Tackling Hermeneutical Injustices in Gender-Affirming Healthcare

As any trans person will tell you, it is a scary time to be living in the UK. One reason is that gender-affirming healthcare is becoming increasingly hard to access. In December 2024 the Health Secretary made a ban on prescribing puberty blockers to trans adolescents permanent, following the recommendation of the deeply flawed Cass Review. This ban has been criticised by several relevant professional bodies, diverges significantly from the consensus on best practice in peer countries, and flies in the face of decades-long histories of these drugs’ safe and effective use.

                                               
           

As a result, trans adolescents are being forced against their wills to undergo puberties distressingly at odds with their gender identities. Simultaneously, trans adults hoping to access gender-affirming healthcare from the NHS are being made to wait several years for their first appointment at a Gender Identity Clinic (GIC). These long wait times are taking a considerable toll on their mental and physical health. Moreover, convincing the relevant doctors at a GIC of their need for gender-affirming healthcare is no longer always sufficient since some GPs are unilaterally refusing or reversing GICs’ recommendations to prescribe hormones to their trans patients.

  

Trans identity and hermeneutical injustice

In addition, convincing the relevant doctors at a GIC of their need for gender-affirming healthcare is not always easy. Doing so is a matter of a patient rendering it intelligible to these (usually cis) doctors that they are indeed trans. This can prove difficult when the relevant doctors employ overly-narrow conceptions of transness. For instance, gay patients sometimes struggle to render their transness intelligible to doctors who assume that to be trans is necessarily to be straight. 

Similarly, non-binary patients sometimes struggle to render their transness intelligible to doctors who assume that to be trans is necessarily to identify as either a trans man or a trans woman. Moreover, that doctors sometimes work with such overly-narrow conceptions is a result at least in part of trans people having been deprived of opportunities to shape how people think about transness. In sum, trans adults sometimes suffer hermeneutical injustices when attempting to access gender-affirming healthcare from the NHS.

What can be done?

What should be done to prevent such hermeneutical injustices? In a recent paper, I distinguish between two sorts of strategy that might be pursued to this end. Interests-as-given strategies would take for granted trans patients’ interests in it being intelligible to the relevant doctors that they are indeed trans, and aim only to enable them to satisfy these interests. For instance, we might look to educate the relevant doctors or to engage in political activism aimed at propagating better-fitting conceptions of transness. 

All previously proposed strategies for preventing hermeneutical injustices are of this sort, yet it is sometimes possible to go about preventing hermeneutical injustices very differently. An interests-in-question strategy would instead look to do away with trans patients’ interests in it being intelligible to the relevant doctors that they are indeed trans, and thus with the possibility of these interests’ unfair nonsatisfaction. 

Consider that trans patients only have these interests in the first place because the prevailing gatekeeping model makes it a requirement on the provision of gender-affirming healthcare that trans patients first convince the relevant doctors at a GIC of their need for it. I argue on grounds of trust, privacy, and respect that the NHS ought to cease making this a requirement. One way to do so would be by switching to an informed consent model, under which pretty much all that a well-informed adult capable of consent would have to do to access gender-affirming healthcare would be to ask for it – an example of a more materialist strategy for preventing hermeneutical injustices. 

Unfortunately, in a time of intense anti-trans backlash it seems unlikely that the NHS will make such a progressive move anytime soon. We thus may need to think about what else can be done to prevent such hermeneutical injustices in the unjust meantime.

Nick Clanchy is a Postdoctoral Research Fellow with a joint appointment at the Canada Research Chair on Epistemic Injustice and Agency (UQAM) and Le Centre de Recherche en Éthique (UdeM) in Montréal, where they are also a member of the philosophy department at McGill.

Most of Nick's work is dedicated to thinking about hermeneutical injustices. They also have research interests in trans philosophy, the philosophy of love, and the work of a number of figures on the margins of philosophy - especially Roland Barthes. 

More about Nick and their work can be found here.