The Potential Contribution of Nursing to the Care of Clients with Gender Dysphoria: Preliminary Report

Phil Clegg, M.Sc., R.G.N., R.M.N.

Senior Lecturer in Nursing, Leeds Metropolitan University Social Science Research.

Rosemary Pearson, B.Sc.Hons, R.G.N.,R.M.N.

Specialist Nurse Researcher, Leeds Gender Identity Unit.

 
Abstract: This paper describes a pilot study, based on taped interviews with 10 clients of a Gender Identity Clinic, to explore the potential role of the clinic nurse on the basis of the views, experiences and needs of service users.
The study used a maximum variation sample to include clients who: a) are being assessed for Gender Reassignment; b) are undergoing endocrine treatment; c) have undergone surgical reassignment of gender; d) are receiving no treatment.
The study is broadly based on a phenomenological approach. Open interviews were used to determine respondents' feelings about their Gender Identity, general health, emotional health and experience of nursing services. Analysis of transcripts produced 81 data categories, from which four dimensions of need were generated: Social (the need for 'acceptance'); Intrapersonal (Coping with feelings/utilising energies); Cognitive (the need for information) and Interpersonal (problems in relationships). Seven different nursing roles are proposed on the basis of the results obtained.

Introduction.

This paper describes a pilot study of 10 clients of a Gender Identity Clinic to explore the potential role of the clinic nurse on the basis of the views, experiences and needs of service users as revealed in a series of taped interviews.

Sample.

Clients of the Gender Identity Clinic studied include those who:
a) have undergone Gender Reassignment,
b) are awaiting and/or who are being assessed for Gender reassignment,
c) are long-term clients of the clinic.

Ten clients of the clinic were chosen to represent these different groups as follows:

• New client F-M (female to male) and Partner
• Being treated with hormones. M-F.
• Being treated with hormones, awaiting operation. M-F
• Being treated with hormones, awaiting operation. M-F
• Post-op (recent) M-F and mother
• Post-op (recent) M-F
• Post-op (over 10 years) M-F
• Post-op (over 10 years) M-F and friend who is also post-op M-F (over 10 years)
• No active treatment. M-F.
• No active treatment. M-F (numerous health problems) and wife

These clients thus form a 'maximum variation sample' capturing the range of stages in the GIC treatment programme.

Methodology.

The interviews held with the above informants were, broadly speaking, of semi-structured type. The content of the interview was structured around clients' perceptions of their health care needs and well-being, and the care they have received from the Gender Identity Clinic Nurse and other health service staff, where appropriate. Interviews were tape-recorded, since we were attempting to elicit complex information-rich accounts, which would involve topics of some sensitivity. It was felt that whereas tape recording might initially have an inhibiting effect on informants, other forms or data collection such as note taking would depersonalise the interviews and detract from the researchers ability to listen actively to the developing narratives.

Reliability and Validity.

In conducting interviews in the manner outlined above, there was always the danger of putting words into the mouths of informants if for no other reason than to keep the interaction going. However, it was found that informants readily shared their experience with little prompting from the researchers. A factor which may have been important here was that one of the interviewers was previously known to informants as the Clinic Nurse. This meant that rapport was quickly established and initial inhibitions quickly overcome. A second interviewer was present in addition to the first interviewer on four of the ten interviews studied. The purpose of the second interviewer was to monitor the interviewing process and to give feedback to the first interviewer on aspects of the interviewing process that appeared to be causing problems.

By taking a 'reflexive' approach to data analysis, the processes by which the data were obtained, and the actions of those who obtained them, became part of the data and formed part of a process of critical self-examination that proceeded throughout the research. In this way the authors feel that the views and experiences of informants have been fairly and adequately represented.

Data Analysis.

Transcripts of data were subjected to separate content analysis by each researcher and a detailed list of categories of informants' experiences, problems and needs was derived together with lists of key words and phrases supporting the existence of each category. These were then discussed by the researchers and a consensus was negotiated. This produced four categories of need containing 81 sub-categories. Seven nursing roles are proposed partly on the basis of these categories of need and partly on the basis of data specifically indicating clients views on service provision.

