Charing Cross Gender
Identity Clinic
January 2013
About me
Dr Stuart Lorimer
MBChB MRCPsych
Gender Specialist
(Consultant,
Liaison Psychiatry)
Charing Cross
Gender Identity Clinic
Oldest
 Largest
 12-1300 new
patients per year
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General Principles
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Multi-disciplinary
 Psychiatrists, Psychologists, Surgeons,
Speech therapists, Electrolygists,
Gender-specialist nurses
Multi-opinion
Reversible
Less reversible
Irreversible
Emphasis upon transition
(= Real Life Experience, RLE)
Referral
GP
GP
PCT
Psychiatry
GIC
Central
Commissioning
GIC
Patients
Trans men (FtM)
- 38%
 Trans women (MtF) - 62%
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Average age at presentation - 35
 FtM - 21
 MtF - 41
Age of presentation
Frequency
10
5
0
18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78
19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77
Timing of presentation
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Adulthood / autonomy
Fulfilment of obligations
Period of reflection
Finitude
Gradual / evolving
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Abrupt / “out of the blue”
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Sexuality
Study of 125 referral letters
 73 attracted to women
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32 bisexual
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(11 FtM, 21MtF)
11 asexual
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(18 FtM, 55 MtF)
(2 FtM, 9 MtF)
9 attracted to men
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(3 FtM, 6 MtF)
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Other
Sexuality
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
Components of transition
No “standard” transition
Biological
Psychological
Social
Biological
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Physical comorbidity
Facial / body / scalp hair
Speech modification
Feminising / masculinising hormones
Tattoo removal, etc.
Surgery
 Genital
 Facial
 Other
Psychological
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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
Social
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Name change
Family relationships
Safeguarding rights / advocacy
- employment
- legal
- custody
Social customs
Diagnosis I
ICD 10
 F64.0 Transsexualism
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F64.1 Dual-role Transvestism
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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
Wears clothing of opposite sex
No sexual motivation
No desire for a permanent change
F65.1 Transvestic Fetishism
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Acting / dressing like opposite sex, for sexual gratification
Clinically significant distress / impairment
Diagnosis II
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Dynamic / evolving
Controversial / sensitive
Diagnosis versus Pragmatism:
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“Will this work?”
F64.9 Gender Identity Disorder, Unspecified
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Genderqueer
Non-binary
Neutrois
Etc.
Tailored service
Assessment I
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Introduction
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Preferred prefix, Initial & surname
 Why now?
 What were previous obstacles?
Early memories
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Clothing & presentation, Associated feelings,
Sexual?
Puberty
Family
 Genetics, Supports
Psychiatric history
Physical history
 Smoking, Self-medicating?
Assessment II
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Social / occupational history
 Supports
 Role in transition
Relationships
 Physical intimacy
 Relationship with genitalia
Cultural history
Plans for the future
 Transition?
 Timescales
 Hormones
When do we recommend
hormones?
Post surgery
 Full time transition
 Coherent / imminent transition plan
 Already on hormones?
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Lower doses to alleviate dysphoria
Hormones
MtF:
 Oestrogens
 Anti-androgen
FtM:
 Testosterone
Low level oestrogens in non-transition
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
Challenges
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“The Transsexual Imperative”
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Medical colleagues
 84% of UK doctors think gender
services shouldn’t exist within the
NHS
Longer term
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Re-referral
Diagnostic overshadowing
Ongoing advocacy
Regret (approx. 1-2%)
Detransition
GIC myths
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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
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They deliberately play Good Cop / Bad Cop
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Bad Cop
“Transsexual and
Other Disorders of
Gender Identity: A
Practical Guide to
Management”
Dr James Barrett
(2007)
MANGE
TAK!