From Psychiatry to Endocrinology – A social transition for Transsexualism?

The interplay between social factors and medicine has always been both complicated and fascinating, in that social opinion is influenced by medical interpretation whilst medical ethics, nomenclature and policy are driven by popular opinion. This is illustrated in how conventional therapies can be seen as ethical violations when viewed in retrospect, or more poignantly in how Homosexuality was removed from the International Classification of Diseases in 1990 following sustained social pressure. Recently, the World Health Organisation has been experiencing similar social pressure to remove Transsexualism from the ICD in an attempt to likewise achieve depathologisation.

Since individuals with Transsexualism do indeed require medical intervention, unlike their counterparts who define elsewhere within the LGBT spectra, the situation currently arising is too complex to be seen as a direct parallel to that of Homosexuality in the early nineties. If the World Health Organisation were to succumb to current social pressures, and so to the associated petitions being presented to them by the so-called ‘transgender community‘, this may indeed succeed in reducing the social stigma associated with the condition. However, it could also trigger the withdrawal of the treatment provision currently available to those individuals. The issue which therefore arises is that of whether the social stigma surrounding transsexualism could be relieved whilst ensuring treatment provision is not withdrawn in the process.

Social stigmatisation of mental health conditions is commonplace at present, and I can only speculate that a desire to move away from this label and the associated discrimination is at the heart of this campaign. However, there have also been calls from within the medical community for depsychopathologisation – specifically from the World Professional Organisation of Transgender Health (WPATH) – which is unsurprising given that there has never been a published report in either a psychiatric or psychotherapeutic journal of transsexualism or transgenderism being cured. Indeed, it is accepted by majority of authorities that “in almost all cases the only successful treatment [for transsexualism] is gender reassignment” (Pfafflen and Junge, 1998) – a process achieved through a combination of purely physical interventions. As such, the necessity of traditional psychiatric intervention within the treatment of Transsexuality is questionable at best.

At present, the role of psychiatry within the treatment of Transsexuality is akin to that of a safety net. The condition is affective in nature and so the diagnosis is one of exclusion, as opposed to being based upon empirical evidence or scientific testing. Indeed, it is the case that the psychiatrist merely excludes differential diagnoses whilst assessing patients for co-morbidities prior to referring them on to other specialties for physical intervention. In the absence of a more definitive method of confirming the diagnosis this is indeed essential, although continued involvement from the psychiatrist may be unnecessary after the completion of this initial process. However, at this point it is important to recognise that psychiatric and psychotherapeutic interventions are both distinct specialties in their own right, and whilst the involvement of a psychiatrist may be unnecessary, psychotherapeutic interventions might still prove beneficial.

So, if depsychopathologisation were to be facilitated through the reduction of psychiatric input, which specialty might be best placed to assume responsibility for these patients? Aside from the general practitioner, who is charged with the coordination of care, arguably the most important input comes from the Endocrinologist. Shortly after their initial psychiatric assessment, patients undergo hormone replacement to facilitate physical transition and, unlike the transient nature of the associated surgical intervention(s), this intervention continues throughout life. As such it is clear that the contribution of the Endocrinologist in the treatment of this condition is not only one of the most critical, but also one of the most enduring.

So, is there even any evidence to suggest that the medical community might be justified in revising the classification? From a clinical standpoint, a major advantage of this reclassification would be the increase to patient safety. At present, although General Practitioners are advised to monitor hormone levels through blood testing, many fail to do so and even more are uncertain as to what would be considered abnormal. Explicit guidance is made available to GPs, both through the WPATH and through booklets provided by specialist endocrinologists based at Gender Identity Clinics, but it can often be excessively time consuming to find the information required within these documents, or too difficult for the GP to interpret the data which confidence. Consequently specialist Endocrinologists are frequently consulted despite best efforts to make this information accessible.

Further to this issue is that of the of availability of treatment. The Engendered Penalties study commissioned by the Equalities Commission in 2007 found that as many as 1 in 3 GPs still refuse to provide treatment in the case of transsexualism, either due to their own prejudices or due to a gap in their own knowledge surrounding treatment protocols. This results in a postcode lottery based not on the availability of funding, but rather based on the attitudes of the doctors surgeries or individual clinicians from whom help might be sought. Whether this issue arises as a direct consequence of the known inequality faced by those with mental-health conditions in primary care is unknown, however it seems fair to say that, even within the medical community, changing attitudes towards transsexualism would be beneficial to those with the condition. Especially when the recent restructuring of the NHS means that GP commissioning bodies are now an inevitability.

