transition

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Business as usual? A look at the draft English protocol for gender dysphoria

The main achievement of England’s new draft protocol for transition-related services is not to offer progress, but to codify certain elements of existing practice.

In this sense, it somewhat resembles Scotland’s new protocol, which was published a couple of weeks ago.

The Scottish protocol appears to have been based largely upon the services offered by Sandyford, the nation’s largest gender identity clinic. The English protocol seems rooted in current practice at Charing Cross, which plays a similar role within England and Wales. The differences between the documents hinge largely on the differences between the progressive policies instituted at Sandyford, and the more conservative attitude of Charing Cross.

In this article I’m going to examine some aspects of the draft English protocol that have really struck me, before discussing political elements of difference between the English and Scottish protocols. I also briefly talk about the survey that is being distributed alongside the draft guidance.

The Good

Language – The language used within the draft English protocol largely acknowledges the complexity and diversity of trans experience. It encourages a respect for patient identities in terms of correct name, pronoun usage etc. (regardless of legal status). There’s even an explicit acknowledgement of non-binary identities, although this is somewhat undermined by binary assumptions elsewhere in the document, and a focus upon transitions that follow the typical “female to male” or “male to female” routes.

Referrals – The document provides some important clarifications for referral to a gender clinic: that individuals do not have to have lived in their preferred gender role prior to referral, that neuro-diversity and mental/physical health issues should not be a barrier to referral, and that psychotherapy is not a necessary precursor to referral. However, these points are not made as strongly as they could be, leaving some room for (mis)interpretation.

Treatment process – The document states that two appointments should be sufficient for a diagnosis of gender dysphoria (to be diagnosed according to the ICD-10 criteria, as opposed to DSM-IV). The prescription of hormones should (if appropriate and desired) follow this diagnosis, and surgery should follow within approximately two years. This might all sound very familiar to Charing Cross patients, but may work to reign in some of the more eccentric practices of smaller gender clinics such as Nottingham.

Overall – It will be beneficial to have this protocol at hand to bring local referral practices and the actions of smaller GICs in line with national standards.

The Bad

Referrals – Referrals must come from a GP or specialist (psychiatrist or psychologist), with clinics able to insist upon referral from a specialist. This means that long-winded battles for referral look set to continue as normal. In contrast, the new Scottish system appears allows individuals or GPs to refer to any clinic.

Treatment process – The protocol states that it is informed by the most recent edition of the WPATH Standards of Care. However, it seems (again, contrary to the Scottish protocol) to ignore large parts of the Standards of Care in favour of current Charing Cross practice.

For instance, FtM spectrum individuals must have been on hormones for at least six months and full-time for at least a year before top surgery is considered, and patients must wait at least two years before being offered genital surgery (although a referral appointment for surgery may take place after 18 months under some circumstances). This last point in particular is justified with reference to ICD-10. Interesting here that guidance for diagnosis from 1992 is given precedence over guidance for care from 2011.

Trans youth– There is an acknowledgement of the benefits of hormone blockers for under-18s, but (unlike the Scottish protocol) no real engagement with the possibility of hormones and surgery for trans people aged between 16 and 18. The protocol continues to relegate all young people to specialised – and limited! – youth services.

Overall – The document pays lip service to the WPATH Standards of Care but does not really live up to the spirit of those guidelines. This is particularly evident when the draft document is compared to the Scottish protocol. Patients are expected to put up with a long-winded, complex system in which treatment is spread out over many years.

The Ugly

Get a job – Patients are still expected to be in education or employment in order to gain a referral for genital surgery. If you don’t have a job or you’re not on a course, you’re expected to be involved in some volunteering role. It’s all about demonstrating your ability to move through the world in your “new” gender prior to irreversible surgery.

This requirement is patronising, stupid, and fetishises trans genitals. What other surgery requires that those who undergo it are in work? Why is it that genital reconstruction is seen such a massive step, but the permanent changes that come with long-term hormone therapy is not? Yes, surgery is a big deal, but it’s clear that clinicians regard this surgery as something else entirely.