Further details of the methodology employed in this study are given in a fuller account of this study currently under submission for publication.

Results

The four dimensions of need identified from the data were as follows:

A Social Dimension: 'Acceptance'
An Intrapersonal Dimension
A Cognitive Dimension
An Interpersonal Dimension.

The following roles for nurses are proposed on the basis of the data:

Providing Support through Programme Pathway

• Helping client prepare for 'adopted role'
• Helping relieve anxieties concerning programme
• Giving person to person contact

Nurse as Patient's Advocate

Nurse as Patient Educator

• Life Skills
• Health Education

Nurse as Counsellor

• Coping with feelings/utilising energies
• Dealing with problems in relationships
• Sexual Counselling

Nurse as Provider of Information

• on programme, treatments and resources
• Feedback from Health Monitoring

Nurse as Alleviator of Acute Anxiety

Nurse as Provider of Physical Comfort

Discussion of Results

Social Dimension: Acceptance.

This dimension emphasises the social context of informants' experience. Issues of power, prejudice and stigma were to the fore here as well as the need to be accepted for the person one is or aspires to be. Thus dealing with harassment, hostility, violence and threats of violence, rejection, and insensitivity were categories within this dimension.

Many categories encapsulated a sense of pain associated with the transsexuals status as an outsider in our society. Thus being 'read' (identified by the general public as a transsexual) was identified as a painful experience ("a bad day is if someone points a finger") serving to emphasise the sense of loneliness and social isolation expressed by many informants. Non-acceptance in the form of indifference was just as difficult to accept as overt staring or pointing ("in fact, nine times out of ten, (people) just can't be bothered reacting, that's the difficult bit").

In some cases, clients appeared to need some sort of social marker of their transsexualism. Thus acceptance onto the GIC Programme appeared to serve a broader function of social recognition, almost as if it were a rite of passage. One client thus stated that acceptance onto the programme was "like winning a million dollars", since "it was like someone believed in you." By accepting the client onto the programme, the clinic appeared to be fulfilling a need for approval or validation of the client's identity as a transsexual.

Several other informants, who had undergone gender reassignment, described how people, who were apparently uncertain about their gender identity, sought such approval and validation of identity from themselves. One informant said: "I've had people say to me 'do you think I'm transsexual'. I have to say 'well I don't know'. They're expecting some blazing statement: 'I dub thee transsexual'." The phrase "I dub thee transsexual" is interesting since this informant had been through the programme of the GIC, and therefore had been so 'dubbed' herself. She had in effect acquired the status of an an 'approved transsexual' whose passage across the gender divide had been medically sanctioned and certificated. Small wonder then that others should seek to use her status to validate their own experience in some way. This begs the questions: 'How important to transsexuals is the treatment programme as a rite of passage?'; and 'Are there other rites of passage that might provide alternatives to medical treatment?' It is worth pointing out that rites of passage across gender identity do exist in other cultures (for example, the native American initiation ceremonies for hermaphrodites and transvestites (Devereux, 1937; Hill, 1935 cited by Edgerton, 1969)

Initiation ceremonies for transgendered people in Native American culture appear to be based on an acceptance of the inevitable and a principle of social sanction. In contrast, the approach dictated by the medical model in relation to Gender Dysphoria has social control of the passage between genders as a primary feature. The unequal power relations inherent in such control appeared to lead clients to experience difficulties in their relationships with medical staff. These included problems caused by fears of being rejected and feelings that they were not being accepted on their own terms.

Thus one informant indicated that she had difficulty in communicating her real needs to her psychiatrist. This difficulty appeared to be caused by her perceptions of what would please him, and her apparent need to conform to these perceptions: "At the back of my mind I had this feeling 'No he (psychiatrist) won't be happy yet (i.e with her progress in female role). No he won't be happy just yet'"

In the interests of clinical objectivity, the medical encounter necessarily entails that clients be scrutinised and 'categorised' as one client put it. Such scrutiny is however not always welcomed by clients who are sensitive to issues of rapport and whose self-esteem may be low. Indeed the medical gaze (to use Foucault's term) was a source of anxiety and of confusion.

