Tickbox diagnosis: can you measure trans feeling?

Nottingham Centre for Transgender Health are currently developing a “Gender Dissonance Severity Scale”.

Gender Dissonance Severity Scale

I can see why some practitioner-researchers might think this is a good idea. The clinical protocols at GICs such as Nottingham currently require trans patients to demonstrate that they can cope with living a “trans” life in order to access “irreversible” treatments such as hormone therapy. At present, this is demonstrated through patients’ adherance to the “Real Life Test”.

“[I]t is the view of many clinicians working in the field – including some of whom are transgender themselves – that living as their experienced gender allows individuals to test their gender identity in the real world before the initiation of potentially irreversible treatments […] transgender people who have poor social and interpersonal skills may be more likely to encounter difficulties when socially transitioning.. […] In order for an individual to be accepted for treatment, they need to socially transition first, which includes not only living as their experienced gender but also changing their name and most legal documents.

(Arcelus et al., 2017)

Wouldn’t it make life easier for clinicians though, if they could also ascertain whether or not their patients feel sufficiently trans?

Enter the Gender Dissonance Severity Scale, which aims to explore “how people feel about their gender, body and quality of life”.


What is being measured?

There are a number of problems with the concept of the Gender Dissonance Severity Scale. The most fundamental is the question of how far you can adequately and consistently measure feeling.

This is a particularly a problem for nebulous concepts such as “gender dysphoria” and “gender dissonance”. That these phenomena exist is not in doubt – many trans and non-binary people across the world can attest to the reality of dysphoric feelings in relation to our bodies and/or gender roles. But these experiences vary greatly from individual to individual, mediated by collective factors such as social context and culture as well as individual differences.

Moreover, dysphoria varies within people as well as between people. A person might feel less dysphoric one day, and more on dysphoric another – depending on factors such as where they’re going, who they’re seeing, how their bodies look, how their bodies feel. A person might feel more dysphoric, for instance, if their facial hair looks particularly thick, if they’re having their period, or if they’re about to attend an appointment at a clinic that assesses their transness. Or they might feel less dysphoric, for instance, if their hair looks great today, if their gender identity feels more aligned with their body, or if they’re about to attend an appointment at a clinic that might grant them access to hormones.

So any attempt to measure gender dysphoria or dissonance may be thwarted by the ever-shifting nature of the thing that is supposed to be measured. One person’s dysphoria can be another person’s euphoria. And a measurement that is “accurate” for a patient on one day might be “inaccurate” on the next.


Who is doing the measuring?

In recruiting participants to assist them in developing the scale, researchers based at Nottingham GIC have argued that the scale will help measure the “effectiveness” of treatment: i.e. how interventions such as hormone therapy and surgeries improve patients’ quality of life. This is no doubt an admirable goal, and will expand upon existing evidence that trans people benefit from having transitioned.

However, there is another proposed use for the scale, as described in the following excerpt from a request for research participants.

From the findings, we hope to develop a new outcome measure that could be used by GP’s to make referrals to transgender health services.

This is a very troubling proposal. It suggests that the Gender Dissonance Severity Scale could perhaps be used as a form of screening mechanism before trans patients are even referred to a gender clinic. Patients could perhaps be refused treatment altogether if they don’t appear to be “dissonant enough” according to the blunt measure of the scale.

Pre-prepared questionnaires are already being used to assess patient distress for those needing to access NHS mental health services through IAPT. Patients are often invited to answer questions on the phone, with access to services depending on how well they meet the questionnaire criteria.

It seems therefore that the Gender Dissonance Severity Scale could potentially be used as an additional layer of gatekeeping, reducing referrals to gender clinics (which are currently seeing a record number of patients) at the expense of those in need of care who happen not to meet the specific criteria of the test.


Subverting measurement

Of course, trans patients have a long-standing approach to dealing with barriers to care: we share information amongst ourselves, learning the “right answers” to give in clinical contexts. This is great for the individual trans person who wants to jump through the necessary hoops in order to access care, but an awful situation for clinical research, where supposedly firm findings might be built upon the decidedly shaky foundation of trans people making up the answers that they think clinicians want to hear.


Towards collaboration?

There is already a lot of mistrust between many trans patients and gender identity specialists. The development of flawed measures such as the Gender Dissonance Severity Scale may only compound this.

While Nottingham GIC does have at least one trans clinician involved in developing their research programme, they have yet to engage more widely with the trans research community. Moreover, few opportunities exist for clinicians to learn about their patients’ desires and interests outside of a context where they have a great deal of power over said patients’ healthcare. But these are issues that can be addressed: through better community outreach, communication, and collaboration, as well as reflexivity and humility on the part of researchers.

