Honest, open and non-judgemental health care
The cliniQ service is offering trans and non-binary people health care with dignity, writes Elaine Cole.
The cliniQ service is offering trans and non-binary people health care with dignity, writes Elaine Cole
Trans* people often receive poor care from general and specialist health services, with many reporting negative experiences at gender identity clinics. CliniQ in London’s Soho area is run by trans* people and the clinic’s healthcare team to ensure an inclusive, non-judgemental service. All nurses who come into contact with trans* people should ensure they are trans* aware – which includes taking great care with the use of pronouns.
‘General health clinics do not have the knowledge to treat me or to address me how I should be addressed,’ says Zie. ‘It leaves me feeling unsafe, so I am not comfortable discussing my health with those nurses.
‘They are unaware of, or do not acknowledge, trans people and non-binary people. I was always anxious about going to clinics and this was made worse by all the assumptions made about me by nurses and doctors. And because I was not treated with dignity and respect, I was uncomfortable about going back.’
The experience of Zie, who identifies as non-binary, is common among trans people accessing standard NHS services, for either their sexual or general health needs.
Non-binary is an umbrella term for people who do not identify with a binary gender pronoun, but as a combination of the two or as neither gender. Zie prefers to use the pronoun ‘they’ rather than be referred to as ‘he’ or ‘she’. Non-binary can be an identity in its own right, not something in comparison to male or female.
A 2012 study on trans mental health (see below) found that when accessing general health services, more than 60 per cent of respondents felt they had to educate a health worker, and more than 50 per cent were told the professional did not know enough about a type of trans health care to provide it.
The survey shows that even gender identity clinics do not always get it right. And the consequences are grave – 20 per cent of respondents had wanted to harm themselves in relation to, or because of, involvement with a gender identity clinic or health service.
Zie says services are difficult to access: ‘Forms always ask whether the patient is male or female. Healthcare professionals have always assumed I am male, and that I use the pronoun “he”, rather than “they”.
‘They get confused when I try to explain and automatically classify me as a gay man. The clinics are often sectioned into male and female, with the men being treated by male nurses and the females being treated by women. It is difficult to navigate.’
Fortunately, Zie has found a place where they are treated with dignity and respect and says their health has improved immeasurably as a result.
The Trans Mental Health Study 2012
In 2012 the Scottish Transgender Alliance, in partnership with trans groups and Sheffield Hallam University, conducted research into trans mental health and wellbeing. It is the largest survey of its kind in Europe.
Of those who had used health services 62 per cent had experienced negative interactions at a gender identity clinic (GIC), 63 per cent in general mental health services and 65 per cent in general health services. At GICs, 8 per cent of participants had been ridiculed for being trans, 6 per cent discouraged from exploring their gender and 7 per cent experienced someone using the wrong pronoun on purpose.
The survey also put trans mental health into a social context:
- 38% of respondents had experienced sexual harassment
- 13% had been sexually assaulted
- 6% reported they had been raped
- 37% had experienced physical threats or intimidation
- 19% had been hit or beaten for being trans
- 25% had to move away from family or friends for being trans
- 16% had experienced domestic abuse
- 62% had alcohol dependency or abuse issues
- 49% had experienced some form of abuse in childhood
- 88% currently or previously experienced depression
- 53% had self-harmed at some point
- 11% currently self-harm
- 84% had thought about ending their lives
- 35% had attempted suicide at least once
London service cliniQ is the only weekly sexual health and wellbeing service for trans* people in the UK.
CliniQ was founded and is developed, delivered and led by trans* communities in partnership with the team at its Soho clinic. Staff are either trans* or trans* aware and offer services covering sexual, physical and mental health and wellbeing to trans* people, friends and families. They respect clients’ lifestyles and way of presenting, and use their chosen pronouns.
They offer instant HIV testing, hepatitis B testing and vaccination, cervical smear testing and deliver hormone injections. Counsellors are on hand to provide support on sexual abuse and drug and alcohol use, as well as advocacy and mentoring.
The clinic’s non-judgemental approach is key. For example, cliniQ nurses will offer liver function tests to clients who are buying hormones via the internet – purchases that a trans* person might be unlikely to admit to their GP.