Thus one informant spoke of their feelings of inadequacy when meeting the surgeon for the first time: "(I felt like) a first time amateur singer going on stage, trying to sing a duet with a professional singer."

Another informant, referring to the psychiatrist's examination of their motivation, spoke of feeling as if they were in a no-win situation: "It seemed as if I was in the wrong for not having a boyfriend and then questionable when I did get one. As if, "If you're keeping him happy do you really need surgery. What are you doing for him (sexually)?"

The issue of acceptance in relation to medical staff is only partly a question of being able to tell one's story in one's own terms. It was also a question of being accepted as a responsible adult, able to exercise one's own judgement and right to make choices about life: "I want to feel that I have some control over my life, that I am not being dictated to. I would rather make my own choice and live with the consequences."

It was also a question of acceptance as a human being, the need for human contact and human warmth within clinical environments being raised by several informants. Thus one client said: "Sometimes I appreciate the professional detachment that doctors have to have, but sometimes it's difficult to see there is anyone else in the room with you"

On the other hand, clients expressed their appreciation of the clinic nurse as a 'friendly face', 'a point of contact to talk things over', 'someone who knows your problems and can accept them'. This seems to indicate that the nurse might be in a position to form a relationship with Gender Dysphoric clients, that was different to the Doctor-Client relationship in some way, possibly because the nurse, unlike the doctor, is not in direct control of the means of making the trans-gender journey. Nevertheless, the nurse is in a position to support the person on that journey.

It was clear from the accounts of post-operative clients that 'professional detachment' was not the only issue of acceptance affecting client's relationships with professionals. Professional insensitivity, judgemental attitudes, rudeness, breach of confidentiality and avoidance behaviours all contributed to clients anxieties during and after hospitalisation. Thus clients were distressed when Doctors and other staff referred to clients in the male gender, when nurses looked at them and talked to them 'differently' when their gender status became known, and when their gender status was revealed against their wishes to other patients on the ward. In a sad echo of Isobel Menzies' seminal work, over 30 years ago, on the defence-systems of the hospital environment, (Menzies, 1970) nurses used 'business' as a means of avoiding contact: "The whole time I was there I felt like saying 'O God, I don't feel too well' but I can't ask the nurse yet because they are a bit busy. I'll wait, I'll wait, I'll wait.' and you'd find by the time they had quietened down, the shift had changed and they were all busy again"

Such avoidance behaviours by nurses and doctors meant that not only were client's anxieties raised ("I was afraid of the nurses" said one informant) but also that clients were not provided with the information they required: "In my past life I have had operations for this that and t'other . . . it's always been explained to me. Look you've done this, we are now going to attempt to do that. If that doesn't work we will try this. After we've done that we'll give it a go, and if it doesn't work out we will try this, but in the meantime this is going to happen to you and that's going to happen to you. It's always been explained to me all down the line (in contrast with GRS)"

The problems identified here in relation to professional groups are of considerable importance when considering the transsexual's progress though the medicalised world of the Gender Reassignment system. However, as indicated above, informants' problems in relation to social acceptance were much broader than this. Social isolation and loneliness, lack of confidence, low self-esteem, fear of rejection and difficulties in forming social and sexual relationships were recurrent themes in the data. Some informants were frightened of going out of the house, the reasons for which, included: fear of what people would think; because they thought they "looked terrible"; because they felt "ground down" by people's attitudes; or because they feared being physically assaulted. Several informants were virtually housebound whilst others had experienced periods of being housebound in the past. Some informants appeared to find it difficult to form relationships:

Thus different informants stated: "I can't imagine me having a relationship . . . I haven't had a relationship in twelve years." "I'm celibate because I don't want to get involved with people." "I have found it difficult to meet men since (GRS)."

Problems of self esteem and social function are not confined to clients with Gender Dysphoria. However, two aspects of the dimension 'acceptance' which related specifically to such clients are:

1) the problem of how to reveal one's history, especially to prospective partners; and

2) the need to rehearse and practice the gender role that has been 'adopted'.

