Transsexual and Other Disorders of Gender Identity

A Practical Guide to Management

James Barrett

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781315345130
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

For the vast majority of children acquiring speech and language skills is an effortless process. However there is a sizeable proportion of children for whom this is not true. Difficulties they experience may be associated with other conditions such as cleft palate or hearing loss or they may have no obvious cause. This book provides a comprehensive picture of the difficulties that occur when speech and language does not develop in the young child. Divided into two sections the first focuses on how such children should be identified and assessed. The second section provides specific insights into communication difficulties in different conditions. Each is written by an expert practitioner and is illustrated with specific examples. Based on best clinical practice and research-based evidence it is a practical guide fully referenced for those who wish to develop knowledge further. It is essential reading for all professionals who work with children particularly those who work in community settings.

1

Disorders of gender identity

James Barrett

This is a highly politicised area. It has been subject to the attention of political and sociological theorists, of radical activists and conservatives. It can be viewed in a huge number of different and sometimes sharply opposed ways.

One school of thought holds that people with gender identity disorders have always been with us. Expositions about the two spirit people of North America often follow such statements. This generalises out to the view that such states are part of life’s rich tapestry, and ought not to be medicalised. This seems to be anthropology at the expense of anything medical. It has much to commend it, although it is notable that those who propound it may still seek medical attention, often at the expense of others.

In stark contradistinction is the view that gender identity disorders represent a wholly physical problem, either in that every organ bar the brain is inappropriately of the other sex, or that there has been some kind of endocrine or birth anomaly. Proponents of this view seem to maintain that hormonal and surgical approaches are all that is required, and that the feelings that necessitate these interventions cannot themselves need attention. This viewpoint appears to be that of medicalisation at the expense of even a hint of psychologisation.

It ought not to be surprising that psychiatrists support the view that psychiatry has a central role to play. I am not a trained sociologist or anthropologist. My views may be seen as risible by many, and offensively wrong by others. For this I can only apologise and suggest that nobody can please everybody. I describe in the psychiatric section of this book an approach that seems to work acceptably well, and that has a track record in many years of practice, as well as in theory.

The other sections of this book deal with other aspects of the management of disorders of gender identity. Each has also been written by someone expert in their field and represents up-to-date practice. The approaches they describe presume that the patients have already been screened by competent psychiatric practice. Without this screening they will have, at the very best, only limited success.

2

Second opinions

James Barrett

The routine use of second opinions is so fundamental to the management of gender identity disorders that it has to precede almost all else.

There is often a ‘gold standard’ in the world of general medicine; frequently also an associated protocol. Either the sodium is over 120 mmol/l, or it is not. Either the titre of anti-double-stranded DNA antibodies is above the relevant threshold, or it is not. Not so in psychiatry. It shares with histopathology the quality of ultimately resting solely on individual judgement, despite all attempts to operationalise diagnostic practice. And psychiatrists and histopathologists show such high inter-rater and intra-rater reliability that, despite the lack of gold standards, numerically clear cut-offs and protocols, the whole show keeps on the road at least as well as do those of medicine and surgery.

Any diagnosis carries with it an associated prognosis. Because of this, time reveals the truth or falsehood of any histopathologist’s or psychiatrist’s diagnostic attempt. Widespread metastases suggest that the lesion was not benign after all. The relentless progress of negative symptoms suggests that it probably was not a transient drug-related psychotic episode.

No one is perfect, including histopathologists and psychiatrists. The former group use a complex system of cross-checked quality controls, taken from cases with known outcomes, to measure whether individual histopathologists make the neccessary grade. Psychiatrists do nothing of the sort.

I would argue that psychiatrists (and perhaps physicians also) need to be more like histopathologists. This might at the very least take the form of much readier recourse to a second opinion. At the moment, such an opinion is the right of every doctor and every patient in the UK NHS, but this right is very seldom exercised. It may please the cash-conscious service managers that this is so.

The management of gender identity disorders is one part of psychiatry where it seems to me (and to the World Professional Association for Transgender Health, Inc. (formerly the Harry Benjamin Gender Dysphoria Association)) that a high-quality second opinion is not just desirable, but rather is a necessity. The diagnosis of transsexualism leads to irreversible hormonal and surgical treatment. Mistakes are, in human terms if in no other, very costly.

If each psychiatrist managing patients with gender identity disorders were to get the diagnosis right 99% of the time, they would be doing very well indeed. If they appropriately referred patients for gender reassignment surgery 99% of the time, it would be an impressive performance. Yet, even if this state of affairs were to apply, still one in every 100 of these paragons’ patients would be wrongly diagnosed and correspondingly wrongly treated.

