Montana Journalism Abroad

Excessively long wait times for gender-affirming care leave transgender people feeling stuck

EDINBURGH, U.K.—While working his part-time job at a Chinese takeaway restaurant, Matthew McCook minimized interaction as much as possible when he took customers’ orders and handed them food. He was afraid they wouldn’t see him how he wanted to be seen, as a man. He felt stuck in the wrong body, unable to express his true identity. Every time McCook was identified as a woman, he sunk deeper into himself, further from the outside world, becoming hypersensitive to other people’s depictions of him.

“It definitely solidified all of my insecurities,” he said. “You become so focused on what everyone else is thinking.”

McCook is a 20-year-old transgender man from Edinburgh. He stands around 5-foot-3. He has rainbow shoelaces in his black Converse and a kind face framed by dyed-red hair that’s combed to one side. His smile is bright and it appears often, but that hasn’t always been the case.

McCook was assigned female at birth and prior to his transition, he felt more like a shell of a person. He retreated inward and was uncomfortable with his appearance.

“Looking in the mirror, you see something incomplete,” McCook said. “It looks distorted and wrong.”

Gender dysphoria is the feeling that one’s physical anatomy does not align with their gender identity, and it’s something that many transgender people face. Living in a dysphoric state for too long can lead to severe mental health struggles like depression, anxiety and suicidal tendencies. 

In Scotland, this condition is made worse for many trans people because of how long they have to wait for gender-affirming healthcare through the government-run National Health Service. 

According to a 2024 research report from Public Health Scotland, transgender people in Scotland face some of the longest wait times for healthcare in the United Kingdom. At the end of March last year, more than 5,500 people were on the waitlist for an initial appointment, and more than 1,400 of them had already been waiting for over three years. According to 2024 census data, there are only about 19,000 trans people in Scotland. This means over a quarter of all trans people in Scotland are on a waitlist for gender-affirming care through one of only four gender identity clinics in the country. Compared with the average wait time of about 18 months for trans healthcare in the U.K.as a whole, trans people in Scotland face substantially longer waits.

According to the governing documents for the NHS, all patients have a legal right to wait no more than 18 weeks for non-urgent or specialized healthcare. This means the wait times that trans people in Scotland face for treatment directly violate government ordinance and their inherent right to receive healthcare.

These forced waits for care can exacerbate mental health issues in a vulnerable population, where incidents of self-harm are extremely prevalent. According to a 2017 study from Stonewall, an LGBTQ+ advocacy group that surveyed 3,713 LGBTQ+ students aged 11-19 in the U.K., 92% of trans people aged 19 or younger have thought about taking their own lives, 84% of young trans people have self-harmed, and 45% have tried to take their own lives. McCook is no stranger to the reality of these statistics. He has attempted suicide three times, he said, and had two trans friends die by suicide.

“Pretty much all trans people have attempted suicide at least once,” he said. “You’re an outlier if you haven’t.”

McCook witnessed what a lack of gender-affirming care can do to trans people like him, and he didn’t want to be stuck waiting, too. After being on an NHS waitlist for over a year with no noticeable progress, he opted to seek care privately, at great expense.

According to data from TransActual, a U.K.-based advocacy group, the rate for a single gender-affirming care appointment through a private practice is around £250-500. Transitional healthcare often requires multiple appointments with a variety of different providers, hormone prescriptions and cosmetic surgeries, so the total cost of care quickly compounds.

“It was simultaneously the best and worst choice I’ve ever made. It was so much money, but at least you’re getting something,” he said. “That’s the best you can hope for here.”

For many trans people in this position, paying for transitional care with their own income feels impossible. That leaves them with few good options. They either wait an indefinite amount of time for public care, or find another way to support their transition.

McCook opted to start a GoFundMe campaign after seeing the crowd fundraising site work for others. He launched two separate fundraisers, the first for his initial appointments and prescriptions, and the second for a £10,500 cosmetic top surgery to remove his breast tissue. After marketing his GoFundMe page on social media, in community groups and among friends, he was able to raise enough money to successfully fund his treatment by combining the donations with his personal income.

When McCook was finally able to receive the treatment that so many trans people in Scotland long for, his life changed. He got top surgery right before his 20th birthday from a private surgery practice called Cosmedicare. After the operation, McCook said he gained confidence and opened himself up to the world more than he had in a long time.

“It’s completely changed how I interact with people,” he said. “Everything started seeming brighter.”

McCook is just one example of a trans person in Scotland who had to take charge of their treatment independently and find creative solutions to offset the public system’s delays for gender-affirming care.

Arthur Frain is a 23-year-old trans man from Dunfermline, north of Edinburgh, who has been on the NHS waitlist through the Sandyford Clinic in Glasgow for more than three years. Frain came out as trans when he was 13. Because of restrictions on gender-affirming care for people under 16 in the U.K. and parents he called unsupportive, Frain had to wait until he was 18 to access treatment. Even after he was old enough and had gained independence, he waited years for an initial appointment with no start to his treatment in sight. This led Frain to take an unconventional, unsupervised route with his transitional care.

