Doctors are failing to help people with gender dysphoria

This has provoked some interesting responses.

The true incidence of gender dysphoria is very hard to assess. Population surveys, when done, give wildly different answers depending on the questions asked, of course, and many have been undertaken with the intention of demonstrating an unmet need for services.

Treatment for gender dysphoria has historically been provided predominantly by psychiatrists and psychologists because ‘transsexualism’ was considered a psychiatric disorder (although never an illness). The difficulty is that gender dysphoric people don't seem to be ‘psychiatric’ in any other way at all, having in common with homosexual people the disconcerting habit of being generally perfectly well.

Is this a minority rights issue, and nothing to do with medical practice; akin to other minorities, perhaps?

The difficulty with this approach is that the only useful treatments involve psychological assessment, endocrine prescribing, surgery, speech therapy and epilation. Definitely medical and paramedical stuff then, it seems, with exactly the same ethical and clinical responsibilities to apply. The informed consent Prof. Playdon espouses is exactly the same as that which applies in other areas of medical work; nothing can happen unless the patient wants it and also the practitioner personally believes it is in the interests of the patient. The exclusion of mental illness doesn’t mean that patients have a right to whatever they want, regardless of the view of the practitioner.

Further, treatment for gender dysphoria involves initial knowledge and skills from many disciplines but the addition of experience and training in this field. The endocrinologist or surgeons in a Gender Identity Clinic would know more about the psychology of gender dysphoria than would most community psychiatrists, the psychiatrists more of the endocrine or surgical aspects than most general endocrinologists or surgeons.

I am reminded of the Australasian Platypus.

The first specimens were dismissed as a joke of some sort.

But then more came, and alive and kicking at that. There followed a mighty taxonomological struggle. They were reptiles or perhaps some sort of bird, surely, as they were warm blooded, laid eggs and were venomous. On the other hand, the fur argued for mammals, but they didn’t have proper breasts, the defining feature of the mammals, and that business of being venomous is more of a reptile-like thing, is it not? And they do lay eggs...but warm blooded...perhaps a bird of some sort...?

In the end, it was all solved by everyone admitting that the Platypus was real, important, couldn’t be dismissed and didn't fit any existing category very well. It got its own, special category where it has paddled, very happily, ever since, albeit joined by echidnas and some long-extinct fossilised forebears.

Exactly the same pertains to those who treat people with Gender Dysphoria. Some of us started as psychiatrists, some as psychologists, some as endocrinologists or speech therapists and others as surgeons. What we have all become, though, is a Gender Identity Specialist with an origin in a particular discipline. We have all acquired the additional skills and experience we need, which lie on top of the general training in our original profession. My patient interviews are not ‘psychiatric’ (and, accordingly, it seems from Prof. Playdon’s point of view, automatically unacceptable regardless of content) just because I come from an originally psychiatric background. They relate specifically to gender dysphoria. My earlier training does enable me, though, more easily to exclude or take account of psychiatric problems.

Two other responders have mutated my concerns into an opportunity to promote their own, presumably profitable, remote, web-based practices. This seems to me to represent a dangerous distortion at best. A Gender Identity Clinic provides exactly the kind of skilled, multidisciplinary working and face-to-face assessment that produces the current excellent outcomes. On-line or telephone consultation might be a possible adjunctive addition for some patients already known to the clinic but could never be more than that.

I have some sympathy for Dr Luke, in truth. It does, indeed, seem that NHS England Specialised Commissioning blithely announced that prescribing would be done by GPs (and gamete storage undertaken at a CCH level, too) without actually confirming with the CCGs that this would be the case; Gender Identity Clinics are commissioned entirely on this basis. I suspect that it was assumed that there would be no problem. I have to disagree with Dr Luke by saying that I don’t think there should be. The more skilled work of assessment, both psychological and endocrine, gets done by the Gender Identity Clinic. Any GP asked to prescribe is being asked to do so in the context of a patient where all the risk-benefit analysis has been done by those with the experience to do it and who have made the commitment to be available for further consultation on an indefinite basis. The actual prescribing and monitoring is decidedly uncomplicated; for post-operative patients no more than four three-month prescriptions and an annual blood test (any abnormalities found can be discussed with the clinic). This is, surely, less demanding than very many conditions routinely dealt with in a primary care setting.