Would this be achieved simply by the removal of the mental-health label? Naturally, disassociation from such a label would help Transsexualism to be seen as less ‘abnormal’ by the general populace, and thus closer to being perceived as part of natural variation rather than as a horrific ailment. Indeed, a number of cultures have developed centred around alternatives to the hetronormative, binary-gender system commonplace in the west and the differences in attitudes towards those who reject their assigned gender is striking. Not only do a number of these nations – most famously, Thailand – have innate, non-derogratory terminology in the common vernacular used to refer to these individuals, but they are even seen by outsiders to be a part of the national culture. Furthermore, the media have a positive attitude towards these individuals; newspapers will often print winners of female and ‘kathoey’ beauty contests side-by-side, and prominent figures in film, music and modelling are able to be openly Transsexual without fear of persecution. In fact, the reputation of such nations on their handling of such issues are such that many people, from what are traditionally seen as more developed countries, travel great distances to such places just to seek medical treatment. If a signifiant proportion of our patients are willing to go to such extreme measures to ensure that they are treated with dignity, respect and to get the quality of treatment they deserve then surely we should be paying greater attention to the policies of these nations?!

It almost seems fair to say that Trans* people within the UK are scared of their doctors, so much so that they actually feel the need to run away. This is unsurprising considering evidence which has consistently arisen in the form of direct quotes included in studies conducted into this area (see, for example, Engendered Penalties [2007] or the Trans Mental Health Study [2012]) but, more recently, also through social media. Twitter has become an increasingly powerful tool in the past few years for groups of people to share their experiences and disgust at failing systems, and this is particularly true in the case of the #transdocfail hashtag which sparked an article in the New Statesman and triggered further investigation by the GMC in the process. The stories shared show a pattern of discrimination, abuse and cruelty against those seeking help from doctors and other professionals within the NHS. A pattern which needs to be broken, and a pattern which surely warrants internal change.

This being the case, could it be that Transsexualism could find a new home under the umbrella of ‘endocrine conditions’? Consistently studies have suggested that the brains of those with transsexualism are anatomically different to those without the condition, which would imply that the condition might be better classified as a ‘Disorder of Sexual Development’ (DSD) similar to many intersex conditions, and so fall into the remit of endocrinology. Similarly the treatment methodology, which effectively centres around the correction of what some may consider to be an extreme hormonal imbalance mirrors that of other conditions found within this classification. Finally, and as previously discussed, the social ramifications of this change have the potential to completely revolutionise the way that the condition is seen both by the medical community and by the general populous. This alone has the potential to do more for the health and wellbeing of those with transsexualism than any medical intervention or breakthrough ever could, and if that is not reason enough in itself to plant the seeds of change then I, for one, do not know what is.

—-

The above essay was written by a friend of mine as an entry for the Society for Endocrinology’s Undergraduate Essay Prize. Both they, and the society, have kindly granted me permission to repost it here. I hope you found it interesting. 

– TransMedic

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20 comments on “From Psychiatry to Endocrinology – A social transition for Transsexualism?

  1. The linked petition very clearly does not propose to depathologize in a way that leaves anyone without treatment:

    “This doesn’t mean that we should be excluded from the health system: pregnant women are not sick, but they have medical protocols and assistance. The same should happen with trans people.

    The WHO should actively be developing a classification that allows trans people to get the medical help them need to transition without depending on a mental health diagnosis that serves to stigmatise them.”

    I wish people writing about this issue would stop attacking straw men.

    • transmedic says:

      Hey David-Sarah

      To some extent, I completely agree with you. In a completely ideal world transsexualism would be able to be declassified in its entirely and that would be the end of it. Treatment would still be accessible the world over, depathologisation would achieve – as is hoped – better social acceptance and less stigma, and it would indeed lead to a much better situation for all affected. The issue which arises with this, however, is that firstly we are in a time of austerity when – I think its relatively fair to say – a large proportion of the population (at least in the UK)_ would believe it is more than justifiable to cut off trans-healthcare in its entirety in order to save money. This is partially due to a lack of understanding as to the efficacy of the treatment, as well as the necessity, and partially due to inherent prejudices.