Concealment of one's history may carry a high personal cost both in terms of personal stress, the integrity of one's relationships, and indeed personal safety. As one client said, "I just don't fancy the consequences if the person found out (that they were transsexual)." However, for some informants the issue was by no means clear cut and it appeared that this area might merit further exploration both in terms of research and the application of 'helping skills'.

As regards rehearsal of role, this has obvious benefits for clients' self esteem. However not all clients appeared to have a clear idea of the full reality of the role they were adopting. They made mistakes in presentation that could easily be 'read' (e.g. a wig that did not match the eyebrows, using confrontational behaviour rather than say assertive behaviour). The rectification of such 'errors' would appear to have implications for clients' self esteem and reality testing.

Intrapersonal Dimension: Coping with Feelings.

This dimension focuses on the emotional energies of clients. There is of course an intrapersonal component to the dimension 'acceptance'. However, whereas in the previous section the emphasis was on social phenomena and the individual's ability to respond to harmful forces, the emphasis here is on emotional phenonomena and the individual's capacity to utilise various forms of emotional energy in the pursuit of life goals.

The two dimensions are not mutually exclusive. However, they represent different planes of analysis: The individual in relation to society versus the individual in relation to self. The categories emerging from the data were found to form two groups:

1) Negative emotions such as feelings of confusion, dissonance (in relation to sexuality), anger, misery, despair, fear and hurt; and

2) Expressions of positive emotional energy.

These included feelings of determination, hope, anticipation, self-respect, satisfaction, and personal worth. The data also included other expressions of positive well-being such as 'being decisive' (i.e. in relation to decisions about Gender Identity) and showing openness and genuineness in relationships with others. The dimension is thus of bipolar nature. These two poles reflect the two ends of a continuum of adjustment to the desired Gender Identity. At one end of the continuum, informants described the full gamut of unhappiness, loneliness, isolation depression and despair they had felt at various times in their lives as a result of their Gender Dysphoria. At the other end of the continuum, informants described situations in which they were able to draw upon inner resources and personal strengths. Thus whereas some informants were immobilised by their inner conflicts and stresses, withdrawing into depression and alcohol abuse, other informants described traits which kept them moving towards their aspirations. Thus a number of clients alluded to the need for resilience and determination, as indicated by the following examples: "You have to go through all this (by) yourself" (informant under hormonal treatment). "It's like when you are going to give up smoking, it has to come from inside" (pre-op). "You've got to find this courage to actually go and do it" (pre-op). "All the way through it (process of reassignment) I had to be strong (to get what I wanted)" (post-op). "I used to have a saying of my own 'don't let the buggers beat you'." (post-op).

As one might expect, some of the most positive expressions of feeling were produced by the results of surgery ("I feel complete in myself at last"; "I have nothing but admiration for him (the surgeon)"; "no more worries"). However, positive emotional energies of the kind previously described were found in informants over a range of treatment types, including no active treatment, and may therefore more accurately be considered aspects of human adjustment rather than merely outcomes of treatment modalities. On the other hand, acceptance on a gender reassignment programme was by no means a universal panacea for clients emotional problems. This indicates that there may be a place for a less 'treatment-oriented' and more 'person-oriented' approach to caring for clients with Gender Dysphoria. Although such an approach is unlikely to replace medical and surgical services for these clients, it may serve as a useful adjunct. The bipolar intrapersonal dimension of client need revealed by the data under study seems to fit well with humanistic perspectives on the development and realisation of human potential embodied in, for example, Maslow's concept of 'self actualisation' or Rogers' 'fully functioning' person. Such perspectives could potentially be useful as frameworks for facilitating the adjustment, development and mental health of individuals with Gender Dysphoria, no matter at which point along the 'continuum of gender' they happen to find themselves.

Cognitive Dimension.

