Archive for January, 2012

General Medical Council meeting on Trans issues

On Friday, myself and a number of other Trans activists had a productive meeting with the General Medical Council (GMC) in London, on professional standards and continuing professional development. The GMC are running a consultation which nominally finished Friday, although we were told that responses sent after then may still be read so there is still time to get your views in.

Staff we spoke with certainly seem receptive and switched on to the extent that once Sarah started quoting the Equality Act at them from her written copy, one staff member was able to join in and finish the quote from memory. The difficulty for us and the GMC is taking the discussions and situations we were having, working within the remit of the GMC to turning them in to more generic guidelines for doctors. (The GMC can only regulate individual doctors, so has no influence on NHS funding decisions for example.)

Much of the meeting was taken up with Trans folk telling their “War Stories” and I think the GMC staff were surprised at how cynical we were as a community as well as the widespread nature of problems and their general severity. One particular story had a GMC staff member put her head in her hands and exclaim “Jesus!”

Some scenarios had been prepared as discussion points of which two recounted fairly typical NHS experiences that will be familiar to any Trans activist: GPs refusing to have anything to do with Trans patients due to moral objections; NHS Gender Identity Clinics (GICs) refusing to prescribe hormones due to lack of what they perceive as adequate documentation; Doctors (And GICs!) old-naming patients. The GMC were keen to point out that these were most definitely not what they would regard as good medical practice!

Of the first of those examples, a GP refusing to even refer a patient based on the doctor’s religious belief, there was much discussion. The GMC guidance on this is unclear, but suggests a doctor can refuse to treat in certain circumstances but instead refer the patient to another GP who can help, which is pretty routine in the case of contraception. However, that guidance is from 2008 and pre-dates the Equality Act 2010 and it was pointed out that the GMC would expect the doctor to refer. However, an activist quoted a doctor working at a Gender Identity Clinic who had never seen a GP refuse treatment on ethical/religious grounds and transfer a patient to another doctor to handle. Instead, they just prevaricate and find other excuses not to handle the issue.

It was also pointed out that you can’t completely divorce medical care from moral judgements, because things can get very fraught when you’re talking about end of life care and abortion – it’s simply not realistic to expect all doctors to react in exactly the same way in these cases – but Gender Identity is one area it seems clear that the GMC do not expect doctors to be exercising any sort of ethical or religious opt out when it comes to simple referrals.

This one case is a pretty good example of the troubles of activism. Whilst it would nice to rush in and say we should prosecute a doctor that refuses to treat on religious grounds and says so, if they’re transferring you to another doctor then they are in doing better than many GPs currently do. Thus, any guidelines the GMC produce as well as needing to be generic should make sure that they don’t push GPs more towards prevarication without explicitly saying why, which is not in the best interests of the patient even if it defends the doctor from a possible legal challenge.

Another interesting point, and this is something I do tend to run up against reasonably frequently, was that our experiences in some areas are not that much different from other marginalised groups who require access to medical treatment. Several examples were cited by attendees of people being forced to see a psychiatrist or gender specialist for clearly routine gynaecological or similar treatment and the GMC has had heard similar stories from the disabled community. (E.g. In the case of someone with Down Syndrome who presents with a broken limb, the doctor will see the Down Syndrome as something to worry about, even if it’s entirely irrelevant)

Sometimes, it feels as if we have more in common with the disabled community than we do with the rest of the LGB community.

The other major area for discussion was how to handle Continuous Professional Development, (CPD) which is quite a new area for the GMC as only being a recent and still developing requirement for doctors. At the moment, a doctor can practice for 40 or 50 years after finishing their training with no further updates required, so the GMC are looking to require regular recertification of some sort for doctors (as an IT professional I have to do this every 2 years!) However, there is some difficulty in identifying what the nature of any other activity should be as the GMC is limited in how much specific direction can be given. Peer discussions and conferences are clearly a good idea, but how do you ensure that it is appropriate content? For example, the recent and controversial Royal College of Psychiatrists conference that was cancelled would have counted for that organisation’s CPD, but is not something most people would have regarded as promoting best practice. Outside of the Trans arena and more generic, how do you stop doctors attending conferences on “talking cures” or homoeopathy as part of their CPD.

