Intended for healthcare professionals

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Trans health needs more and better services: increasing capacity, expertise, and integration

BMJ 2018; 362 doi: (Published 08 August 2018) Cite this as: BMJ 2018;362:k3371

Gender dysphoria: assessment and management for non-specialists

I am your trans patient

Long term hormonal treatment for transgender people

Rapid Response:

Re: Trans health needs more and better services: increasing capacity, expertise, and integration

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.

(1) Trans health needs more and better services: increasing capacity, expertise, and integration. BMJ 2018;362:k3371
(2) (last accessed 16 August 2018)
(3) (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.
(7) (last accessed 16 August 2018)

Competing interests: No competing interests

17 August 2018
Richard Byng
GP and Professor in Primary Care Research
Susan Bewley, Chair of Health Watch; Damian Clifford, Consultant Liaison Psychiatrist; Margaret McCartney, GP and freelance writer
University of Plymouth
Faculty of Medicine and Dentistry, Univeristy of Plymouth. N14, ITTC Building, Davy Road Plymouth Science Park, Derriford Plymouth, PL6 8BX