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.

Scripts, Standard Minds, and Unjust Treatment in Healthcare Settings

Today's post comes from Gen Eickers and summarises their recent book on social scripts and their importance in healthcare:

In healthcare, epistemic and other forms of injustice are seen when patients’ lived experiences or knowledge are dismissed or undermined, resulting in unjust treatment. One key factor in this may be the role of scripts — specific normative knowledge structures that healthcare providers, for example, apply when interacting with their patients.

How do scripts work? In Scripts and Social Cognition: How We Interact with Others (Routledge, 2025), I argue that social interactions are normatively structured and that scripts, due to their reliance on social norms, provide an apt resource for explaining how we navigate the social world. Social interactions are subject to (context-sensitive) conditions of social appropriateness. 

Scripts allow us to retain extensive information about social interactions—including what is and isn't socially appropriate in each situation. That is, scripts serve as guidelines for social behavior that specify expectations about others’ behavior as a function of their identity, situational context, the cultural setting, and respective roles in that context. 

My script account, spelled out in Scripts and Social Cognition, introduces social forces (i.e., social structures, norms, and roles) to explore what structures social interaction, and to gain an understanding of whether and how scripts are related to social norms, structures, and roles. In so doing, it also sheds light on the ways that social categories, such as gender, disability, and class, impact social interaction. As social norms are stored in scripts, scripts also enshrine various biases. 

These impact our social interactions and the way we understand other people. So, scripts not only capture how to behave as someone in an institutional social role (e.g., an academic) in a framed social situation (e.g., a colloquium), but scripts also capture how to behave as a person with a specific social identity (e.g., a disabled trans man) or social group membership in a specific context. 

This accounts for the social structures in which social interactions are embedded and addresses the issue that members of less dominant social groups (such as queer, trans, Black, disabled, mad communities) are particularly subject to interactive injustice. That is, members of less dominant social groups may often find themselves to not be perceived, interpreted, or treated as equal social agents in social interactions. In this way, scripts can be considered loci of social knowledge, and sometimes they may be loci of unjust treatment.

Scripts that guide interactions in healthcare settings are often shaped by medical norms and cultural assumptions about health, which, in turn, can lead to the (further) marginalization of patients’ voices. Unjust treatment in healthcare settings may arise when the concept of a 'standard mind' is narrowly defined but universally applied. In a lot of healthcare or medical contexts, mental health and health in general is viewed through a standardized lens that excludes many subjective experiences that don't conform to norms around health, and, thus, don't fit this standard. 

When such 'non-standard minds' express their lived realities, their experiences are often disregarded. For a specific interaction within a healthcare setting this might mean: when a patient expresses symptoms that don't align with the standard scripts a healthcare professional has, the patient's account may be dismissed as unreliable, and care may be denied.

Consider, for example, a trans person seeking support by healthcare professionals in order to receive hormone replacement therapy. Healthcare professionals often rely on DSM or ICD categorizations of transness, which define transness via gender dysphoria, i.e., a negatively valenced experience, sometimes even framed as suffering. 

This dysphoria framework is shaped by norms around health and is taken to be the standard model for how trans minds work. But not all trans people experience their transness via dysphoria, or through a dysphoria framework. 

In such cases, the standard scripts applied by mental health professionals don't fit, and as a result, patients may be denied authority over their own experiences; an injustice that disproportionately affects those in multiply marginalized groups. Though I think our minds, standard or not, do have tools to do better: scripts can be combined and adjusted – for example, by gaining awareness of trans realities, different scripts may emerge about how to interact with trans people. The standard healthcare script, thus, may be complemented by scripts pertaining to gender equality.

Gen Eickers’ research is located in the philosophy of mind and emotion and the philosophy of technology as they intersect with social epistemology, social ontology, and trans and feminist philosophy. They  approach philosophical research in an interdisciplinary way, including sociology and social psychology in their work. They work primarily on scripts, social norms, social interaction, emotion, injustice, transness and gender, and social media.