      The parallel that is consistently being drawn between pregnancy and transsexualism is a bit less clear than people within the ‘transgender community’ (sorry, I’m not fond of the term – hence the quotation marks) seem to be grasping. The care of pregnant women arose due to the high fatality rate during childbirth and so would better be described as falling under the remit of preventative medicine rather than a treatment in its own right. Since transsexualism does indeed require treatment (as opposed to ‘watchful waiting’) the same could not be said in this case; it [pretty much] always requires some sort of medical intervention be it from a psychiatrist, endocrinologist or urogenital/plastic surgeon. It is this differentiation between ‘preventative care’ and ‘active intervention’ (for want of a better descriptive term) which makes it more difficult to draw this parallel than people seem willing to accept.

      Again, I can completely see where you’re coming from and I wish that the situation were indeed simple enough that this could be the case. However, I believe that this particular straw man needs to be replaced with a more resilient idol.

      Thank you for taking the time to comment 🙂

      • I take the point that changes in diagnostic criteria carry risks because they could be exploited as an excuse for cost-cutting. However, the current situation is not at all acceptable; trans people suffer delays of years or more to access basic treatment, and this is partly because the gatekeeping is done by psychiatrists. Also, NHS “reform” is happening anyway, whether we like it or not. So no option to maintain the status quo is really available.

      • Henry Hall says:

        It is not depathologisation to say that a transwoman has no ovaries and is consequentially in need of estrogen therapy. Exactly the same as a non-trans woman who has no ovaries.
        Pathology diagnosis “ICD-10 Q50.0 Congenital absence of ovary” should be given to both.

        Equality is really not too much to ask for modernly. The key is to reassign the sex [u]in the medical records[/u] before treatment, instead of after treatment as at present.

  2. Henry Hall says:

    The situation is made needlessly confounded by vested interests who benefit from promoting fear, uncertainty and doubt. A transsexual person commonly apparently has no somatic abnormality when viewed as a member of their assigned sex. View as a member of the “other” sex then the somatic disfigurements are both obvious and profound.

    So it simply comes down to this – should we assigned sex to a person on the basis of scientific knowledge, of religion, or on the basis choosing the assignment that best promoted individual health? So the ICD solution becomes easy – introduce what is (in ICD-10 terms) Z codes that basically say – Z93.93 – Medically reassign to the “other sex” for reason that it promotes health to do so.

    Once that is done the somatic disfigurements are both obvious and profound and medical treatment is therefore indicated.

    That something promotes health in the professional opinion of the attending physician really should be all the justification that is needed. NOTHING MORE, and nothing less.

    But then is this were done the medical profession would be promoting health instead of science, business or religion. That has not happened with transsexual people in the past, their health has been promoted only as a last resort.

  3. Chen says:

    1. Those who require medical intervention do not necessarily identify as “transsexual”. Some genderqueer people who don’t identify as “transsexual” want varying degrees of “medical intervention” as well.

    2. Social stigmatisation of mental health conditions is commonplace at present, and I can only speculate that a desire to move away from this label and the associated discrimination is at the heart of this campaign.”

    I think we should fight against the social stigmatisation of mental health conditions in general, whether or not transsexualism is considered to be one.

    Some trans people have mental health conditions too which are not intrinsically based on their trans status. And frankly sometimes there is prejudice against mentally ill people within the trans community as well.

    3. “Not only do a number of these nations – most famously, Thailand – have innate, non-derogratory terminology in the common vernacular used to refer to these individuals, but they are even seen by outsiders to be a part of the national culture.”

    I’m sorry to say this, but this is an over-romanticisation of the situation for trans people in Thailand. It’s true that traditional Thai culture is more tolerant of trans people than traditional (Christian) Western culture, but this does not mean trans people are fully accepted in Thai society and don’t experience significant prejudice in some ways. Furthermore, compared with the modern secular West, Thailand is actually lacking in some ways when it comes to trans rights, one example is that all trans people are considered to be “3rd gender” legally even if they are binary-identified and someone who is born male (or female) cannot legally change their sex, in modern Western countries like Britain you can do this. Even in “communist” countries like China and Vietnam you can do this (though it’s a lot more strict than in Britain). Also in Thailand all males are required to do military service, and since there is no legal change of gender allowed, technically trans women have to do military service as men as well. For obvious reasons many trans women choose not to do this, and because of this they are discriminated against in employment due to this “bad military record”.