I am somewhat ashamed at some of the comments I hear from my GP colleagues regarding their role in trans care. The issues of 'not knowing enough' and 'not having enough time' are just indefensible, and in the current era of litigation-happiness, it will be interesting to see the results of such cases.

We are the ultimate generalists, and treating trans people should be just part of our every day bread and butter. Those who guide us (The GMC and NHS) have issued clear guidelines on what we should be doing yet doctors still feel able to refuse to do blood tests on patients wishing to start hormone therapy, or who are already taking it. They feel justified in not referring people to Gender Identity Clinics because they feel that trans issues are 'cosmetic'. They feel justified in not providing people access to medical support and guidance, because they 'don't know enough about it'.

Gender Variance is a condition where the birth gender does not match the individual's perceived gender. Gender dysphoria occurs when there is psychological distress because of this variance. I see far too many cases of dysphoria which are highly exacerbated by the medical profession, and the statistics of self-harm and suicide are spine-tingling. How much of this do we actively contribute to?

You don't need a mental assessment before you are allowed to marry your life-long same-sex partner, you don't need a mental assessment if you are born female and would like breast enhancement, you don't need a mental assessment if you ask for an HIV test because of your intra-venous drug use. But if you are trans it seems you might do, and so many patients tell me of the discrimination they face from the medical profession once they have mentioned the 'trans' word.

Our Gender Clinics are bursting, and with more and more trans people summoning up the courage to seek help, let's start helping them in Primary Care. We are good at it - every day we deal with patients' problems related to families, workplace and friends. Every day we are on the alert for severe mental illness which may be clouding judgement. Every day we prescribe hormone therapy and do tests to make sure hormone replacement therapy is as safe as possible. We are not talking about medication that is unknown to us, we are talking about medications such as estradiol and testosterone.

If we lack knowledge, we should seek it. If we have personal, ethical views then we should set them aside. Maybe we don't have 'time' to do it all, but to do nothing is wrong. Small steps go a long way to help this vulnerable group of patients.

References:

1. http://www.gmc-uk.org/guidance/ethical_guidance/28851.asp (accessed 8th April 2016)
2. http://www.england.nhs.uk/wp-content/uploads/2013/10/int-gend-proto.pdf (accessed 8th April 2016)

While Dr Barrett’s views are both timely and welcome, it seems ironic that a gender psychiatrist should give lessons on ethics to the rest of the NHS. In spite of recent calls from Amnesty International, the European Union, and the European Commission to depsychopathologise trans people, UK Gender Identity Clinics still generally coerce their patients into extended psychiatric treatment, often lasting for years, without consent, and in the absence of any identifiable mental health issues, apart from being trans. By contrast, in the USA, while support from psychotherapists and psychiatrists is available to trans people during their transition, it is not mandatory: the experience is that patients engage with mental health care in a much more productive way when it is elective and when they decide the duration of the encounters.

As Dr Barrett says, being trans never was a mental illness: it became one in the 1960s, when a ‘turf war’ between endocrinologists and psychiatrists was precipitated by the first Gender Identity Clinic, founded in 1962 at the University of California, Los Angeles, to ‘cure’ gay, lesbian, and trans people by conversion therapy. It was continued by falsified research published by Professor John Money at Johns Hopkins University – the infamous ‘John/ Joan’ case – in which he claimed to show that an accidentally penectomised baby boy was gender reassigned and settled into a female social role successfully as a child and adolescent: nurture, not nature, decided a person’s sex, and inadequate nurture could be ‘cured’ by psychiatry. That falsification was revealed by Professor Milton Diamond, at the University of Hawai’i at Mānoa, in 1997 (See bibliography attached and J. Colapinto. As Nature Made Him: The Boy Who Was Raised as a Girl. Harper Perennial. 2000).

Psychopathologisation in the 1960s and 1970s was accompanied by social exclusion and for fifty years, trans people have struggled to regain legal equality with other UK citizens, something that is still not achieved. For many of them, as their narratives at #TransDocFail show, their experience of Gender Identity Clinics was and continues to be one of psychiatric abuse of the right to informed consent that every other competent NHS patient enjoys. The hope is that the forthcoming new National Service Specification will transfer the management of services for trans people to physicians and will make psychiatric involvement as elective for trans people as it is for all other UK patients, not least to ensure the proper use of scarce NHS resources. The NHS has certainly been far from perfect in its treatment of trans people, as the need for new GMC guidance indicates, but psychiatry needs to scrub its own pots before being critical of everyone else’s kettles.