Trans health needs more and better services: increasing capacity, expertise, and integration
BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3371 (Published 08 August 2018) Cite this as: BMJ 2018;362:k3371Gender dysphoria: assessment and management for non-specialists
I am your trans patient
Long term hormonal treatment for transgender people
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Dear Editor – thank you so much for including an article on the subject of Transgender Health Care in the BMJ of 18-25 August 2018. I am a GP with no special training in this area, but two close family members of mine are in this situation. Everyone needs to appreciate what an extremely distressing condition this is, for the person at the centre and their families. It is not necessarily connected with an underlying mental health problem. It can take many years for the person to come to the realisation, and then at that point they feel ready to take action, and are met with an equally distressing waiting time for specialist service. Even in Specialist centres, there seems much delay and organisational difficulties. GPs have, however, received some guidance about prescribing. I agree that a community based service may work well for continued follow up and monitoring, but only if first of all, the patient has been seen by a specialist and a management plan made.
Yours sincerely,
Competing interests: No competing interests
Why has there been a 240% increase in referrals to gender dysphoria clinics over the past five years?
I know one of UK's first transgender clinics was being held at Charing Cross Hospital London in the 1970s. Although use of oral contraceptives began in the 1960s, oestrogens had been given during pregnancy to women since the 1940s for over 80 "reasons" The carcinogenic and teratogenic effects of DES - diethylstilboestrol were given widespread publicity as has the adverse effects of environmental oestrogens on fish and male sperm counts. However the increasing use of powerful long-acting progestogens has been welcomed irrespective consequences as has the use stimulating hormones for, often repeated, IVF attempts. Also progesterone is often given during pregnancy but no one seems to be counting the costs to the children..
My academic lectures are included in my website www.harmfromhormones.co.uk
Competing interests: No competing interests
When exactly did the medical profession start to believe that gender is a fluid concept, or that you could be trapped in a body of the opposite sex?
Historically sex and gender have refered to the same thing.
Sex is determined at birth and is immutable.
Think otherwise? Prove it.
This is not scientific.
How can a medical profession believe such things and maintain its integrity?
When we pursue such an attack on gender as a fixed thing we attack what it means to be human. We need to see what we all stand to lose.
Once again where is the proof that sex can be wrong, or change?
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What will happen to doctors who cannot go along with this?
Competing interests: No competing interests
A recent feature (1) implies workforce development and new services will improve transgender healthcare. It is important to address capacity and so reduce distress caused by current services’ waiting lists as well as providing sensitive services for those who decide not to pursue treatment, who regret treatment or who detransition.(2)
However, the article does not question the steep rise in referrals, especially of girls, to gender identity clinics (GICs) nor concern itself with potential harms of self-diagnosis and prescribing, or medical over-diagnosis and over-treatment. Comprehensive services must be commissioned locally before ongoing, costly, life-changing interventions and life-long medications are provided after discharge from specialist clinics, and risk:benefit must be understood. GPs are portrayed as reluctant to engage, and yet the BMA General Practitioner Committee (3) is clear they should not be expected to provide ‘bridging’ prescriptions for those who have started taking internet acquired hormonal medication without specialist support.
Proposed ‘terminology’ may mislead and fudges the reality of biological sexual dimorphism. Sex is not “assigned”, but determined at conception and in early embryonic life. Biological characteristics of male and female have “historically” been observed at birth and likely this will continue. Sex should not be confused with gender - a social construct. Although internal subjective identity, legal status and external appearance can change or be re-aligned, a person’s underlying biological sex cannot.
The absence of robust independent evidence of the type normally expected by the BMJ when contemplating significant medical interventions was disappointing. “Diagnosis” is portrayed as a straightforward application of criteria which then leads to treatment, with little understanding of why people seek help. Research is needed to explore the interplays between gender dysphoria, mental health problems, autism spectrum disorders, sexual orientation and unpalatable roles in our highly gendered society.(4) More understanding is required into the complex interactions between autogynephilia (a male’s propensity to be sexually aroused by the thought of himself as a female) (5), sexuality and sexual preference, male to hyper-sexualized female transgenderism, and hormonal or surgical treatment. Good Medical Practice requires doctors both to discuss uncertainties about the effects of treatments (6) and also to work with trans communities to create new knowledge together.
The national reconfiguration underway provides a one-off opportunity to embed research, including trials for key uncertainties such as supportive wait-and-see versus intervention strategies for young people, to learn more about the impact of using categorical diagnoses and providing irreversible hormonal and surgical treatments. High quality independent mixed methods research should be used to explore the different ways of conceptualizing and making an assessment, formulation or diagnosis. Medicine needs to be held to regulatory and ethical standards (such as ‘first of all, do no harm’), rather than allowing a system where healthcare professionals simply respond to client expectations.(7) A survey of doctors could helpfully highlight this important issue and describe physicians’ views.
While the proposal to measure outcomes and experience of those receiving interventions is to be welcomed, there is a vital opportunity, and ethical imperative, to create an ongoing cohort study for all those referred, so that outcomes can be measured at a population level over time. We disagree with the campaign group Action for Trans Health’s claim that ‘the continued existence of GICs amounts to wilful abuse of trans people’.(7) People who are questioning their identity or see themselves as transgender should have access to high quality joined-up and person-centred healthcare based on good evidence. Creating that evidence to inform quality standards is imperative.
