A Visit to Foucault’s Clinic – The West London GIC at Charing Cross Hospital

The West London Gender Identity Clinic at Charing Cross Hospital became part of the National Health Service in 1973, after being founded in 1966 as an informal referral service for transgender people in need of medical support.  There are now eight centres in the UK specialising in gender identity services, but Charing Cross GIC is by far the biggest.  It receives around 1,500 referrals a year from GPs (half of the UK total) – a figure which has been doubling, roughly, every five years.  Its primary function (according to its website) is to co-ordinate the work of surgeons, psychiatrists and endocrinologists in order “to provide holistic care from a biopsychosocial model focusing on the biological/medical, psychological and social aspects of gender”, for people “with issues related to gender, most commonly gender variance associated with gender dysphoria”.

 

Much of the work of the Charing Cross Gender Identity Clinic seems to be geared towards redeeming its terrible reputation.  This reputation is not undeserved, and the clinic itself must accept full responsibility for having earned it.  In 1979, the BBC screened a three-part documentary series entitled ‘A Change of Sex’, which followed transwoman Julia Grant in her quest for gender-reassignment surgery.  In the scenes filmed during Grant’s appointments at the GIC, the psychiatrist assigned to her (John Randell – who died two years after the programme aired) displays an arrogance, condescension and megalomania so horrifying that it is difficult not to believe he is a character-actor, created to demonise all psychotherapists, and to portray the GIC as an uncaring edifice of chillingly Orwellian proportions.

(During Julia Grant’s consultations, Randell delivers a series of schoolmarmish proclamations, with an intonation that rises incredulously at the end of his sentences.  Among his supercilious edicts are the following gems: “It may be that you’re identifying with certain stereotypes of the female gender role, but that doesn’t make you a woman”; and “I’m not prepared to consider any other approach until you’ve done one year as a female… and if you don’t like that, well, then you must find another doctor”; but my personal favourite, when Grant confesses to undergoing breast-augmentation surgery without Randell’s approval, has to be, “I must confess, I take exception to your doing that…  It’s a medical matter: it isn’t a personal choice.  I like to be informed.  You see, once again you’re overstepping the mark, and I don’t like it – not one bit.”)

My first visit to the Charing Cross clinic occurred in June, 2014, when, following referral by my GP, I was invited to a pre-preliminary ante-introductory promotional taster/welcome session.  It was a harmless enough experience: a presentation via PowerPoint, essentially, describing the work of the GIC, the background of its staff, the numbers of patients it saw every year, and a warning (which, because it is included in all their correspondence, I would soon learn by heart) of what would happen if anyone failed to attend their appointments.

After the presentation, the forty-odd people in attendance were invited to share any concerns or questions we might have…  And that is when the mood in the room turned ugly.  I realised that some patients feel quite strongly that they have an axe to grind against the clinic.  The dominant motif of their concerns was the delay in attention they had experienced (consultations scheduled for dates so far in the future that patients couldn’t be sure if they should arrive by taxi or hover-car; appointments cancelled by the clinic without rhyme nor reason, when the patient has already gone to significant trouble to rearrange their own lives around a clandestine trip to London), but it was also evident that many patients felt the primary function of the clinic was to give them psycho-social hoops to jump through before they could complete their transition.

It wasn’t just the theme of patients’ questions that saddened me, however.  It was obvious from the anger in many voices that people had been damaged by aspects of their treatment by clinicians at the GIC.  The shakiness I could hear in their questions – the evident fear that they might burst into tears before they had articulated their frustrations – was a symptom of their dehumanisation as a result of their subjection to what Michel Foucault calls the ‘medical gaze’.  The concept of the medical gaze is developed and placed in its socio-historical context in Foucault’s 1963 book, ‘The Birth of the Clinic’, and it symbolises the separation by clinical professionals of their patients’ bodies from their patients’ identities.  This separation is not merely a medical convenience to facilitate the efficient treatment of disease, Foucault argues, but a product of political forces that form the broader context within which medical practice takes place: the discourse with which disease is discussed and diagnosed is just as much concerned with maintaining hegemonic relationships between the powerful (that is, the educated doctor) and the powerless (the uneducated patient) as it is in other social institutions, such as schools, parliament, prisons, the economy and the church.  In the case of medicine, the balance of power is preserved by ensuring that only medical professionals have access to the decision-making processes of their clinic, and by excluding patients from the discursive practices (and their associated jargon) in which those decisions are made.  The patient is thus reduced to little more than the subject of diagnosis and treatment – the cadaver over which decisions are made – rather than an influential voice in those decisions: medicine (which, in the case of the GIC, would mean access to counselling and voice coaching, the prescription of hormones, and the allocation of surgical resources) is something which is thus done to the patient; not done with them.

