Transgender Equality: Moving Away From Psychiatry

At midnight last night, the House of Commons Women and Equalities Select Committee released its report on Transgender Equality. Chaired by Maria Miller, evidence gathering ran to five oral sessions and over 200 written submissions...

At midnight last night, the House of Commons Women and Equalities Select Committee released its report on Transgender Equality. Chaired by Maria Miller, evidence gathering ran to five oral sessions and over 200 written submissions.

(Impending Egg-related Metaphor No.1:)

For my money, it's something of a curate's egg: generally good, disappointingly soft and runny in parts. There was a notable absence of gender clinicians (in specifically clinical rather than advisory capacity) in the oral sessions. A shame, as I think some of the undercooked bits might've firmed up with the question, "yes, but what does that actually mean in practice?"

There's much to welcome, and much that will doubtless be pored over in the days to come, interpreted to suit this or that agenda. What jumped out for me, straight off, was Paragraph 209:

We are concerned that Gender Identity Services continue to be provided as part of mental-health services. This is a relic of the days when trans identity in itself was regarded as a disease or disorder of the mind and contributes to the misleading impression that this continues to be the case. Consideration must be given to the transfer of these services to some other relevant area of clinical specialism, such as endocrinology (which deals with hormone related conditions), or their establishment as a distinct specialism in their own right.

When, still wet behind the ears, I started my active engagement with trans (and, later, explicitly non-binary) communities, almost every Q&A session would throw up something along the lines of, "do you think this is a psychiatric condition?" I was, naively, surprised that this was viewed as contentious, since it seemed obvious to me that, no, issues of gender identity were and are an entirely natural variant of normal human experience.

So that's what I'd answer. The follow-up question - typically delivered with a slightly John Humphrys air of "gotcha!" - was "why, then, are you, a psychiatrist, in this field at all?"

It's an entirely valid question. Usually, I'd point to the fact that I dual-trained in Liaison as well as General Adult Psychiatry. Liaison is that sub-specialism that deals with the interface between physical and psychological health. Liaison psychiatrists provide input to patients in general medical or surgical services, in- and out-patient. Liaison Psych gives the lie to the assumption that the mere involvement of a mental health specialist in one's care means that one's condition is primarily "a disease or disorder of the mind". This is not and has never been the case. Ultimately, it's about pragmatism - who has the appropriate skill-set to do the work - and Liaison Psych isn't a bad starting point.

Psychiatry, in a more general sense, comes with a hefty dollop of stigma, historical and current, and one could never claim this is wholly undeserved. In this particular field, transsexual people were largely treated by endocrinologists - hormone specialists - prior to establishment of the Gender Identity Clinic at Charing Cross Hospital, in 1966 (one outcome of the April Ashley case is that psychiatry was elevated in importance and began to assert itself as lead, following policies imported from John Hopkins University, in the US).

Did psychiatry, then, "steal" the field of gender away from endocrinology? Some would say so. There's a strand of feeling, in certain trans lobbying groups, that the presence of psychiatrists remains The Problem: if some fantastically specific (and, thankfully for me, notional) designer virus were to eliminate all gender psychs overnight, endos would rush in to fill the vacuum, GPs would fully embrace their duty of care and the lot of trans and non-binary people would be a happy one.

No. All indications, at least at present, suggest otherwise. The Select Committee's report points out that GPs, in particular, "too often lack an understanding of: trans identities; the diagnosis of gender dysphoria ... and their own role in prescribing hormone treatment."

It's also fair to say that young endocrinologists are hardly stampeding to work in this field. More's the pity; we sorely need them.

The second of Paragraph 209's suggestions - that gender evolve into "a distinct specialism in [its] own right" - appears, to me, the better option. Over the decade and a half I've been in this field, I feel I've drifted further and further from my psychiatric (even Liaison Psychiatric) roots. Initially, this worried me but, actually, I don't think it's necessarily a bad thing. On a visceral level, practising gender medicine doesn't feel like practising psychiatry. There are elements of psychiatry - as there are elements of counselling, endocrinology and general medicine - but gender is very much its own entity.

(Impending Egg-Related Metaphor No.2:)

This isn't just my own experience of the field. In his inaugural speech as President of BAGIS (the disconcertingly named British Association of Gender Identity Specialists), Dr James Barrett likened gender medicine to the discovery of the platypus, in the late 18th century, by European naturalists, with vexed arguments over whether it was a bird, a mammal or something stitched together from bits of both.

Similarly, a variety of clinical specialisms might lay reasonable claim to ownership of gender care but, like the platypus, it's its own creature, distinct and different.

Existing gender services must rise to the coming challenge. Psychiatrists and psychologists are, I believe, always likely to be a part of the whole, providing valuable (and often necessary) input but the prevailing trend is already toward a multidisciplinary approach - clinicians from a diversity of fields coming together to provide a truly comprehensive approach, properly tailored to the individual - and the Select Committee's findings should be recognised and welcomed as a step in the right direction.


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