Imagine, now, that two of these superbly good psychiatrists worked together and only actively treated those patients upon whom they were agreed. The rate of misdiagnosis and inappropriate treatment falls to one patient in 10 000. It should now be obvious, if it was not before, why this is the best way to manage this group of patients. It might be a good approach to apply to lots of other sorts of medical and psychiatric problems, too.

Mathematical calculations of odds are one thing, of course, and the real world is another. This method will fail to work as suggested above if the first psychiatrist asks for a second opinion only in cases where there is diagnostic or therapeutic doubt. Personal reflection and history tell us that some of the most wrong decisions were very confidently made. Clearly, in a relatively low-volume system like a gender identity clinic, every major diagnostic and therapeutic decision deserves a cross-check.

Further, the cross-check must be just that. It cannot be simply a rubber stamp from someone who sees his or her role as that of agreeing with the first opinion. Nor can it be that of always agreeing with the patient without regard to the first or any other opinion. Rather, it has to be a frank and independent view based on data that are as unchanged as possible from that which gave rise to the first opinion.

I have worked in such an arrangement for years, and have found it both rewarding and supportive. Sometimes I disagree with the opinion of my colleagues. Sometimes they disagree with me. We are still on good terms, and I know they have saved me from making mistakes. I hope I have done them the same service.

In the case of a disagreement, a third party takes a view. If the third opinion is unable to resolve the diagnostic or therapeutic question, the patient is called for an interview with all of us at once – including the surgeons, endocrinologist, psychologist and speech therapist. This is a quicker decision-making process, which accordingly is usually more acceptable to patients. Often the patients seem surprised that we openly disagreed with each other, and more often yet they are surprised to learn that about four times in five patients get their preferred course of action after such a group interview. Usually these meetings arrive at a consensus, and a plan that everyone has agreed upon is a plan that everyone gets behind and pushes.

The World Professional Association for Transgender Health, Inc. (formerly the Harry Benjamin Gender Dysphoria Association) is clear that no one should be referred for gender reassignment surgery without a proper second opinion. It seems best that no one is commenced on hormones without getting the same degree of care. It seems unsatisfactory that only one person, no matter how experienced or well read, and particularly no matter how confident, should initiate hormone treatment. It is clearly even more unsatisfactory for exactly the same individual to subsequently refer the same patient for gender reassignment surgery, either unsupported or supported only by someone lacking the knowledge or inclination to disagree.

This approach brings with it logistical problems, of course. The need for second opinions requires either clustering of expertise or an increased amount of potentially problematic communication and patient travel. In contradistinction, from the point of view of health provision planning, it would seem better to scatter the psychiatric expertise evenly across the population.

I suspect that for very large and populous countries there might be enough patients to merit more than one clinic (east and west coasts of the USA, for example). Smaller but densely populated countries such as Japan might better be served by one centrally located clinic.

Major difficulties are faced by small and sparsely populated countries – the Republic of Ireland or New Zealand, for example. I suspect buying into the services of larger neighbours, either in toto or for second opinions and surgery, or perhaps teaming up with neighbouring small countries to make a joint service, might best serve countries of this sort.

For very large countries with discrete but widely separated densities of population (Australia, or Canada, perhaps) there seems, unfortunately, little alternative to the need for a good deal of travelling.

Part 1

The referral process and screening

3

Referrals

James Barrett

Referrals to the Charing Cross Hospital Gender Identity Clinic are accepted only if they are made by a community mental health team psychiatrist or psychologist, or the child and adolescent gender identity disorder services.

This was not always the case. Before the administration around funding referrals was introduced, it used to be that general practitioner (GP) referrals were accepted. There were considerable problems with this arrangement.

The first problem was that many GPs seemed unwilling to refer direct to a tertiary centre, no matter how insistent the patient or how appropriate the referral would have been. They might have been worried about accessing scarce resources without a supporting local psychiatric opinion.

The second problem was the reverse of the first. It was that of GPs who seemed willing to refer to a tertiary service regardless of the appropriateness or otherwise of the ensuing consultation. Sometimes the patient and assessing gender identity clinic were bemused by these sorts of referrals.

Because of these problems, referrals are now required to come from local psychiatric services and not direct from GPs. The arrangement seems to have worked. GPs seem not to be scared to refer patients on, and the frequency of bemused but otherwise contented transvestites, lesbians, gay men and acutely psychotic people has proved acceptably lower.

