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TRANSGENDER HEALTH of Related Interest TRANSGENDER HEALTH of related interest Gender Diversity and Non-Binary Inclusion in the Workplace The Essential Guide for Employers Sarah Gibson and J. Fernandez ISBN: 978 1 78592 244 2 eISBN: 978 1 78450 523 3 Counseling Transgender and Non-Binary Youth The Essential Guide Irwin Krieger ISBN: 978 1 78592 743 0 eISBN: 978 1 78450 482 3 The Voice Book for Trans and Non-Binary People A Practical Guide to Creating and Sustaining Authentic Voice and Communication Matthew Mills and Gillie Stoneham ISBN: 978 1 78592 128 5 eISBN: 978 1 78450 394 9 Transgender Employees in the Workplace A Guide for Employers Jennie Kermode ISBN: 978 1 78592 228 2 eISBN: 978 1 78450 544 8 Trans Voices Becoming Who You Are Declan Henry Foreword by Professor Stephen Whittle, OBE Afterword by Jane Fae ISBN: 978 1 78592 240 4 eISBN: 978 1 78450 520 2 TRANSGENDER HEALTH A Practitioner’s Guide to Binary and Non-Binary Trans Patient Care BEN VINCENT, PhD Foreword by Dr. Stuart Lorimer Jessica Kingsley Publishers London and Philadelphia [permissions granted] First published in 2018 by Jessica Kingsley Publishers 73 Collier Street London N1 9BE, UK and 400 Market Street, Suite 400 Philadelphia, PA 19106, USA www.jkp.com Copyright © Ben Vincent 2018 Foreword copyright © Dr. Stuart Lorimer 2018 Front cover image source: [iStockphoto®/Shutterstock®]. The cover image is for illustrative purposes only, and any person featuring is a model. All rights reserved. No part of this publication may be reproduced in any material form (including photocopying, storing in any medium by electronic means or transmitting) without the written permission of the copyright owner except in accordance with the provisions of the law or under terms of a licence issued in the UK by the Copyright Licensing Agency Ltd. www.cla.co.uk or in overseas territories by the relevant reproduction rights organisation, for details see www.ifrro.org. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher. Warning: The doing of an unauthorised act in relation to a copyright work may result in both a civil claim for damages and criminal prosecution. Library of Congress Cataloging in Publication Data A CIP catalog record for this book is available from the Library of Congress British Library Cataloguing in Publication Data A CIP catalogue record for this book is available from the British Library ISBN 978 1 78592 201 5 eISBN 978 1 78450 475 5 Printed and bound in Great Britain OR Printed and bound in the United States To Kine Contents Foreword . 11 Acknowledgements. 13 1. Introducing Trans Terminology 17 Glossary . 21 Terms to avoid . 34 Conclusion . 37 2. Fundamental Concepts 39 Sex and gender . 40 The history of the medicalisation of trans people . 47 Diagnostic manuals . 51 3. Administration and Patient Interactions 61 Inclusive language in service provision . 62 Examples of gendered language . 64 When can gendered language be appropriate? . 65 Misgendering . 67 Non-binary people and inclusive language. 67 Language use in gendered medicine . 69 Changing names and gender markers on medical records. 70 Additional name change options in Scotland and Northern Ireland . 73 Helping a patient change their passport . 73 Trans-affirmative therapeutic interactions. 74 4. The Referral Process 77 General information for professionals making a referral to a GIC . 78 England . 80 Information for Welsh referrals . 89 Scotland . 70 Northern Ireland. 93 5. Care Separate from Transition 95 Health disparities between cisgender men and cisgender women . 97 Primary care unrelated to trans status . 103 Secondary and tertiary care . 103 Conclusion . 118 6. Children and Adolescents 119 Myths and misconceptions . 120 ‘It’s just a phase’? – desistance . 121 Parental influence?. 124 Are trans children and adolescents mentally unwell? . 124 Following the crowd? . 125 Conversion therapy . 127 The importance of support. 127 Risks of an unsupportive environment . 129 Guidance for parents . 129 Guidance for schools . 130 Guidance for clinicians – referrals. 131 The Tanner stages . 134 Puberty/hormone blockers . 134 Fertility . 139 Role of the GP in managing blockers and hormones for young people . 140 Gonadotropin-releasing hormone (GnRH) analogues . 140 Triptorelin (Decapeptyl® SR, Gonapeptyl® depot). 141 Goserelin (Zoladex®). 142 Leuprorelin (Prostap® SR DCS) . 143 Progestins . 144 Medroxyprogesterone Acetate (MPA) (Provera®, Depo-Provera®) 145 Additional prescribed interventions . 146 7. Gender Affirmation 147 Criteria for hormone prescription. 147 The GP’s role in hormone provision . 148 Estrogen (Estradiol) . 152 Different preparations, doses, and deliveries . 155 GnRH analogues . 158 Antiandrogens . 158 Bicalutamide (Casodex®) . 