1. Sam the Man Gender identity problems plus !

2. First contact ! We received the following letter

4. Second contact ! Then this letter

7. Formal referral Then the following in a letter from the CMHT.

8. Referral Deaf from birth Uses BSL ‘on the autistic spectrum’ Seen by National Deaf Services Age 31 Sister, 24, brother, 33. No early milestones available Deaf schools Living in supported accommodation

9. Gender development Felt different from age four Always wanted boys’ clothes Hated a skirt at school Liked short hair Hated pink – liked blue. Distressed at puberty Family allow her to live as a man Doctors ignore her requests for attention

10. MSE Interpreting difficult No obvious psychopathogy in terms of psychosis or mood disorder Copes independently, in the main Referred to local psychiatrist with an interest in GID He referred to GIC at WLMHT

11. Next contact ! We got the following letter

17. Seen ! Distressed from 7, when had to wear a skirt for school Last unequivocally female at sixteen Consecutive OCP to stop periods Also evening primrose oil Accepted as male Small circle of acquaintances No friends Looked androgynous, in shirt, tie and jacket. Bloods taken

18. Dealing with deaf patients Bright lighting for the lip readers Face to face contact One cannot keep notes One ought not to have a beard One ought to allow greater amounts of time

19. Seen for second opinion Came with support worker, herself deaf, but a lip-reader. Consent had been discussed, after the first appointment, and was elicited in front of me, as follows later.

20. MSE in the deaf Amplitude and vivacity = volume and tone Facial expression is 70% of the work FTD is hard to assess – BSL is agrammatical Clang associations are sign similarities Neologisms are new signs One can see stuttering The deaf may make sounds The deaf do not laugh or clap The deaf may experience auditory or BSL hallucinations

24. Examination Signing slow, and of poor amplitude Almost no facial expression when signing Poor eye contact I could follow little of it, despite Maketon Seemed to be autistic Aspirations to a girlfriend Not clear what this would involve as far as Sam was concerned Some sexual contact with a male, years earlier – not enjoyed

25. Outcome Felt to have primary transsexualism Felt also to be autistic Felt to be a good candidate for androgens Bloods were normal Detailed explanation given Detailed letter written to home team Hoots of appreciation

26. Review Now looks like a young Chris Evans Much more animated facial features and eye contact Signing of larger amplitude, but still childishly formed I could understand the signing Vocal pitch dropped. Hoots of appreciation of lower pitch. About to go on a trip to Longleat with male friend

27. Next Consider for bilateral mastectomy Consider prospects of paid work in computing