I suspect that since this policy was introduced there has been a generally increased awareness of gender identity disorders and the possibilities for treatment. If direct GP referrals were reintroduced, there might be no increase in inappropriate referrals. As it is, this filtration through local community mental health teams now serves also to satisfy the funding arrangements currently in force in the UK. For this secondary administrative reason, it is likely to remain in force for the time being. However, direct GP referrals might be appropriate in settings where either an even more centralised or a wholly privatised healthcare system applied.

A separate problem is that of patients who do not keep appointments, particularly a first appointment.

This had been a problem at the Charing Cross Hospital Gender Identity Clinic. Patients repeatedly confirmed that they would attend first assessment appointments and then failed to show up. Each time, they stridently asserted that the next time they would.

Of course, it was impossible properly to judge the motivation behind such behaviour without ever seeing the people concerned. From the content of the referral letters, though, it was suspected that many of these patients (who tended to be male) were mildly gender dysphoric individuals, who saw having an appointment at the gender identity clinic as a validating statement of some sort. It was suspected that their gender dysphoria might well have been so slight that simply having possession of a symbolic appointment letter was the only step they wished at that time to make.

Though such behaviour might be understandable, it nonetheless placed an unacceptable load on an overburdened system. Our response was to offer no further appointments in the event of either non-arrival or cancellation on the same day. Such patients now need to be referred again. The local psychiatric services are advised to explore the reasons for non-arrival and not to re-refer unless they are confident that the behaviour will not be repeated.

Similar approaches now apply to patients who fail to arrive at follow-up appointments or cancel on the same day. A further appointment is given only if the patient or their GP actively requests one. Two non-arrivals in a row require the patient to be re-referred by local psychiatric services as if they were a new patient, partly because so much time may have passed since they were last seen that there would be too much to cover in a single follow-up appointment.

Being a tertiary referral centre is being the last resort, as well as being viewed as a diagnostic paragon. There are strengths and weaknesses to these positions. One notable weakness is that this is definitely where the buck stops. One finds oneself interviewing someone who is six feet four and grossly overweight, ravaged by acne and looking like a nightclub bouncer. This is someone with a declared drive to change gender role and with little realistic idea of the difficulties that will be involved; someone who has already resigned from a forklift truck driving job and who has hopes of being a model (‘I’ve got the height, you see!’).

This person has already been seen by everyone else in the referral chain. Yet no one has explicitly said that there might be problems ahead. One wonders whether no one appreciated this, or whether no one had the courage to say so. Either way, it seems that it is often the role of a specialist clinic to impart mixed, if not frankly bad, news. The imparter is sometimes blamed for the unwelcome news.

4

Diagnosis

James Barrett

Taking a history

Taking a history in a gender identity clinic is much like taking a history in a general psychiatric setting, but with extra emphasis on sex and gender matters. What follows is my preferred practice. This is not to say that it is somehow fundamentally ‘right’, merely that it works for me.

Firstly, why is the patient here? What is the problem?

Responses to this can be informative, ranging from ‘I don’t know, my psychiatrist told me to come here’ through the rather stereotyped ‘I’m a woman trapped in a man’s body’ to ‘my soul is male but my body is female’. A high degree of concreteness and fixity on hormonal treatment sets the tenor for subsequent conversation. It suggests that there will be a low tolerance for suggestions of a delay to treatment on the grounds of a need for further psychological assessment.

Family is relevant in the usual sense – serious mental illnesses with heritability, transgenerational predicates etc – but also in the sense that gender identity disorders can run in families, and may be associated with homosexuality or transvestism in other family members. Accordingly, it is worthwhile asking if any family members are gay, cross-dress, or have a gender identity disorder. Lastly, this sort of family history can help reveal a partial androgen insensitivity syndrome (see ‘Chromosomal and hormonal abnormalities’, p. 51 and Chapter 12, p. 157)

Next, medical history

This is as standard, with particular concentration on anomalous pubertal development and any earlier surgery overtly or cove...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Preface
• About the editor
• List of contributors
• 1 Disorders of gender identity
• 2 Second opinions
• Part 1 The referral process and screening
• Part 2 The real life experience
• Part 3 Non-surgical treatments
• Part 4 Surgical treatments for born males
• Part 5 Surgical treatments for born females
• Part 6 Post-operative psychological follow-up
• Part 7 Legal issues
• Recent case law
• Afterword
• Index