1. Charing Cross Gender Identity Clinic January 2013

2. About me Dr Stuart Lorimer MBChB MRCPsych Gender Specialist (Consultant, Liaison Psychiatry) Dr Stuart Lorimer MBChB MRCPsych Gender Specialist (Consultant, Liaison Psychiatry)

3. Charing Cross Gender Identity Clinic Oldest Largest 12-1300 new patients per year Oldest Largest 12-1300 new patients per year

4. General Principles Multi-disciplinary Psychiatrists, Psychologists, Surgeons, Speech therapists, Electrolygists, Gender-specialist nurses Multi-opinion Reversible Less reversible Irreversible Emphasis upon transition (= Real Life Experience, RLE) Multi-disciplinary Psychiatrists, Psychologists, Surgeons, Speech therapists, Electrolygists, Gender-specialist nurses Multi-opinion Reversible Less reversible Irreversible Emphasis upon transition (= Real Life Experience, RLE)

5. Referral GP GP PCT Psychiatry Central Commissioning GIC GIC GP GP PCT Psychiatry Central Commissioning GIC GIC

6. Patients Trans men (FtM) - 38% Trans women (MtF) - 62% Average age at presentation - 35 FtM - 21 MtF - 41 Trans men (FtM) - 38% Trans women (MtF) - 62% Average age at presentation - 35 FtM - 21 MtF - 41

7. Age of presentation

8. Timing of presentation Adulthood / autonomy Fulfilment of obligations Period of reflection Finitude Gradual / evolving Abrupt / “out of the blue” Adulthood / autonomy Fulfilment of obligations Period of reflection Finitude Gradual / evolving Abrupt / “out of the blue”

9. Sexuality Study of 125 referral letters 73 attracted to women (18 FtM, 55 MtF) 32 bisexual (11 FtM, 21MtF) 11 asexual (2 FtM, 9 MtF) 9 attracted to men (3 FtM, 6 MtF) Study of 125 referral letters 73 attracted to women (18 FtM, 55 MtF) 32 bisexual (11 FtM, 21MtF) 11 asexual (2 FtM, 9 MtF) 9 attracted to men (3 FtM, 6 MtF) Other

10. Sexuality

11. Transition: noun 1 a change or passage from one condition, state, subject, place, etc to another Approx. 80% GIC attendees transition Conscious process of self-examination Can happen at any age Stressful / risky / dangerous Exhilarating / empowering Continuous Diversity ---> needs a tailored approach Approx. 80% GIC attendees transition Conscious process of self-examination Can happen at any age Stressful / risky / dangerous Exhilarating / empowering Continuous Diversity ---> needs a tailored approach

12. Components of transition No “standard” transition Biological Psychological Social No “standard” transition Biological Psychological Social

13. Biological Physical comorbidity Facial / body / scalp hair Speech modification Feminising / masculinising hormones Tattoo removal, etc. Surgery Genital Facial Other Physical comorbidity Facial / body / scalp hair Speech modification Feminising / masculinising hormones Tattoo removal, etc. Surgery Genital Facial Other

14. Psychological Perceived obstacles to transition - family / employment Guilt / “hurting” others Moving at a comfortable pace vs procrastination Adjustment - status - sexuality - body Faith & reconciliation Gender euphoria Psychological comorbidity Perceived obstacles to transition - family / employment Guilt / “hurting” others Moving at a comfortable pace vs procrastination Adjustment - status - sexuality - body Faith & reconciliation Gender euphoria Psychological comorbidity

15. Social Name change Family relationships Safeguarding rights / advocacy - employment - legal - custody Social customs Name change Family relationships Safeguarding rights / advocacy - employment - legal - custody Social customs

