The Charing Cross Gender Identity Unit

A report of the presentation given by Dr. D. Montgomery

MB, ChB, FRC Psych., FRCNZ Psych. Consultant Psychiatrist. Clinic Director, Charing Cross GIC. Trustee Gender Trust
Gendys Conference, 1994

It's pleasure to be here, although I sometimes wonder whether I am a spokesperson for all those National Health Services psychiatrists in gender identity who "don't have enough time to see the patient referred to them. If they do have enough time and they do get an appointment with us, that we are non-understanding and non-empathic, don't get the right diagnostic categories, and we don't know the subject anyway." (laughter)

I will first talk about the history of the gender identity clinic in it's current structure. I am working at Charing Cross with five sessions, that's half-time. I work also half-time as a consultant psychotherapist, particularly a group psycho-therapist. Quite a lot of my time is now taken up with administration, as the new health service financial structures demand a lot of administration. Richard Green has joined our team, and we are very pleased that such an eminent expert has joined us, and has decided to live in the UK. Richard has six sessions, four clinical and two as Director of Clinical Research and we are certainly looking forward to researching the vast amount of work that's possible in this clinic.

When Richard saw some charts on my wall he said "You must have over a thousand patients on the books." Actually, we have nearer 2,000. Dr. Dalrymple has joined us as a locum clinical assistant on Tuesdays and Thursdays. Dr. Ghazal Afzal is our research psychologist who will probably leaving us later this year. And, in the past, we had Charles Mate Cole as a research psychologist. Mr. James Dalrymple, our consultant surgeon, with three sessions. James Barrett is a psychiatrist at the Maudsley, and has been associated from his medical school days with research projects. Pauline Carty is our secretary and Stuart Campbell is our co-ordinator. Stuart is a vital new member of the team. I take a little bit of pride in having told our administrators that if they didn't give us a VCR co-ordinator a couple of years ago, our clinic would fold, and fold quickly, because referral sources, of course, are all over the UK, including Northern Ireland, Ireland, Scotland and Wales. We also, of course, get some international referrals, which are funded differently. I told them that if we did not collect the contractual referral money then we would go broke. We were lucky to get Stuart in place quite early, and, we virtually have been path finders for Riverside Mental Health Trust in setting up VCR structures and administration. We've got Olive Thompson at the reception desk, but we've just lost our business manager who unfortunately has gone elsewhere.

I mention the ex-staff here because I think we had some real staffing problems in 1993.

John Randall was working there in the 60's, through to his sudden death in 1982. His interest in the subject and his expertise collected patients from all over the UK and set up a pattern of clinical work and a clinical culture, which was influenced by international colleagues from other countries, but he had his own particular style. Various people today have referred to that style and culture and some of the policies which I think are certainly foreign to me and don't exist now. Ashley Robin stepped in as an emergency in the early 80's, after his first retirement from the health service. He worked two sessions in the gender identity clinic as consultant and two in the drug and alcohol service at Charing Cross. While he was there, he appointed me as clinical physician in 1984/85. He took his second retirement at the end of 1985 and I became locum consultant at that stage. Charles Mate Cole, my colleague, was there part-time as a psychologist and researcher. Charles was anxious to devote a lot of time to the clinic, both clinically, administratively and with research - and was very underpaid, as it was only a part-time appointment - but with energy and enthusiasm and the extra hours. He is now in Halifax, Nova Scotia, as an Assistant Professor in psychology. Dr. Freschi was a Senior Registrar at St. Bernard's Hospital, a training psychoanalyst, who held two clinics at Charing Cross. Russell Reid also pitched in, in the early 80's, after John Randall's death, an honorary session. Dr. Alfred Hohburger worked with us on an honorary basis for a quite a while, then as a locum consultant psychiatrist, and then as a substantive consultant psychiatrist for four sessions until his sudden death in July of last year - and we remember him with respect, this morning. John Stevens worked with us for two sessions a week for about two years. He has an interest and an expertise and an understanding of the subject which we miss. His next appointment in the health service demanded that he give all his sessions to his new post. He tried to come back and work with us but at the moment isn't able to free up any sessions.

