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

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

“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 thatIt 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.

Photograph: Getty Images
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After his latest reshuffle, who’s who on Donald Trump’s campaign team?

Following a number of personnel shake-ups, here is a guide to who’s in and who’s out of the Republican candidate’s campaign team.

Donald Trump’s campaign chairman, Paul Manafort, stepped down last week. A man as controversial as Trump himself, he has departed following the announcement last Wednesday of a new campaign manager and CEO for Team Trump. Manafort had only been in the post for two months, following another campaign team reshuffle by Trump back in June.

In order to keep up with the cast changes within Team Trump, here’s the low-down of who is who in the Republican candidate’s camp, and who-was-who before they, for one reason or another, fell out of favour.

IN

Kellyanne Conway, campaign manager

Kellyane Conway is a Republican campaign manager with a history of clients who do a line in outlandish statements. Former Missouri Congressman Todd Akin, whose campaign Conway managed in 2012, is infamous for his comments on “legitimate rape”.

Despite losing that campaign, Conway’s experiences with outspoken male candidates should stand her in good stead to run Trump’s bid. She is already credited with somewhat tempering his rhetoric, through the use of pre-written speeches, teleprompters and his recent apology, although he has since walked that back.

Conway is described as an expert in delivering messages to female voters and has had her own polling outfit, The Polling Firm/WomanTrend for over 20 years and supported Ted Cruz’s campaign before he was vanquished by Trump in May. Her strategy will include praising Trump on TV and trying to craft an image of him as a dependable candidate without diminishing his outlier appeal.

She recently told MSNBC, “I think you should judge people by their actions, not just their words on a campaign trail”. Given that Trump’s campaign pledges, particularly those on immigration, veer towards the completely unworkable, one wonders what else besides words he actually has to offer.

Perhaps Conway, with her experience of attempting to repackage gaffes will be the one to tell us. Conway also told TIME magazine that there is “no question” that Trump is a better candidate than Hillary Clinton. Given Trump’s frightening comments on abortion, to name just one issue, it’s difficult to see how this would prove true.

Stephen Bannon, campaign CEO

While Conway may bring a more thoughtful, considered touch to Trump’s hitherto frenetic campaigning, Stephen Bannon promises to bring just the opposite.

Bannon is executive chairman of right-wing media outlet Breitbart, also the online home of British alt-right provocateur Milo Yiannopoulos. Once described by Bloomberg as “the most dangerous political operative in America”, the ex-Goldman Sachs banker can only be expected to want to up Trump’s rhetoric as the election approaches to maintain his radical edge.

Trump has explicitly stated that: “I don’t wanna change. I mean, you have to be you. If you start pivoting, you’re not being honest with people”.

As Bannon leads a news site with sometimes as outlandish and insensitive views as Trump himself, one can safely assume that Bannon will have no problem letting Trump “be himself”.

The Trump Brood, advisers

While his employed advisers come and go, the people that have been unwaveringly loyal to Trump, and play key advisory roles, are his four adult children: Donald Jr, 38, Ivanka, 34, Erik 22 and Tiffany, 22. With personalities as colourful as their father’s, the Trump children have been close to the campaign since its inception.

Donald Jr personally delivered the bad news to Lewandowski, the younger Trumps describing him as a “control freak”. Although it’s common for the offspring of politicians to take part in their parent’s campaigns (see Chelsea Clinton), in Trump’s case the influence of his children goes undiluted by swathes of professionals. This, despite his actual employed campaign directors being experienced establishment figures, adds credence to the image of Trump’s brand as family-based and folksy, furthering also his criticism of Hillary Clinton as being “crookedly” in the sway of bankers and elites.

Lewandowski’s ultimate downfall has been attributed to his attempts to spread negative stories in the media about Jared Kushner, Trump’s son-in-law and husband of Ivanka. Ivanka and Kushner were long-time critics of Lewandowski for his indulgence and encouragement of Trump’s most divisive instincts, and apparently they were integral to his firing.

Whether any good came from this is hard to discern, as Trump still managed to insult the Muslim community all over again with his comments last month about the late solider Humayun Khan, also insulting veterans and “gold star” families in the process.

OUT

Paul Manafort, former national campaign chair

Although Trump called his departing campaign manager “a true professional”, Manafort has recently been beset by personal controversy and criticised for failing to deliver results. Manafort has taken the blame for the poor polling results that have followed Trump’s awful last few weeks, with Trump’s recent (lacklustre and unspecific) apology representing a complete change of tack.

Despite his many years of experience in politics, Manafort fell out of favour with Trump partly because of his spending on media, such as a $4 radio appearance in Ohio, Pennsylvania, Florida and North Carolina. Trump was judging these investments worthwhile.

Manafort’s personal cachet was also diminished by his dodgy links to ex-clients including Ukrainian former prime minister, the pro-Russian Victor Yanukovych. As Trump has already racked up a number of Russia-related gaffes, continued association was Manafort would have likely proven electorally unwise.

Corey Lewandowski, former campaign manager

Campaign manager until Trump’s team shake-up in June this year, Lewandowski was not the picture of a calm and collected operative. With a list of antics behind him such as bringing a gun to work and then suing when it was taken away from him and lacking the experience of ever having directed a national race, Lewandowski was a divisive figure from the start of Trump’s bid for the nomination.

Although Lewandowski most often accompanied Trump on the nomination campaign trail, it was Manafort, even then, who was in charge of most of the campaign’s logistics, making use of his 40 plus years of experience to do so.

Trump was clearly taken with Lewandowski’s aggressive campaign techniques, as he stood by him even when Lewandowski was charged with battery against former Breitbart reporter Michelle Fields. Although the charges were later dropped, these kind of stories do not bode well for Conway’s hopes for a more women-friendly Trump.

***

Perhaps this latest round of hiring and firing will do him some good, but with only three weeks to go until absentee voting begins in some states, the new team doesn’t have much time.