ONTD Political

Why are NHS doctors are still treating trans people like they’re mentally ill?

2:44 pm - 11/17/2012

“You’re an attractive girl, why do you want to do this?”

“Do you ever wear make-up?”

“Are you domineering in sex with girls?”

The questions above come from a NHS psychiatrist.

On the receiving end, JR*, 23, polite, wide blue eyes, job in video production, started crying five minutes into the interview. She kept crying for the remaining hour and twenty-five minutes with the psychiatrist, a man in his fifties. Through other questions about why she had only got her hair cut short aged 19, whether her past relationships with women as a lesbian had been casual or serious, whether she was capable of forming lasting relationships, details of how she behaved in bed with them, and what age she’d thought she was gay, she had to explain the expression “gay scene”.

He asked me: ‘When did you cut your hair short?’ I said, ‘When I was 19’. You kept it long till then? Did boys come up to you?

It was harder to explain that having a short haircut was not the main sign of the creeping sense of misaligned gender that JR had begun to feel five years ago.

That particular techniques in bed didn’t mean that she wasn’t like a woman. And that issues of fashion, haircut even sexuality were in many ways irrelevant to the feeling of being in the wrong body.

“He wasn't rude at all,” JR said of the psychiatrist, “just coming from a completely different angle at every point.”

Well-intentioned, he seemed uninformed about transgender people, gay people and, to an extent, women.

The question about whether she was “domineering” in bed is a case in point.

“I said that I had generally been with more feminine women, but that I didn't associate being feminine with being passive” JR recalled.

Raising her worry that being more gender-ambiguous would affect her job prospects, JR got this reaction:

“He said: ‘No you don't have to worry about that. The only time that would be awkward is if a more senior male colleague made an advance on you and that might affect your promotion chances’.”

That interview was four months ago and JR was sent to the psychiatrist because she is transgender and the NHS sends all transgender people to psychiatrists.

Uncertainty about gender is still listed in the psychiatrist’s diagnostic bible - the Diagnostic and Statistical Manual of Mental Disorders (pdf) (DSM) - produced by the American Association of Psychiatrists and used globally.

The most recent NHS guidance states that being trans is not a mental illness, but the feeling of a mismatch between biological sex and gender identity, and the discomfort that comes from that. It is caused by brain development, they say:

The condition is increasingly understood to have its origins before birth. Research studies indicate that small parts of the baby’s brain progress along a different pathway from the sex of the rest of its body. This predisposes the baby to a future mismatch between gender identity and sex appearance.

Yet the institutions we have in Britain still route trans people through psychiatrists, and in many cases still treat them as though they are mentally ill.

“Psychiatrists often get asked to play a role in sorting out problems when other people can’t, and it’s not always very admirable,” says Christopher Cordess, Professor of Psychiatry at University of Sheffield.

“This sort of reference – when you have to go to a psychiatrist to get a signature – is society’s way of coping when it doesn’t know what to do but wants to keep a cap on something.”

He cites the case of abortion, also still “gatekept” by psychiatry.

“Psychiatry is horribly political.” said Cordess. “When I was training, homosexuals used to be referred to psychiatrists, now that’s slightly embarrassing.”

It was in 1973 the American Psychiatric Association declassified homosexuality as a mental health disorder.

And while the NHS is strapped for cash, changing attitudes doesn’t need to be expensive.

The 6,000 British people who are trans and who would like help for gender issues must first approach their GP, and then the GP must refer them to a psychiatrist. The psychiatrist refers them to a Gender Clinic where the patient can finally receive specific counseling, hormones, or if they wish reassignment surgery. The patient’s local Primary Care Trust must be prepared to pay for that place.

“We actually wrote a paper called ‘Not so much a care path.. more a kind of steeple chase’” said Christine Burns, activist and member of an Advisory Group on trans issues for the Department of Health. Each of the three players in the referral process can be obstructive.

