Barbelith Underground > Head Shop > Concerns regarding the lack of effectiveness of gender reassignment

Got this from Press For Change, it's the text of a piece in this weeks Big Issue...

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Story by Zena Alkayat and Judy Kerr
The Big Issue, w/c 17th Oct 2005
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Transsexual people are being forced to seek care in private hospitals or go abroad for costly surgery due to the raft of obstacles they face in the NHS - from "dogmatic" psychiatrists to disorganised administration - campaigners have claimed.

Activist Persia West has written a scathing account of the inadequate service transsexuals receive when going through the process of a sex change, in a report that focuses particular on the Gender Identity Clinic (GIC) at Charing Cross hospital, responsible for the vast majority of gender reassignment surgery in the UK.

The study, funded by Brighton And Hove NHS Primary Care Trust, and Spectrum, the lesbian, gay, bisexual and transgender forum, raises serious questions about the treatment at the GIC, which has around 500 patients a year.

Transpeople interviewed by West accused psychiatrists encountered during formal assessment of being "unreasonable, erratic and irrational". Some psychiatrists were said to be "dogmatic and fixed in their views as if one size fits all... and [transpeople] simply have to take what they are given."

Interviewees, who included a conductor, academic, priest, engineer, lawyer, pilot and care assistant, also complained they were "pathologised as mentally-ill" within a system that denied them "choice and respect".
Patients complained that further treatments they considered absolutely essential, such as laser treatment or electrolysis, were labelled merely 'cosmetic' by commissioners, a position they found "grimly amusing". One trans woman claimed: "If they really understood us, they wouldn't treat us like this."

A female Brighton GP who has been working with trans patients for over 10 years, and contributed to the report, wrote: "Not one of my patients with contact with the GIC team there had a single positive thing to say about either the process or consultations. The difference in treatment [on the NHS and abroad] on all levels is stark. Invariably women who went abroad talk of a positive experience where they were treated with respect, kindness, and great professionalism. Contrastingly, those who continued to operation with Charing Cross reported patronising attitudes, insensitivity and no sense of caring."

Echoing many of the trans interviewees, the doctor added: "The NHS seems to be designed to test nerve, resolve and mental strength at every opportunity rather than understanding. There should be easier access to aspects such as hair removal, speech therapy, and there must be psychological support built in, rather than judgement."

Another local doctor canvassed on his transsexual patients wrote: "On the whole there seem to be many areas of discontent. . . Another problem is the strictness of criteria imposed by Charing Cross. This is particularly true on the working in role front, as most transsexuals may well have problems getting jobs in their new chosen gender before surgery, partly due to being self conscious about their bodies. . . there seems to be a constant wall for transsexuals to come up against."

The report further criticised the lengthy and often delayed process that leaves patients uncertain as to whether they will receive treatment or not. In addition, interviewees claim Charing Cross is plagued with a wide range of administrative problems - including paperwork often getting lost and appointments often being cancelled at short notice without reason.

Furthermore, despite the catalogue of alleged problems, the report reveals some patients were unaware of a system for complaint - and felt too scared to complain in case of a negative reaction from psychiatrist consultants.

The author, West, who had her own gender reassignment surgery in Belgium, claimed: "Anyone who can afford it will choose private, or go abroad to Europe or Thailand where they will receive quality care with more understanding."

One of the recurring criticisms levelled by campaigners at the NHS is the over emphasis on the medical side of sex change at the expense of the "extreme emotional challenges" patients undergo.

A trans woman who has first-hand experience of the trauma involved, Sophie, spent 20 years on heroin, was imprisoned on a drugs offence and constantly "ran away from the truth", before deciding to seek surgery.
"I couldn't afford private care so despite the negative stories I heard, I had to go through Charing Cross," she told The Big Issue. "It was the lack of support that was the most challenging. The NHS has no framework set-up, like a counselling service, to support people like me. My family had stopped talking to me and it was so hard to stay off the drugs. I practically starved myself to pay for private counselling that I desperately needed."

