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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Battle for Mosul: will this be the end of Islamic State?

The militant group's grip on power is slipping but it has proved resilient in the past.

The battle for Mosul is the latest stage in the long struggle to defeat Islamic State. The group has been around since the late 1990s in one form or another, constantly mutating in response to its environment. Undoubtedly its ejection from Mosul will be a significant moment in the group’s history, but it is unlikely to be its final chapter. The destruction of the group will only be complete when some fundamental changes occur within Iraq and the war in Syria comes to an end.

IS’s roots go back to a training camp established by the militant Islamist Abu Musab al Zarqawi in the late 1990s in Herat, Afghanistan. Founded as an army to overthrow the apostate regimes of the Levant, it fled to northern Iraq in the wake of the US-led invasion of Afghanistan post-9/11 where it re-established itself as a force alongside Ansar al Shariah, a hardline Salafi jihadi organisation.

As American attention shifted from Afghanistan to Iraq, the group was ideally placed to become one of the leading lights in the post-Saddam Iraqi insurgency. Brutally announcing itself to the world in August 2003 with successive attacks on the Jordanian Embassy in Baghdad, the UN headquarters and a Shia shrine in Najaf — the latter being the deadliest attack in Iraq that year with a death toll of 95 — the group grew to assume the mantle of al-Qaeda in Iraq. By 2006 this brand had become somewhat damaged through the brutal sectarian campaign the group waged, and when its founder, Zarqawi, died it sought to reinvent itself as the Mujahedeen Shura Council. This incarnation did not last long either, and eventually it assumed the title of the Islamic State of Iraq (ISI), alongside a more Iraqi leadership.

This was the start of a diffcult period in the group's history. Its excesses in Iraq (including indiscriminate slaughter of Shia Muslims to stir sectarian hatred and filmed decapitations of prisoners) lost it local support and led to the tribes in Sunni Iraq rising up and supporting the government in Baghdad's fight back against the group. By 2009, when the west abruptly stopped paying attention and withdrew from Iraq the group was largely perceived as in decline, with the Shia Muslim-led Iraqi government appearing to slowly assert itself more effectively across the country.

The terrorist attacks by the group continued. And the new government started to advance an increasingly sectarian agenda. These two played off each other in a downward spiral that was given a fresh boost of blood when the civil war in Syria erupted in 2011. Drawing on its existing networks (that were leftovers from when Syria was used as a staging point by the organisation to launch attacks into Iraq), the leadership sent a cell to Syria to explore what opportunities existed within the emerging fight there. This cell became the seed that grew into Jabhat al Nusrah and ultimately IS – a label the group adopted when in June 2013 IS leader Abu Bakr al-Baghdadi decided it was time to reveal this link between his Iraqi group and Jabhat al Nusrah. This led to divisions and the breaking up of the two organisations.

For IS, however, it was the beginning of an upward trajectory, building on this division to grow itself substantially in Syria (with Raqqa as its capital) and in 2014 taking over Iraq’s second biggest city of Mosul. We then reach the apex of IS’s success and the biggest expansion of the group yet.

It now seems that this growth had a shelf life of just two-and-a-half years. As the group appears to be losing Mosul, it is likely that we will see the beginning of a period of retraction. But this will not be its end – rather, it will flee back to the hills and the ungoverned spaces in Iraq and Syria from where it will continue a persistent terrorist strategy in both countries. Here it will bide its time until the moment presents itself to rise up. Waiting until the governance in Iraq and Syria fails its people again, the group can paint itself as the protector of Sunnis and once more build on that group's disenfranchisement to win supporters and occupy a space vacated by local governments.

IS's grip on power might currently be slipping but as history has shown, it has waxed and waned depending on the context it is operating in. We are now going to see a period of withdrawal, but unless attention is paid by the global community, it will expand again in the future.

Raffaello Pantucci is Director of International Security Studies at the Royal United Services Institute (RUSI). Visit his website at http://www.raffaellopantucci.com