I mention all this because there has been a rapid turnover of staff through the 80's and we hope that we are now moving into a period of stability. As far as the sessions go - you can see that there are seventeen psychiatrist/ psychologist sessions and we have to subtract about five of those. So, we come down to about twelve clinical sessions a week.

We did over 300 patient referrals a year. If you work it out, we've got just over one full time psychiatrist, I think you can see that the work load is impossible in volume. There are delays in getting appointments from three months to six months or even longer, depending on whether your health authority provides ECR funding or not. And often there are delays in getting an appointment, because the local health authority has stalled, or hasn't made up their mind, or are just inefficient about processing the ECR documents. Now once these are given an approval we can usually arrange for an appointment within about three months.

Our patient population consists of about 80% biological males and about 20% biological females. The range of the work that we do is large, and we assess patients coming to us with various gender identity disorders. We are not just a clinic for transsexuals. We have always been a gender clinic dealing with the psychiatric assessment of a range of gender identity disorders. From 1988/89 I've looked at the number of patients that we saw that year and the percentage who called for surgery within the next five years. About 20% male to female and 20% female to male had had some form of gender reassignment surgery within five years. So that left 80% who hadn't. The question was: Where were that 80%? Many of them were still in the clinic, being assessed or counselled or managed, and are still in their real life test. Some had dropped out of the clinic; perhaps some had gone privately to other professionals. Some had come into us and decided that a transsexual pathway, was not for them and that they didn't require any of the other psychiatric or counselling services that we offered.

There are various ways of thinking about gender identity disorders and the various gender dysphoria syndromes, such as primary core transsexualism, secondary transsexualism, the heterosexual transvestite, the asexual cross- dresser, the female transsexual, the small - the very small - number of patients with a biological component. As psychiatrists, we have to think about and evaluate a significant number of patients who come to us and assess the complications or the significance of other psychiatric disorders. You can manage them concurrently with the gender identity disorder, or co-operate with the local psychiatrist or GP. in the management of psychiatric disorders. Depression is a very common component of gender identity disorder and may be reactive or may be more severe and would require anti- depressants and biological treatment. A small number of our patients have more severe psychiatric disorders and we have a small number of patients in the clinic who have psychotic disorders and some with very severe personality disorders. Some have paranoid problems. Some patients come to us with what is best called dismorphobia which is a an unrealistic delusional, a strong belief about one aspect of your anatomy, and it's usually to do with the secondary sexual characteristic- things like thinning of the hair or baldness or facial hair, sometimes it's more generalised - to the specific effect of testosterone in general on the body. Dismorphobia may be focused on the testicles or on the neutralisation of their testosterone and usually want castration, surgical castration rather than chemical castration, but that's a small group. We've got a range of work that we have got to consider.

We are getting more and more bureaucratic in the health service. We are getting more referrals than patients seen. But we are seeing approximately 23 new patients per month. Of those 8 will be first opinions, although we are trying to get that number up now and we're trying to get our waiting list of new patients down. Total patients attended include patients seen in a group therapy programme, which number about 40 to 50 per month.

Our group therapy programme began about five years ago, out of my interest as a group analyst and also out of a wish to provide a much more frequent contact with the clinic for those patients who were geographically and psychologically available. Unfortunately some of our groups are getting so full that we probably don't have space to deal with many more patients.

But it is certainly a very efficient and effective counselling service for those patients who can attend. I spoke a little bit about that programme two years ago here and I think I would just like to take questions now if I could about our work and the relationship of our clients . . .

Q: You say that you are getting more patients now, what are your opinions about the reasons that you are getting more patients?