Doctor training is one reason why. Christine says:

“Gender issues are treated probably less than one day in their whole medical training. There is a wide-spread attitude that trans people are so rare that you’ll never come across one. You get people who say ‘we don’t need to know about that because we don’t have any of those here’.

“That means you get people with unmet needs.”

Then there are the Primary Care Trusts who believe that trans people don’t exist.

“Some PCTs have not invested in enough places at the Gender Services Clinic” Christine says.

There are ten English regions with PCTs covering approximately four to six million people. Each of those will see 80-100 patients presenting to GPs each year. Some PCTs are not planning/ paying for enough places. You’ll hear things like ‘oh we don’t have those here’.

It is attitudes that Stuart Lorimer, a leading gender specialist in the NHS’s Charing Cross Gender Identity Clinic, wants to change:

“By far the most difficult, obstructive phenomenon that we face as a clinic is the attitude that we face from medical colleagues – GPs, other psychiatrists” he says in a 2009 interview on Burns’ website.

“I vaguely remember a time in the past when nobody knew anyone who was gay. And there were very peculiar mythologies about gay people. And then that seemed to change with increased visibility and now everyone knows someone who is gay, and that gave people a human view of things.

“Generally speaking, doctors who have helped someone through their transition, experience it as positive. I think the negative feelings usually spring from ignorance.”

According to a 2006 survey about trans medical care, 80 per cent of GPs have good intentions and want to help, but the majority of them – 60 per cent – lack information.

'Engendered Penalties' by Stephen Whittle surveyed 872 trans people and also found that 19.5 per cent of GPs were not trans friendly, in fact the opposite.

A negative attitude, and even just ignorance can have a bad impact on a vulnerable patient. And these people are vulnerable.

An August 2012 survey into trans mental health by the Scottish Trans Group and Sheffield Hallam university – found that depression affected 62 per cent of the 889 trans people questioned, anxiety 56 per cent. In the general population it affects one in ten.

These people were having a bad time in all areas of the NHS: 63 per cent reported one or more negative experiences in mental health services, 65 per cent in general services and a shocking 62 per cent at a Gender Identity Clinic, according to the survey.

Of those, just under a third felt that their gender identity was not validated as genuine, instead being perceived as a symptom of mental ill-health. A quarter felt uncomfortable being asked about their sexual behaviours.

The first-hand experiences quoted by The Scottish Trans survey tell some shocking tales:

My doctor sent me to see a gynecologist instead of the Gender Identity Clinic. He said he didn’t see trans people but he wanted to have a look at me. He then called in my husband and asked if he was ok with me transitioning - I felt abused.

Another quotation cited a bad experience with a psychiatrist who suggested the only appropriate pronoun for the patient was “it” and claimed that bisexual people didn’t exist.

A third reported:

Questions were overly irrelevant, prying and sexual. My first doctor asked about masturbation repeatedly, which made me very uncomfortable...

A fourth simply detailed the mental stress caused by the delay, confusions and misunderstandings.

On the other hand, Jay* a 24-year-old languages student in London who saw a psychiatrist and received a referral to the Charing Cross gender clinic earlier this month, said the psychiatrist was pleasant and reasonable.

Christine urges a balanced view:

There are good doctors and there are bad doctors, and there are good doctors having a bad day and there are bad patients.

There are people who have bees in their bonnet, and think they can cure transgender people by talking. It depends really on whether you are the first person that that doctor has seen.

There may also be an economic argument for a more sensitive system: happier people cost less. The Scottish survey showed that 44 per cent of trans people used mental health services more before transition, and none used mental health services more after having been through gender services.

Questioned as to why there was such a variable quality of treatment for trans people in the NHS and such a high incidence of negative feedback, the Department of Health said that they were moving to regulate care commissioning from Primary Care Trusts so that there will be enough places at Gender Clinics, and to create a national body that would be responsible for keeping care standards consistent across regions.

The Department of Health reiterated that being transgender is not considered a mental health disorder by the NHS but that the role of psychiatrists was an important one to ensure that “gender issues have their root in gender dysphoria and are not caused by other more complex psychiatric problems”.

