3Terminology Used interchangeably: Gender Dysphoria Gender Identity DisorderTranssexualism
4DefinitionICD:10 (WHO 1992) definition of transsexualism (F64.0)A desire to live and be accepted as a member of the opposite sexUsually accompanied by a sense of discomfort with, or inappropriateness of one’s anatomic sexA wish to have hormonal treatment and surgery to make one’s body as congruent as possible with the preferred sex.The transsexual identity should have been present persistently for at least two years.It must not be a symptom of another mental disorder, such as schizophrenia or associated with any intersex, genetic or sex chromosome abnormality.
5Differential Diagnosis F64.1 Dual Role TransvestismThe wearing of clothes of the opposite sex for part of the individuals existence in order to enjoy the temporary existence of membership of the opposite sex but without any desire for a more permanent sex change or associated reassignment. No sexual excitement accompanies the cross dressing.
6Differential Diagnosis F65.0 FetishismReliance on some non living object as a stimulus for sexual arousal and sexual gratification e.g. texture – plastics, leather, rubber, garment etc.
7Differential Diagnosis F65.1 Fetishistic TransvestismThe wearing of clothes of the opposite sex principally to obtain sexual excitement. The creation of the appearance of a person of the opposite sex also occurs e.g. wig, makeup etc. Clear association with sexual arousal and the strong desire to remove clothing once orgasm occurs exists. Commonly precedes the development of transsexualism.
8IncidenceMTF 1:21000 (Wilson et al (1999) British Journal of General Practice)FTM 1:90000 (Van Kesteren et al (1996) Archives of Sexual Behaviour)MTF/FTM 3:1 (DeGuypere et al (2007) European Psychiatry)UK TS people (estimate from Gender Identity Research & Education Society 2004)
9Aetiology Unclear Hermaphrodites – historical, Hijras Psychosocial – gender identity (pink for girls, blue for boys)Genetic – Kleinfelter’s, Turner’s SyndromesEnvironmental – gender roles (boys = hunter gatherers)Childhood psychological experiences – outward expression of gender behaviourNeuro developmental – atypical effects produce sex reversal in bed nucleus of stria terminalis
12Companions on Journey Patients themselves Parents often want opposite birth gender babyParents often dress baby in opposite gender clothesGames of opposite birth genderFriends of opposite birth genderRitual destruction of hoarded clothes
13Companions on Journey Patients themselves Teased/bullied at school PE/games ordealShower room ordealProfound confusion with pubertyStealing clothes of opp. birth gender e.g. washing lineGetting caught by family
14Companions on Journey Patients themselves Attempts to assimilate e.g. job choiceFailed marriage (s)Dressing persists in privateGoing out fully dressedInternet, U tube, Television etc.
15Companions on Journey General Practitioner Assessment History Physical examBlood testsReferral to specialist services
16Companions on Journey General Practitioner Liaison with others Health issues e.g. smoking, diet, weight, alcohol, exercise etcBlood test/blood pressure monitoringGeneral health reviewsPrescription/administration/monitoring e.g. hormonesfunding
18Companions on Journey Psychiatrist Assessment Diagnosis “Gatekeeper to services”“Right thing at right time”Monitor real life experienceSupport, counsellingLegal matters e.g. documentation, birth certificateHolistic approachFunding issues
19Companions on Journey Style Therapist Deportment - standing - sitting - walking- social situationsHair - styles- wigsMake up - foundation- choicesClothes - age appropriate- occasion appropriateSafety - personal- public placesFeedback - 1:1 +/- group- audio/video
20Companions on Journey Support Voluntary sector e.g. GIRES, Beaumont Society, WOBs, MermaidStatutory sectore.g. Gender clinic groupsInformation leafletsProtocols for service deliveryOpinions and second opinionPatiente.g supportGroup workFrom families
21Companions on Journey Speech Therapist MTF - raise pitch - female type resonance- telephone- 1:1 +/- group work- audio/video feedbackFTM - deeper voice
30Leicester Gender Identity Clinic Programme Directors: KHOOSAL, Deenesh, Psych TERRY, Tim, UrologistLocation: Leicester General Hospital (UK)Nuffield Hospital, Leicester (International)Date clinic was founded: 1994Total male to female procedures: 517Total female to male procedures: 42Total orchidectomies: 62No. of publications: 10Date Gender Governance started 1998
31G3 Gender Clinics Belfast Edinburgh x Glasgow x Leeds Leicester NewcastleNorthamptonNottingham xSheffieldYork
32What do user’s value (local research) 1. Easier access to servicesFiscal constraints2. Professional – GP, Specialists, NursesUser organisations – GIRESCarers3. Early age for surgery4. Reduction in long term post op complications
33Characteristics of our service users (local research) 1. They tend to be perfectionists2. Even more preoccupied than eating disorder patients about body image3. Seek to acquire classical hour glass figure so no confusion can arise
34Outcome FTM: 97% success rate MTF: 87% success rate Green and Flemming (1990) Annual Review of Sex ResearchFTM: 97% success rateMTF: 87% success rateSmith et al (2005)98%: no regrets after surgery91.6%: satisfaction with overall appearance8.4%: neutral regarding overall appearance
38The Actual Reality Funding variables - post code lottery Idiosyncrasies - some parts but not allFunding cake – resource competitionDifferent processes – NICE/CCG/LocalTx Guidelines – WPATH, UKStandardsLegal – IVF, Anti Discrimination laws
40ConclusionShifting goalposts make patients and professionals very angry
41ConclusionGender reassignment is an acceptable option for patients who meet the criteria.Just as IVF is for couples wanting children.Govt has now clarified the latter, so why not for GID? Shouldn’t dividing the cake fairly be the issue?