The practical upshot of this sociological theorising is that, by presenting myself at the Charing Cross Gender Identity Clinic, I am participating in a discourse in which I am not an equal partner.  If British society determines that gender nonconformity is a deviation from the norm – and that it is a pathologised condition requiring treatment – then the behaviour of specialists at the GIC towards me is, ipso facto, going to reflect that.  Keeping me waiting and ill-informed; condescending to me; assuming I am incapable of deciding for myself what is best for me; withholding access to medicines and surgical procedures until I have fulfilled certain conditions (such as meeting with a psychotherapist); and generally acting as the gatekeepers to my future…  These are all symptoms of a political climate in which I am marginalised, disenfranchised, and made to feel unworthy of the tiny slice of NHS funding I want.

Frame Foucault
Ceci n’est pas une clinique: ‘The Birth of the Clinic’ by Michel Foucault (also available in English)

I had my first appointment with a doctor at the GIC in October, 2014 – eighteen months after my referral by a GP – which meant I’d had plenty of time to study criticisms levelled against the clinic on social media, and to read the clinic’s response to them.  Frustration with the GIC falls into two broad categories, and, accordingly, its rebuttals and ‘myth-busting’ attempts do, too.

Most conspicuously, patients (and potential patients) at Charing Cross complain of agonising delays in being seen, and then of interminable waits for clinical decisions to be made about them.  Appointments made months in advance can be cancelled by the GIC at very short notice, and then (most aggravating of all, it seems) without any reason being given, apart from an airy platitude about how schedules are subject to change.  When cancellations occur, I learned, patients often blame themselves, and fear that they are being discharged by the clinic because they haven’t satisfied all the criteria that have been imposed upon them.  (No such criteria exist in a form that is shared with patients, of course, but when one has turned to the GIC as a last recourse, it must be hard not to be paranoid.)  In its literature, the GIC addresses this criticism only by acknowledging that waiting-times need to improve, but it does not outline how its staff might bring this about.  A delay in attention from the GIC may not seem earth-shattering to anyone who is not frantic for help with issues relating to their gender identity, but it would be a mistake to underestimate how desperate for support some patients are.  If you have been reduced to a state of crippling depression by anxiety over your body and your place in society – and the GIC has become a beacon of hope in an otherwise cruel and uncaring sea – a wait of any duration is a wait too long.

The other main criticism of the GIC is that patients feel demeaned and disempowered by the way staff (from the receptionist to the consultant surgeons) behave towards them.  According to its welcome pack, “a number of false beliefs and misconceptions have arisen” about the professional conduct of staff at Charing Cross.  Some of these beliefs “stem from the way the GIC operated in the past”, whilst others are a result of “the approaches of previous clinicians”, but it is a myth, the handbook asserts, that the Gender Identity Clinic is looking for a particular profile when it chooses which patients it will treat.  Accordingly, potential visitors should not assume that they must already be living in their preferred gender role by the time they attend; be hell-bent on reassignment surgery; have no reservations or doubts about the course of treatment they wish to pursue (and, indeed, what sort of man or woman they wish to become); abandon all other forms of help they might have sought (such as attending a private clinic); nor expect deliberately provocative, aggressive or challenging behaviour from clinicians (staff at the clinic do not “play good cop/bad cop”, apparently).