The spokesperson added that the psychiatric assessment “could be a useful opportunity for the patient to discuss their condition with a professional.”

As for the psychiatrists calling patients “it”, and trying to work out what gender someone should be based on their haircut, the Department of Health said they would be commissioning a clear guide on transgender treatment that will be published this year.

* Names changed for the purposes of the article and pronouns used with agreement of interviewees.

Source: http://www.newstatesman.com/voices/2012/11/why-are-nhs-doctors-are-still-treating-trans-people-theyre-mentally-ill
mephisto5 17th-Nov-2012 07:33 pm (UTC)
Trans* healthcare is such a postcode lottery at the moment- it's one of the few things the Health Bill will fix.

Reading this article, I guess I was fortunate that my mental health evaluation really was just one interview and it was easy enough to blag my way through- just pretend you've never been depressed, taken drugs, had suicidal ideation or self harmed. It was kind of just treated as a formality.

With reference to more general gatekeeping procedures, it would be interesting to see how the experiences of trans* woman compare to those of trans* men. I read up on trans* people's previous experiences of one of the doctors at ChX GIC, and the reviews from trans* men tended to be way more positive than those from trans* women. When looking at these services, I think it's important to highlight the impact transmisogyny may be having on doctors' attitudes and patient care.
suzycat 17th-Nov-2012 08:41 pm (UTC)
I think there is a lot of ingrained misogyny full stop in medicine sometimes. When I was reading the awful remarks some of these doctors had made, it made me remember how I saw a dermatologist about my terrible contact dermatitis when I was hairdressing - which at the time I took very seriously as my career - and was basically told that I would need to quit because otherwise the condition would worsen and I'd have difficulty doing ordinary housework and bathing my babies when I got married and had children. I was at the time intending, I guess, to get married and have children "someday" but I was devastated by the attitude. (And I never DID get married and have children!)

And that was just a bloody skin condition that was not that big a deal in the grand scheme of things. How much worse when your whole IDENTITY is at stake and dismissed?
the_physicist 17th-Nov-2012 08:51 pm (UTC)
i think location plays a huge factor and i'm not sure what the reforms will do for that? i mean, Charing X is just like... a world away from Leeds. I've heard so much bullshit about Leeds.

from what i read up, it's about 80% trans women and 20% trans men that get treatment on the NHS. i haven't read up the reviews, but it would be interesting to see what the bias is. i would not be at all surprised if things were worse for trans women, especially at Leeds.
mephisto5 17th-Nov-2012 08:55 pm (UTC)
Sarah Brown et al. dbasically persuaded dept health that funding for trans* treatments should become centralised, rather than the responsibility of PCTs (which are being abolished) or their replacements (CCGs)- so there's fewer govt. bodies to complain to/sue to get treatment. Should make the process easier.
the_physicist 17th-Nov-2012 09:08 pm (UTC)
that does sound like a slight improvement at least, as funding can be difficult in some parts of the UK from what i've heard.
poisondusk 17th-Nov-2012 07:50 pm (UTC)
This is the trouble with trans patients being routed to the specialist clinics via regular psychiatrists. I know they're supposed to screen us for mental illness, but most of them have never had a trans patient before, and know next to nothing about how to treat us. I guess I was 'lucky' in that I also have an anxiety disorder and the psychiatrist I saw was more interested in whether it needed medicating than the specifics of my dysphoria and my sexuality, but I did get a few weird questions (like whether I was sexually attracted to a friend of mine who came up when I was discussing people I was and wasn't out to).
papasha_mueller Errr...17th-Nov-2012 08:18 pm (UTC)
@Why are NHS doctors are still treating trans people like they’re mentally ill?@

Because they're mentally ill?

suzycat Re: Errr...17th-Nov-2012 08:38 pm (UTC)
My understanding is that there has been a big issue about that precisely because while a lot (if not all!) trans people don't think of themselves as mentally ill, they need to be "mentally ill" in order to get treatment that otherwise they couldn't possibly afford. I don't even know if it is possible for a transperson to just get hormones, surgeries etc electively. You could be the richest person in the world but could you pay a doctor to give you the things you needed in this way? I don't know.
mephisto5 Re: Errr...17th-Nov-2012 08:51 pm (UTC)
There are really two issues: whether trans* people are mentally ill, and whether gender identity disorder should be removed from the DSM.

