Introduction

In the last chapter I suggested that self-determination theory is a widely researched and an empirically evidenced theory of human needs fulfilment and motivation and offers a potentially valuable conceptual framework for understanding why the current policy environment has not led to the anticipated improvement in equity, quality and safety of clinical care with trans, sex/gender expansive and intersex people. I also looked towards a more sustained move towards patient-centred selfdetermination models of healthcare provision, regardless of whether that provision is privately or state funded.

In this chapter, I will look at how self-determination is affected by and affects medical self-governed institutions, the elevated professional and social position of physicians, and the UK's development of a patient-centred approach to healthcare. This will not be an extensive genealogy of the UK system as that is too vast a subject to do justice to in a single chapter. Margaret Stacey (1992) has written an excellent detailed analysis of the importance of the role of the GMC in the UK in relation to the protection of both physicians and patients. Although Stacey's book is almost thirty years old, it still holds much relevance in the ways that medical registering and physicians’ appraisals and revalidations have been and continue to be evaluated, and to some extent how the role of the patient/consumer functions (see also Quick, 2018; Gladstone, 2000). I will draw on some areas of contention that allow us to see some of the biopolitical assemblages that generate key forces in everyone's self-determination efforts related to health (Irving, 2008).

One key question I will address in this chapter is on what grounds are physicians given the role of arbiters of sex/gender declarations at birth? The General Register Office started to register births, deaths and marriages in 1837 in England and Wales. Previously, baptisms, marriages and burials were recorded in poorly kept parish registers, which were maintained by Church of England clergy. With the establishment of a civil system it was hoped that improved registration of what were seen as vital events by the polity would help in the organization of voting, planning, taxation and defence, and protect property rights through the more accurate recording of lines of descent.