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of whether the social stigma surrounding transsexualism could be relieved whilst ensuring treatment provision is not withdrawn in the process.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

There has been a lot of talk about the depathologisation of transsexualism recently, including mentions of a petition to the ‘World Health Organisation’ to have it removed from the ICD11. Interestingly, the trans community appears to be divided on the subject with many being behind the move as they feel that they are not mentally ill and so should not be treated as such, whilst others are against the move fearing the affect this might have on their access to treatment – especially those in countries with socialised healthcare systems (such as the NHS).

As both a healthcare professional and as a member of the transgender community, I am firmly against the depathologisation of transsexualism for precisely this reason. I feel that in a world where it is necessary to fight for treatment – as I did – despite the fact that it is included within publications such as the ICD and DSM, depathologisation would make it nigh on impossible for someone to access the care they need. However, I also do not feel that transsexualism (as it is currently called clinically) should be perceived as a mental illness.

There is an important yet subtle distinction between depathologisation and reclassification of the condition from psychiatric to another more suitable heading. Depsychopathologisation – as this process is known – has actually been called for by the ‘World Professional Association for Transgender Health‘, whilst outright depathologisation has not. Similarly, it is worth noting that several western governments have also already stated that they will no longer consider transsexualism to be a mental illness; most notably the British government in 2002, the French government in 2009, and the European Parliament in 2011.

It seems fair to say that progression is forthcoming and has been for some time. As such, as a community we no longer need to be asking whether we are getting anywhere, but rather whether we are heading in the right direction. Whilst it might be tempting to follow in the footsteps of our friends and allies within the Lesbian and Gay Communities by setting our sights on outright depathologisation, I fear this would be incredibly foolish. After all, although our communities face many of the same trials and tribulations there is a key distinction; we are seeking medical intervention as a consequence of our identity.

A number of people have taken to attempting to construct parallels between pregnancy and transsexualism, in an attempt to highlight the fact that medical intervention can be routinely given for something that is not recognised as a medical condition. Whilst I do not deny that pregnant women receive medical attention, it is important to note that this would be best described as ‘watchful waiting’ rather than ‘active intervention’. This is to say that the care given during pregnancy is preventative in nature, designed to bring down what has traditionally been a very high mortality rate. Meanwhile, the treatment given in transsexualism aims to correct a diagnosed underlying condition.

Pregnant people are provided with dietary advise, medical imaging and easy access to specialist practitioners so that any problems which might arise are caught early and dealt with. Additional treatments are reactive in nature and there is no definitive pathway in terms of intervention. In fact, I would go so far as to state that the treatment provided is not for the pregnancy itself, but rather for the numerous health conditions which are associated both with foetal development and with the additional strain which pregnancy puts on the body. This is completely different to the treatment of transsexuality in which – following the standard series of assessments – there is an almost standardised linear treatment pathway of hormonal and then surgical intervention.

So, why is transsexualism even classified as a psychiatric condition to begin with? The simple answer is that it’s not so much due to the condition itself, but rather the differential diagnoses which it needs to be distinguished from. In short, these can be classified into the two categories; intersex conditions and delusions. The former should be excluded by karyotyping* (i.e. chromosomal analysis) whilst the latter can only be excluded through psychiatric assessment. Since, from a clinical perspective at least, the intervention of a psychiatrist is required it would be sensible to classify the condition as being psychiatric in nature, in spite of a lack of evidence that this is the case.

I’m certain that a number of people reading this article will question why the intervention of a psychiatrist is needed at all. If I know – and am certain – that I am a gender other than that which I was assigned at birth, then why does this need to be confirmed by a member of the medical community? After all, a small number of hour-long interviews can never give a true representation – or even a representative cross-section – of the underlying cognitive processes of something as complicated as a human being. Especially with regard to something as subtle as gender dysphoria, or anything based on a complex amalgamation of nature, the products of socialisation and of the perception of both the self and of gender roles within society, right?

I feel that the role of the psychiatrist is largely misinterpreted within the transgender community. Yes, this might be down to individual experiences of psychiatrists who take a more domineering or controlling role than maybe they should, or even a general distrust of psychiatrists or doctors in general. However, the fact of the matter is that in the case of transsexualism the role of the psychiatrist is akin to a safety net. The issue with surgical intervention and, to a lesser extent, hormonal intervention is that the effects are [largely] irreversible and – as such – have the potential to do a great deal of harm if left without proper regulation. As such, it would a failure in the duty of care of the medical profession at large if this ‘safety-net’ was not in place. Although some might argue – and have experienced – otherwise, the role of the psychiatrist in the treatment of transsexualism should not be one of a gatekeeper, but rather that of a concerned ally assessing your certainty so as to ensure you do not do irreparable damage to your life. This might not be the case in all practice; but should be the case in best practice.

This places transsexualism in the unique position where it is a non-psychiatric condition which requires psychiatric intervention so as to ensure that the medical profession can still fulfil their ‘duty of care’ prior to involving the endocrinologist or urogenital surgeon. The obvious question which arises therefore is under which heading – if not psychiatric – should this condition be classified? Neurobiological? Endocrine? Surgical? Other? Moreover, which of these headings actually have distinct sections within the ICD?

Personally, I would suggest it be reclassified as a form of intersex condition. Yes, there may be no evidence to suggest that it should be treated as such but there is little to no evidence which would suggest it should fall neatly into any other category either; psychiatric included.

*In reality this is not usually undertaken due to the costs associated with karyotyping. Moreover, it could be argued that actually performing a karyotype would be a waste of resources since it would not affect the underlying dysphoria or alter the treatment pathway.
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Edited 21/10/12 to include references. Apologies for the delay – I was having issues with my internet connection.