Michelle Ross, convenor of the Trans* Women’s Sexual Health and Wellbeing Group at the Terrence Higgins Trust and cliniQ co-founder, says the clinic has secured the trust of the trans* communities by putting it at the heart of what they do.
Zie agrees: ‘The founders knew that to make cliniQ successful they would have to find out what trans* people want and need from the service.
‘Other services are tailored to LGB (lesbian, gay and bisexual). They put a T (trans) on the end and think they know what they are talking about.
‘You can go to cliniQ about anything and no judgements are made. The nurses understand and are trained in dealing with trans* issues.’
‘Once a client is seen by a nurse, it is all about being honest and open’
Zie has heard of many cases where nurses have not listened to what their patient is saying – including one case where a patient explained that they were male and needed a smear test, and the nurse responded: ‘I’ll just put you down as a gay woman then, that will do.’ Zie adds: ‘Actually, that is not fine and destroys trust.
‘If a nurse sees that their service is being used by trans* people and have identified they need training, they should find it so they can better help their patients.’
The clinic’s sexual health nurses Richard Cameron and Jenna Thomas agree that training is essential. Mr Cameron says: ‘We make sure our patients are aware that all staff have received trans* awareness training.’
Ms Thomas adds: ‘Once a client is seen by a nurse, it is all about being honest and open – asking questions in a clear way, but also explaining why I need the information. We don’t want people to feel we are nosy – we want them to understand how useful that information is to us.’
The modern but welcoming clinic environment plays a large part in all the sexual health services, says Ms Thomas. ‘However, that environment is also created by the people who work here. The relationship between the nurses and other members of the cliniQ team is pivotal. We respect each other and that is clear to the patients.’
One way cliniQ has embedded itself into the community is by providing a space for trans* people and their friends to meet for a coffee.
From the beginning of the service two years ago, the team has sought its clients’ views using questionnaires. Consequently, the service is always evolving. Zie says: ‘When feedback is given, it is quickly implemented. I pointed out that on the triage forms there wasn’t a section for me to explain the issues I needed to deal with – now the forms have a box I can write in.’
There have been challenges. One of the biggest has been letting people know the clinic is there. ‘Clinics such as this often do well by word of mouth and building up a reputation, but this takes time,’ says Ms Thomas. ‘We were fortunate that senior management were supportive.’
Now trans* people come to cliniQ from all over the country. Zie says: ‘If cliniQ had not been available I would not be where I am today with my gender identity and my general health – and I definitely would not be able to share my experiences’.
What you can do to build trust with trans* patients
CliniQ co-founder Michelle Ross offers some advice to nurses on how to build trust with their trans* patients:
Put trans* people at the heart of services
CliniQ was founded and is developed, delivered and led by trans* people with the team at the London clinic. Any service like this needs to be set up and delivered with the ethos ‘nothing about us without us’. Without this ethos, services are less likely to succeed.
Take care to use the correct pronouns
Nurses can have an impact on a trans* person just by the way they greet them. One of the issues trans* people struggle with on a day-to-day basis is the way people misgender them. No matter what someone looks like, ask the patient how they identify and what pronoun they want to use. If you get it wrong don’t be over-apologetic – just say sorry and then make sure you get it right in future.
Make sure your forms are suitable for trans* patients
Forms should enable trans* people to tell healthcare professionals which pronoun to use. I am currently working with Public Health England, along with my colleague Aedan Wolton, on appropriate forms that have two simple stages of recording identities that will apply to everyone.
Most importantly, ensure staff are trained
All our nurses received three days of training in trans* issues. We have great nurses, but all of them have gone through that journey of awareness. Training is crucial and at cliniQ we offer training to a variety of organisations and health professionals.
Ms Ross was the lead in developing the groundbreaking Trans* Health Matters Sexual Health and Wellbeing booklet and web pages for trans* women. She is convenor of the Trans* Women’s Sexual Health and Wellbeing Group at Terrence Higgins Trust (THT). Find out more about cliniQ at cliniq.org.uk or @Clini_Q
Trans* with an asterisk, as used by the team at cliniQ, indicates that the term is not exclusive, but includes people across the entire spectrum of trans*-identified presentations and behaviours.