A person wishing to make a gender transition is required to live as that sex for a minimum of two years. In Sophie's case this was particularly stressful because she did not yet look or feel feminine but was reluctant to ask the GIC for help, fearing they would delay her surgery because they thought she wasn't coping with life as a woman. "The problem is the reality that no amount of make-up can cover up a hairy face. You can imagine how people stare, they can be very hostile on the street," she recalled.

Claire McNab, the vice-president of Press For Change, a campaign group for transsexual people, told The Big Issue: "The feeling that we must jump through hoops to persuade the psychiatrists we need treatment is ridiculous. There should be a better understanding and a way for people to communicate their problems without fear of treatment being refused."

The leading psychiatrist that transpeople turn to for private surgery, Dr Russell Reid, backed the move for more support. He said: "Depressive, reclusive behaviour is common in transpeople who have trouble receiving treatment in the NHS." Reid has found that five per cent of Britain's estimated 5,000 transpeople suffer from social isolation or chronic depression and nearly two per cent commit suicide.

However, a spokeswoman for Charing Cross GIC defended its service. "We endeavour to provide the best support, care and advice to those wishing to undertake a sex change. We understand that the process clients have to go through before they receive surgery can be frustrating, but it is necessary to ensure this radical treatment is not taken lightly as the process is irreversible."

"A key priority at the moment is the expansion of the clinic and we will be moving to bigger premises in the coming months. This will reduce the time people have to wait to be seen - a problem which has occurred due to an increase in the number of referrals."

"We have also set up a clinical improvement group to look at issues such as waiting times, attitudes of psychiatrists and the quality of information given. In November, we will be meeting a group of clients to discuss these areas and their experiences. We have a complaints procedure and would encourage anyone who is unhappy with the care they have received to contact us to discuss their concerns further."

Campaigners are now hoping that a unique new approach being developed in Brighton, that aims to meet the full range of physical, mental and emotional needs of patients undergoing a sex change, can act as a model for others to follow. The West Sussex Health And Social Care NHS Trust is working with specialists and transpeople on a new service which takes account of the personal trauma they endure.

Sue Morris, the executive director, leading the initiative, said: "We hope to offer a more tailored style of support by working with GPs, social services and the council." The future aim is to remove the need to go to London for treatment by ensuring local specialists can offer a complete 'one-stop-shop style' service.

"Changing the fundamentals of your identity is going to be stressful. We need support, not to be tortured on the way," concludes West.

I find it really bothersome that people feel they can throw around the word "torture" to describe something which looks to me like receiving free but inadequate care from a doctor who might, if one is unlucky, treat one with the curiosity with which some might regard a lab specimen, when I'm likely to be accused of treason by overzealous fellow citizens if I use the same word to describe, oh, prisoners being hooded, beaten, and electrocuted by soldiers from my country.

I am willing to believe, because I have heard it from many people who have claimed to have this experience, that there are doctors in the UK (just as there are elsewhere in the world) whose attitudes toward their trans patients tend towards dehumanizing them, pathologizing them, and playing a role more like that of an obstacle to treatment than a facilitator of it. I believe that certain models of the origin of transgender identification, when held to be absolutes, facilitate this attitude. I believe that this situation makes life more difficult for people who already have a hard time of it. I believe that more communication is needed between people who experience what life as a trans person is like and people who provide care for trans people. I even believe that a harm-reduction model can be appropriate and useful for state-provided trans services, a theory I may have the opportunity to examine more closely in the coming few months. I do not believe that anything approaching torture goes on at the GIC, and I think light use of that term undermines people's efforts to create real change.

Reid has found that five per cent of Britain's estimated 5,000 transpeople suffer from social isolation or chronic depression and nearly two per cent commit suicide.