The first one is a very personal thing: personally I do consider myself mentally ill i.e. there's something wrong with my brain in that it expects the rest of my body to be a shape that it isn't, however I know that a lot of trans* people don't and it could equally well be said that it's not a mental illness but more of a birth defect with the body developing in a way that doesn't match the brain's pattern. It all depends whether you give more weight to the brain's view of what should be there or the rest of the body's growth of what is there. Ultimately, it wouldn't matter so much if we didn't insist on seeing mental illnesses as belonging in a separate category to 'physical' illnesses, but I digress.

The second was addressed very thoroughly by Natalie Reed and her blog post is well worth reading.
suzycat Re: Errr...17th-Nov-2012 09:08 pm (UTC)
THank you, going to read it now.
wesleysgirl Re: Errr...17th-Nov-2012 11:51 pm (UTC)
Thank you very much for sharing your input on this. I appreciate it. :-)
poisondusk Re: Errr...17th-Nov-2012 09:03 pm (UTC)
While it's not possible to get hormones and surgeries electively in the UK, many people do choose to see private specialists. This is much faster because you can simply bypass your GP and the psychiatric referral and go directly to someone who knows what they're doing, and there's no waiting list. The consultations and hormone prescriptions aren't astronomically expensive (though obviously not everybody can afford them) but the surgeries are, and some people use private treatment to get things started and then try to switch into the NHS system later on (which technically you're able to do, but the NHS doesn't always like it).
suzycat Re: Errr...17th-Nov-2012 09:07 pm (UTC)
Ah, good to know!
papasha_mueller Re: Errr...17th-Nov-2012 09:09 pm (UTC)
To me what you say sounds more like a legal issue.
Sorry, I don't know much about US healthcare.
otana 17th-Nov-2012 09:35 pm (UTC)
This article isn't about the US, it's about the UK.
the_physicist Re: Errr...17th-Nov-2012 08:41 pm (UTC)
i hope you're being sarcastic. because i'm not mentally ill and i hate being treated as such.
papasha_mueller Re: Errr...17th-Nov-2012 09:05 pm (UTC)
I actually meant the doctors.

the_physicist Re: Errr...17th-Nov-2012 09:10 pm (UTC)

still, i'm sure there are plenty of mentally ill people who don't have a problem with treating trans* people with respect.

i think it's because the doctors are shitheads.
kyra_neko_rei Re: Errr...17th-Nov-2012 09:31 pm (UTC)
I'm disinclined to believe that assholery, ignorance, and condescension are mental illnesses, any more than gender identity disorder (which I think is a physical disorder, because it's the body, not the brain, that is the wrong gender).
poetic_pixie_13 Re: Errr...18th-Nov-2012 09:53 pm (UTC)
Being an asshat and a bigot is not caused by mental illness but an individual's own choice to be a douchecanoe. But thanks for playing, I guess,
mephisto5 Re: Errr...17th-Nov-2012 09:05 pm (UTC)
Whether trans* people are mentally ill and/or should be classified as such for the purposes of obtaining state/insurance-funded medical treatment is a matter of debate for the trans* community. It is not a debate that benefits from one-liner cis opinions.
zombieroadtrip Re: Errr...17th-Nov-2012 09:09 pm (UTC)
From the article: The condition is increasingly understood to have its origins before birth. Research studies indicate that small parts of the baby’s brain progress along a different pathway from the sex of the rest of its body. This predisposes the baby to a future mismatch between gender identity and sex appearance.

A trans* person's physical body is at a mismatch with his or her gender. They very specifically did not attribute this mismatch to a defect or condition in the brain, merely that the brain and the body are not in agreement.

