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”. David 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.

Identities II

I feel powerless with doctors, and wanted something to communicate my value: how can I show that I am a worthwhile person, and should be treated well? This shows a lack of trust in the medical profession. Well, I have had particular experiences with doctors.

My medical practice wrote to arrange a medication review. I take prescription hormones, and wondered about just ignoring it; but they might not give me a repeat prescription. I have a named GP but don’t like him. He did not know what it was when I described my retrograde ejaculation, and did not seem to care. So I did not want to see him again. I made an appointment with the first GP available, a woman in her forties. The male GP then got the receptionist to phone me up: I had been discharged from the gender identity clinic, was I happy with that? Yes, happy enough, thanks for asking two years after it happened. Then he wanted my blood pressure taken. I was happy to see a nurse to do that but did not want to go twice to the practice. We established that the female GP could probably do that.

She has a small fan just directed at her, but barely strong enough for the airflow to be noticeable, though the whine was. The motor had overheated. So that it just points at her is incompetence getting a decent fan in this heatwave, not discourtesy. I am a middle class person. Don’t fob me off. I was delighted to notice the booklet from “All too human”, a Tate exhibition, lying about her room. I said how much I loved the show.

She started telling me how much she had enjoyed it, especially the Lucien Freud. I loved the- can’t remember the name, Cookham man, entirely different view of him. [Stanley Spencer, of course.] She knew a woman who had curated the — gallery, which had done a retrospective of David Bomberg and showed a lot of the Jewish artists who escaped the Holocaust to London. After, I thought, yes, Germanic surname, Biblical first name, she is Jewish, I would not have considered it but for what she said. Is that why Jewish artists specifically appealed to her? Freud could be the greatest artist in that show. I would be interested in a Quaker artist, or a Scot, there.

Later, I thought of what I might have said- that Jewish refugee immigration did a great deal of good for this country- something I believe, something that fits with my attitude to refugees now, something that might have built connection there. I want to build connection. I sympathised as the fan died. She did some standard tests for why I might be TATT (Tired All The Time) from physical causes, and noted my blood pressure is within normal range. Under 140/90 is OK.

I started it, and am not sure she should have been so open to small talk. She wants to be able to relate to me, as well as I to her. I liked her as a human being and want her as an equal. I went off to the phlebotomist, who had to hunt for a vein, waggling the needle inside my arm. Piercing the skin was the most painful bit of that.

Trans children and adolescents in Australia

Australian doctors affirm trans children, and show why affirmation works: Trans or gender diverse children with good health and wellbeing who are supported and affirmed by their family, community, and educational environments may not require any additional psychological support beyond occasional and intermittent contact with relevant professionals in the child’s life, such as the family’s general practitioner or school supports. Others need a skilled clinician working with the family, to help them support their child. Where there are other mental health problems, they should be treated together with GD.

Parents who do not support their child’s transition may make their mental health worse. “Do no harm” does not mean refusing gender-affirming treatment:

Withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including increasing depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications.

Social transition improves emotional functioning. It should be the child’s decision, and may be just at particular times or particular places. Social transition brings trans children’s depression, anxiety and self-worth to the same level as cis children’s. Doctors may need to be advocates, telling schools this is what the child needs. An endocrinologist should see the child before puberty starts.

Children referred in adolescence need different treatment. The child may have spent a long time coming to understand their gender dysphoria, and considering how to explain it to parents, so will want immediate support and medical help, but a parent might see this as sudden, and have difficulty adjusting. The child needs a comprehensive exploration of the adolescent’s early developmental history, history of gender identity development and expression, emotional functioning, intellectual and educational functioning, peer and other social relationships, family functioning as well as immediate and extended family support.

Once there is significant breast growth and menstruation in a trans boy, puberty suppression is not recommended. Gender dysphoria around menstruation can be reduced with norethisterone. Testosterone in trans boys may produce irreversible facial and body hair growth and scalp hair loss. Deepening of the voice is irreversible. Clitoral enlargement and vaginal atrophy may be reversible, but this is unknown.

Oestrogen in trans girls will reduce muscle mass and strength, soften skin, and decrease libido and spontaneous erections. These effects are probably reversible. Breast growth is irreversible. The testicles will shrink, and sperm production decrease: it is unknown if these effects are reversible.

Teenagers vary in their maturity, and ability to make decisions with complex risks and benefits. However delaying hormone treatment in trans girls means increased masculinisation of face and body, and suppressing puberty without starting stage 2 treatment (gender-affirming hormones) can weaken bones. Refusing treatment reduces an adolescent’s sense of their own autonomy and agency.

GPs should give an initial assessment, including of the family support and functioning, and advise on the effect of treatment on sexuality, sexual pleasure, and fertility.

A trans boy may have chest masculinisation surgery as young as 16. There should be a joint decision with child, parents and clinicians coming to consensus, taking account of the child’s maturity. However the guidelines advise delaying genital surgery until adulthood, because it will make the patient sterile, and may reduce sexual pleasure and interest.