I can’t understand how this can possibly be acceptable at the best of times, but at a time of recession and mass unemployment it strikes me as particularly cruel and unreasonable. How to account for individuals who cannot find a volunteering role in their local area? Individuals with anxiety issues? Individuals who are told by the Job Centre not to volunteer, with the threat of benefit withdrawal hanging over this order? And how can this possibly be acceptable when trans people face considerable inequalities in the job market (with trans unemployment estimated at 50% in some European countries).

Physical examination – GPs are apparently “expected” to perform a physical examination of trans patients. Why? No reason is given. The document simply states that: “The GP will be required to carry out a basic physical examination and investigations, as a precursor to those physical treatments which may later be recommended.”

I simply cannot comprehend where this idea comes from. For many trans people – particularly those contemplating physical transition – the very idea of a physical examination is extremely unpleasant and can cause severe distress. There are times when pre-operative trans people might require a physical examination: such as immediately prior to surgery, or during a sexual health check-up. These experiences can be deeply unpleasant, but at least they’re necessary.

GPs are not trained to understand the complexities of trans people’s relationships with their bodies. In fact, most GPs don’t receive any training on trans issues whatsoever. What are they meant to be looking out for during such an examination, and how are they supposed to know? An invasive examination such as this should only be performed when necessary, by someone who knows exactly what they’re doing.

Discussion: England vs Scotland

The headlines from the Scottish protocol included a number of moves to bring treatment more in line with the most recent edition of the WPATH Standards of Care. These included provisions for self-referral and referral by GP, less waiting time for surgeries, access to a wider range of treatments (e.g. hair removal) and full access to treatment for individuals aged between 16 and 18.

Whilst representatives from groups such as the Scottish Transgender Network played a vital role in putting provisions such as these on the national agenda, it’s important to recognise that many of them had already been implemented by Sandyford GIC.

The message seems to be that the English clinics – who are almost entirely responsible for the development of this draft protocol – are not interested in developing new practice, let alone conforming with the seventh edition of the WPATH Standards of Care. Instead, they seem keen to maintain a tight control over the processing of patients, an approach that renders the draft protocol even more strict than a new national commissioning policy that is being simultaneously developed.

Survey

The survey that accompanies the draft protocol is extremely short. This makes it quick and easy to fill in, but the form also seems to have been designed to shut down unwanted criticism. The Department of Health appears interested only in how current experiences match up to the proposed protocol, and seems keen to avoid any kind of critical feedback on the document.

It is, however, possible to offer you opinion on the nature of the protocol itself. Here are some tips for doing so:

  • Where your experiences differ from the protocol in a positive manner (e.g. you didn’t receive a physical examination from your GP), emphasise how your experience was more positive than would be the case should the protocol be implemented as-is.
  • Where your experiences differ from the protocol in a negative way, emphasise any manner in which you think the protocol could go further to ensure better treatment.
  • If you have sought care outside of the NHS for necessary treatments (e.g. hair removal for trans women) explain why this treatment should be a necessary part of the protocol

Final thoughts

The introductory text to the survey suggests that current political and financial pressures on the NHS prohibit the introduction of any real changes within the draft protocol:

DH wants the final document to outline the current position for transgender people seeking gender reassignment services through the NHS. The document should outline what support and services a transgender person can expect to receive in the tight financial constraints currently placed on the NHS.

This doesn’t really make a huge amount of sense. Yes, if more trans people have access to services (e.g. laser hair removal), this will cost money. But surely there is a lot more money to be saved through progressive reform?

Insisting on longer real-life tests, longer waits for surgery and so on won’t save a lot of money in the long term. A similar amount of trans people will be accessing services: they’ll just have to wait longer as individuals in order to access the a services. The money will still be spent. So why have such long waiting times?

Insisting on referral through a specialist (i.e. psychiatrist or psychologist) won’t save money. How does the NHS possibly benefit financially from insisting that trans people see more specialists rather than having them directly referred to a gender clinic by their GP? This is particularly the case when specialists decide that they need to assess people over multiple appointments before referring them to a gender clinic. The individuals concerned experience a frustrating delay, and it costs more money because the NHS is paying for all these extra appointments.

This isn’t really about the money. It’s about gatekeepers maintaining a certain level of control over patients, and putting certain ideologies into practice. It’s about picking and choosing which parts of ICD-10 and WPATH SOC 7 fit best with their pre-existing ideas, and using those elements to justify existing practice. It’s about conservativism over progression: a wasted opportunity.