The physiological and psychological benefits of information-giving upon outcomes of health care are well documented in the nursing literature (Boore, 1978; Byssshe, 1988; Hayward, 1975) Patients who are well informed are more likely to adjust to hospitalisation, cope with stressful procedures, experience less pain and recover quickly from surgery Summers, 1984; Sutherland, 1980) Information enables patients to take more control over their health care and simultaneously feel more confidence in medical treatment, factors which have knock on effects in terms of well-being and self-efficacy (Latter et al, 1992; Porter, 1994)

In relation to the treatments available to clients in this study, several informants stressed the need for information on the effects and side effects of hormonal treatments. Sometimes informants felt that they needed more information than they had been given, or needed some reinforcement of their understanding. Problems in getting information were exacerbated when the client had to see a succession of doctors. Thus one informant said that "you get the feeling there is nobody actually dealing with you" and that "I've found that information is not passed on." The same informant went on to discuss a change in medication which had resulted in a distressing increase in facial hair. She felt that she had not received the background to the doctor's strategic thinking and therefore could not set her own concerns in context: "I want to feel that I have some control over my life, that I am not being dictated to. I would rather make my own choice and live with the consequences"

In relation to surgery, informants accounts indicated a certain reticence on the part of surgeons in discussing surgical strategies and potential post-operative problems: "In my past life, I've had operations for this that and t'other . . . it's always been explained to me. Look you've done this, we are now going to attempt to do that. If that doesn't work we will try this. After we've done that we'll give it a go, and if it doesn't work out we will try this, but in the meantime this is going to happen to you and that's going to happen to you. It's always been explained to me all down the line."

Such apparent reticence may be related to a conscious or unconscious avoidance of patients by surgeons or it may be related to other factors not revealed in this study. However, to get the sort of information on surgery that they required, a number of informants appeared to feel it necessary to go to other clients who had already been through the operation or to organisations such as SHAFT.

One subject that was dealt with in this way was "What would sex be like?': "I asked what is sex like after you've had the colon . . . but I asked girls who had already had it done . . . A lot of people have asked me, since if it feels like anal sex, then that's the last thing they want."

Similarly, another informant stated: "Some people are very concerned whether or not they have an orgasm after the operation. I just hoped for the best." (Since this client's experience of orgasm, may be of interest to other pre-operative patients, it is included here: "It takes me a long time, I don't know if anyone would have the patience. The fact is I can.")

In relation to post-operative care and potential post-operative problems, one informant's experience would be worth studying as a case study in its own right, the problems identified being:

• Lack of information on wound care (prevention of infection)
• Lack of information on basic hygiene in new gender.
• Lack of information on problems occurring around the time of discharge (e.g. bowel and urination problems) and
• Lack of information on what to do in event of further problems occurring after discharge from hospital.

Upon discharge this client was uncertain how to wash herself, since she had dissolvable sutures, and thus how to make sure no infection made its way into the wound. She was also distressed that nobody had checked to see if she had passed urine or that her bowels "were OK" as had happened after previous operations. The fact that she was constipated added to this distress. Her anxieties reached their height, however, when she discovered that: "There was what I can only describe as a thin, about half the thickness of a pencil, about an inch long chocolate brown slimy looking worm, that's the only way I can describe it. It appeared between the lips (of newly formed vulva)"

Although the district nurse made an early appointment for this client, she remained in a state of high anxiety, saying: "Am I going to be in shit street between now and Friday (when appointment scheduled)? I am scared."

In fact it was only after the arrival of the clinic nurse to undertake the research interview that her anxieties began to subside. The incident also had a happy conclusion insofar as the physical problem proved to have resolved by the time of the appointment. Nevertheless, the incident not only shows a need for adequate briefing prior to discharge but would also seem to indicate a need for those nurses who make follow-up visits to such clients to have specialist knowledge and experience of this area of care.