The New Zealand Adolescent Health Survey suggested that 1.2% of adolescents identify as transgender. The guidelines suggest that this means referrals will continue to rise. Only an atmosphere of support and acceptance will enable a child to make a proper decision.

Guidelines pdf.

Gender incongruence

Is the ICD-11 (International Classification of Diseases) redefinition of “Gender incongruence” a progressive change to the medical treatment of trans people? Almost too progressive. Trans people are accustomed to seeing psychiatrists. What will we do when we can’t?

Gender incongruence, in the new ICD, in effect from 1 January 2022, is not a mental illness. Desire for physical alteration is the diagnostic criterion. To be diagnosed with gender incongruence, you need to want rid of your primary and secondary sexual characteristics, or to want those of the opposite sex to your birth gender.

This is the definition: Gender incongruence is characterized 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. Gender incongruence of adolescence and adulthood is characterized by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, as manifested by at least two of the following: 1) a strong dislike or discomfort with the one’s primary or secondary sex characteristics (in adolescents, anticipated secondary sex characteristics) due to their incongruity with the experienced gender; 2) a strong desire to be rid of some or all of one’s primary and/or secondary sex characteristics (in adolescents, anticipated secondary sex characteristics) due to their incongruity with the experienced gender; 3) a strong desire to have the primary and/or secondary sex characteristics of the experienced gender. The individual experiences a strong desire to be treated (to live and be accepted) as a person of the experienced gender. The experienced gender incongruence must have been continuously present for at least several months. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.

So thinking you are a woman, though you have a penis, would not fit this definition. The desire to be accepted socially as a woman is not enough, even though most people only show off their genitals to sex partners. There is a separate diagnosis for childhood, but it too requires dislike of ones own sex characteristics and desire for the target gender’s. We will have to just accept ourselves, without long agonising sessions with counsellors and psychiatrists!

Gender Incongruence comes under ICD-11 17, conditions related to sexual health, which includes physical illnesses but also paraphilic disorders. It uses “desire” as a diagnostic criterion. That desire will be assessed by a psychiatrist. Might there be a similar desire which was a mental illness, such as a psychotic delusion? I can’t find the appropriate treatment in ICD 11: it does not exclude an attempt to reconcile the person to their physical characteristics.

For me, the role, expressing myself as a woman, was more important than the physical changes. It liberated me to be myself. I now believe my passionate desire for the physical changes came from social pressure, the idea that the “true transsexual” wanted these changes, and only “true transsexuals” should transition. I regret my physical alterations, probably in part because the operation was not as successful as it was in others I have talked to. I have had a significant loss of sensitivity.

The Guardian correctly reported that GI no longer comes under “mental, behavioural and neurodevelopmental disorders”, and quoted Lale Say, co-ordinator of the WHO department of reproductive health and research, who said, “We think it will reduce stigma so it may help better social acceptance for these individuals”. I am glad not to be called mentally ill. That is a relief. I am concerned that there might be greater pressure to have surgery and hormones. I am not convinced they are necessary, or that they would improve our happiness if we were not told they were necessary.

There should be two rigorously separated approaches to gender incongruence. One is the medical approach: really, those of us who want to present in the other sex without surgery or hormones should not need to see a doctor, so that reasonably concerns itself with medical treatment, but some might need help with other mental conditions. The other is the legal/social approach: those of us who transition, intending to live life long in the acquired gender, should be treated like others of that gender. Those who intend to transition or manifest as non-binary should not suffer discrimination because of it. As long as the legal definition does not require medical diagnosis, people may not be pressured into unnecessary medical treatment. We might benefit from support, even though we are not ill: transition is difficult. Hair removal and voice training might be available.

It is necessary to define a medical condition to say what a health service or health insurance should pay for, and what doctors should do. The desire to alter your body in this way is not a mental illness. The health problem, for those who desire the changes, is that the changes are necessary.

The desire to transition may involve mental distress- can I manage it? How will work, family, community react? Am I deluded in wanting this? Psychotherapists could be part of helping a trans person resolve these issues. Gender dysphoria- distress arising from others’ expectations of us based on sex- exists and is mentally debilitating. Mental health services have a role in helping with it. The mental illness is not a deluded belief that you are part of the true gender. The mental illness is the difficulty you feel realising that, given the social pressure you suffer to conform to the assigned gender. Gender dysphoria, discomfort with gender role, exists and is debilitating, and one cure is transition. Internalised transphobia could be a medical condition.

The document will be sent to WHO member states, and will take effect from 1 January 2022 if adopted.

The definition was amended.

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.

I am not sure how or when. According to wikipedia the “stable version” was issued on 18 June 2018, with the initial, longer version, and officially endorsed on 25 May 2019. The shorter version is now on the WHO website. Member states must decide when to implement ICD 11.