Sex matters in mental health care

NOTE: This harrowing testimony about the way female patients are endangered by gender self-identification policies on NHS wards was written by a whistleblower who wishes to remain anonymous.

I was once a patient in a locked, mixed sex psychiatric unit where I found sanctuary in a women-only lounge. Now I work for an NHS Trust that says sex doesn’t matter and a new hairstyle or a new name is enough to give men access to women-only facilities. I’m furious – and I’m frightened for our patients and staff.

A decade or so ago, I was very ill with depression. So ill that I was twice admitted to an NHS psychiatric hospital, each time for about 3 months. I was suicidal and although the people caring for me agreed that psychiatric wards can be frightening places, I was too much of a danger to myself to stay at home. 

Being admitted was a terrifying experience, but the constant monitoring and containment kept me alive when I was trying to die and I will always be grateful for that. The environment on the wards was often frightening and chaotic, staffing was too low for meaningful engagement with patients and my recovery was a long, slow process. But I did recover and have been happy and well for many years. I have been able to resume my career, enjoy my marriage and treasure my life.

I was admitted to two different hospitals but in both the place I felt most safe was the ‘Ladies Lounge’. This was a room that was just for women, a small lounge with a TV where women knew they would only encounter other women. I remember sitting quietly with an elderly Muslim woman who spoke no English, both of us not really watching TV, not talking, but safe. I remember a woman there who would only eat out of a dog bowl because vicious abuse had left her feeling worthless, another woman who kept trying to stab herself in the genitals because she had been brutally violated. I am still friends with a couple of women I got to know there. All of us are victims of childhood abuse by men. To the extent that I have fond memories of being a psychiatric inpatient, they are of the fragile safety of the Ladies Lounge.

Many people on these locked wards, both men and women, were very ill indeed. As funding has shrunk, the criteria for being admitted gets more and more severe, so that wards are places where only people who are a danger to themselves or others can be looked after. Many were having manic or psychotic episodes, there were aggressive outbursts almost hourly, patients were shouting at the voices only they could hear, raging against their containment, having to be restrained. The alarm would often go off as someone tried to escape.

Nevertheless, the tacit and explicit rule that the Ladies Lounge was for women only kept it a relatively quiet and safe place. 

I remember a man who sometimes raged but mostly had delusions that he was the Messiah. He would walk the corridors bestowing blessings on patients and staff, speaking in a language only he understood. He once stood on the threshold of the Ladies Lounge and was about to come in, but it was easy and natural for us to say ‘No, this is the Ladies Lounge, you’re not allowed’. He blessed us from the doorway and left. Other male patients would occasionally try to come in but the same would happen – they were sent away by patients or removed by staff, by force if necessary. The rule was clear and simple – no men in the Ladies Lounge. 

Mixed sex services by stealth

I now work for Nottinghamshire Healthcare NHS Trust, a large mental health trust in England. I love my job, and our frontline staff work under immense pressure to provide care and treatment for some of the most vulnerable and distressed people in our communities.   

However, I am deeply afraid that the Trust’s “Trans and Gender Diverse Patients Policy and Procedure”, which has just been issued for internal consultation, effectively removes the right for women and girls to have single sex services or spaces like the Ladies Lounge – those small islands of safety in a sea of chaos and crisis.

Stonewall Star Performer

Nottinghamshire Healthcare NHS Trust provides medium and high secure mental health hospitals, inpatient mental health wards for adults, older adults and young people as well as services in the community. The Nottingham Centre for Transgender Health is part of this NHS Trust and has had a large part in writing the policy. The Trust is a Stonewall Diversity Champion and was a “Stonewall Star Performer” in 2016. The Chair of Directors of this Trust used to be on the Board of Mermaids. The policy’s list of sources of further information includes Mermaids and Stonewall.

The “Trans and Gender Diverse Patients Policy and Procedure” sets out the Trust’s position on providing services to trans patients, including legal responsibilities and best practice advice for clinicians. It provides definitions and guidance for making decisions about where to accommodate or nurse “trans and gender diverse” patients, how they should be addressed, how data should be handled. It quite rightly emphasises that, like all patients, trans and gender diverse patients should be treated with sensitivity, dignity and respect, and protected from abuse. 

But the definitions of ‘trans and gender diverse’, ‘transition’, ‘gender’ are so broad, fuzzy and contestable that I don’t see how men can be kept out of women and girls’ spaces. The existence or importance of sex as a protected characteristic is ignored. 

‘Fair, equitable and inclusive services’?

The purpose of the Trans and Gender Diverse Patients policy is to help the Trust “deliver fair, equitable and inclusive services”. However “it has been concluded that a full Equality Impact Assessment is not needed”. No mention is made in the policy of the rights or dignity of women on the basis of the protected characteristic of sex, or of the rights of people of some faiths who might be excluded by the fact that under this policy, decisions about where to accommodate patients are not to be made on the basis of sex.

Terms which the policy deems outdated or unsuitable include cross dresser, transsexual, transvestite and even gender dysphoria. Terms which acknowledge the difference between sex and gender are thus removed from permitted use. 

Instead the policy uses ‘Trans’ and ‘Gender diverse’ as ‘umbrella terms’ to encompass “those whose gender identity does not match the expectations of their sex assigned at birth”. The umbrella includes the no longer speakable transvestites and transexuals as well as the modern “genderqueer, gender variant, bi-gender (both man and woman), pangender, genderless, agender, neutrois, third gender or gender fluid”. This policy applies to the treatment of all these groups of people – but also notes that the language is constantly evolving and could even be out of date already. 

What does it mean to transition? 

‘Transition’ is defined as “the process of changing from one gender role to another”. Gender roles? Roles? This policy states that gender is as superficial as a role, but also that someone has a ‘true’ gender. In addition, this ‘true’ gender can change through a lifetime. This NHS Trust is delivering healthcare on the basis of roles, which can change over time, but at any one time are ‘true’. 