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Have your say on England’s “gender dysphoria services”

Following hot on the heels of the new Scottish protocol for transition-related services, the Department of Health has published a draft guide for England.

They’re not holding a formal consultation on the document (meaning that it’s not available on the Department of Health website), but are “seeking the views of stakeholders […] to find out if the ‘journey’ outlined in the document reflects the experience transgender people actually have and, where there are differences, what they are.”

This is a really important opportunity for you to offer feedback on the proposed guide to English services.

A copy of the document is available below:

Gender Dysphoria Services – An English Protocol

When you’ve read the document, you can share your views through the following link:

Survey

I’m planning to post my own analysis of the draft protocol when I’ve had time to read through it properly.

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Passing as human in “Buffy”

I’m currently re-watching Season 5 of Buffy The Vampire Slayer and it got me thinking about how trans people are perceived by others. The link isn’t a particularly obvious one, I’ll grant you, but bear with me.

In Season 5 of Buffy, a new character is introduced: Dawn Summers, Buffy’s younger sister. Dawn quite literally appears during the first episode of the season, artificially inserted into Buffy’s life by some desperate monks. She is (or was) the Key: a ball of pure energy capable of granting access to a demon dimension. The other characters’ memories are changed to accommodate the idea that Dawn has always been a part of their life, and everyone perceives Dawn as a normal teenage girl.

Everyone, that is, other than those see things differently. On a number of occasions Dawn is approached by men driven mad by demon god Glory. “You’re not real,” they tell her. “You don’t really exist.” Buffy discovers Dawn’s “true nature” in a trance, and even Joyce (the girls’ mother) see that there’s something “wrong” with one of her daughters whilst suffering from the dehabilitating effects of brain cancer.

I thought about this just the other evening after I wandered into the ladies’ to check if a somewhat inebriated woman (who’d been in there for a while) was okay. It turned out she was fine and just about to leave, but she gave me a funny look as I walked in. “This isn’t the men’s, is it?”

I don’t think there’s a single trans woman who hasn’t had this experience, or something very similar. Many have to endure being misgendered every day. I’m very lucky these days: I suspect that I “pass” as a cis woman around 99% of the time. Still, that doesn’t mean I’m always gendered correctly: now and again, there are always those who mistake me for a man.

Those who misgender me are usually either drunk adults, or children. Some might think that sober adults are more likely to figure I’m trans and gender me correctly out of politeness, but I’m not convinced this entirely accounts for it. I’ve been misgendered a number of times in front of people who don’t know I’m trans, and they always greet such incidences with incomprehension and amusement. How could anyone be so stupid as to think I’m a man, they wonder? After all, I’m obviously a woman.

I figure that once you’ve assigned a gender to a person in your head, it takes a lot to overturn this. This is one reason why coming out is so hard for trans people, but it also tends to make life a lot easier for those who wish to successfully pass as cis women or men. Once people have got it into their head that I’m a woman, they tend to think that anyone who sees me as a man is mad.

In “Buffy”, people with mental disabilities perceive Dawn as different, as non-human. Buffy initially dismisses such people as mad and deluded. Drunks and kids aren’t (always) so harsh, but I do think that different ways of thinking affect the chances of perceiving something (or someone!) in a particular way. People who think differently seem more likely to see something in me that others can’t.

Here’s the catch. Dawn is percieved is non-human, but in actual fact she isn’t just passing as a teenage girl: she is a teenage girl. The monks altered memories and created a personal history for Dawn, but at the same time they made her flesh and blood. Buffy reassures Dawn that they are sisters: they share Summers blood. Dawn may not always have been human, and some can see this, but she now is human.

Similarly, the people who perceive me as male are misguided. They’re right in believing that there’s something about me that’s different, but they’re wrong in assuming that I’m therefore not woman. They see my transness, but can’t comprehend this. Sometimes I’m asked “are you a man or a woman”, but far more often my appearance is translated into “effeminate man”. To people who have always known me as a woman, this is very strange!