Mainly, it seems we simply need to be making doctors aware that GID exists and is something that the NHS handles because many GPs don’t know about this. If they know that and have some vague idea where to start searching for details on how to refer, things should improve. Doctors also need to not diagnose things they’re not competent in, as I have seen letters to patients from non-GIC psychiatrists saying “I don’t think you have GID” or “you might have it, but it’s not serious enough that I’m going to refer you”. All they should be doing is checking the patient isn’t in need of other mental health services (GICs do not have the resources to handle routine psychiatric issues or suicidal patents, for example) before referring, not blocking referrals based on their own untrained diagnosis.

In terms of all the above, the ball is now in the GMC’s court with respect to producing the next set of GMC guidelines. It won’t contain anything Trans-specific (It’s too small a document for that) but now they’re aware of the kind of problems we face, they can hopefully find some appropriate wording to push doctors in the right direction.

Finally, there was some discussion on Fitness-to-Practice and complaints in general, even though that was not the topic of the meeting. It seems that PALS and other NHS complaint routes have different standards than the GMC and it may, in some cases, be more appropriate to complain to the GMC directly in the first instance rather than PALS when it is an issue of transphobic actions by doctors or general clinical care. This is something we (as a community) can hopefully produce some how-and-who-to-complain-to advice on in future, but it also does not necessarily need to be a patient or fellow doctor that raises issues with the GMC for investigation, which raises some interesting possibilities for the community to act rather than having to rely on patients early in transition – who will fear reprisals from doctors.

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Trans Diagnosis 101: Leeds GIC show how not to do it

It seems that Leeds GIC may be having a bit of an identity crisis of their own, given that in response to an FOI request by Emma Brownbill they make it clear they do not really know what they’re diagnosing people with.

First, lets look at the background to the request. Emma’s first question to the GIC was to ask for “the numerical designation and diagnostic criteria for Primary Transsexualism in DSM-IV”. This is as a result of some interesting statements on their web site, including one referring to “primary transsexualism… (In accordance DSM IV)”.

Why is listing “Primary Transsexualism” odd? It is a diagnosis regarded as outdated at best and appears in no current credible medical literature. It is certainly not in the DSM-IV – the Diagnostic and Statistical Manual of Mental Disorders and has never appeared in any edition. Even more so, the latest editions – DSM-IV onwards, first published nearly two decades ago in 1994, avoid the use of the term “transsexualism” at all and instead refers to “Gender Identity Disorder”. The last time “transsexualism” as a diagnosis appeared in the DSM, “homosexuality” was also listed.

This isn’t just playing with words, as they are very different diagnoses. If you have a diagnosis of “Primary Transsexualism”, you can’t identify as homosexual in your preferred gender.

Is this some confusion on behalf of administrative staff who put some outdated documentation up on the web site for their FAQs? It seems not.

The first part of the answer the GIC supplied was a cut-and-paste response from the World Health Organisation’s International Classification of Diseases edition 10 (ICD10) entry on transsexualism. This is a completely different document from the DSM-IV, plus the word “primary” still does not appear anywhere in the ICD definition. The second part of their answer is headed “Primary Transsexualism in DSM-IV” (Remember, that term doesn’t exist in the DSM!) and the criteria they give do not match those in the DSM-IV for Gender Identity.

So what do we have so far – a GIC that is a little confused over the differences between two of the three key documents defining the main diagnosis they would expect to be dealing with?

Sadly, their response continues to dig them a deeper hole when it comes to the third key source.

They were also asked what training their staff had in “as mandated by the WPATH Standards of Care (SoC)”. The response? “Although our Trust takes into consideration guidance such as the WPATH Standards of Care (SoC), our Trust primarily follows the guidance of the Harry Benjamin International Standards of Care.”