Transition is also defined as the process of changing gender expression. Someone can transition socially “by changing their name, pronoun, clothing, hair styles, and/or the ways that they move and speak.” Putting on lipstick and heels, affecting a new walk could thus turn a man into a person who can use women’s facilities. 

“No specific set of steps is necessary to ‘complete’ a transition”.

The policy states that “The Trust expects trans and gender diverse people who have been consistently living in their preferred gender role to be treated for all purposes as a person of that role”. However, no information is given about what ‘living in a preferred gender role’ involves, or what ‘consistently’ means. Nevertheless: 

“Once the patient’s transition to their true gender role has taken place, the Trust expects all its staff to treat the individual in a manner appropriate to that gender and to use forms of address which refer to that gender and to use the acquired name and appropriate pronouns. Failure to do so could lead to disciplinary action under the Trust’s Conduct Policy and/or prosecution in a criminal court.”

Remember that ‘Transitioning’ is defined here as the process of changing gender expression or ‘gender roles’. It can be simply changing one’s name, clothing or hairstyle. Therefore a person’s transition could have ‘taken place’ when they change their clothes or say they are using a different name that day. They must then be treated as though they have changed sex, under threat of disciplinary action or prosecution. In fact:

“A trans or gender diverse patient should be nursed in an environment corresponding to their current gender whatever their stage of their transition.” 

The policy does acknowledge the need for risk assessment:

“It is important to note that the management of risk to self or others may be an overriding consideration to the patient’s gender within an inpatient setting.”

“As with any patient accessing in-patient treatment, an assessment of the risk the patient may pose to other patients’ sexual safety must be undertaken when deciding on the setting in which to treat the individual.”

The risks to the trans patient are considered widely:

“Equally, the risk to the trans or gender diverse patient should also be considered from not only a sexual, but psychological perspective of being nursed in a ward different to their current gender.”

There is no mention of the psychological risk to women of being nursed on a ward alongside men who wear women’s clothes, or walk ‘like a woman’, or claim to be a woman.  Not all women believe these things turn men into women.

“Transphobic concerns expressed as discomfort”

Should a member of staff feel uncomfortable (or afraid, or horrified, or furious) about the practical implications of the policy, this will presumably be deemed ‘transphobia’:

“It will be important to respect the feelings of all those concerned, however concerns alone are insufficient to prevent trans and gender diverse people from being treated as people of their gender. Just as the Trust will not adapt practice in light of racist concerns expressed as discomfort, so the Trust will not adapt practice in light of transphobic concerns expressed as discomfort. This will include such things as use of toilets, changing facilities and single sex accommodation.”

Who will decide what counts as legitimate concern and what is transphobia? No guidance is given for what counts as transphobia. Is it transphobic to be unhappy that a man who identifies as ‘pangender’ and feels most comfortable on a women’s ward should be accommodated there, even if he is otherwise undistinguishable from other men? Is it transphobic for a female patient’s family to object to an ‘agender’ man on her ward? Pity the already overworked staff trying to deal with this.

“Forthcoming legislation”?

The policy claims to set out how the Trust will meet “its duty and requirements under current and forthcoming legislation”. Forthcoming legislation? This Trust appears to have knowledge of future legislation. Or perhaps, like the Essex University policy reviewed by Akua Reindorf in 2021, this policy “states the law as Stonewall would prefer it to be, rather than the law as it is”. 

People who know more about the legal situation can tell me if this is acceptable or accurate:

“You must assume that a trans or gender diverse person who has changed their name by statutory declaration or Deed Poll is a member of their new/true gender for all purposes unless you are told otherwise.”

“Patients who have made an application or who have made a successful application to the Gender Recognition Panel are entitled to full legal recognition in their acquired gender and must be treated as such. Therefore, they should be nursed in their recognised legal gender. Failure to do so will be in breach of criminal law.”

I was under the impression that if it is a reasonable means to achieve a legitimate aim (such as the psychological and physical safety of women in mental health distress and physical vulnerability) then someone can be excluded from single sex services even if they have a Gender Recognition Certificate. I’m not an expert, I’m happy to be corrected. 

There is enough in this policy that troubles and frightens me. 

I think of myself ten years ago, and women and girls in the same situation today – seeking some sort of sanctuary from life threatening mental illness on a mental health ward, only to find it is a chaotic and frightening place. They may then seek sanctuary in the only women-only space they have access to – only to find that patients and staff can no longer prevent entry to that space by any man identifying as ‘genderqueer’, or a man who is clearly a transvestite, or just a misogynist who enjoys violating women’s spaces and exerting power by showing them they can’t say no. If my mental health doesn’t hold up, this could be me in the future. This could be any woman or girl you know, or love, or are. We are less safe as a result of policies like this – policies which invent definitions, are logically incoherent, sex-denying and legally questionable.

This has got to stop. For their safety and dignity, patients and carers deserve to know about this policy.

Solidarity to the young woman who wrote this piece about her experience of “The living hell of a mixed sex psychiatric unit”, published by Women’s Rights Network a few days ago. 

One thought on “Sex matters in mental health care

  1. moleatthecounter says:

    I have been involved in this nonsensical new world for several years now and I have to say that “true gender role” is one of the most meaningless phrases I have ever heard.

    In an official policy document too – It is as almost as if they don’t really know what they are talking about – and worse, trying to enforce.

    Like the meandering, fluid word ‘spiritual’ – I still await a clear definition of the new meaning of ‘gender’ – and until that arrived i shall adhere to the linguistically correct definition fo gender is it refers only to groups and populations. Until recently, an individual could not have ‘a gender’.

    Liked by 1 person

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