GPs and the gender clinic queues

Waiting lists are up to five years for gender identity clinics. What could GPs do?

Brighton GP Samuel Hall, who has a specialist interest and 450 trans and nonbinary patients, said that prescribing hormones and other trans healthcare is “not specialist care” and that GP practices should deliver it, though they need more training and support.

Well. Trans people want hormones. They help us transition, they help us appear of our true gender. They inhibit fertility, perhaps permanently, and medical ethics says “Do no harm”, but we would say the benefits outweigh the risks. A GP should be able to understand those risks- if there is an increased risk of embolism, monitor for that.

The British Medical Association guidance says GPs should understand gender incongruence. The Royal College of General Practitioners position statement from 2019 notes that trans patients seeking gender affirming care will first contact their GP, and the GP may be the first person they tell about their gender, but GPs are not trained in gender identity issues and are instructed to refer on. They want more research on outcomes of treatment, including “wait and see” (do nothing), and more expert services.

The BMA recognises that patients will self-medicate if we cannot get NHS prescriptions. The BMA and GPs advocate for timely treatment. The Royal College of Psychiatrists suggests GPs could prescribe hormones and hormone-blockers, but the General Medical Council advises GPs should only consider this if the patient fits all of three criteria:

they are already self-prescribing or likely to, from an unregulated source- so a GP would not take over a private prescription
The patient’s risk of self-harm or suicide would reduce, and
The GP has sought the advice of a specialist and prescribes the lowest acceptable dose.

Even though they say “untreated, gender dysphoria can severely affect the individual’s quality of life and potentially lead to mental ill-health”, they don’t seem to recognise particular benefits from hormones in themselves. Hormones do have particular risks, which they take into account as reasons not to prescribe, especially pre-op. I may have a look round to see what is established about the benefits of hormones in gender diverse adults.

So you may be able to get hormones from your GP, but it is difficult. Once the gender clinic recommends hormones, the GP should prescribe them, but that may be in five years’ time.

GPs should use the forms of address and pronouns we prefer. They should recognise our distress and the difficulty of confiding in someone. They can refer to specialists directly, and should do so.

Simon Gilbert writes that gender dysphoria is uncommon but not urgent, so GPs should be able to identify it and refer on. GPs treating risk unknown unknowns. Another GP writes he has had three trans patients in twenty years. GPs should not have to deal with trans patients “because another part of the NHS is crap”. GPs feel overworked and underqualified on trans care, and we should recognise their difficulties too. For too many GPs, managing patients means saying the right things so we use as little of their time as possible. Patrufini Duffy writes that GPs are overloaded with social problems on top of having no time to deal with their lists of patients, so cannot take on gender prescribing.

The BMA says GPs should work with us on fertility care, including sperm or egg storage.

The BMA recommends an intermediate service to provide care up to but not including surgery. There is such a service in Wales. Such a service could refer “complex” cases on to a more specialist service, but the definition of “complex” would change as its skills, experience and competency develop. The BMA pressing for more gender clinics might be a way of absolving itself of responsibility for prescribing now. It says GICs, not GPs, should manage the GIC waiting list and should not ask GPs to reassess patients in an attempt to delete some patients from the waiting lists.

Pulse, a magazine for “health professionals only”, reported on the gender clinics asking GPs to review patients on the waiting lists, and sought quotes and allowed comments from GPs.

Seven years post-op, my new GP explained that the risk of thrombosis indicated I should come off hormones. It was a disaster. I went back on; but one risk named to justify the prescription was osteoporosis. We need to be able to justify hormone prescriptions.

Picture from the Wellcome Collection shows how seriously doctors take themselves.

Different types of detransitioners?

Is the “Society for evidence-based gender medicine” a serious scientific body, or a hate group? On its home page, I found the false, debunked claim that 61-98% of childhood gender dysphoria resolves. But, its hundred members write scientific papers! Look, look, it’s got footnotes and everything! Unfortunately, it is profoundly silly.

Pablo Exposito-Campos suggests that there are two kinds of detransitioners- those he calls “core,” who have seen the light, and “reidentified with their biological sex”, and “non-core”, who detransition because of social pressure. The treatment each should receive from doctors should differ.