Five percent? Chronic depression or social isolation is at only five percent? If this figure is accurate it must be a comparative heaven to be trans in Britain; thinking of the trans people I know in the US I think something close to majority of us have experienced social isolation or ongoing depression for at least a year of our lives. In addition, a quick Google search gives an (unverified, uncited) estimate of the annual suicide rate among British as about 5,000, which is pretty high to begin with. Not anywhere near 2% there, of course, but I think you'd find the rates of depression and suicide among trans people as compared to general population are similar or even higher elsewhere in the world. It would be ridiculous to blame these cases on the availability of free but arguably less than sensitive care.

I also think that there needs to be a change of attitude in the trans community about the potential for transition regrets. First of all we need to encourage people who have modified their bodies in ways they now regret to actually tell this story within our communities, rather than driving them to the fringes. I have seen people ostracize "regretters" from trans communities— this is inexcusable. But secondly, there has to be something a lot more concrete than "oh be careful, you might do something you'll regret." That, as a warning to delay steps which can seem, rightly or wrongly, as the only way out of an intolerable situation, is not effective. Regret? What's that mean? I've done a lot of things I regret, and I'm pretty fine with that. What about this kind of regret will make it so unbearable that there will be nothing left for us to do but kill ourselves, terrible failed trannies that we now are? Which specific parts of transition— which is too often thought of as a monolithic whole— are irreversible? Some people find it impossible even to reverse social transition, for instance, while some people get to the point of dramatic changes due to hormones and certain surgical interventions, and then return to their former lives with some but not insurmountable difficulty. And why is there no emphasis on how to deal with that regret, should it occur, or even the thought that it might be possible to deal with it? Might transition regrets not be the end of any hope for a healthy life? And if that's so, what exactly is it that trans people need to be protected from?

In the case of NHS care I think the threat is unnecessarily spending the state's money. Which is more than fair, in my (foreigner's) opinion. NHS, like any hospital or clinic, has a form of triage going on. Maybe the predictors for the possibility of regret need refinement, but that's not something we're going to discover overnight. It's not something we'll discover without listening to one another, either.

I understand that the GPs interviewed about their patients' experiences at Charing Cross are in private practice, yes? Can they be expected to be objective? Aren't the patients they are interviewing already self-selected as a pool of people who either a) didn't try the GIC or b) tried the GIC and then turned to private practice, presumably because the GIC was unsatisfactory in some way?

Still, there is a real problem here. Obviously my own attitudes have changed since my initial responses to this thread, when I took pretty much uncritically the assertion that GIC doctors will not approve access to medical transition if their patients do not fit narrow parameters of femininity or masculinity. I was afraid a similar attitude would hinder my own transition here in the US, which assuredly made me more vehement than I would have been if I were more disinterested in the subject. However, I don't think we would be hearing these complaints in such numbers and with such consistency if there weren't something genuine going on, either on the part of a few doctors, or as a matter of policy which is being misinterpreted by the patients affected by it. Either way, one problem is that some people who need care are not going to get it— either because they actually will be denied care based on their failure to fit the providers' preferred model of transgender identity, or because they will be too afraid of denial to approach the NHS for services they can't afford elsewhere. A second, perhaps even more worrying problem, is that people are going to the GIC with preexisting notions about some rules or formula and just following the formula in order to hasten approval. In the best case scenario this will have the opposite effect, as therapists will easily see through it in most cases, or will see the patient's discomfort in this exaggerated role as a sign that more work is needed before any transition can take place. Or it will actually succeed, possibly leading to someone making a mistake because they haven't been honest with their providers. In the worst case scenario, IMO, it will cause the trans person to be trapped in a loop of trying ever harder to fit the "rules," becoming more and more miserable, thus more thoroughly convincing the therapist that they aren't suited for transition, which may lead them into deeper and deeper depression and social— what's that word? maladaption? And I think this scenario may well be what people are seeing, in many cases.

Alright. I'm starting to feel silly going on about this from the perspective of someone who has never been to seek trans-related serviced in Britain. Everything I just said should be taken with as much salt as is necessary to swallow a completely uninformed opinion based on hearsay, press releases like those above, and comparison of same to my experiences of private care in the US. *kicks soapbox back under the bed* Now please feel free to shred.