Status of Gender Identity Disorders

1. Status ofGender Identity Disorders By 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 15000 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. 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 Companions on Journey

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

18. 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 Companions on Journey

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. 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. 1.1. support Group work From families Companions on Journey

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

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

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

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

25. 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 Companions on Journey

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

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

28. 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 - cosmesis Companions on Journey

29. London and new centre in Leeds Surgical Centres

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

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 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?