In this study, the need for information went beyond medical and surgical treatments to include broader issues of adaptation and well-being within the new gender role. Thus for example, on visits to several clients, it was obvious that a certain intimacy existed in the clinic nurse's relationship with her clients. This intimacy was expressed in comments by the nurse on what clothes suited and what were less suited, and also in comments on clients use of wigs and make-up. The clinic nurse's advice appeared to be valued by clients, and bearing in mind the importance of 'passing' to clients, it is possible she served as a valuable resource in relation to clients self esteem and reality perception. That there is a need for such a resource was in fact emphasised by one respondent who pointed out the need for: "Somebody who can say, 'Well look, why don't you try it this way, or 'Why don't you try that', or 'Why don't you go here', 'Why don't you go there.'."

Interpersonal Dimension.

Informants lived in a variety of situations as regards their family and personal relationships. Two remained married, one lived in a long standing relationship with someone of the same (biological) sex, one lived with their mother. Of the six informants who lived alone, two appeared to have satisfactory social lives, three appeared to be socially isolated to various degrees, and one did not discuss her social situation. Of the socially isolated informants two had formerly been married. Informants' difficulties in forming relationships have been discussed above.

However, as one would expect, the desire for Gender Reassignment created stresses within existing relationships that were not easily resolved. In two cases, marital breakdown had already occurred, either because of the husband's Gender Identity or because of subsidiary problems such as heavy drinking. However, in a further two cases, informants indicated that their wives continued to support them in their 'adopted' Gender Identity. Thus one informant stated: "We have a relationship, that is very strong which she (wife) does not want to lose."

This does not mean that such relationships were free of tension in regard to issues of gender identity and expression of sexuality. Sexual counselling was not discussed with informants. However, the data support the view that that there may be a need for this in some cases.

Problems in relationships with parents and with children were mentioned by various informants, perhaps the most poignant of these being the cases where an informant was or had been unable to discuss their Gender Identity with a parent. Such instances formed the subject of much emotional turmoil, indicating that there are times when clients with Gender Identity problems may need considerable support in their dealings with primary relatives. Failure to resolve such conflicts might have implications for clients' mental health, especially in the longer term. (Down, 1995)

Potential Nursing Roles.

In the above, it was stated that in supporting the client of the GIC on their journey across gender, the nurse might play a role that was different to that of the doctor. The needs identified in the above analysis will now be the basis for further exploration of this role. The approach taken is one that acknowledges clients' needs in relation to the treatment programme of the GIC but which is 'client led' rather than being prescribed by the technical aspects of treatment.

The programme pathway may be considered as consisting of:

• Preparation for Adopted Role (Continuous through Programme)
• Endocrine Treatment
• Surgical Reassignment
• Post-operative Follow-up and Support.

(This pathway adheres to the standards of care prescribed by the International Gender Dysphoria Association (Walker et al, 1985))

In relation to the first of these stages (preparation for the adopted role), the data revealed a variety of difficulties, problems and needs including issues of power, prejudice and stigma, problems of self-presentation, a variety of emotional problems, and problems associated with maintaining relationships. Thus nurses caring for Gender Dysphoric clients should consider the importance of developing counselling and patient education roles in relation to these clients. Assertiveness skills, family education and social skills aimed at improving self-esteem are areas of patient education which 'Gender Dysphoria' nurses might include within their domain of practice (Miller, 1983; Bond, 1986; Fontaine, 1996) The need to explore the consequences of different courses of action (for example, whether or not to reveal one's history) within the adopted gender role is another such area.

In addition, the poverty of relationships and sense of vulnerability that pervades much of the data appears to indicate a need for strategies aimed at mental health promotion within this client group. According to Caplan, 1964 there are two components to such work:

1) the combating of harmful forces in the community; and

2) strengthening the capacity of people to withstand stress.

In the case of the informants in this study, the 'harmful forces' appeared to be those resulting from stigma, prejudice and social rejection whilst, within individual informants, the 'capacity to withstand stress' could doubtlessly be enhanced though mental health promotion strategies aimed at increasing self-esteem and ability to perceive, test and adapt to the reality of their desired gender role. These two components of mental health work thus appear to reflect two separate aspects of the dimension 'acceptance'.