The trouble is retransitioners, whom Exposito-Campos does not mention. It is always possible that a detransitioner will retransition, just as it is possible a trans person will detransition, and what they say, even what they believe, is no guide to this. Someone who finds a supportive community among detransitioners hijacked by anti-trans campaigners, like Ky Schevers, finds themself pressured to say things they later go back on.

So various questions might help understand what a detransitioner might do. Where, if anywhere, are they getting social support? Are they likely to try to find the positives in any experience? Do they blame themselves, or other people, for their problems?

Do you think of gender dysphoria as a psychological symptom you have, or trans as a kind of human you are, like a left-handed or gay person? Exposito-Campos imagines GD is merely a symptom.

Charles Kane, now presenting male in their work as a barrister, has gone at least M-F-M-F-M, and possibly spent some time working male, playing female. When they first transitioned they wrote a book about finding their true self. When they detransitioned for the first time they had penis reconstruction and made a complaint against their psychiatrist, saying they had had a nervous breakdown. When they retransitioned, initially they did not have surgery again, but then did.

And, when they first transitioned they could not see their children, and when they retransitioned it was after their son saying “I love you whether you are a male or a female”. I cannot almost understand Kane’s complaint, when they were under so much pressure. But I can blame such as Exposito-Campos.

He uses the uncertainty of what patients might do as a reason to hold back on gender treatment. He claims clinicians have “epistemological responsibility” to know the future, what the patient might do. Might they regret and revert? If so, the clinician should be wary of supporting their initial transition.

This is the threat of the British government’s suggestion that cis to trans conversion therapy should be illegal. It does not exist, but a detransitioner might argue that support for their transition was such criminal conversion. So, clinicians will be deterred from supporting people through transition. However Exposito-Campos wants conversion therapy from trans to cis to be available- he says patients should be able to choose “non-affirming care”. But we only “choose” such care because of religious indoctrination, internalised transphobia, or fear of societal transphobia.

He says, the doctors should not create “unrealistic expectations” of transition, because that is the problem for those who detransition under social pressure. Do doctors ever do that? You can’t know what transition will be like, any more than you can know what a job will be like when you have the interview. I thought it would be terribly difficult, then found it was difficult in unexpected ways.

Exposito-Campos writes that some people detransition after a few months, others take several years. For him, it is as if they are realising they made a mistake. But some time living in the true gender may be the best thing for someone. Then their other circumstances change, and they revert.

We continue to suffer gender dysphoria after transition. He writes that even those detransitioners who decide they were wrong to transition will still suffer gender dysphoria after detransition. They need other ways of coping with it. But the detransitioners who know they are still trans, but detransition because of social pressure? He thinks they may decide they were never trans. Again, his bias is to think anyone who transitions is making a mistake, just some of us never realise it.

What does he think those who revert because of social pressure, but still know they are trans, need? He suggests they need information on stopping hormones, though they might want to continue. He says they need psychological support to deal with discrimination and anxiety, but not with gender dysphoria, which he does not mention for them. He also says they might need support making a legal claim of medical malpractice: again, he wants to deter doctors from supporting transition.

It’s a paper, it seems, and it has been published. It is readily available. But the “typology” of detransitioners does not fit real lives, and he will only support patients who do what he thinks they should. Which is what he accuses others of when they affirm their patients’ transition.

“Society for evidence-based gender medicine” is just another fancy name for a tiny group of anti-trans campaigners.

Medical services for trans people

The parliamentary committee are not our friends, and have recommended keeping trans medical bottlenecks at the moment when trans medical care could open up. They recommend more gender clinics, when gender clinics should be shut down.

Trans is easy to recognise. Trans men are people assigned female at birth who are convinced that they are men, want to be treated as men, or want to express themselves as men. They may want bodily alteration to appear more clearly to be men, to themselves and to others. Trans women go the other way. We know who we are.

That settled conviction is in some way different from those mental illnesses which divorce one from reality. I don’t understand how, particularly, but my understanding of myself as a woman is different from my friend’s schizophrenic daughter’s belief that there is an electronic device in her head which enables the Government to know what she was thinking. My desire to express myself female is more like a gay man’s desire for a particular male partner- incomprehensible to some straight men, but not “insane” or “psychotic”.

