NHS v Private Treatment for Transsexuals

Dr. Russell Reid

Consultant Psychiatrist, London Institute.
Gendys Conference, 1998


Similarities and differences:

Both NHS and private treatment purports to:

1. Follow the Harry Benjamin Standards of Care, and

2. Adhere to the principles of

  • Psychiatric diagnostic assessment
  • The prescription and monitoring of hormones
  • Monitoring of the Real Life Test of crossgender living and working (every three months) for one or two years prior to
  • Referral for genital reassignment surgery.

The Number Involved:

  • New referrals to the Free University Hospital; approx 150 per year, of whom 80-90, or 60%, go on to receive hormones and surgery.
  • New referrals to Charing Cross (NHS); approx 250 per year (with a 1000 active patients).
  • New referrals to Dr. Reid (private); approx 230 and 120 follow -ups per year.

NHS Treatment Involves:

At Charing Cross Hospital GIC, patients must have attended at least twice and have seen two psychiatrists prior to cross-gender hormones being recommended. As well the Charing Cross Hospital GIC policy requires patients to have changed their names legally, and if married to have completed divorce proceedings and started their Real Life Test before hormones are recommended.

At Charing Cross Hospital patients are required to attend every three months and if possible attend regular group therapy sessions. From the Clinicians point of view, group therapy is a more efficient way of monitoring their patients, i.e. to see more patients in a limited period of time, and to observe them interacting in a social situation, albeit rather contrived. It also provides an opportunity for the Clinician to explore areas of their patients' knowledge in the area of gender and sexuality.

In my view, properly run groups are a helpful adjunctive therapy for some Transsexual patients. Usually group Therapy consists of 8-10 persons who meet regularly for 1½-2 hours weekly under the guidance of a group therapist/facilitator.

NHS treatment involves a team approach with a number of Clinicians including psychiatrists, psychologists, counsellors, endocrinologists and surgeons (as well as speech therapists and electrologists). In a sense this is clinical psychiatry by committee, in which decision making and responsibility is shared by the clinical team. This creates a cumbersome bureaucracy and slows down patients' progress. The system seems designed to protect gender disordered patients from themselves.

In an ideal world the NHS team approach should provide the best standard of care for persons with Gender Identity Disorders. The Free University Hospital in Amsterdam seems to serve the gender disordered population of Holland with a high standard of service by dedicated academic professionals. Significantly, the Free University Hospital team is run mainly by Endocrinologists. The team was set up in 1975 by Professor Louis Gooren and consists of three Endocrinologists, four Psychologists, two Psychiatrists, and two Plastic Surgeons.

Harry Benjamin International Gender Dysphoria Association's Standards of Care for Gender Identity Disorders.

The first edition was produced in February 1979, further editions followed in 1980, 1981, 1990, and most recently June 1998. The first edition was a 12 page booklet with an Introduction Statement of Purpose, Definitions, Principles and Standards of Care.

The latest edition is 26 pages of closely typed information on the subject of Gender Identity Disorders, what they are and how they should be dealt with.

The Standards of Care are Clinical Guidelines, intending to provide flexible directions for the treatment of Gender Identity Disorders.

Hormones, and when to prescribe them:

This has been hotly debated in the various editions of the Harry Benjamin Standards of Care. In the original draft it was recommended that the patient must have lived successfully in their cross-gender role for at least three months before initiating hormones. This requirement was rescinded in the 1980 edition. Principle 11 in the 1979 First Edition states "hormonal sex reassignment is both therapeutic and diagnostic in that the patient requesting such therapy either reports satisfaction or dissatisfaction regarding the results of such therapy".

The 1998 Edition states "the administration of hormones is not to be lightly undertaken because of their medical and social dangers."

Three criteria exist:

  • Aged 18 years.
  • Demonstrable knowledge of what hormones medically can and cannot do and their social benefits and risks.
  • Either a documented real life experience should be undertaken for at least three months prior to the administration of hormones,
    A period of psychotherapy of a duration specified by the Mental Health professional after the initial evaluation (usually a minimum of three months) should be undertaken.

Under no circumstances should a person be provided hormones who has neither fulfilled criteria number 3 or number 4

My clinical experience with the use of hormones has led me to conclude that the early use of feminising hormones is useful and appropriate because they have the effect of

  • Reducing the intensity of the gender dysphoria
  • Inducing pleasing feminising body shape changes, and
  • They act as a diagnostic test for Transsexualism by virtue of their feminising and anti-libidinal effects.

Surgery: Private-v-NHS.

Cost, currently £9,000 from Mr Royle at the Sussex Nuffield Hospital in Woodingdene, East Sussex. His waiting time is 4-6 months.

Dr Michel Seghers in Brussels charges 6,000 US dollars, approximately £4,000. His waiting time is 3-4 months. Patients are in hospital for 5 days after which they move to a nearby hotel, but visit Dr Seghers daily thereafter for another 5 days, or until they are ready to travel home.

In the private treatment of Transsexuals, in my view there needs to be a flexibility of approach rather than an adherence to rigid gender clinic policies, albeit based on the Harry Benjamin Standards of Care.

The decision to recommend hormonal and surgical treatment is based on the conclusion reached through the diagnostic assessment that the person's gender problems cannot be resolved with counselling or therapy and the only reasonable expectation is that the person will benefit from hormonal and surgical sex reassignment.

Reid, R., (1998),NHS v Private Treatment for Transsexuals GENDYS '98, The Fifth International Gender Dysphoria Conference, Manchester England. London: Gendys Conferences.
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