The importance of providing information on treatments and expectations of care, and the role of the nurse as a resource person have already been discussed. Information-giving, of course, is not solely the responsibility of the nurse. However, nurses might have a specific role in giving what Nichols (1984) calls "Informational Care." This is a strategy for building up optimum levels of information by regularly checking what a person does and does not know, and then identifying gaps, distortions, unrealistic ideas, lack of understanding, and confusion and anxiety caused by insufficient and forgotten information.

The above roles have been deduced from the general analysis of client's needs. Other roles can be deduced from informant's specific references to the treatment programme. These indicated that clients had a number of anxieties in relation to the programme, including anxieties concerning their acceptance onto, and subsequent progression through the programme. Thus one informant thought that he (F-M) would be rejected because he "got emotional." Another thought that taking anti-depressants would "go against" him. Yet another said that a visit to the GIC was "like an interview" and finally another talked of the need to be "strong" and be "tough" in dealing with doctors. The data revealed a variety of conflicts between clients and doctors. These included: conflicts about what is important to gender identity, and conflicts about treatment options. Thus in relation to the first of these, talking like a woman, dressing as a woman, and working as a woman were not necessarily seen as important for gender identity by clients, but apparently were highly valued by doctors according to informants. In relation to treatment options, choices were apparently sometimes presented in a stark and insensitive way. Thus one client, who complained to a doctor that steroid treatment was ruining her sex life, apparently was told: "You can have ulcerative colitis or a sex life - which do you want?"

There were disagreements between clients and doctors about the appropriateness of different surgical procedures. Thus one informant had been in conflict with doctors about whether to construct a 'blind vagina' or do a 'colonovaginoplasty'; and also about whether or not to 'shave' the Adam's Apple. The background to these disagreements may have been to do with technical considerations and levels of risk. However, the informant felt "fobbed off" by the explanations given, apparently feeling that medical staff were unable to see things from her point of view. This is further indicated by the following extract: "For nearly a year I was carrying a yoghurt carton in my bag so that I could go to the toilet. For the clinic to think I could do that for the rest of my life was a joke. It's incredible that someone could actually say to you: 'Well what's wrong with that'. So I said 'No, it's not acceptable'"

The issues of social control and the difficulties experienced by clients in communicating their needs have already been explored in relation to 'acceptance' as a dimension of client need. In relation to nursing roles, however, the issues reemerge in relation to nurses' potential to act as Patient's Advocate, a term which has emerged with increasing frequency in numerous recent debates on nursing ethics (Evans, 1991) There was some indication in the data that this was a role that was valued by informants. Several components to the role were apparent. Thus one informant valued the fact that the clinic nurse had spoken on her behalf: "I didn't think I'd get the possibility of the operation, until I spoke to you (clinic nurse) and you told Dr . . . . . . You made it possible for me to talk to him, like I say I get annoyed with people."

Another informant found that the presence of the clinic nurse gave her the support, she needed to make her needs known: "All I can say, there is no way on this earth that I could have found it within me, to go into see him (surgeon) without in this case you being there."

In another instance the hospital nursing staff's impersonal manner and habit of ignoring a client's calls for assistance, had caused her to be not only stigmatised but afraid. The situation apparently improved after the clinic nurse raised the issue with the staff on the clients behalf.

In addition to the advocacy role this indicates the importance of a liaison role for GIC staff.

A support need identified from within the data concerned the need for feedback on the client's general health status.

One informant thus commented very favourably on the health monitoring service initiated by the clinic nurse.

In relation to problems arising in relation to surgery, some of the issues have already been discussed under the cognitive dimension.

These related to roles of information giving and also the alleviation of (acute) anxiety. In addition one could add the role of providing comfort. Severe physical pain, discomfort due to immobility, sleeplessness, and as noted previously, problems with bowels and passing water were all mentioned as having been inadequately dealt with. Such dissatisfaction raises many questions about the nature of contemporary care.

Conclusion.

This study has opened up many questions concerning the care of clients with gender dysphoria, and indicated potential areas for development in relation to the role of the nurse in a Gender Identity Clinic. Further research will be needed to evaluate these developments in the nurses role, and to articulate good practice within it.

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