2 Standards of Care

3   Diagnosis

The diagnostic criteria normally used for diagnosing transsexualism (often termed 'Gender Identity Disorder' (GID) by psychiatrists) are laid down in the American Psychiatric Association's Diagnostic and Statistical Manual, 4th edition (referred to as 'DSM-IV').

In summary however, the key features of GID are:

The diagnosis is properly made by a Consultant Psychiatrist with special experience of gender problems; however a GP, Counsellor or general Psychiatrist might reach a tentative diagnosis and would then refer the patient to a suitable specialist.

Care is necessary when the patient has a separate psychiatric condition such as schizophrenia. In some cases, such conditions may mimic transsexualism. Existence of a separate psychiatric condition does not necessarily contraindicate gender reassignment provided that GID can be clearly demonstrated to exist independently of other conditions. In particular, depressive conditions are very common among transsexuals (for obvious reasons depression can be a consequence of severe gender dysphoria) and should be treated alongside the GID.

Once the diagnosis is made, the specialist will probably prescribe hormone treatment and possibly other procedures such as speech therapy. In addition, routine blood tests are required for TS patients under hormone treatment; provision of most of these services will usually be a matter for the patient's GP in consultation with the patient's Consultant Psychiatrist.

The principal Gender Identity Clinic (GIC) within the NHS is located at Charing Cross Hospital, London. There are also a few regional GICs. It appears at present (as reported by patients) that all the NHS GICs are severely overworked with long waiting lists, and struggle to provide timely treatment to patients; there is also widely reported patient dissatisfaction, particularly with Charing Cross. For these reason, many patients opt to have a private Consultant Psychiatrist perform the diagnosis and recommend treatment, some of which can be NHS provided depending on local policy.

A special comment is warranted regarding the treatment of patients with a physical intersex condition (true or pseudo hermaphroditism, Androgen Insensitivity Syndrome, Congenital Adrenal Hyperplasia, Klinefelter's Syndrome etc.): The Standards of Care state that such patients should first be treated with recognised treatments for the intersex condition; then in the event of continuing gender dysphoria should be treated as ordinary transsexuals. This is often not an ideal course: all too many examples exist of intersexed patients who have been arbitrarily assigned (by use of surgery and/or hormones) to one sex or the other shortly after birth, only for it to become painfully apparent later that the wrong choice was made. These problems are often compounded later by misguided attempts to 'reinforce' the assigned sex by surgical, hormonal or behavioural intervention. The greatest caution should be exercised in cases of gender dysphoria accompanying a physical intersex condition and the advice of a Consultant Psychiatrist experienced in gender identity issues should be sought before any intervention is considered.

4 Counselling and Psychiatry



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