Whilst the literature produced by the GIC may overtly deny or condemn the dismissive and prejudicial behaviour of its specialists in the past, reports about patients’ experiences on social media suggest that a culture of hectoring and condescension continues at the clinic unabated: the only difference is that is has gone underground.  The Foucauldian belief in the primacy of the doctor’s expertise and knowledge, and the worthlessness of the patients’ wishes and experience, exists in a way that is so insidious – so subconsciously endemic – that clinicians cannot help but allow it to govern their behaviour.  The doctors know best.  Thus, patients report being told that failure to change their passport to reflect their preferred gender role displays a lack of commitment to transition.  Patients who cannot demonstrate a rich and varied social life are considered at risk of spending their existence post-transition friendless and isolated, whilst those who do not have the dietary and exercise regime of an Olympic athlete (or who have the temerity to do something as wicked as smoke) are considered to lack the necessary self-discipline for coping with post-surgical care or a lifetime of taking hormonal medication.  Patients who show signs of depression are assumed to have other issues that need resolving by a therapist before their gender identity can be addressed, and patients who have sought treatment at private clinics are thought to be obsessional, or are accused of being disloyal to the expertise of Charing Cross’ own doctors.

The Gender Identity Clinic addresses a third issue that does not emerge as a concern in the discourse of its critics and patients, namely: people who cancel – or fail to turn up to – appointments.  The numbers of people who do not attend appointments is, according to the GIC handbook, “unprecedented”, and one of the factors “which has contributed to our long waiting-list”.  By placing the blame for delays on patients in this way, the GIC abdicates from its own responsibility for the length of time it takes for a referral to be seen.  Furthermore, the clinic’s guidelines offer no apology for delays, preferring, instead, to threaten patients with sanctions for non-attendance: “if you reschedule three appointments, you will be discharged with no return and will have to seek gender care at another UK GIC”.  The Charing Cross clinic is so omnipotent, in other words, that they can even claim ownership of their patients’ time: ‘We reserve the right to mess you around,’ they are saying; ‘to keep you waiting, and reschedule appointments with neither notice nor explanation, but if you try and do the same to us, we will kick you out.’  John Randell would have been proud of his legacy.

(That said, I find the very notion of not attending an appointment at the GIC difficult to fathom.  Why would anyone – after waiting over twelve months to see a specialist there – wimp out at the last minute?  Unless one has a phobia of being mercilessly patronised, there is nothing to wimp out from: everything at the clinic moves at such a snail’s pace that no-one who visits is at any risk of being rushed or pressurised into a decision they don’t want to make.  I can only assume that the people who do not attend either change their minds entirely about transition; cannot bring themselves to tell their loved-ones what they are up to; have taken matters into their own hands by going private; or have suffered such a catastrophic breakdown that they have ceased to be capable of anything constructive.)

Frame GIC
‘You will never find a more wretched hive of scum and villainy’: a warm welcome from the GIC seems assured when one admires the pleasant, inviting aesthetic of its hallowed, street-side portal

My first meeting with a consultant at the GIC was, after months of anticipation, a spectacular anti-climax.  My employment status was the principal concern of the consultant I saw, along with how my friends and family had responded to (and stuck by me following) my transition.  My hobbies and interests came under scrutiny, too, but, when I mentioned having been a leading-light in my local amateur Gilbert and Sullivan society, I was subjected to line of questioning that was stilted and awkward.   On the surface, the psychologist’s questions seemed designed to engage me in small-talk about Victorian operetta (“What’s the name of the opera that followed ‘The Mikado’?  I know it begins with R, but the name has temporarily slipped my mind…”), but I now realise the veracity of my claims about the activities that occupy my spare time was being tested.  (The answer is ‘Ruddigore’, incidentally, and I didn’t need to pretend that I couldn’t remember it, either.)

I tried to enquire what was meant by the word ‘assessment’ as it is used in the language which describes appointments at Charing Cross.  (Patients are invited to two assessments at the GIC, designed to “reach consensus about the best way forward with your care”, “gain a broader perspective on your situation”, and “help us gain a clear idea of how we can help you”.)  Were there certain indicators the psychologist was looking for? I asked; Was it possible for the clinic to reject a patient on the strength of this interview?; and, Is thirty minutes enough to gain a sufficiently rounded picture of someone to inform a decision that will affect the rest of their life?  I would like to say I received satisfactory answers to these questions.  I would like to say that, but it wouldn’t be true.