The committee say there are huge waiting lists. 13,500 trans people were waiting as of January 2020, before covid. Their evidence was a BBC report. The report’s figure came from Freedom of Information requests to each gender clinic, but some figures date back to July 2019 and the committee heard evidence that lists have increased since then. One clinic’s waiting time was increasing by five months each year, even before covid.

A trans person should be able to go to their GP and say that they are trans, and get a prescription for hormones. If the trans person understand that hormones may reduce their fertility and sexual response, that should be enough. The GP might want a psychiatrist to make absolutely sure that the patient was not psychotic, but should be able to check that themself. They might not like the idea of a healthy testicle being amputated, but they should accept that orchiectomy is beneficial, just as they should accept that abortions are necessary.

The trans person needs hormones, hair removal and speech therapy for women, and psychological support for the transition, which can be the most stressful experience in a person’s life. They may not need medical treatment at all- if a trans person wants to transition without threatening their fertility they should be able to do so.

So NHS England funding the Royal College of Physicians to develop education in gender dysphoria medicine is a backward step (report, para 194). Physicians, medicine, not surgery. These physicians would have the boring task of giving hormone prescriptions to patients who asked for them.

In Wales, there is the germ of a new path. There are around 70 GP “clusters”, and any GP who wants can train to be the lead on gender identity within the cluster. Cat Burton from GIRES gave evidence that most people approaching their GP just want to talk to someone about dysphoria arising from presenting in their assigned gender. They might not transition socially. They might just take hormones. Whether the “tiny minority” who have surgery is a small proportion of those who transition, or of those who approach their GP whether or not they transition, is unclear from the report. How Cat knows and who she asked, whether there was a survey and how systematic it was, is not clear from the report. I had thought trans men needed chest masculinisation to transition socially.

I would love to know how many more people talk to their GP about dysphoria, than transition. That would show how terrifying transition is, because of all the prejudice.

However, the Committee recommends more “trained and specialist clinicians”, para 197. They would keep the bottlenecks, even though they admit the new pilot clinics cannot make surgery referrals (para 191) and cannot reduce the waiting lists.

If there was the political will, the NHS could cut the surgery backlog by temporarily reporting private surgeons who perform the operation across the EU.

The committee found trans people have difficulties accessing primary health care. Some GP practices make difficulties over recording correct name and gender. A trans man with a cervix still needs smear tests. Getting them is a computer problem, but the NHS should be able to sort that.

Michael Brady, national adviser for LGBT health, said GPs needed training in order to be “more comfortable” using correct pronouns and managing trans patients (para 204). In other words, GP practice is filled with prejudice.

The committee found that LGBT people are more likely to be mentally ill, but there is insufficient mental health care and GPs might seek mental health support from GICs, though they do not give it. Psychiatrists treating for other conditions challenge trans people’s gender identity.

After the LGBT consultation in 2017, the government committed to an LGBT action plan rectifying the problems it identified. The committee found the Johnson government has gone back on this. Liz Truss confirmed that, para 218. She said she was working on banning conversion therapy instead, as if doing both were impossible.

The committee considered nonbinary recognition. The government and EHRC said it was too difficult. There were complex practical consequences for public life. The LGBT action plan had committed to seeking evidence on nonbinary recognition, but even that had not been done (para 225). The committee was reduced to demanding the government explain what difficulties might prevent nonbinary recognition, but since ministers refused to appear to give evidence, that recommendation is unlikely to be followed. The committee called on the EHRC to research the area, but with Lady Falkner, Akua Reindorf and others on its board this is unlikely.

While there was a majority on the committee for all these restrictions on trans rights, anti-trans campaigner Jackie DoylePrice voted for them to be even more restrictive. Her constant ally was Phillip Davies, men’s rights activist and anti-feminist MP.

Doctors can give medical treatment to trans children

Trans children can be treated for their gender dysphoria, says the Court of Appeal. This is a huge relief to parents and children. It is for the NHS to decide whether the treatment should be available at all. It is for doctors, parents and children together to decide whether puberty blockers should be taken in individual cases. The courts cannot set out how doctors should approach future cases.