That’s a big oops: The HBIGDA renamed itself to WPATH in 2006. It’s the same organisation, and this response rather suggests they’re working off the older (2001) version 6 of the standards of care published before the HBIGDA renamed, not the latest

It’s pretty unforgivable for a Gender Identity Clinic to have no idea about any of these documents and suggests they’re not really sure what they’re diagnosing. Sadly, although Leeds GIC were the target of this request, it’s not unusual to hear of such things within other areas of NHS healthcare for trans folk too.

P.S. I’m not endorsing the DSM-IV-TR wording or definition here – it’s problematic in a number of ways, but it’s the most progressive one.

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Sexual “fraud”, this time in the English courts

The whole sex-by-deception thing is back in the courts, this time with a teenager from England. (Telegraph)

The facts are broadly similar in both cases – a woman1 poses as male and has relationships with other women, but this time she ends up in trouble due to sexual assaults on the women, rather than them simply being unhappy when they find out the full situation as that happened later. From what I can tell, these were all short-lived relationships with girls Barker already knew, and not the longer-term ones we saw in the previous Scottish case. It also sounds more as if Barker is lesbian rather than somewhere on the Transgender spectrum which may have been the case with Brooks.

The main issue appears to be the sexual assaults and Barker has pleaded guilty to those. But what is concerning is the one count of “fraud” mentioned in the Daily Mail that’s also got a guilty plea. The Mail makes this sound as if the fraud charge is related to sexual activity. However, Barker also attempted to get compensation for a made-up assault so this may be straight-forward financial fraud rather than anything else.

Either way, a simple guilty plea does not set case law.

1Or at least someone who has not started medical transition or gone full-time as male.

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Fining so-called “no-show” patients is a bad idea

It has been suggested this morning (Telegraph) that NHS “no-show” patients should be charged a fee – basically a fine by another name.

Norman Lamb, a key adviser to Deputy Prime Minister Nick Clegg, told the Sunday Express: “We should consider introducing a charge for missed appointments.

“People have to understand when there is only a limited amount of money available it means cuts on care that could go on other patients.”

I’m surprised this has been suggested and I am most definitely against it, for two reasons.

Firstly is having heard stories about the historical (thankfully!) practice of Charing Cross Gender Identity Clinic to discharge patients who failed to show up for two appointments. However – and this is the reason I’ve said “so-called” no-show patients – stories of appointment letters turning up after the appointment and people being discharged as a result were common. In some cases, letters simply did not turn up at all.

Some bits of the NHS have very good administration but in any organisation of this size, there will be areas where the paperwork is not of the same standard. It is dangerous to make a universal assumption that the NHS is functioning correctly and fine patients, probably already suffering from appointment confusion, if it is not.

Secondly, what should the fine be? £100? That’s an awful lot of money to someone on benefits who really needs the NHS and does not have the mental energy to spare appealing fines if the administration is messed up. It’s not a great deal of money to someone who is earning a decent wage and thus is not so dependent on the NHS. £20? That’s still a big blow to someone on the poverty line but just a meal out for the middle-classes.

What has also been suggested are SMS reminders for those patients who supply a mobile phone number, something that both my hairdresser and my dentist (And I suspect many other similar organisations) use. I would prefer rolling out this more positive, cooperative approach across the NHS first before we even consider the authoritarian penalty approach.

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The apostrophe must die

I’m mildly amused but mostly slightly irritated by those seeking to attack the decision by Waterstones not to use the apostrophe in their name any more. I’m annoyed mostly because of their reasoning – it’s really not that inconvenient, right?

Wrong.

My surname is O’Connell. In general, I don’t use the apostrophe when I enter my name on computer systems. It does not appear on my bank cards for example, because I asked them to take it off when I changed my name. It’s not on my blood donor card, because I did not put it on the forms when I signed up.

But some people will “helpfully” reinsert it if I leave it off. This leads to problems. Not just the Little Bobby Tables problem, but that’s bad enough when systems won’t let you enter it but still require an exact match on your name. More than once I’ve started at a company to find my email is “Zoe.O’Connell@company.com” which isn’t a valid address.

And you can forget personalised domains, because someone is bound to try zoeo’connell.com which also won’t work.