Why then, do you assume that it is the brain half of this equation that is "ill?" Or incorrect?

If posed the question which of the two more accurately defined "who" you are, your brain or your appearance, would you really answer "appearance?" Why is it that trans* people are defined not by their mind, but by their body? What makes the body a more accurate identifier in trans* people that it doesn't everyone else?

EDIT: I see you were making comment on the doctors... disregard this grumpy rant

Edited at 2012-11-17 09:13 pm (UTC)
alicephilippa Re: Errr...17th-Nov-2012 09:23 pm (UTC)

Failing to fit a gendernormative role does not make someone mentally ill.
mephisto5 Re: Errr...18th-Nov-2012 10:13 am (UTC)
Nor does it make someone trans*.
meran_flash Re: Errr...18th-Nov-2012 07:52 am (UTC)
lol I've been waiting for you to say something overtly offensive instead of your usual m.o. of covert shittiness.
koshkabegemot 17th-Nov-2012 09:05 pm (UTC)
Disgusting that these views are still so pervasive.
the_physicist 17th-Nov-2012 09:05 pm (UTC)
My issue is that they keep saying they don't view it as a mental illness, yet the system is set up exactly like you would treat someone with a mental illness and the onus is on us to prove we aren't mentally ill.

Which can be triggering to people like myself who have had to deal with growing up believing that being... myself... was something wrong that needed to be forcibly cured. I have been through so much bullshit in my life, I don't want to go through more. And I'm really non-confrontational, meek, and quiet, so I don't trust myself to speak up once I get trapped in the system. I've tried to get my courage up to see a psychologist as I need a damned letter, but... I can't. Not yet. So I'll be another trans* person outside of the system, even after coming out. Screw hormones if it means going to a doctor, honestly. I can't with doctors.
the_physicist 17th-Nov-2012 09:18 pm (UTC)
My doctor sent me to see a gynecologist instead of the Gender Identity Clinic. He said he didn’t see trans people but he wanted to have a look at me. He then called in my husband and asked if he was ok with me transitioning - I felt abused.

Doesn't surprise me in the least. The only doctors I ever talked to about my issues were similarly dismissive. Worse, they gave me such misinformation and made me feel like i was some 'freak'. And I didn't appreciate the genital examination either. Fuck doctors, seriously.
otana 17th-Nov-2012 09:37 pm (UTC)
Raising her worry that being more gender-ambiguous would affect her job prospects, JR got this reaction:

“He said: ‘No you don't have to worry about that. The only time that would be awkward is if a more senior male colleague made an advance on you and that might affect your promotion chances’.”

What the fucking FUCK. When is this EVER appropriate to say? Especially coming from a trained professional. JFC.
the_physicist 17th-Nov-2012 09:47 pm (UTC)
dear lord, urgh, i'm so sorry you had to deal with someone like that. i know what it's like. a doctor told me i couldn't know what gender i was until i'd had some cock and maybe my problem was just that i hadn't had any. i was 14 years old (and a CSA and rape survivor, though he didn't know that).
the_physicist 17th-Nov-2012 11:01 pm (UTC)
*hugs* very understandable that you react badly in similar situations now with doctors around for example. and yeah, even worse that you were trying to get help, that this was the person you were meant to be able to trust, and she said all that crap.

tw ... i'm not even sure what. let's just say sexual assault and transphobia and intersexphobia

I wasn't really sexually molested by a doctor, but at the same time... it felt like that. As a CSA and rape survivor the genital exams they did on me (I'm intersex)... it definitely felt very violating to me. I'm sure even if i wasn't a survivor it would have felt that way, tbqh. Not just the uncomfortablness of having an ice cold metal ruler shoved down there for them to determine i wasn't masculinised enough for them to give a shit about gender identiy ("nope, you're clearly a woman. it's not like you can have sex as a man, and you have a uterus. so let me reiterate, because you seem to be stupid and unable to get this: you're a woman.")