The case of Gillick established children under 16 could make their own decisions about treatment if the doctor thought they were mature enough to do so. At the time, contraceptive treatment for children was controversial. The Court of Appeal restores the ability of mature, competent children under 16 to make decisions for themselves, supported by their parent and doctors. This affects all children and all treatment, not just puberty blockers.

There are eleven million children in Britain. In 2019, 2519 were referred to the Gender Identity Development Service, GIDS. They faced a delay of up to two years before assessment. Of the children assessed in 2019, 161 were referred for puberty blockers.

The High Court had accepted the evidence produced by the anti-trans campaigners, even though it was controversial. They decided that when adolescents started puberty suppression, only 1.9% did not go on to cross sex hormones. Even if that were true, it could have been because the children were truly trans and properly consented. It did not apply to patients of the GIDS. 1648 patients were discharged in 2019/20, and of a random sample of 312 of them, 16% (49 children) had been referred to endocrinologists for puberty blockers, but only 55%, 27 children, were approved for cross-sex hormones. Two of the 49 did not commence treatment, and five were discharged without being referred to adult gender services (so would not get CSH on the NHS).

So a tiny proportion of those who will eventually transition happily were referred to GIDS, and of those only a few were treated. The system shows great reluctance to treat trans children, and the courts should not impose more. The doctors prescribe puberty blockers to alleviate the current distress of gender dysphoria. The children and parents seek it in order to avoid the characteristics of the assigned sex, and gain the characteristics of their true sex: allowing this is the way the distress can be relieved.

Doctors and parents together assess whether a child can understand to consent to treatment. It’s hard to see what a judge or other lawyers could add. The legal question is fairly simple: does the child understand the treatment, and does the doctor consider it is in the child’s best interests. The judge does not know the child better than the doctor does. So a court application might forestall a future legal challenge to the decision, but cannot give additional certainty that the decision is right, only delay, worry and expense.

The High Court gave guidance on when treatment might be permissible. The Court of Appeal said the High Court could not do that. At para 56 they quoted Lord Scarman in the Gillick case, saying a legal rule giving certainty about when a child could consent would be inflexible and could obstruct justice. If such certainty is necessary it should come from legislation after a full consideration of all the relevant factors. Courts only hear the evidence brought by parties to a particular case.

They quoted the House of Lords in Burke’s case: “The court should not be used as a general advice centre”. It should not make wide-ranging decisions about difficult ethical questions, only about the particular question between the parties.

The NHS had given detailed rules on the management of the GIDS, including when puberty blockers might be prescribed. The High Court had found these rules to be lawful. Therefore, there are restrictions on the evidence the court in a judicial review could hear. The anti-trans campaigners had lodged their expert evidence late. They never sought permission to lodge it. The Court of Appeal said in a judicial review the court would usually prefer the evidence of the defendant.

The High Court had gone beyond what a court should do. Keira Bell has made unguarded comments about appealing, and anti-trans campaigners will continue to attack the GIDS by any means available, but it appears this particular attack has failed for now.

This is a feminist victory. The Gillick case, which enshrined children’s rights to necessary contraception and abortion, is safe for now. Feminism wins when in alliance with LGBT+. Everyone loses when “feminists” or “LGB” split from LGBT+ rights.

The decision.

A diagnosis of Trans

Why should a trans person go to the doctor?

Last century, there was the concept of “Gender Identity Disorder”. The idea was that a man who thought he was a woman, or a girl who thought she was a boy, had a mental illness, a delusion, that should be cured if possible. So children who “desisted” were counted as cured, and some children were referred to psychiatrists merely for non-stereotypical gendered behaviour. That’s why there is old research claiming huge desistance rates, which transphobes still trot out to oppose treatment of actual trans children.

Or, there was “transsexualism”, a syndrome where people believed they were of the other sex, and the treatment was transition, hormones and surgery, to help them express themselves as well as possible in the other sex. In DSM V, the diagnosis is “gender dysphoria”. The idea is that being trans is not a disease, and needs no cure, but the distress arising from it is.

From the 1930s, some doctors were prescribing hormones and performing surgery, but in Ancient Rome trans women, the priestesses of Cybele, might drink the urine of pregnant mares to get the oestrogen they needed. They did not know what a hormone was, but they knew what it did.