    There is culturally much to admire in many non-(Christian) Western cultures which do tolerate trans people to some extent. Actually the (pre-European) Native Americans tolerated trans people much more than Thailand does. Even pre-Christian pagan cultures in Europe had some tolerance for trans people. But over-idealisation of the situation in Thailand for trans people is wrong.

    • Henry Hall says:

      >> Thailand all males are required to do military service, and since there is no legal change of gender allowed, technically trans women have to do military service as men as well.

      Not exactly. They are required to register for military service. Those who have no testicles are excused on medical grounds. Those who express a desire to be rid of their testicles get a period of time to make it happen. At the last published survey (2006) about 0.6% of putative males qualified in this way.

      • Chen says:

        Firstly, I do not believe in compulsory military service for everyone. Secondly, I think it is a form of gender inequality to only draft men. Thirdly, not all trans women want to have bottom surgery, and you shouldn’t consider only those that have had surgery as women in the social sense. (This should be trans 101 in the contemporary progressive West, no?) And there is also the lack of the possibility of a legal change of gender.

  4. ldsgender says:

    “populace” not “populous”

    Good article though.

  5. Henry Hall says:

    >> 2. Social stigmatisation of mental health conditions is commonplace at present, and I can only speculate that a desire to move away from this label and the associated discrimination is at the heart of this campaign.”

    It is a desire not to have a psychiatric diagnosis when there is no psychiatric disorder present.
    That obscenity is modernly now perpetrated on transgender, transsexual people and no others. It was formerly done by Joseph Stalin to equally awful political prisoners and by the NHS on homosexual people. It is a desire not to have vital somatic treatment held hostage to cow-like compliance with unneeded and unwanted psychiatry.

    • Chen says:

      Objectively I do not think transgenderism is a mental illness. I also agree that modern Western psychiatry has certain problems and issues. However, trans rights is not the only thing I care about. I also believe in the rights of people who have mental illnesses. I think it is discriminatory to socially stigmatise mentally ill people, and this is just as bad as transphobia is. I do think that some trans people do have prejudices (sometimes implicit) against mentally ill trans people (to clarify, I’m not saying you or anybody else in this thread is guilty of this). Transgenderism itself is not a mental illness but trans people being human can still get mental health issues like anyone else which are not intrinsically related to their trans status, however transphobia can make the symptoms worse and psychological conditions can also make transphobia worse. On the other hand, I can also see how separating Transgenderism from mental illness can potentially benefit trans people with mental illnesses as well, because actually confusing the two together is good neither for gender transition nor for treating the psychological condition. In some places people with mental health issues aren’t even allowed to transition, and this is certainly at least partly due to confusing the two together.

      My point is essentially that one should not simply accept that the social stigmatisation of mentally ill people is a given fact of life that cannot be changed. This is a bit like how some gay people say since gender-variant people will always be discriminated against, then we don’t want anything to do with them. Of course gay and trans are two different things, just like trans and mental illness are two different things, but fundamentally we should care about the rights of all people. There is a saying: “my feminism is intersectional or it’s bullshit”. Similarly, “my trans activism is intersectional or it’s bullshit”. I don’t believe in any kind of “single-issue activism”.

      • Elusia says:

        I think it important, as you say, to “not simply accept that the social stigmatisation of mentally ill people is a given fact of life that cannot be changed.” … However, I also feel it important to consider that if there IS social stigma, then a group of people who do not belong to the stigmatised group in reality should not be attached to it for convenience. Put another way, ALL social stigma regarding mental illness is undue and is wrong… but it is doubly so for a group who don’t have mental illness to be forced to endure it.

        With that said… the terms man/woman, male/female, sex/gender are easily confused, but regarding a suggestion mentioned earlier, “congenital absence of ovaries” is never going to be an appropriate diagnosis, medically speaking, even in the case that someone formerly assigned as male is immediately accepted as female upon their say so… to do so would be unscientific and thus medically unsound. Such a diagnosis would ignore a whole medical history, and like it or not, that history can be important. To make such a diagnosis without ignoring that history would be disingenuous and clinically unsound.