A: It's a very complex question, with a very complex and long answer. I do think that there is greater public awareness about gender identity disorders, there is greater publicity about it. Social attitudes to gender identity and sexual disorders are now, I think, more tolerant than they were a decade or two ago, and therefore there is less shame and anxiety about seeking help at the earliest stage in one's distress. Along with depression, it's now longer tolerated to the same extent. People come forward more quickly. I suspect that the changing social roles and power structures between the sexes may be leading to a shifting of the boundaries in gender identity as well.

Q: What financial restraints are there in the unit?

A: We've got to stick to financial targets. I actually think that the health structure, the financial structure in the health service has probably helped us more than hindered us, in that in the past we were a poor relation tucked away and encapsulated and recognised as having some kudos and expertise, but it was all funded by the local health authority, so that people coming from all over the UK were funded by the Riverside Health Authority, out of their budget. The new structures mean that we can now produce our own income and justify employing myself and the other psychiatrists, the secretaries. We now have to justify all these salaries, for any income we are going to produce.

Q: How wide a catchment area do you cover?

A: We will accept referrals from all over the UK and Ireland, providing the funding comes with the patient.

Q: How many Gender Identity Units are there?

A: Not very many. We are by far the biggest in the UK if not Europe, if not the world, I think, in terms of patient referrals. There is small clinic just for the Leeds/Yorkshire catchment area. Professors Goldberg and Linton used to have a clinic here in Manchester but I think all the Manchester patients are probably being referred to us at the moment. There are occasional psychiatrists scattered around the UK that have an interest in gender identity disorders, without professional back up on the whole. Dr. Christie Brown still has his clinic at Maudsley Hospital but I think it's probably running down rather than increasing.

Q: I think Dr.Dunleavy sees a few doesn't he?

A: Yes, Dr. Dunleavy in Newcastle and his colleagues have a small clinic there. There is also the child and adolescent clinic at St. George's.

Q: (Dr. Russell Reid) I get the impression that quite a different population arrives at Charing Cross compared with the population that now see me. I have had experience of both. I get the feeling that the private patients that I see with gender disorders are often the better prognosis group, if only because they have got their life together to pay the fee. What are your comments regarding that?

A: I think we have a wide range of patients from high ego strength, successful people with good jobs and good income and we have referrals from unemployed people who are struggling with life in all sorts of ways and not just with their gender identity disorder. So I am sure that these people can't afford a private fee and, inevitably, it is a function of their social adaptation and their ego strength.

Q: What about health authorities that refuse funding?

A: This is a problem. There are certain health authorities around the UK which will not approve a referral to our clinic. Certainly the referring doctor has to be informed that they have refused funding and he should inform that patient. Sometimes we inform the patient directly, but we advise them to see their local psychiatrist, and we try to activate them to get a referral through that route. You can go to the Citizens Advice Bureau where you can seek legal help. In spite of these efforts, some patients are still not getting funding approved. I think it's a tragedy because it's as if these professional facilities don't exist and these health authorities are declining to fund. In time the numbers will build up and then, maybe, a new policy will emerge. At Charing Cross, we will try to get some documentary information and some education to the directors of public of health, that may inform them and help them to change their mind. But the Health of the Nation document is meant to diminish mental health problems through depression and suicide attempts. Yet if gender dysphoric patients aren't offered expert help and advice I can see that their depression and distress will have to continue.

Q: Do you feel that in the time the clinic may include, perhaps as an interim measure across the country, reference to counsellors and therapists. If, perhaps, you are only seeing a patient once every 3 months or whatever, there may be a vast area that can be covered by therapists in that interim period.

A: Yes, we welcome other professional people who can provide expert help and guidance in the local situation. I guess there are expert, professional and experienced people around but, if we don't know about them, maybe we are reluctant to recommend them.

