This report finds that trans and non-binary service users experience discrimination and harm in mental health care settings. It sets out recommendations for policy and practice that may help to ensure the needs of trans and non-binary service users are not undermined or neglected.
About the report
Within mental health services, there is a growing call for single sex wards, as part of the push for the modernisation of the mental health estate. This follows recommendations in the Independent Review of the Mental Health Act to ensure wards are “genuinely” single sex. The White Paper on the Reform of the Mental Health Act was released in April 2021 with a clear call for single sex spaces:
“The definition of single sex accommodation should be tightened up to ensure a genuinely single sex environment with separate access to any shared daytime space.” (Reforming the Mental Health Act, 2021).
Through desk-based research and a survey, led by a trans and non-binary researcher, we have asked the question: what are trans and non-binary people’s experiences of single sex spaces in mental health settings in England?
We have asked this question in order to centre the experience of trans and non-binary service users on single sex wards and to better understand what needs to change to make mental health settings safer places for trans and non-binary people experiencing mental distress.
Our findings, also set out below, show that trans and non-binary service users experience discrimination and harm in mental health care settings. This includes through harassment and bullying, a lack of privacy, and the mishandling of access to other gender-affirming care while in mental health settings. Transphobia in mental health settings means that gender diversity is still considered pathological by some clinicians, and the state of funding, waiting lists and staffing levels in the NHS impacts the possibility and willingness to provide trans-inclusive care.
Our recommendations start with the acknowledgment that single sex wards are not the best standard of care, and then consider the wider ways in which services (and their policies) must change to ensure that the needs of trans and non-binary service users are not undermined or neglected.
- There is significant variation in trust policies relating to trans and non-binary service users. This can include variation within trusts.
- No matter how inclusive policies may be on paper, there are many internal and external factors that can negatively impact their potential to limit harm. These can include working culture in individual trusts and the wider politicisation of trans rights.
- Gaps exist between trust policies and the experiences of trans service users that indicate a serious need for monitoring, training, and a better standard of care for trans and non-binary service users.
- There is a lack of collaboration with trans-led organisations and centring of trans experiences in trust policy.
- Policy can reflect a legal requirement regarding a protected characteristic, however this does not mean that a trust is trans-inclusive or that practice will be sufficiently changed by addressing the legal status of a group.
Experiences in care settings
- Trans and non-binary service users face discrimination and harm within care settings from staff and other service users.
- Service users may hide their gender identities and avoid requesting the use of their pronouns or name, where these differ from their records. This indicates that healthcare settings are perceived as unsafe places to express gender that differs from that assigned at birth.
- Experiences of trans service users include deadnaming, misgendering, outing, invasive and inappropriate lines of questioning, and a general lack of support in maintaining gender presentation.
- Experiences of trans and non-binary service users are linked to a broader feature of inpatient mental health services which is that privacy and dignity may become secondary to practices of continuously monitoring service users.
- Support for maintaining gender presentation in hospital may not be available or accessible.
- Access to gender-related care whilst an inpatient in a mental health setting can be restricted, which can mean that service users miss out on appointments, gender affirming surgeries, and other care related to their transition. This kind of care can often take a significant amount of time to access in the first place.
Recommendations for services
- Recognise that single sex wards are not the best standard of care for all service users, in particular, trans and non-binary service users, and take steps to assess and mitigate possible negative impact.
- Locate the problem in services, not in service users: ask how services and practice can change to support and include trans and non-binary service users.
- Name the political nature of trans health in policy, education and practice, and the ways in which the needs of trans and non-binary service users may be being neglected or undermined in services.
- Set out how gender-affirming care and physical health needs of trans patients in mental health inpatient settings will be met with emphasis on not being an obstacle to gender-affirming care.
- Evaluate trust policies in the wider context they sit in to understand if trans inclusion is a thread that is picked up across trust policies or if it only features in trans-specific policies.
- Develop policies and monitoring processes in partnership with local and national trans and LGBTQ+-led organisations.
- Produce documents with clear input from trans and/or non-binary service users in the policy.
- Seek to understand the experiences of trans service users and monitor the effectiveness of policies accordingly.
- Support staff to lead by example, set out clear expectations for staff behaviour and staff roles in ensuring the dignity and safety of trans and non-binary service users.
- Provide supervision for staff to develop inclusive practice and to identify where their ways of working and norms may be exclusionary.
- Develop transparent processes for reporting failures in care and pathways for remedy.
- Ensure that service users have access to advocates who are aware of relevant Trust policies.
- Embed trans inclusion into other equalities areas, for example, consider how resources such as the Patient Carer Race Equality Framework (PCREF) can address the needs of trans and non-binary people of colour.
We’d like to sincerely thank everyone who contributed to this work. We are deeply thankful to our survey respondents, who shared with us personal and powerful testimony about their experiences on single sex wards. We are also grateful to partners in the LGBTQI+ sector who supported the development of this idea and shared their knowledge and insights with us. Finally, a special, warm thanks to Ave Bellows who developed this research whilst working with NSUN as a policy intern.