This is the ICD 11 definition of “Gender incongruence”, classified as a “condition related to sexual health”: Gender incongruence is characterised by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex. Gender variant behaviour and preferences alone are not a basis for assigning the diagnoses in this group.

That is, you need a diagnosis if you want hormones or surgery. A doctor, probably a gender specialist, decides that the incongruence between your gender and assigned sex is such as to justify treatment.

It does not say that anyone who does not want treatment is thereby not trans. Trans is just part of ordinary human diversity. You can transition to live in your true gender, without ever taking hormones or having surgery.

There is no reason for trans people to be medicalised. Sometimes the cis ask us if we’ve had surgery, as if they would grudgingly tolerate a trans person who has, because they were in some way “really trans”. But that’s their stuff, not ours.

And some trans people want hormones and surgery. Dora Richter attempted to remove her penis with a tourniquet when she was six. That is a deep, psychological need. They have gender incongruence, and that will remain a medical condition, though not a psychological one.

The British Government wants doctors, in fact gender specialist psychiatrists, still involved in gender recognition in England and Wales, even though “gender dysphoria” is outdated. But what diagnosis? If the specified diagnosis is “gender incongruence”, that means that you can’t get gender recognition unless you desire surgery. That would be worse than now.

They suggested the doctor assess psychological readiness or “fitness to proceed”. Dr Michael Brady, the LGBT medical adviser, rejected that. How can doctors assess it? Transitioning is stressful and difficult. The prejudice you face is terrible. They don’t know what will happen.

So, because the government want doctors still to be involved, we end up with a diagnosis of gender dysphoria. In the DSM V, that diagnosis makes some sense. Psychiatrists want to argue that they should be able to claim money from medical insurance for helping people with distress. In gender recognition, it makes no sense at all. Someone might be so delighted with their imminent transition that they feel no distress. On a two year waiting list, someone might have transitioned already, and the doctor is reduced to writing, “they tell me they used to be distressed, presenting in the assigned gender”. Again, it’s medicalising trans people, who only need doctors if they need hormones or surgery.

What of the JR111 judgment? It says that it is not against our human rights to require a medical diagnosis, but it is against them to use the word “disorder”, which is in the Gender Recognition Act. The judge can make an order that the Act is to be interpreted in a particular way, or declare it incompatible with human rights- which puts a moral but not legal obligation on the government to amend it.

The government wanted doctors involved to avoid applications variously described as vexatious, unmeritorious, frivolous or unadvised. The first three seem to be from cis people mocking the system. Perhaps Graham Linehan would try it. The British public has enough common sense to deal with Graham Linehan. He would gain nothing, and if there’s a requirement for a statutory declaration he might face a charge of perjury.

The fourth, unadvised, is particularly obnoxious. A doctor would have to decide that, though we were trans, we just could not cope with the stress of transition. People transition on a wing and a prayer, because we have to. No-one knows it will be successful.

The British Government v Trans People

A Northern Irish court case has revealed Liz Truss and Boris Johnson’s labours to inflame a culture war against trans people, after the previous Conservative government had decided to treat us reasonably. The anonymous JR111, let’s call her Jennifer, applied for judicial review because the government blocked her from getting a gender recognition certificate. For example, the government has a list of specialist psychiatrists qualified to diagnose “gender identity disorder and transsexualism” for a GRC, but none of them practise medicine in Northern Ireland. Continue reading

Health rationing and Covid

Over 30,000 people are in hospital in England with Covid. What does this mean?

The British Medical Association says doctors are stressed, anxious about their own health and that of their families, working more than normal hours and possibly beyond their competence in order to avoid serious harm. Final year medical students are fast-tracked, retired doctors are returning to practice. Doctors are working outside their normal specialty. The BMA drily states, “The skills of these professionals may not meet pre-pandemic expected standards of fitness to practise”.

The General Medical Council, appointed to govern doctors’ fitness to practise, reassures doctors that their careers will not necessarily be affected. They will take into account “the stress and tiredness that may affect judgment or behaviour”.

Hospitals lose their ability to admit patients for other matters. It is a terrible time to have a heart attack, stroke or cancer. GPs will be dealing with most health need, and so will cancel non-essential services, and use telephone or video consultations.

