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of whether the social stigma surrounding transsexualism could be relieved whilst ensuring treatment provision is not withdrawn in the process.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.

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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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On *the* Institution of Transgender Discrimination Within Healthcare

Anyone who’s read some of my earlier blog posts will know that I’ve a keen advocate of education of LGBT issues with in Medical Schools, as I feel early education – and thus the removal of ignorance – is an important and effective tool in the prevention of LGBT discrimination at the hands of doctors. I feel that the example that is set in the early years of medical education – as is the case in life – has a heavy hand in shaping the sort of doctors which are produced and, as such, it is hugely important not only that medical students are taught the skills and knowledge that allows them to be effective healers, but that it is done so in an environment free from prejudice and discrimination. In many ways, whether the attitudes held by staff – and especially senior staff – are explicit or more implicit is completely irrelevant as it still eventually sets the same negative example for young doctors, and nowhere is this issue currently more pressing than at Warwick Medical School.

In a story broken in tandem by TransActivist and NoMoreLost (both of whom have very different, but equally interesting takes on this story) it seems that Warwick Medical School have shown a pattern of transgender discrimination towards a student who has been consistently doing their best to assist the school in improving their record in terms of LGBT issues. Given the article which the school were so proud to have printed in a prominent medical journal earlier this year –  in which it is stated that they were discussing rectifying the lack of education given to their students on LGBT issues  – the irony that arises from is practically caustic. It seems that Warwick Medical School are keen to present themselves as LGBT friendly, progressive and anything other than transphobic to the public eye, whilst fostering an atmosphere which – according to students I’ve been in touch with – is hugely homophobic, ablest and generally unsupportive toward anyone less-advantaged or in need of assistance. This is, according to friends and colleagues, an attitude which they have held – and have failed students with – for a number of years, and one which doesn’t look likely to change any time soon.

So, what does this say for the Warwick Doctor? If a child were raised – or in this case educated – in an environment where discrimination is tolerated and support is, effectively, neglectful at best then what sort of adult would you expect them to become? Would they be emotionally healthy or stunted? Would the environment really get the best out of them? And, particularly important in the context of this article, would they know that discrimination – whether to an LBGT patient, disabled parent or (in the case of one colleague) a carer – is simply not acceptable?  At the very least, I feel it is fair to say that these adults would lack empathy, sympathy and as such not be the sort of person you would like to be shaking hands with on the way into the consultation room. Luckily for their students – and even more fortunately for NHS patients – they are not raising children, as else I fear social services would have a field day. It is probably important to point out that even in spite of this adversity the so-called “Warwick doctors” I have met are competent and hugely caring, but very few of them have anything positive to say about how their Medical School treats their students, and even fewer of them would say that the School sets an example which should be followed.

Whilst I am certain that Warwick Medical School are not alone in their failure in this area, I find this particular case of discrimination to be especially troubling since it appears to be the case that any other Transgender student who passes through their doors will find themselves subject to exactly the same heinous treatment. According to Elusia over at NoMoreLost, WMS are currently refusing to make changes to prevent further violation of the Equality Act 2010. This is particularly surprising at a time when, according to the most recent quality assurance visit conducted by the GMC, the school is currently undergoing a curriculum review; and so one would hope that they would be particularly open to positive change. Especially when Tomorrows’ Doctors – the document which governs the curricula of british medical schools – effectively states that a medical school must be able to provide evidence of addressing equality and diversity matters within  assessment covering (amongst other characteristics) gender identity [article 62]. As such, if this situation is as clear-cut as it appears to be, it is not only seems that Warwick Medical School are not only guilty of Indirect Discrimination under the Equality Act 2010, but that they are also failing to meet the requirements laid down by the GMC.

It is interesting to consider what the response of the Medical School might have been in the case wherein she had been required to undergo excision of a tumour as opposed to Sexual Reassignment Surgery [SRS]. If they had indeed agreed that in the case of an excision a reasonable adjustment could and should be made (i.e. in the form of an individual examination) then it would indeed be the case that Warwick Medical School are discriminating against transgendered individuals in their totality, but what of the opposite? Were no reasonable adjustment made here either (bearing in mind that transgender also counts as a disability under the definition of the Equality Act 2010) then it would be the case that Warwick Medical School are discriminating against injured, sick and disabled people in their totality. Not what you would expect – or hope to see – from an institution that hopes to train people to care for those very people it appears to be showing prejudice against.

Perhaps even more interesting to this is the current stance being taken by Coventry and Warwickshire Friend who are currently refusing to take sides in this dispute, stating as their reason that this has happened before with Warwick Medical School and as such they feel it would be unwise to get involved. Their trustees cite specific examples of  “a student who was diagnosed with cancer and had to take a temporary withdrawal but tragically died”, “another student being given the choice of either 2 weeks or a year to recover from depression” and numerous “students who make the choice to become pregnant have to also take a temporary withdrawal for a year”. I guess, Warwick Medical School are nothing if not consistent in their appalling treatment of students (not to mention the example they’re setting!).

Further to this is what appears to be a flagrant disregard for the student’s right to confidentiality on not one, but two occasions – especially given her status as transgender and the additional protection this grants to her under the Gender Recognition Act 2004. It goes without saying that confidentiality is hugely important within medicine since doctors are essentially strangers that we allow to be privy to the type of information usually reserved for those closest to us so that they might assist us with whatever our ailment may be. Confidentiality, and the importance thereof, is drummed into trainee doctors from day one, as is the fact that the breaching of that confidentiality – that inherent trust that is given to us based solely upon our position – is completely unacceptable (and, quite rightly, a disciplinary matter). The fact that a Medical School could set such a poor example to its students – even if we completely disregard the additional protection bestowed by the Gender Recognition Act – is completely deplorable and, quite frankly, the school should be ashamed.

Warwick Medical School have been asked for comment by numerous people at this point, but as of yet have refused to comment. Meanwhile, the GMC have responded, saying: “We encourage med students to contact us if they have evidence that their school isn’t meeting our standards”. Personally, I feel that it will also be interesting to hear what the GMC have to say about this matter is the student does indeed choose to get in touch with them; especially at a time when both they and the department of health need to be being seen as acting – and improving – on issues relating to LGBT discrimination.

 

Update 03/09/2012 = More on this topic here

 

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I intend to keep a list of articles on this subject below. Please contact me if you would like yours to be added:

Trans? Disabled? In need of surgery? Best to avoid Warwick Medical School – Writings of a Trans Activist

Discrimination? You Bet! What might you expect from Warwick Medical School – No More Lost

LGBTQ Summer 2012 Newsletter Supplement – National Campaign Against Fees and Cuts