I cannot with doctors. I was unregistered for years. This year i finally registered with a doctor again, but not without a lot of sobbing and breaking down and getting my partner to do virtually everything for me with regards to registering for a doctor's service. I still haven't been though.
the_physicist 18th-Nov-2012 12:33 am (UTC)
the not wanting to deal with doctors stuff is something i thought i could easily get over. me getting over it hasn't happened though. i figure if i can't get over wanting to go to the doctor to transition medically i clearly don't actually need to transition medically that badly, so i should probably just let it be. yeah, screw all the cool medical options XD , they comes with scary doctors attached to them. lol.

and yeah, i also have this letter sitting there telling me to go to a cervical cancer screening. yuuurrh... hmmm. ANYWAY, i've never been to a gyno except once when i was a kid. but that was to have my heart ultrasounded because for some reason they hospital didn't have a working ultrasound (i know, like, wtf?!) but the gyno had one, so they sent me there. but that doesn't actually count. i really have no plans on ever going to a gyno if i can avoid it. i just get anxious when i think about anyone looking at my bits again in some kind of medical context. i don't want to be told again i should get them changed surgically so i can look 'nice for a guy'.

well, i'm sure people would be better about it now, i know i'm just being unreasonably anxious, but i cna't help it and i can't seem to get over this at the moment and there isn't much impetus too right now. :/
oudeteron 17th-Nov-2012 10:58 pm (UTC)
and claimed that bisexual people didn’t exist.

Did they go to the same ignorant jerkwad I had to deal with??? And, yeah, of course I withheld any info that wasn't strictly relevant in that "conversation" so that the whole hassle would be over with minimal damage. Which is a state of affairs that would be bad in any sort of psychology-related environment, come to think of it. Doctors shouldn't be there merely to inspire fear. I sure was not interested in talking about my perfectly fine personal life to some unprofessional bigot whose entire involvement in the absurd procedure would be one session and a signature.

This is not how "helping" someone who is already at a disadvantage should work.

Honestly, I just resent the fact that people are even made to see gatekeepers to have their own gender "verified" by some "authority". The whole idea that the medical establishment should decide who is "correctly trans*" is, I'd say, downright dangerous when one thinks about the power imbalance that runs like a red thread through it all. And it won't be eliminated until the sort of gatekeeping that comes with pathologizing trans* people isn't over and done with.

tl;dr: Not surprised by this article, but no less pissed off for it.

And this comment might be a tad personal but I've had an unpleasant run-in with The System recently and I just don't even care right now, so there you go.
romp 18th-Nov-2012 12:57 am (UTC)
"England has always been disinclined to accept human nature."
Maurice by E. M. Forster (not that N.A. is so much better)

I'm sorry for all the horrible experiences. One of the most common pieces of info I see in resources for the trans* community is a list of "safe" doctors and the experiences here underscore why that is.
anjak_j 18th-Nov-2012 12:16 pm (UTC)
As someone who is genderqueer, an omni-romantinc asexual, and who has multiple mental health conditions - I've seen many mental health professionals over the past decade - none of the negative experiences described here surprise me at all. I learnt pretty quickly not to bring up my gender or sexual identity within the NHS unless absolutely necessary.

Most of my experiences with NHS psychiatrists relate to my mental health conditions, though my gender and sexual identities have been a topic of discussion - and nothing positive has ever come of me talking about either of these issues; in fact, in one case, I had to forbid both from being discussed further because the psychiatrist was just that ignorant.

To be perfectly frank, I generally don't see the NHS's mental health services as fit for purpose anyway - they're often over-stretched, under-funded, and vary too much from PCT to PCT. Many psychiatrists seem to be inadequately trained regarding certain issues/conditions. And outside of certain disorders, services for children, teens and young adults are almost non-existent.
rylee900 19th-Nov-2012 03:46 am (UTC)
Idk why people like this become psychiatrists/psychologists in the first place. It pisses me off. IMO, that's meant to be someone you can trust to understand your shit, and to see people treating their patients like this makes me sick.
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