Dr David Levy. In an NHS public statement the Review of Adult Services will ‘assess not the only the quality of (i.e. effectiveness, safety and patient experience) and stability of each service, but also whether the existing service model is still appropriate for the patients it is caring for.’ (NHS England, 2024). In an effort to gain insight into the selection process that led to the appointment of Dr. David Levy to lead the review, a Freedom of Information (FOI) request (FOI-2408-2131259) was submitted to NHS England. The response from the NHS revealed that "Dr David Levy was the only person asked to chair the review of NHS adult Gender Dysphoria Clinics given his extensive experience of leading review processes.” In the case of Levy, and as was noted about the selection of Hilary Cass, it seems a lack of knowledge of gender affirming care was ‘framed as virtue.’1
Lets not forget that when asked about her knowledge of gender affirming healthcare at the time of appointment, Hilary Cass in an interview replied that ‘one of her friends was trans but otherwise she was coming at it pretty cold.’2 Whilst not casting aspersions on the existence of the mentioned friend, the well-worn ‘I have a friend’ line has become a staple in the arsenal of those seeking to deflect criticism and claim a tenuous legitimacy in discussions surrounding marginalized communities. This strategy, deeply entangled with racialised and gendered histories of oppression, operates as a flimsy shield against accusations of ignorance or, in the case of Cass, unsuitability for the role of Principal Investigator all the while reducing her trans friend to little more than a convenient tool of deflection.3
At the point of writing the NHS announced a public survey as part of the Adult Consultation Review process, with a submission deadline of 19 January 2025, has just past. This comes hot on the heels of the recent targeted Consultation on proposed changes on availability of Puberty Blockers for under 18s that ran from 20 August to 8 October 2024, with the outcomes published on 11 December 2024. In soliciting input from openly anti-trans organisations such as Transgender Trend, Sex Matters, Thoughts Therapists, LGB Alliance (amongst others), the consultation process itself becomes an exercise in false equivalences which under the guise of ‘fairness’ and ‘administrative due diligence’ only serves to legitimise the voices of those who actively oppose the very care under consideration. This false equivalence, which grants equal legitimacy to the voices of those who actively work to undermine the autonomy and wellbeing of trans individuals and those who tirelessly advocate for their rights, is a pernicious manifestation of the same “both sides” rhetoric that has recently served as a smokescreen to the ongoing genocide in Gaza, where its invocation has been wielded as a cynical ploy to obscure the stark asymmetry of power and sow confusion and doubt in the face of clear-cut injustice4.
The inclusion of these groups in the list of “LGBT+ and health-related voluntary community and social enterprise groups” whose input was sought out raises concerns about the validity and impartiality of the process, as it fails to recognise the inherent contradiction in inviting their response. While their presence on the list does not definitively prove that their views were among the 51 responses received out of the 120 organisations consulted, or more specifically, among the 21 responses categorised as coming from ‘Charities and voluntary and community organisation’ (presumably where the LGBT+ enterprise groups would be classified - but honestly who can say with these consultations) it highlights the vague criteria used to determine which stakeholders were deemed relevant.
Despite this biased selection that raises serious concern about its ideological basis, a majority of respondents to the consultation (59%) opposed a ban on puberty blockers and acknowledged that such a ban would harm trans youth. It appears that even those cherry-picked for their views could not present enough support for the government's predetermined agenda.
Such discursive manoeuvres utilised by branches of the State in its bid to reassert its cisgender-ness5, is but one front of the current anti-trans information landscape that resuscitates the long standing fictions of transgender ‘newness’ and ‘untrustworthiness’. We can see evidence of this in the now closed Adult Consultation Survey for people who have used NHS gender clinics in the past five years, current and former NHS gender clinic staff and the family and friends of those have used NHS gender clinics in the last five years.
TransActual provided feedback on the Survey prior to its publication including its ‘bizarre’6 inclusion of friends and family responses, requesting changes to either remove it or at the least include if the trans family member would agree with what they are saying. On a practical level we know the transgender statistics experiencing homelessness (25%), domestic abuse (28%), hesitation in accessing gender affirming care due to fear of consequences from family (42%) make for startlingly reading.7 The NHS offered no amendments, or even explanation, as to why this survey was to include family and friends.
There is a breath-taking cruel optimism to a Survey on the effectiveness, safety and patient experience of the current modes of adult gender affirming care which requests input from the friends and family of trans people but not the thousands of trans people on waiting lists yet to receive a first appointment. Even if the number of affected individuals is irrelevant (just 1 person would be too many), the staggering reality that a single Gender Identity Clinic out of 7 in England, the Tavistock and Portman GIC in London, has 16,538 waiting for a first appointment (accurate as of December 2024) should be a compelling enough reason to include their voices in all, not just some, consultations on adult gender affirming care.