Psychiatrists plan transphobic conference

The Royal College of Psychiatrists’ Gay and Lesbian Special Interest Group (an organisation clearly well-qualified to meddle in trans affairs) are planning a delightful meeting in London next month.

Described as an “extremely stimulating meeting exploring the most recent academic, clinical and contemporary thinking on transgender issues, for all people interested in this field, Transgender: Time to Change will include contributions from a number of disturbingly transphobic speakers.

Let’s have a look at the programme for the day, shall we?

A meeting organised by the
Royal College of Psychiatrists’
Gay and Lesbian Special Interest Group
Friday 20th May, 2011
15 Belgrave Square, London SW1X 8PG

9.30am Registration

10.00am Morning session: Chair: Professor Michael King

10.10am Dr Domenico Di Ceglie: From Disorder to Diversity: Current views and controversies in the management of Gender Identity Disorder in Young People

10.45am Ms Julie Bindel There is no such a thing as a real woman (or a real man, for what matters). A feminist perspective on Gender Identity Disorder

11.20am Ms Christina Richards: Trans: What the empirical literature tells us

11.55am Discussion

12.30pm Lunch

13.15pm Afternoon session: Chair: Shawn Mitchell

13.20pm Dr James Barrett: Disorders of Gender Identity – what works

14.00pm Dr Az Hakeem: Deconstructing Gender and Parallel Processes: Features specific to a Specialist Transgender Psychotherapy Service

14.40pm Panel discussion – all speakers

15.15pm Finish

15.30 – 16.15pm GLBSIG AGM – all welcome

My, what a line-up. Where to begin?

The most obviously questionable speaker is Julie Bindel, a woman with a long history of transphobia. Bindel makes it her mission to subject trans people in general – and trans women in particular – to the very same treatment that she (rightly) decries as sexism when it is aimed at cis women. She has consistently argued against the provision of medical treatment for transsexed individuals. She has threatened to sue trans individuals and feminist organisations that dare condemn her damaging actions. What the hell gives her the right to comment on the psychiatric treatment of trans people?

However, Natacha Kennedy rightly points out that Dr Az Hakeem is considerably more dangerous. He runs a “specialist psychotherapy service for patients with transgender and other gender identity disorders” (source) at the Portman Clinic, meaning that he has a great deal of power over trans patients. Let’s have a look at what he has to say about us:

“The experience of many psychiatrists, psychoanalysts and psychotherapists working with transsexual patients is that they are individuals who, for complex reasons, need to escape from an intolerable psychological reality into a more comfortable fantasy. By attempting to live as a member of the opposite sex, they try to avoid internal conflict, which may otherwise prove to be too distressing.”

Regarding Hakeem’s approach to trans research, Kennedy points out:

There is so much wrong with Hakeem’s 2010 paper in which he claims to be able to ‘cure’ trans people it is hard to know where to begin. These kind of claims have been repeated throughout the chequered history of psychiatric engagement with trans people. His kind of treatment “talking therapies” as Julie Bindel calls them, “reparative therapy” being one of the many euphemisms employed by the “treatment has also been tried on gays and lesbians and been shown to fail, causing only feelings of trauma, guilt and suicidal tendencies.

His paper makes assertions for which he provides no evidence and his methods, selection of research participants and the nature of their participation in the study appear to be opaque in extreme. In addition there is no mention of research ethics which are particularly important when one is publishing research about individuals with whom one has a professional-client relationship.

Gosh. I’m sure glad this man is going to be sharing a platform with Bindel.

Who else do we have? Ah yes, Dr Domenico Di Ceglie. The conference blurb points out that he works for the Tavistock Clinic, a service that offers approximately sod all a very limited “service” for trans children and adolescents. Contacts of mine who have attended this clinic explain that therapists have patronised them, steered the conversation away from any real discussion of gender, and refused to offer treatment. Realistically, hormones are banned until you’re 18 for the vast majority of trans teens in the UK. Looks like you’re doing a sterling job, doctor!

James Barrett is a controversial fellow, to say the least. He’s deeply unpopular with some of his patients at Charing Cross, whilst others like him. He’s provided a great deal of help to many, but is a bit obsessed with the idea that people need to be in employment or education in order to earn treatment. He has been known to block treatment for individuals who have disabilities that prevent them from working.

Finally, we have Christina Richards, another Charing Cross psych. Shockingly, Christina brings the number of trans people speaking at this conference up to a grand total of one.

As a community, we shouldn’t simply let this pass. Most of these speakers aren’t just dodgy, they’re downright dangerous. We need to be asking the Royal College of Psychiatrists’ Gay and Lesbian Special Interest Group what the heck they think they’re doing, raising awareness of this travesty in the LGBT media, and if necessary picketing the meeting. If we let this go without a fuss then the vile propaganda of individuals such as Hakeem and Bindel will only spread unchecked.