16. Diagnosis I ICD 10 F64.0 Transsexualism Desire to live and be accepted as a member of the opposite sex (with hormones / surgery) Present for at least 2 years Not a mental disorder / delusional abnormality F64.1 Dual-role Transvestism Wears clothing of opposite sex No sexual motivation No desire for a permanent change F65.1 Transvestic Fetishism Acting / dressing like opposite sex, for sexual gratification Clinically significant distress / impairment ICD 10 F64.0 Transsexualism Desire to live and be accepted as a member of the opposite sex (with hormones / surgery) Present for at least 2 years Not a mental disorder / delusional abnormality F64.1 Dual-role Transvestism Wears clothing of opposite sex No sexual motivation No desire for a permanent change F65.1 Transvestic Fetishism Acting / dressing like opposite sex, for sexual gratification Clinically significant distress / impairment

17. Diagnosis II Dynamic / evolving Controversial / sensitive Diagnosis versus Pragmatism: “Will this work?” F64.9 Gender Identity Disorder, Unspecified Genderqueer Non-binary Neutrois Etc. Tailored service Dynamic / evolving Controversial / sensitive Diagnosis versus Pragmatism: “Will this work?” F64.9 Gender Identity Disorder, Unspecified Genderqueer Non-binary Neutrois Etc. Tailored service

18. Assessment I Introduction Preferred prefix, Initial & surname Why now? What were previous obstacles? Early memories Clothing & presentation, Associated feelings, Sexual? Puberty Family Genetics, Supports Psychiatric history Physical history Smoking, Self-medicating? Introduction Preferred prefix, Initial & surname Why now? What were previous obstacles? Early memories Clothing & presentation, Associated feelings, Sexual? Puberty Family Genetics, Supports Psychiatric history Physical history Smoking, Self-medicating?

19. Assessment II Social / occupational history Supports Role in transition Relationships Physical intimacy Relationship with genitalia Cultural history Plans for the future Transition? Timescales Hormones Social / occupational history Supports Role in transition Relationships Physical intimacy Relationship with genitalia Cultural history Plans for the future Transition? Timescales Hormones

20. When do we recommend hormones? Post surgery Full time transition Coherent / imminent transition plan Already on hormones? Lower doses to alleviate dysphoria Post surgery Full time transition Coherent / imminent transition plan Already on hormones? Lower doses to alleviate dysphoria

21. Hormones MtF: Oestrogens Anti-androgen FtM: Testosterone Low level oestrogens in non-transition MtF: Oestrogens Anti-androgen FtM: Testosterone Low level oestrogens in non-transition

22. When do we recommend surgery ? Genital 18-24 months of full time transition with evidence of social / occupational functioning stable, improving gender dysphoria on hormones for at least 12 months Chest (FtM) 12 months of full time transition on testosterone for at least 6 months Genital 18-24 months of full time transition with evidence of social / occupational functioning stable, improving gender dysphoria on hormones for at least 12 months Chest (FtM) 12 months of full time transition on testosterone for at least 6 months

23. Challenges “The Transsexual Imperative” Medical colleagues 84% of UK doctors think gender services shouldn’t exist within the NHS “The Transsexual Imperative” Medical colleagues 84% of UK doctors think gender services shouldn’t exist within the NHS

24. Longer term Re-referral Diagnostic overshadowing Ongoing advocacy Regret (approx. 1-2%) Detransition Re-referral Diagnostic overshadowing Ongoing advocacy Regret (approx. 1-2%) Detransition

25. GIC myths You have to wear a skirt to the GIC You have to be living “in role” to have treatment You have to (say you) want surgery You have to be suicidal You have to be heterosexual You can’t admit to stress / illness / doubt You have to give a standard trans narrative They deliberately play Good Cop / Bad Cop You have to wear a skirt to the GIC You have to be living “in role” to have treatment You have to (say you) want surgery You have to be suicidal You have to be heterosexual You can’t admit to stress / illness / doubt You have to give a standard trans narrative They deliberately play Good Cop / Bad Cop

26. Bad Cop

27. “ Transsexual and Other Disorders of Gender Identity: A Practical Guide to Management” Dr James Barrett (2007)

28. MANGE TAK!