Fix the computers? I wish it was that easy but humans can’t handle it either. I’ve been stuck at the front gates of data centres or on the phone to some call centre more than once because they are typing “O-Connell”, “O,Connell” or even just Connell on the computer to search for me.

I’ve ranted about this before, back in 2009:

I’ve decided that I’m going to change my name to संसृति कुमारी. This is, as far as I can figure out, the closest you can get to “Life Maiden” (Zoe Imogen) in सम्भाषनसंस्कृत (Sanskrit). I shall write to everyone – banks etc. – and inform them of my name change. Of course, they’ll all write back and tell me that they’re very sorry, but their computer systems can’t handle सम्भाषनसंस्कृत letters.

To which there’s a simple reply – You can’t handle the stupid apostrophie in my surname as it is without breaking things, why would having it in Sanskrit make any difference?

So, until someone can fix the whole Internet and teach all humans everywhere to enter data properly, I’ll stick without it.

(As an aside, there is likely not even supposed to be an apostrophe in the name anyway. I’ve seen various explanations but it’s most likely simply an anglicisation that happened during the first censuses of Ireland to mean “of the Connell clan”, “son/daughter of Conall” etc.)

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A less negative Trans NHS experience

I have been asked to pass this on anonymously about experiences with the NHS-run Havens service in Paddington, largely to reassure people that they know what they’re doing if they find themselves in the unfortunate position of needing their services. I won’t say it sounds like a positive experience because of the reasons one might go there in the first place, but it is at least not negative.

The content below deals with the aftermath of a sexual assault. Some readers may find this triggering. The text below is precisely as I received it and has not been edited or censored in any way.


I’m a trans man. I’ve been on testosterone over a year, pass completely, but have not had surgery.

I’ve written this account and asked for it to be shared anonymously, about my experiences at the Haven Paddington. For people who don’t know, the Havens are three clinics in London that deal with the aftermath of rape and sexual assault, and help collect forensic evidence. I was seen at the Haven Paddington the day after Boxing Day. This was about 80 hours after the rape that required it. I didn’t do anything about reporting it until Boxing Day, when I went to our local hospital with two friends. There, I was given a hep B jab, no PEP (it was high risk for HIV transmission) or morning after pill due to other medical conditions that precluded me taking them. They gave me a phone number for the Havens, who told me to dial the non-emergency police number. Eventually, about 10pm, the police arrived and wrote down exactly what happened. About midnight I was sent home, awaiting a phone call from the Met Police sexual offenses team.

They rang and it was arranged that I’d be phoned on the Monday morning to go to the Haven Paddington. They were willing to take me there and back. They came to collect me, and one friend, and we headed there. I was pretty terrified, and when we got there, I went outside to smoke straight away. The idea of being what felt like violated again so soon after the original rape was unbearably painful, and the fact that they would need to do transvaginal and cervical swabs terrified me – I have a lot of dysphoria, and also following the rape, I really didn’t want to.

The first thing I had to do was paperwork. The first form had a sex box, and the options were []male or [] female. I chose to check male. The second form had gender, and if I recall correctly it was []male []female []trans male []trans female []other []prefer not to say. I chose male again. I was a bit apprehensive about the whole thing, wondering what boxes they’d expect me to check, but was reassured that I’d marked the correct boxes if that was how I identified.

I then had to go through a check box form of things that had happened to me, and read over the initial statement I’d given the police. I made a couple of changes to that, and the doctor noted the language I was using, and used that when we went over the form, avoiding saying words like “breasts” or “vagina”. This was very reassuring, she clearly understood my gender identity. It had been explained by the police that I was a trans man, they knew from the initial statement, and I didn’t have to, she understood what that meant, how to be sensitive with words, and made a point of using male pronouns for me.