So there it is. “Passing” trans people are sort of like Dawn: the few who “read” us as trans tend to wrongly leap to the conclusion that we’re therefore not real (real women, real men, real humans, whatever)…but they’re so very wrong.

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(Guest Post) Turn and Face the Strange

The following was written by Louis, who recently experienced an appointment with “Dr Jiff” that unfolded pretty much as outlined.


“But let me tell you, this gender thing is history. You’re looking at a guy who sat down with Margaret Thatcher across the table and talked about serious issues.”
– George H. W. Bush

One morning, as I awoke from anxious dreams, I discovered that in my bed I had been transformed into exactly the same body as I had been the night before.

Examination of my whole organic structure proved this to be true, and as my mother greeted me normally in the kitchen, my feeling of de-centralised horror was crystallised. Most people, upon waking to find themselves the same, would find reassurance in the stability of their own identity – unchanged by the nights stargazing. To the average man or woman, the roaming of a well-gendered mind at rest is a pleasure. I, however, on that morning, realised that my unprecedented disquiet was the beginning of something. I was right. I have not been quite at home with myself since.

Psychology today is a noble hobby, halfway between a humanity and a science. I tend to lean towards the side of art.

On the 9th December, 2010, I find myself sitting in the office of Dr Jiff in University Hospital Coventry. It’s the psychiatric clinic. I’ve spent half an hour waiting outside, before being beckoned, with a smile, into this room, where I am to give the performance of my life. My part: Myself, as the National Health Service wants to see me. The office is large and sparse, with high, grey windows and navy blue carpet. It’s warm, however, and my chair is comfortable. Not a couch, but a plain lavender seat by the doctor’s desk. Dr Jiff himself is something of a surprise. After all I’ve heard, here is a man in his twilight years: rotund, moustached, with yellow sweat patches under his arms. A fair tie, mind you – M&S perhaps.

He has an affable face, and is delightfully frank in all things… though as usual for a psychiatrist, his eyes are mirrored walls. This is our first meeting. As I write, I expect many more: my performance this day is a surprising success.

To begin to understand the nature of my madness, I would first have to explain what madness actually is, in a social context at least. I’m sure you have your own ideas on the matter, but here’s my take on the state of things. Madness is a state of mind which society as a whole (or perhaps the ideal that society projects of itself, and never seems to actually get to) finds to be outside the bounds of “normal”. Sometimes madness is considered genius. Sometimes geniuses go mad. More often than not, madness is considered a rather dangerous or undesirable thing to have around. The more cutting amongst you may have noticed that I didn’t define what “normal” is. That’s because I truly have no idea.

In Psychology and Psychiatry, different kinds of madness are categorised and given different names. The name for my particular type of madness is Gender Dysphoria. It has an average occurrence, according to the NHS, of about 1 in every 4000 people in the UK – though it is important to note that these are only those individuals seeking treatment. Estimates have been made suggesting that 1 in every 1000 people may experience gender dysphoric feelings, or even 1 in every 120. Some psychiatric organisations have suggested that there are perhaps 500,000 gender dysphoric people in the UK, and 10,000 who have successfully asked for, and received, treatment. Statistically speaking, you’ve probably met at least 3 people with some level of gender dysphoria within the last 5 years of your life. Whether or not you were aware is a moot point.

The treatment of my disorder is seen with some contempt by the general populace – it requires the breaking of ancient rules of civilisation. This sounds more exciting than it really is. In day to day life, I’m perpetually astonished by how seriously people take gender labels, and how violently they will react against those individuals who wish to put their hand up halfway through the lesson, and say “Excuse me, I think you got that bit wrong.”

On the 19th of August 1992, a gender dysphoric person was removed surgically from its mother’s stomach and placed (screaming, purple and bloody) into the world, possessing all the appearance of female genitalia. Because of this, a somewhat tenuous, but deeply historic and traditional, social categorisation was made, and it was assigned the gender role of “female”. However, the gender label which it now identifies with, if it has to at all (and that is a whole other debate), is “male”. Some people interpret this in the following way:

“She wants to be someone else” OR “She wants to be a man.”

A gender dysphoric person find this degrading and frustrating. As far as they are concerned, they have always been the same person, and will always be the same person, in one form or another. I summarise the following:

“He is a man, and if society wishes to hang so much meaning and status on gender pronouns – a figment of language no less – then it can at least have the decency to let people identify themselves, rather than thrusting identity upon them at a stage where they can’t argue back.”