158 Cyproterone (Androcur®, Cyprostat®, Dianette®) . 159 Spironolactone (Aldactone®) . 159 Finasteride (Proscar®) . 160 Testosterone . 161 Antiestrogens . 164 Non-binary hormone regimens . 165 Voice . 166 Hair removal . 167 Binding . 168 Prostheses . 170 Gamete storage. 171 8. Gender Affirmation Surgeries 173 Referral for surgery . 174 Chest reconstruction – general information. 174 Top surgery for trans men and AFAB non-binary people . 174 Top surgery for trans women and AMAB non-binary people . 177 Vocal surgery to raise pitch . 178 Facial feminisation surgeries . 178 Genital surgeries for trans women and AMAB non-binary people 182 Genital surgeries for trans men and AFAB non-binary people . 184 Regret associated with surgeries. 186 Concluding remarks 189 References. 191 Index . 203 Foreword Who treats gender dysphoria? At the time of writing, this varies throughout the UK. For reasons largely historical, the majority of care for binary and non-binary trans people happens within Gender Identity Clinics staffed by a mixture of clinicians but, in theory at least, any doctor including the GP can initiate and manage hormones. Who should treat gender dysphoria? This is perhaps a knottier issue. In 2016, the House of Commons Women and Equalities Select Committee released its report on Transgender Equality, noting with concern the continued bracketing of gender within the realm of mental health, and suggesting this gave the misleading impression of trans status being a “disorder of the mind”. It recommended transferring gender services to another area of clinical specialism or viewing them as “a distinct specialism in their own right”. I came into this field in 2002 as a consultant in general adult and liaison psychiatry. At that time, gender clinics were the near- exclusive province of psychiatrists. Within a year or two, however, the professional landscape was changing, with psychologists, endocrinologists and even the occasional oncologist joining the fray. This is as it should be. While I believe that liaison psychiatry provides a good skill-set for approaching the topic, gender-related issues can and do arise in all areas of medicine, most commonly in primary care. With greater mainstream discussion – and, for the most part, acceptance – trans individuals become aware of their options and present earlier, typically to the GP. 11 TRANSGENDER HEALTH The aforementioned Select Committee report pointed out that GPs, “too often lack an understanding of: trans identities; the diagnosis of gender dysphoria… and their own role in prescribing hormone treatment”. It is understandable that a GP faced with their first transgender patient might feel out of their depth, trans people and their healthcare having tended to be a mere footnote in medical education. Recalling my own training, it wasn’t until my Royal College of Psychiatrists membership exam in the late 1990s that “transsexualism” merited more than the briefest of mentions. In 2014, I visited the adult gender service clinic in Toronto, run by consultant psychiatrist Dr Chris McIntosh. The set-up felt simultaneously familiar and unfamiliar. One significant difference was that those arriving at the Toronto clinic from all over Ontario were already established on a hormone regimen; Dr McIntosh and his colleagues focused predominantly on assessing people’s eligibility and readiness for gender-related surgery. Had the Toronto cohort self-medicated? No, they were all started on hormones by local services, which then carried out blood testing and adjusted dosage as needed, seemingly without undue difficulty. I wondered whether this related in part to the fact that many Canadian cities have a medical practice located within the LGBT neighbourhood and, over time, clinicians at those practices had become sufficiently experienced to prescribe and monitor with confidence. In terms of similarly LGBT-experienced UK establishments, we have the fantastic cliniQ in London and Brighton’s Clinic T, both of which do an excellent job. The Toronto model went further, though, with what seemed a more formalised hub-and-spoke relationship between the central gender clinic and further-flung general practices. Where issues arose that couldn’t be handled at a local level, the main clinic was well-placed to advise. This seems, ultimately, the way ahead for gender care. Demand is increasing on a global scale due to increasing awareness and, happily, acceptance. We, as a profession, no longer have the luxury of treating trans as an esoteric little micro-speciality. Trans is defiantly mainstream. 12 In this book, Ben Vincent aims to bridge the gap between perceived specialism and everyday healthcare. This is not an abstruse academic textbook, relevant to a select few; it is a meticulously researched “how
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