When British tattoo artist Eva Echo found the courage to come out as transgender, she quickly sought specialist medical care to help her transition. More than four years later, she is still waiting for her first appointment.

Echo, who is part of a potential legal challenge to England's National Health Service (NHS) over waiting times, said the delay left her "drowning" in gender dysphoria — the distress caused by someone's gender identity not matching their body.

"There's no way to tell where I am on the list or when I'm likely to be seen," said Echo, 41, who lives in Britain's second-largest city, Birmingham.