Dr Jiff’s office, on the 9th of December, is a pleasant change from the usual hostility. To begin with, he has assured me that there are “unlikely” to be any problems in my referral. I explain the issues I have had when trying to achieve this in the past, and he shrugs off the ignorance of some in his profession with a simple:

“Some people just don’t go to enough conferences.”

Then:

“Do you masturbate?”

(Don’t tell me that wouldn’t knock you off balance a bit.)

“Yes.”

“Any particular fantasies?”

“Hmm.” I pull the face which I always pull when planning to politely lie. “No, just generic men.”

(Really, I have an imagination.)

“How do you identify – put into words?”

“Gay male, polyamorous.”

“Do you dream in colour or black and white?”

“Colour.”

“How do you place yourself within your dreams?”

(I want to say ‘the victim’, but I don’t.)

“Omnipresent.”

“And male or female?”

“I don’t see.”

“Any suicidal tendencies?”

“Nothing unusual. I saw a counsellor, it’s all in my notes and over with.”

And so on.

This stream of banal, sometimes cryptic, often probing questions, will determine the course of the rest of my life. In the end I “perform” so well that I achieve the referral and more: a fast track to a new clinic, with treatment as good as guaranteed in 3 months. The gatekeeper has been defeated. Apparently, the land of maleness is mine for the  exploration, chatting-up, styling, drawing, eating, sucking, dressing, drinking, writing, injecting, rubbing, wanking, fucking, and taking. And the clothes. I’ll be able to wear a pair of trousers on hips that aren’t just-too-wide, and a suit tailored to fit a new figure – simple pleasures hard won. Why choose soft curves when you can have hard lines? I know which I find easier to follow. But I digress.

“What do you know about the surgical options?” Doctor Jiff asks.

“First you have to ‘live the life’ for 2 years.”

“Yes that’s right, how long’s it been for you now?”

“2 months. Facebook proves it.”

“Good. And what were you considering?”

“Phalloplasty looks generally crap. I want top-surgery though.”

“Yes. The success rates for breast reduction and removal are excellent. How big are your boobs?”

(I can’t describe the impact of words like ‘boobs’ leaving this man’s lips.)

“Small.”

“Well it will be a question of finding the right surgeon, but I can help you.”

“Thanks.”

“Phalloplasty, though, is a tricky one. In 2 years time when you’re eligible, things may have changed completely, but at the moment it’s a poor sport. What you really want is to be able to feel and to experience, which as things stand in the field is not particularly attainable, so unless you suddenly become desperate for a penis, it’s worth avoiding for now. I mean, can you have a really good orgasm with what you’ve got?”

“…Yes.”

“Then that’s good, and anyway, there are things you can do with a strap-on, especially anally, that just can’t be done by natural men.”

(It’s only after I leave the room that it occurs to me to laugh and laugh.)

The question of my sexuality is only mentioned in passing. I have heard several, interesting viewpoints on it. My good friend L___ was rather surprised when I suggested that there was any problem. “But 80% of the female population are straight,” he argued, “So surely 80% of transmen are gay? It’s just logic.” I thanked him for this excellent piece of reasoning.

Others, however, have been less supportive. The first psychiatrist I saw to try and obtain a referral was quite obstinate in her belief that a transman couldn’t possibly be gay, because all transmen must surely be lesbians who just couldn’t face up to their sexuality. “I like anal sex,” I told her, just for the hell of it. She didn’t appreciate that. Of course, there lies another minefield of debate: my under-eighteens counsellor pointed out that with my total lack of sexual  experience of any kind, how could I possibly know what I was attracted to? This, to me, seems like a rather foolish question, and leads me to assert a rather controversial fact:

Nobody knows a person as well as they know themself.

That point made, it is interesting to note the breadth of reactions that a trans or gender dysphoric person may receive in their exploration of this idea. Imagine meeting someone you have known since infancy for coffee. The two of you make small talk and enjoy each other’s company, then out of the blue, your friend tells you that they have to say something important: they are not really brunette at all, they are actually blonde. To the evidence of your own eyes, this is ridiculous, and you say so. No, they explain, the brown is dye. I’ve been covering this up for my whole life.