References.
(1) Trans health needs more and better services: increasing capacity, expertise, and integration. BMJ 2018;362:k3371
(2) https://www.theatlantic.com/video/index/562988/detransitioned-film/ (last accessed 16 August 2018)
(3) https://www.bma.org.uk/advice/employment/gp-practices/service-provision/... (last accessed 16 August 2018)
(4) Lawrence A. (2011) Autogynephilia: an underappreciated paraphilia. Adv Psychosom Med. ;31:135-48. doi: 10.1159/000328921. Epub 2011 Oct 10.
5) Chew D, Anderson J, Williams K, May T, Pang K (2018) Hormonal Treatment in Young People With Gender Dysphoria: A Systematic Review. Pediatrics 141 (4) e20173742
6) Littman L (2018) Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports. PLoS ONE 13(8): e0202330. https://doi.org/10.1371/journal.pone.0202330
(7) https://actionfortranshealth.org.uk (last accessed 16 August 2018)
Competing interests: No competing interests
We agree with Torjesen that we need increasing capacity in gender dysphoria clinics, as many practicing clinicians have limited knowledge in this area.<1>. We would also like to see better guidance on referrals of trans health patients to inpatient services. Gender dysphoria clinics are a special service which is not available in every geographical region. When trans health patients require urgent in-hospital consultations, such as management of hormone therapy adverse effects and post-operative complications, where should they be referred to? Gynaecology, plastics, urology, psychiatry, endocrinology, general surgery or medicine? These patients cannot be immediately referred to the gender dysphoria clinics which are not always nearby and available 24/7. This confusion is especially problematic when emergency department physicians desperately look for admitting services for these patients in the middle of the night.
The admitting service physicians could argue that they have no experience managing trans health patients, and thus decline to admit them. But we cannot simply keep patients in the emergency department until the gender dysphoria clinics are open. Not only do we need better availability of gender dysphoria services, but also, we need to enrich the knowledge and experience of physicians, regardless of specialties, on management of trans health patients.
References:
1. Torjesen I. Trans health needs more and better services: increasing capacity, expertise, and integration. BMJ. 2018;362:k3371.
Competing interests: The authors have been paid for working as physicians, but not for writing this letter.
Re: Trans health needs more and better services: increasing capacity, expertise, and integration
We recently conducted a service improvement project in the North West of England and, during the course of the project, learned a lot about transgender health from the literature, from service providers and from trans people aged over 50 who spoke with us. We were interested to read the recent article1, which refers to “gender dysphoria” and “gender dysphoria clinics”. In order to access treatment for gender identity, trans individuals have, in the past, been required to accept a psychiatric diagnosis.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) uses the term gender dysphoria, which is defined as:
a difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning. It lasts at least six months and is shown by at least two of the following:
1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics
3. A strong desire for the primary and/or secondary sex characteristics of the other gender
4. A strong desire to be of the other gender
5. A strong desire to be treated as the other gender
6. A strong conviction that one has the typical feelings and reactions of the other gender 2
In ICD10 version 2016, code F64 applies to Gender Identity Disorders and lists the following disorders: transsexualism, dual role transvestism, gender identity disorder of childhood, other gender identity disorders, and gender identity disorder unspecified 3. Transsexualism is defined as:
A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex. 3
However, recently ICD11 has taken what is now called “gender incongruence” out of the chapter dealing with Mental and Behavioural Disorders and moved it to a chapter on Conditions Related to Sexual Health. The American Psychiatric Association has stated that:
It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition. 4
Trans individuals (and others) would argue that distress is associated not simply with gender variance but with many factors including stigma and prejudice, long waiting lists and difficulty in accessing services – the recent article1 refers to long waiting lists for treatment. Nevertheless, until the publication of ICD11 in 2018, people who experience gender variance have been given a diagnosis by western psychiatry using either ICD or DSM in order to access treatments for gender identity 5. Taking gender variance away from a psychiatric classification in ICD11 represents progress, but conflating gender with sexual health may introduce further complications.
The result of all this has been a complex relationship between mental health, mental health services, and identifying as trans. In 2018 should identifying as trans be taken in and of itself as indicating mental ill-health? Is it possible to diagnose mental ill-health in the same way amongst trans people as non-trans people? Trans people may be sensitive to suggestions that they are psychologically unwell and concerned that psychological symptoms will be attributed to their trans identity. Removing the assumption that being trans equates to mental ill-health may free people up to access psychological and other forms of healthcare if and when they need it 6.
And yes, we do need to improve services and older trans people who spoke with us felt that shifting more trans healthcare into primary care is key.
1. Torjesen I. Trans health needs more and better services: increasing capacity, expertise, and integration. British Medical Journal 2018;362(k3371) doi: 10.1136/bmj.k3371
2. American Psychiatric Association. What Is Gender Dysphoria? 2016 [Available from: https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-ge... accessed 13 March 2018.
3. World Health Organization. ICD10 online versions 2016 [Available from: http://www.who.int/classifications/icd/icdonlineversions/en/ accessed 13 March 2018.
4. American Psychiatric Association. Gender dysphoria. 2013
5. Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet 2016;388:390-400.
6. Witten TM. End of life, chronic illness, and trans-identities. J Soc Work End Life Palliat Care 2014;10(1):34-58. doi: 10.1080/15524256.2013.877864
Competing interests: No competing interests