Yes, I felt belittled; and, yes, I felt my opinions on my transition and the way I had managed it thus far mattered very little to the consultant who met me…  But was my experience as wholly negative as the ones I had read about?  Not really: I felt vaguely demeaned and thoroughly patronised, but that was about as bad as it got.  My second assessment is in November this year (an epic thirty-six months after my first referral), and, I must admit, any sense I once had that attendance at Charing Cross was an essential step on my transgender journey has completely evaporated.  I no longer feel dependent on the clinic, and I’ve realised that there are alternatives (even for people on a budget) to pleading for the imperious say-so of a GIC doctor for approval for surgery, voice coaching, hormone treatment, and all the more complex, less obvious, aspects of changing the way society views my gender.

As I’ve been waiting for my turn at the clinic, I have learned that I am very unclear about what I want the services of the GIC for.  I am no longer sure the clinic can provide me with anything I am not capable to getting for myself: by communicating clearly and honestly with the people whose help I’ve needed to change my social role, and by working hard to ensure I have continued to present a confident and self-assured face to the world, I have succeeded in transforming myself.  I have found that feminising hormones are relatively easy to obtain with a sympathetic GP, and a therapist – no matter how sympathetic – is no replacement for good friends.  Given that voice coaching is ninety-nine percent down to the amount of work one is prepared to do for oneself, YouTube is as good a place to take lessons as any.  Changing my name and my gender on official documents (like my degree certificate, bank account, passport, driver’s licence, and so on) was just a matter of picking my way, patiently and persistently, through a forest of bureaucracy.  For a fee, I could see an independent specialist (like Dr Richard Curtis at the Transhealth gender clinic in Marylebone), and be treated more like an autonomous human being, capable of making up my own mind about what I do to, and put in, my own body.  When it came to work and hobbies, I discovered that, if I behaved as if the world should continue to treat me with dignity and respect, eventually enough people would – and these people would even begin to compensate for the bigotry and laziness of others.  My attitude to surgery, meanwhile, is something I can only resolve for myself.

By reducing my dependency on the services of the Charing Cross clinic, I have disarmed its ability to intimidate, humiliate, frustrate and disappoint me.  With my newly empowered frame of mind, I can attend my second assessment – not as a quivering vassal of the NHS – but as a discerning consumer, driven by curiosity about what the GIC’s specialists can do for me, rather than what I need to do to satisfy them.

The Gender Identity Clinic at Charing Cross has achieved an unassailable place in UK transgender culture as the only significant institution with the moral and medical right to dispense advice, counselling, support and medication for gender nonconforming people.  Through the discourses of its promotional literature and the conduct of its staff, the clinic has established itself as the ultimate arbiter of gender transition in England.  For all its faults, however, Charing Cross stands as an encouraging symbol of the willingness of the British government to spend time and resources supporting its transgender population.  To become a patient there, however, requires one to accept subjugation to the whim of another; readiness to be condescended to in a way one would never accept in other walks of life; and to dig-in for an interminable wait.  Oh: and to accept that no-one at the GIC ever, ever answers the telephone.

 

An introduction to the services offered by the Charing Cross Gender Identity Clinic can be perused here…                                                                           http://www.wlmht.nhs.uk/wp-content/uploads/2016/04/GIC-patient-information-pack-April-2016.pdf

An excerpt from the dark, tragi-comic BBC documentary, ‘A Change of Sex’ (1979), can be viewed here…                                                                               https://www.youtube.com/watch?v=aeBwniFDDK4

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One thought on “A Visit to Foucault’s Clinic – The West London GIC at Charing Cross Hospital

  1. Wow! What a well crafted piece that says what needs to be said. It’s time the GIC’s were confined to the annals of history. That whole attitude that you report so well has no place in modern medicine. Thank you.

    Like

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