Of course, hair colour is a somewhat less mind-bending issue than gender, but the premise is similar. Imagine the same conversation, but instead your friend reveals that they are homosexual. This is slightly more controversial. To   someone like me it doesn’t matter at all, but of course to many people, this is a genuinely world-altering piece of information. Now, imagine your friend putting down their coffee cup, and telling you that they are actually the opposite gender.

Imagine walking away with that information in your mind.

Surely you know them better than that? Don’t you?

If you need to stick a label on them to understand them, do you really know them at all?

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I used to get angsty, but now I get angry

This post is part two of my response to misha the Duck of Doom, who commented on this post.

In the second half of her comment, misha wrote:

“Its easy. Why do so many of you lot {Angst transsexuals}
get in such a tizzy.
Frak, transitioning is dead easy.
So enjoy it

Also stop making it “the world is against me”
coz it isn’t.
TBH, most of the world doesn’t give a stuff & barely notices us.

So get a grip!
And don’t overcomplicate things.
It really is easy.”

I’ve come across various versions of this argument in different trans communities and in different parts of the net. It’s reflected also in the attitude of many cis people who decry identity politics, suggesting that we’d be more accepted if we piped down and stopped trying to claim special rights; after all, this is the 21st century and we’ve moved beyond the need to define people by particular traits they happen to have.

I don’t buy it.

The world is a very, very difficult place for many trans people. When I say “trans” here, I’m not just referring to transsexed people, but also to the wider spectrum and gender/sex diversity…cross-dressers, drag kings and queens, genderqueer individuals, transgender…what brings us together is that we’re all discriminated against for defying societal sex/gender norms in one way or another.

There are those, of course, who don’t have such a hard path. As misha says, transitioning (for those who transition) can be “dead easy” for some. In my case, for instance, I think I’ve been pretty lucky. Despite the fear, shame and guilt about being trans, I managed to come out in my teens, and generally had a good reaction and support from my friends and family. I managed to access most of the medical services I needed for free on the NHS, a process which took a mere six years with minimal incompetence on the part of Charing Cross. I’ve received relatively little direct discrimination: it’s very rare that I’m denied services or harassed on the street, and these occurrences have become increasingly uncommon as my appearance has changed. I’m very grateful for all of this.

I’m also highly privileged to have had such a smooth transition. It helps that I’m a white, abled, middle-class woman, but I’ve got lucky more generally. I had access to online support networks, meaning that I was able to come out to myself and understand my transness at a relatively young age. My supportive friends and parents mean that, unlike some of my trans friends, I didn’t get abused or kicked out of my home as a teenager or beaten up in the street. The fact I’ve always lived in a PCT that has a decent care pathway means I haven’t had to self-medicate, I haven’t had to wait over a decade to get through the medical system, and I haven’t had to threaten legal action to get treatment which is meant to be guaranteed on the NHS. The fact that I “pass” with ease means that my appearance doesn’t constantly mark me out as different.

This doesn’t mean that my path has always been easy. After all, I have been discriminated against, I have been harassed and insulted in the street, I have experienced extreme shame before coming to terms with myself, and I did have to put up with years and years on waiting lists whilst my body became broader and more hairy. I knew that until recently, it was perfectly legal to deny me access to shops and services.

Knowing that these experiences are pretty tame compared to what other trans people have to go through makes me pretty angry. If I shouldn’t have had to go through what I went through, then there’s absolutely no excusing what others experience. Trans people are likely to be discriminated against in every aspect of public life: when accessing services, in the workplace, during leisure activities and in the street. The attempted suicide rate is unusually high, and violence from others is common. Our identities are systematically erased in the media, which (when not portraying us as freaks) ensures that the only trans bodies that are ever seen are those of middle-aged, middle-class white trans women.

I have a good life and am generally happy these days. The positive benefits of transition have pretty much eliminated most of my angst. But I am so, so angry about the injustices committed in the world. I don’t want a complicated life, but I can’t stand by and let others suffer. I want to harness my rage, and use it to bring about positive social change. This is why I’m an activist, and it’s why I’m ready to take on the world.