The examination was difficult. She gave me a gown, which she assured me was unisex, and I had to expose various parts of my body while she noted down marks. I couldn’t expose my chest, and she was fine with that, let me get away with keeping that covered, though it was upsetting when I got home and showered to see the bruising there, which would have been good evidence. They did take a swab there however, and when taking it, used the word “chest”, rather than “breasts”, which reassured me.
I then had to have an internal exam. For all of this, my friend was the other side of the curtain, I trusted him more than them to stop them if I needed to. The internal exam was painful, my vaginal walls were quite torn up and damaged, and I was having a lot of flashbacks and panicking, but they continued and stopped as and when I asked them to, and offered me a shower afterwards, but understood when I said I just wanted clothes.

At the end of my five hour shift there, they sent me for a psych assessment (which I felt was pointless, ultimately was, but I was offered the option of going voluntarily or being dragged), but this isn’t a necessary part of the process. Before I left, I was given the “adult male” information pack, and offered the “adult female” one as well if I wanted, which I didn’t.

I know the trans bits in here sound small, but having people use words I could handle, and the correct pronouns, made something that horrible and close to unbearable surviveable, and there wasn’t anything more they could have done. I wrote this to both alert people as to what might happen, and also reassure people that my experience, as a trans man, was as good as it could have been.

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Free software users “illegal downloaders” according to OfCom report

A recently released report prepared for OfCom – remember, they’re the folks who are going to be responsible for setting the rules on policing content on the internet – classes anyone downloading free content as someone they “deduce” to be involved in illegal file sharing. Here’s the culprit question:

Q4: Which of these have you used in the last three months in order to download or share files through the internet? Multi-code, Do not rotate
1. Peer-to-peer such as BitTorrent, Gnutella, eDonkey, Limewire and Ares
2. Commercial websites such as iTunes, Blinkbox, Amazon, Lovefilm, Movieflix, Napster, Play, or Spotify
3. Social Networking sites such as Facebook, Myspace, or Bebo
4. File sharing websites such as Rapidshare, Yousendit, or Easyshare
5. Messaging programs such as Windows Messenger or Skype
6. FTP
7. Email
8. Other (please specify)
9. Can’t remember

Apparently an answer other than 2 (Commercial websites) marks you as an illegal downloader. They do note the following:

Of course, those responding to Q4 (methods used to share or download files) may have had things other than the categories in Q3 in mind when talking about file sharing (e.g. photos they had taken) and the question will clearly need tightening in the tracking survey – even when filtering on those downloading or file sharing one of the six categories. This reinforces the recommendation (Recommendation 3 in Section 3) that Q4 be asked for each category of download.

However, even that does not help fully. For example, I tend to download software such as Debian or Ubuntu quite legally (They’re free software) via Bittorrent. It’s not unheard of in the commercial sector either as I have a legitimate copy of DCS: A-10C, a game/simulator that is distributed by the software house themselves over Bittorrent. (Requires a key to activate)

But it’s not just limited to software. Here is the list of categories that the report uses, with examples of legal content I personally have from sources other than “commercial web sites”.

  • Software or applications – Ubuntu, Debian, Thunderbird, many other items.
  • Video games – DCS: A-10C.
  • Films – Sintel
  • TV programmes – None. (I’m currently using NetFlix. I’ll give them the benefit of the doubt and let them refer to BBC iPlayer as “commercial”)
  • Books – Anything from Project Gutenburg.
  • Podcasts – The Pod Delusion.

Unsurprisingly, they deduce a higher number of “illegal downloaders” in the report than people actually admit to.

5 Comments

G3 Readers Awards: Here we go again

G3 Magazine just put Julie Bindel up for an award for campaigner of the year. Initial relation: Rolling of eyes, general “oh dears” and “here we go again”. If you are not familiar with her work, I have a few earlier posts about her tagged. Her significant work in 2011 includes her getting a Royal College of Psychiatrists’ meeting canceled merely by being invited to it.

I don’t expect the protests we had with the Stonewall awards back in 2008, partly just because G3 magazine is known to be problematic anyway and does not have the profile Stonewall does. G3 were on Bindel’s side back in 2008 for example. (Although that does mean that they can not claim to be unaware of her reputation within the community)

But if you do disagree with this nomination and currently read G3, could I perhaps point you in the direction of the much more Trans-friendly Diva Magazine?

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