About two years ago, he managed to find someone who had an extra bottle of testosterone. That’s when he began what he described as a DIY, or do-it-yourself, treatment plan.

“I’ll end up running into someone who will say to me, ‘I have a spare bottle,’” Frain said. “I’ve just been lucky for the last two years, really.”

Frain researched the safety of independent hormone usage before starting the treatment, and he scheduled regular blood tests to monitor his health during the process. Although NHS guidelines advise against unsanctioned hormone usage, Frain was fed up with the lack of support he received from the NHS and took the opportunity to begin his transition anyway.

“I have had nothing from the NHS,” he said. “Nothing but a hard time.”

Frain even tried to acquire a temporary prescription of hormone replacement therapy, known as a bridging prescription, from his general practitioner. This type of temporary treatment plan is designed for patients waiting to receive specialist care, usually at a gender identity clinic. Frain was eligible for a bridging prescription since he had been waiting for gender-affirming care for so long, but his general practitioner denied him because he had been using hormones independently.

“For me, it would have made sense to do that instead of letting me continue to DIY,” Frain said. “But my doctor told me I was a liability to the NHS.”

Although most of the testosterone Frain uses was originally prescribed by the NHS, he has only been able to propel his transition with testosterone prescribed to someone else. The only NHS prescriptions written for Frain himself were for mental health issues in years prior. He said these treatments did nothing to ease his struggles, and he didn’t regain his happiness until he finally began using testosterone.

“I actually don’t think I was depressed or mentally unwell,” he said. “I think I was trans and no one took me seriously.”

Frain’s grievances are similar to those reported by other trans people in Scotland. They’re unable to support their transitions independently, and when they finally get public care, they often have poor experiences with the treatment they receive.

Florence Oulds is the Policy and Public Affairs Officer for Scottish Trans, a transgender advocacy group based in Edinburgh. She and the organization conducted a research report last year that surveyed the experiences of 571 trans and nonbinary people across Scotland. A large chunk of this research uncovered a lack of understanding of trans healthcare within the NHS, and it featured the voices of many trans people who felt their care was inadequate.

“They don’t seem aware of trans healthcare,” said one respondent. “I have had to guide them through my needs.”

Another respondent said they were consistently dismissed during their interactions with medical staff, which resulted in insufficient treatment.

Oulds herself is a trans woman, and she said there are a lot of barriers that trans people in Scotland face that were affirmed by the survey.

“Pretty much all of the things we found out in that survey were pretty terrible,” she said. “It’s not a good picture for the community in Scotland.”

The survey was not limited to healthcare experiences. It also detailed the levels of homelessness, unemployment and experiences with discrimination that trans people in Scotland face.

“We had high rates of people out of work,” she said. “Lots of people told us about struggling to find jobs because of discrimination, and also leaving jobs they had before because of discrimination of their identity.”

Oulds attributed much of this disparity to misguided political discourse, which is heating up in Scotland following a ruling by the U.K. Supreme Court involving the definition of gender in the 2010 Equality Act. 

The Supreme Court announced on April 16 that the definitions of biology and sex in the Equality Act refer to one’s biological sex, or the sex they were assigned at birth. This was a landmark decision against trans rights in Scotland, as it essentially declared trans women are not truly women and trans men are not truly men. It meant trans people are not allowed to use single-sex spaces like bathrooms if they do not align with the sex they were assigned at birth. That led to controversy involving the female toilets at Holyrood, which houses the Scottish Parliament, and protests outside the building by trans people and advocates.

Oulds said legislative and judicial actions like this have fueled a negative public debate regarding trans inclusion in recent years. She is not the only one to have noticed this change.

Susie Green is co-founder and codirector of Anne Health, a private practice that offers gender-affirming healthcare to trans people of all ages, mainly via telehealth. She is the mother of a trans woman who sought private care in the United States, because, at 16, she was too young to qualify for trans care in England. She’s since spent the last two decades working in the realm of trans rights in the U.K. and advocating for trans voices. In the past several years, she has noticed a negative shift in the depiction and treatment of trans people in the U.K.

“We saw things start to get a lot worse, very quickly,” she said. “I found it really difficult to see their rights being rolled back.”

Green said that when anti-trans discourse is propelled by politicians and the media, it directly affects community attitudes toward trans people. She said that many of the harmful narratives about trans people are unfounded, based only in rhetoric.

“The narrative that has been sold with thousands of anti-trans articles has been to demonize trans people in the public’s eyes,” she said. “If you say something enough, sometimes people believe it.”

Green believes trans people in the U.K. deserve the same rights and access to healthcare that everyone receives. She saw how much gender-affirming care helped her daughter, and she wants all trans people to have the same opportunity for identity. During a TED Talk in 2017, Green detailed her daughter’s experience, noting her shift in character and mood before and after the transition. As she flipped through slides of her adult daughter smiling, confident in her own skin, she posed a question.

“She’s happy,” Green said. “Isn’t that all that matters?”

This story is part of a healthcare series produced by the International Reporting program at the University of Montana School of Journalism. Read more from this Scotland-based project, as well as reports from other countries, at Montana Journalism Abroad.