Where all facilities, equipment and staff that could be used to meet patient need are at capacity, “resource allocation decisions between individuals would become inescapable”. Rather than meeting individual need, the health service has to “maximise overall benefit”. This means refusing treatment to some patients. Normally, there is an “obligation to persevere in the face of an extremely ill patient”, leading to breaking ribs attempting to resuscitate a patient on ventilation. Some patients may have treatment withdrawn, even if they are slowly improving, to enable others to be treated, who have a “higher survival probability”.

It is lawful and ethical for a doctor to refuse potentially life-saving treatment where someone else is expected to benefit more from it. Doctors are not assessing the suggested value of a person to the community- younger or older, family responsibilities, work eminence- but their capacity physically to benefit. Individual doctors should be making these decisions according to rules set by their employers. The rules should be open and transparent.

Where care is withdrawn, patients will receive symptom management and end-of-life care for the dying. These decisions have a significant emotional effect on health workers.

Triage is a form of rationing of scarce resources. It sorts patients according to needs and probable outcomes. It can identify those who are so ill they are unlikely to survive, who will be given symptom relief. Priority “will be given to those whose conditions are the most urgent, the least complex, and who are likely to live the longest”.

These decisions should not solely be based on age or disability but likelihood of benefiting from available resources. Where patients cannot be admitted to intensive care they will not receive cardio-pulmonary resuscitation (CPR).

Where large numbers of people have apparently equal chances of survival and length of stay in ICU, at first there will be a queuing system- first come, first served. If patients are not improving, there may be a time-limited trial of therapy, and treatment withdrawn. In overwhelming demand, where a patient’s prognosis worsens care may be withdrawn.

Sometimes a patient’s contribution to essential services, where the workforce is severely depleted, may be taken in account. This means that sick doctors may be prioritized. Well, I would not object to that.

Hospitals are reporting shortages of oxygen. Blood oxygen saturation of 95% is considered normal, but in Southend the target was reduced, to 88-92%.

Cases in England are still rising, because of the Conservative government’s ridiculous promises of association indoors over Christmas, and failure to implement lockdown until after schools were opened on Monday 4th January. Deaths will continue to increase for four weeks. Hospitalisations will continue to increase for two weeks. Hospitals in London are overwhelmed. People who could have been saved with normal health resources will die.

The BMA’s FAQs are here. Their detailed guidance is here.

DSM V Gender dysphoria

What do you need, to get a diagnosis of gender dysphoria? This is the Diagnostic and Statistical Manual of the American Psychiatric Association definition of gender dysphoria:

A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:

1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics).

2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).

3. a strong desire for the primary and/or secondary sex characteristics of the other gender.

4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).

5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).

6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

Under “Diagnostic features” it notes that “There must also be evidence of distress about this incongruence. Experienced gender may include alternative gender identities beyond binary stereotypes… Adults feel uncomfortable being regarded by others, or functioning in society, as members of their assigned gender.”

Medicine is practical. Doctors don’t make people conform to a particular ideal Wellness, but help us continue to function. This definition is focused on the patients, and what we believe, desire and experience.

You don’t need to desire to change sex characteristics. Secondary sex characteristics include facial hair, or the lack of it, so a desire to change that, rather than gonads or genitals, is enough. So the attempt of some gender critical feminists to distinguish between transsexuals (acceptable) and transgender (not) is not backed up by the APA.

Alternative gender identities: the diagnosis recognises non-binary people. It does not state that the appropriate treatment will be hormones or body alteration, but at least recognises they exist. Private doctors may be more keen to give the patient what they want, so recommend surgery or hormones.

The evidence of “distress” is a fudge. Many of us are not distressed by our gender, but by society’s (perceived) response to it. I know I am a woman, but other people rejecting that distresses me. And, I decided that to be distressed by others’ responses gave them too much power over me. I accept that some people think I am a man. I am not going to waste any energy trying to persuade them otherwise, and I am not going to get upset about it. And, being seen as a woman is not necessary for friendship or politeness: they could see me as a transwoman but think that’s OK.

Yet, if you are not distressed, you are not ill. Being trans is not an illness, it is just a way people are. That means the diagnosis would change to something like gender incongruence in the proposed ICD, as it is only necessary for psychiatrists to intervene if someone wants genital surgery. You might like the backing of a psychiatrist- yes, I really am like this, I am a trans woman- but that is more the province of social scientists than of doctors.

