1. Status of Gender Identity DisordersBy
Dr Deenesh Khoosal FRCPsych

2. Alternative title?
GENDER BENDERS

3. Terminology Used interchangeably: Gender Dysphoria
Gender Identity Disorder
Transsexualism

4. Definition
ICD:10 (WHO 1992) definition of transsexualism (F64.0)
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
A 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.

5. Differential Diagnosis
F64.1 Dual Role Transvestism
The 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.

6. Differential Diagnosis
F65.0 Fetishism
Reliance on some non living object as a stimulus for sexual arousal and sexual gratification e.g. texture – plastics, leather, rubber, garment etc.

7. Differential Diagnosis
F65.1 Fetishistic Transvestism
The 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.

8. Incidence
MTF 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)

9. Aetiology Unclear Hermaphrodites – historical, Hijras
Psychosocial – gender identity (pink for girls, blue for boys)
Genetic – Kleinfelter’s, Turner’s Syndromes
Environmental – gender roles (boys = hunter gatherers)
Childhood psychological experiences – outward expression of gender behaviour
Neuro developmental – atypical effects produce sex reversal in bed nucleus of stria terminalis

10. Pathway thought of as journey

11. Companions on Journey

12. Companions on Journey Patients themselves
Parents often want opposite birth gender baby
Parents often dress baby in opposite gender clothes
Games of opposite birth gender
Friends of opposite birth gender
Ritual destruction of hoarded clothes

13. Companions on Journey Patients themselves Teased/bullied at school
PE/games ordeal
Shower room ordeal
Profound confusion with puberty
Stealing clothes of opp. birth gender e.g. washing line
Getting caught by family

14. Companions on Journey Patients themselves
Attempts to assimilate e.g. job choice
Failed marriage (s)
Dressing persists in private
Going out fully dressed
Internet, U tube, Television etc.

15. Companions on Journey General Practitioner Assessment History
Physical exam
Blood tests
Referral to specialist services

16. Companions on Journey General Practitioner Liaison with others
Health issues e.g. smoking, diet, weight, alcohol, exercise etc
Blood test/blood pressure monitoring
General health reviews
Prescription/administration/monitoring e.g. hormones
funding

17. Companions on Journey General Practitioner
Lifelong monitoring blood pressure/blood tests
Lifelong hormones prescription
- administration
- monitoring
Health prostate
- breasts
Health issues smoking, alcohol
- diet, weight
- exercise

18. Companions on Journey Psychiatrist Assessment Diagnosis
“Gatekeeper to services”
“Right thing at right time”
Monitor real life experience
Support, counselling
Legal matters e.g. documentation, birth certificate
Holistic approach
Funding issues

19. Companions on Journey Style Therapist Deportment - standing - sitting
- walking
- social situations
Hair - styles
- wigs
Make up - foundation
- choices
Clothes - age appropriate
- occasion appropriate
Safety - personal
- public places
Feedback - 1:1 +/- group
- audio/video

20. Companions on Journey Support Voluntary sector
e.g. GIRES, Beaumont Society, WOBs, Mermaid
Statutory sector
e.g. Gender clinic groups
Information leaflets
Protocols for service delivery
Opinions and second opinion
Patient
e.g support
Group work
From families

21. Companions on Journey Speech Therapist MTF - raise pitch
- female type resonance
- telephone
- 1:1 +/- group work
- audio/video feedback
FTM - deeper voice

22. Companions on Journey Hair Issues MTF - hair removal
laser, electrolysis
- hair pieces
wigs, hair extensions etc
FTM - facial hair
- body hair

23. Companions on Journey Talking Therapists Psychologist,
Psychotherapist, Counsellors
For patient
For partner
For children
Preop, postop

24. Companions on Journey Endocrinologist
Prescription of hormones, oral, topical, IM
Blood Tests
Monitoring

25. Companions on Journey Employers - antidiscrimination legislation
DSS benefits
Legal change of name - declaration
- deed poll
GRP Gender Recognition Panel
- birth certificate
Gametes storage
- retrieval
- fertility clinics
Informed consent - patient
- significant other

26. Companions on Journey
ENT Surgeon
Laryngeal ‘shave’
Prosthesis

27. Companions on Journey Plastic Surgeon Facial surgery Rhinoplasty MTF
Breast augmentation
Body shape
FTM
Mastectomy
Nipple realignment

28. Companions on Journey Urologist/Plastic Surgeon
Gender realignment surgery
Informed consent
MTF - penectomy, orchidectomy
- vaginoplasty, clitoroplasty, labiaplasty, hood
- cosmesis
FTM - phalloplasty, urethroplasty
- scrotoplasty, testicular implants
Gynaecologist
FTM - hysterectomy, oophorectomy

29. Surgical Centres
London and new centre in Leeds

30. Leicester Gender Identity Clinic
Programme Directors: KHOOSAL, Deenesh, Psych TERRY, Tim, Urologist
Location: Leicester General Hospital (UK)
Nuffield Hospital, Leicester (International)
Date clinic was founded: 1994
Total male to female procedures: 517
Total female to male procedures: 42
Total orchidectomies: 62
No. of publications: 10
Date Gender Governance started 1998

31. G3 Gender Clinics Belfast Edinburgh x Glasgow x Leeds Leicester
Newcastle
Northampton
Nottingham x
Sheffield
York

32. What do user’s value (local research)
1. Easier access to services
Fiscal constraints
2. Professional – GP, Specialists, Nurses
User organisations – GIRES
Carers
3. Early age for surgery
4. Reduction in long term post op complications

33. Characteristics of our service users (local research)
1. They tend to be perfectionists
2. Even more preoccupied than eating disorder patients about body image
3. Seek to acquire classical hour glass figure so no confusion can arise

34. Outcome FTM: 97% success rate MTF: 87% success rate
Green and Flemming (1990) Annual Review of Sex Research
FTM: 97% success rate
MTF: 87% success rate
Smith et al (2005)
98%: no regrets after surgery
91.6%: satisfaction with overall appearance
8.4%: neutral regarding overall appearance

35. The Perfect Transwoman ?

36. The Perfect Transman ?

37. The Reality ?

38. The Actual Reality Funding variables - post code lottery
Idiosyncrasies - some parts but not all
Funding cake – resource competition
Different processes – NICE/CCG/Local
Tx Guidelines – WPATH, UKStandards
Legal – IVF, Anti Discrimination laws

40. Conclusion
Shifting goalposts make patients and professionals very angry

41. Conclusion
Gender 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?