The ‘slow violence’ (Nixon, 2011) of such consultations extend beyond the attritional, accumulative form of harm that patiently dispenses its effects while remaining outside our attention span.8 I have written elsewhere how what we recognise as the present time of violence has twisted into the weaponisation of time as violence that suspend trans individuals in a space of deferred promises and unobtainable futures.9 I argue this is evidenced through temporal exclusions that extend beyond the abstract to a lived reality enforced by State machinations: stalling tactics to access healthcare, bureacratic lags for documents, public consultations on - well - anything related to effectively resourcing trans life, the return to long settled questions etc all serve to maintain trans individuals asynchronicity with the rhythms of non-trans life. Both Ruth Pearce and Cal Horton, leading scholars of transgender healthcare and education have spoken to the persistent demands for consultations. Horton refers to this relentless cycle of consultations as an ‘abusive’ relationship characterised by institutional power imbalance and a perpetual burden placed upon specific (and already exhausted) transgender individuals and their advocates to justify their existence, needs and rights.10 In this sense, the drip-drip of slow violence inflicted upon trans communities beyond a gradual wearing down, constitutes a fundamental distortion of the temporal framework structuring social and political life.
It’s a slippery violence, whose patterns are hard to pinpoint or campaign against with regard to consultations, cloaked as they are in the illusion of ‘good practice’. Such obfuscation is compounded by the contrast between its incremental expansion and the media spectacularisation of trans people, that as a community we have grown accustomed to having to survive alongside. This mediated hyper visibility operates in a temporality of its own, one characterised by the rapid cycling of sensationalised images and narratives that chase each other across screens and feeds. Against this backdrop, the slow violence of biased and inequitable consultations appears all the more insidious, its workings obscured by the dazzling light of the capitalist circus.
The perceived trans threat globally has triggered extensive legislation seeking to restrict access to basic education, organised sport, public washrooms, healthcare, and identity documents, which collectively contributes to the effective erasure of trans lives from civic participation and public sight.11 Unsurprisingly such tactics stretch into the very consultations meant to address the efficacy of gender affirming care where trans individuals find themselves outnumbered 2:1 to the presumed-cisgender NHS gender clinic staff and presumed-cisgender family and friends. With a disproportionate level of credibility and authority, trans people remain beholden to the interpretative frameworks of cisgender others, their self-knowledge subject to the external adjudication of those who claim intimate knowledge of them.
Results for this consultation are due for release in Spring 2025, despite the deck being stacked, they will make interesting reading. A consultation history of giving equal footing to anti-trans voices, the exclusion of those on waiting lists, and the disproportionate weight given to cisgender perspectives all highlight an engagement that continues to be fundamentally compromised from the start.
Hunter, R. (2024) ‘Trans academics warn against ‘politicisation’ of Cass Review in Scotland’, The National. Available at: https://www.thenational.scot/news/24250632.cass-review-must-greeted-caution-scotland-say-academics/
Barnes, H (2024, 8 May) ‘Hilary Cass: “Do I regret doing it? Absolutely not”’ New Stateman
See Perry, T. (2018) ‘A Brief History of the Black Friend’ Black Perspectives, African American Intellectual History Blog
Giroux, H (2025, 30 January) ‘Genocide and the Politics of False Equivalencies’ CounterPunch, https://www.counterpunch.org/2024/01/30/genocide-and-the-politics-of-false-equivalencies/
See Gill-Peterson, J. (2021) ‘The Cis State’ Sad Brown Girl.
Trans Actual (2024) https://transactual.org.uk/nhs-england-survey-2024/
Bachman, C & Gooch, B. (2018) LGBT in Britain: Trans Report [Stonewall]
Nixon, R (2011) Slow Violence and the Environmentalism of the Poor, Harvard University Press
Turner, C (2024) ‘The Transgender Space Invader: Out of Time and Out of Affect,’ European Journal of Culture Studies, 1-9.
Horton, C (2024) ‘Is This an Abusive Relationship?’ https://growinguptransgender.com/2024/10/14/is-this-an-abusive-relationship/
Gill-Peterson, J (2022) ‘Anti-Trans Laws Aren’t Symbolic. They Seek to Erase Us From Public Life’ them https://www.them.us/story/anti-trans-laws-public-erasure-dont-say-gay