The conviction that one has the feelings and reactions of the other gender does not fit me either. I am a gender critical feminist. I don’t think either gender is so limited, and the feelings of both are the same. I believe the reactions are culturally conditioned rather than innate. I believe my feelings and reactions fit the feminine stereotype far better than the masculine.

The convictions need to have lasted six months for diagnosis. There is no need for The Script, a claim that the feelings have lasted since childhood. But the longer the feelings have lasted, the more likely it is that they will persist, so treatment is less risky.

DSM V estimates prevalence at 0.005% to 0.014% in natal males and 0.002-0.003% in natal females. Other estimates go from 0.1-1%.

It’s all a botched job. It is trying to create a working definition for a varied human phenomenon, and people may try to fit that definition to get what we want.

Righteous anger

When I go to see my doctor, I hope we will be discussing my issues rather than hers.

I told her I was tired all the time, and she sent me for blood tests. The practice wrote to me telling me to make an appointment, so I did. I was ambivalent about discussing antidepressants. I have not found them useful in the past, and feel that my depression is caused by circumstances rather than any brain chemical imbalance, particularly by a series of traumas.

-Why have you come to see me today?
-The practice wrote asking me to make an appointment.

She looked blank for a moment. “Well, you remember I told you that your thyroid reading was slightly lower than normal range.” It took me several tries to convince her. Eventually I said, “I have not seen any doctor at this practice since the blood tests. I made the appointment after getting a letter from the practice. Perhaps you wrote a note of what you were going to say, before requesting the letter.”

That got through to her. My thyroid is very slightly below normal range. It could cause various symptoms- heavy periods was one she mentioned, she knows I am trans surely. Not regulating temperature. Putting on weight. She recommended another blood test in 3-4 months, and if it showed a similar result she might try me on a very low dose of thyroid medication.

No, I don’t want to discuss depression after that. She, however, has something to ask me. Her lesbian friend, who she trained with, asked on facebook whether friends thought the word “queer” had been reclaimed or not. She commented, “Yawn,” and some disparaging reference to “political correctness”, and all the queers piled on her. She wondered what I thought, she said.

Well, I feel the word “queer” has been reclaimed: we do “Queer Studies”, after all. But that’s not what she’s asking: she wants me to say the queers should not have rebuked her.

-You’re straight, aren’t you?
-What’s that got to do with it, she blazed. I am taken aback. She says they would not know that. I am too nonplussed to explain that she does not get the nuances around the word. It has been used to belittle and attack people, including some who might be on that facebook thread.

She says being Jewish she understands all about being part of a minority. Now, me being queer means I want to be a good ally to Jews, BAME etc, and I might say that, but she is saying something different, that being Jewish is enough to understand. Her children are so terribly left wing and right on. She wants pensioners to get enough benefit so that they can afford food, rent and heating, but her children are concerned about things like transgender bathrooms.

“Well, I would love to stay chatting but I have patients to see,” she says, dismissing me.

What would be the point of complaining? I don’t really want to make trouble for her, and I don’t think it would achieve useful change.

I was being sympathetic, but the moment I started to hint that they might have reason to object to her comment she became immediately defensive and struck back. Why should it matter that she’s straight? She does not want an answer, only to be assured that she is right to be aggrieved; and perhaps to take out her grievance. I love her righteous anger. I wish I could do it myself, instead of being quiet then resenting.

-Where’s the hurt, you ask, and I answer in that quiet voice which I think shows my most vulnerable self in our conversations.

It’s just hurt. I don’t think it’s anger, or resentment. There’s some perplexity. I feel disrespected and this feels unfair, and my sense that it’s unfair I immediately judge as pointless, worthless whining. I admire her going on the offensive like that, I don’t think I would.

I noted how easily my mood can go up and down. I was worried about that conversation, “you don’t seem depressed”, and then meeting Mr Corbyn got me feeling so much better. Then something happened and I got down, then I started talking about something I was looking forward to- I said “I will do that well”, and knew in the moment that what I said was true- and felt good again. Being able to say to myself that it was just a mood, like dreich weather, would be a good skill.