      • Chen says:

        Elusia, see my other reply. As a trans woman who has a history of mental illness (though not suffering from such at the moment), I do agree that Transgenderism should not be labelled as a mental illness, because conflating the two is not good for my mental health, if nothing else. However, personally I find it impossible to not care about mental health rights due to my personal history, unless I deliberately live in a state of self-denial. I simply cannot just care about trans rights in isolation. And since I am trans as well, I’d hope that my trans sisters and brothers can offer some solidarity, rather than just say “mental health rights aren’t really our business”. As I pointed out, you should realise that actually not labelling trans as a mental illness is good for trans people with mental health issues as well, because mixing the two together is not good for mental health treatment. We do have a common ground to build solidarity on here, trans people with mental health issues (or a history of) and trans people without.

      • Elusia says:

        I would agree, Chen. Mental health issues are not alien to me, either. However, I believe that mental health issues and the associated stigma should be everybody’s business. I am just pointing out that it it doubly wrong to artificially make them the business of trans people particularly without good reason.

  6. Henry Hall says:

    >> My point is essentially that one should not simply accept that the social stigmatisation of mentally ill people is a given fact of life that cannot be changed.

    Transgender, transsexual people do not have a dog in that fight. It is unfair to dump the stigmatization of mental illness on them merely because they are too weak to resist such abuse. They have plenty enough stigma to cope with already without a gratuitous heaping of an extra portion that does not belong. It is not their fight; let stronger people fight the stigma of mental illness. Worse, giving a psychiatric diagnosis while “Objectively I do not think transgenderism is a mental illness.” is – quite bluntly unethical. Yes, unethical.
    Why is the psychiatric profession still willing to do unethical things and pretend that it is OK to be unethical provided it facilitates needed treatment??

    >> “congenital absence of ovaries” is never going to be an appropriate diagnosis, medically speaking, even … to do so would be unscientific and thus medically unsound.

    Fundamental misconception there. Unscientific does not imply medically unsound. If medicine is still the art of healing and promoting health then congenital absence of ovaries is exactly what transwoman have even though the etiology of the condition is new. If transwomen are indeed women and they have no ovaries and never have had any ovaries then they have congenital absence of ovaries by definition.
    On the other hand, if medicine is no longer about healing and health but instead has become a branch of science then transwomen are men rather than women and there is no need to do anything about their health. And congential absence of ovaries is unscientific and thus medically unsound. I submit that medicine is (should be) the art of health, not the science of life.

    I hope you all see this point is crucial. It really is crucial to grasp that medical sex is not the same thing as scientific sex. And legal sex is different again. They are not the same things.

    • Chen says:

      Two things:

      1) I never said I actually agree with labelling Transgenderism as a mental illness in practice either. When I said “objective…”, I wasn’t just talking in the abstract.

      2) Do you understand the concept of “intersectionality”? You seem to treat trans people and mentally ill people as two distinct categories. Do you realise that some people can be both trans and mentally ill? (The mental illness not intrinsically based on being trans) And trans people with mental illness would face even more problems than a non-mentally ill trans person, just like trans people of colour would face more problems than white trans people.

  7. Henry Hall says:

    >> Do you realise that some people can be both trans and mentally ill?

    Do you realise that some transgender, transsexual people are NOT mentally ill? And yet their journey is not depsychiatrised in Europe despite the European Parliament resolution of 28 September 2011 that it should be. See
    http://www.europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//TEXT+TA+P7-TA-2011-0427+0+DOC+XML+V0//EN&language=EN
    especially Item 13 ” … calls in particular for the depsychiatrisation of the transsexual, transgender, journey, …”. If the medical profession refuses to put its house in order then eventually the lawmakers will do it.

    No-one proposes that transgender, transsexual people should be denied access to mental health services if that is what they want. But most do not want it.

  8. Chen says:

    I think you might have missed my point that I do not believe trans is itself a mental illness, but trans people like all other humans could still get mental health issues. In principle I actually support de-psycho-pathologisation of transgenderism partly because I do not believe mixing the 2 together is good for mental health treatment anyway.

    My point is that trans people with mental health issues and those without can actually form an “united front” around this issue, rather than saying that I don’t support the depsychopathologisation of transgenderism.

    • Henry Hall says:

      I”m glad we agree. As soon as psychiatry is removed from the process everyone (except the psychiatrists) will be happy.

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