Q: What about patients who lie to their psychiatrist?<

A: It's hard enough being in your position, as a client, and it's also very hard being in the psychiatrist's position, to enter into a collaboration and talk together. I mean there are no policies to drop people going for gender reassignment procedures that depend on any one criteria. One looks at the whole global picture of the patient and looks at the possibility of a realistic real life test and the positive attributes that each patient brings to that task and we are not unempathetic or uncompassionate people. We don't have a capacity to compromise and modify certain criteria. But if we are dealing with false stories, we are not really in a position to help because then we are dealing with somebody who has got a false self-diagnosis and if you are diagnosing yourself falsely then you are actually in danger.

Q: If we do want to get our gender reassignment surgery, we will do virtually anything to get it.

A: But if you are prepared to lie to get it, then you can't expect the co-operation of psychiatrists. That is all I am saying. There are immense complications involved in the diagnosis of transsexuals. We are talking about transsexualism as if we know what it is. We were talking about psychological characteristics of transsexuals in the last paper. Let me tell you, we don't actually know what transsexualism is clearly enough yet, and we are still working on it. If you are going to make self-diagnosis confidently and then go on a course of management without the expert help of the experienced professionals, who, nevertheless, have their own cautions and confusions, then there is a lot of danger.

Q: You talked earlier about the problems people face outside the social problems We now have care in the community (but we don't know who the majority of the community is?). Do you think that one of the important things is that you should be referring back to the local authorities so that a TS person could apply to go through the process for community living package to support them? I am doing a project on transsexuals and housing - and one of the things that has come back to me is that there are big gaps in care for these people. Maybe the community living package actually gives somebody help in their day-to-day stuff. I don't know whether you have actually thought of that, it's something coming out of the project I am doing right now.

A: I think that there is a dilemma here in that people who are trying to change social gender role, want the help of a gender identity clinic, but also don't want to be psychopathologised into the psychiatric system if they can help it - or the social services system if they can help it. Now I am advocating that you might have to use your local psychiatrist to reinforce your referral to a GIC, but there are a significant number of people with gender identity disorder who do not function well in society, who do not function at work, who need a lot of other support services whether they be psychiatric or social. I think we've got to think of such people as not transsexual - well you know this word is a difficult word - gender identity disordered. And disordered in identity more than just gender. And they are going to lead a lot of help.

Q: A lot of the people's needs, obviously includes money, but also their actual day-to-day needs, which you may not be able to identify, should be pulled together. I think the Community Living Package is a good way of getting help - it also assists you, the psychiatrist because then you have some sort of statement about where people are going, what support they have got. And it actually gives people an input into services because sometimes people just don't understand them. They are such large bureaucracies, with services all over the place, that nobody knows where to go. People come to us, the local authorities, but they need some realistic advice to point them in the right direction for the support services they need. It just seems that Care in the Community has been going for a year and I am just surprised that more transsexuals do not use it. Perhaps it is because they don't know about but it seems to me something which is patchy There is a basis to pull the services together, to help them deal with their lives.

A: One of the things that does happen to disturb people, people with other psychiatric disorders and not functioning in society is the work situation . . . with a gender identity disorder they often fall between two stools. The person out there thinks "I've got a gender identity disorder I must go the Charing Cross hospital for the experts." It might take them 3 or 6 months to get them qualified. And in the meantime nothing is done about the rest of it. And they see us for an hour and half and they might get another appointment. We can act as an expert advisor about gender identity to the referring agent, but the global needs of the client have got to picked up locally and that is often overlooked. I and my colleagues try to find reasonable information in respect of referring agents. I regret to say that we often don't get ongoing information from the local structures to tell you what is happening. It's the additional management that is the problem.

Q: (Barbara Ross) The problem for yourselves is that the referrals come to you and then local psychiatrists and GP's probably decide then, that it is over to you. You see them once in 6 to 8 months, which means they get left in limbo, and feel unsupported. It is difficult for the clients. I know one particular client of mine who has come into Charing Cross quite regularly. If he did get enough time, you would get a really different picture. It's just an observation really. I mean you need more staff and more money.

A: You are right.