Some may recall the somewhat controversial history of the Royal College of Psychiatrists when it comes to transgender issues, and the decade-long wait for their guidelines for treatment of Gender Dysphoria.
Well, the wait is finally over and the guidelines were finally published last week. Given how potentially catastrophic they could have been, the positive nature of the final version is welcome and this is reflected in the long list of endorsements from trusted organisations.
The document is broadly in line with the latest WPATH Standards of Care, and positive points include: (These are mostly clustered around pages 15-16 and 21-23)
- For HRT prescription, transition is explicitly not required. There appears to be an implicit acceptance that HRT without social transition (i.e. without “going full time”) is sufficient for many people with Gender Dysphoria, as it also states no commitment to transition should be expected.
- If a patient turns up already on HRT (E.g, having obtained it online) then as a harm reduction measure, GPs are permitted to prescribe a “bridging prescription”.
- Genital surgery is permitted one year (Rather than the 2 years commonly usually used by the NHS) after transition and starting HRT.
- Revisions required from surgery or other complications should be referred directly to the appropriate healthcare provider and not result in a GIC referral.
- Hair removal should be provided. (Either for surgery or facial)
- The requirements for HRT and surgery are regardless of the direction of transition. The exception is top surgery for trans men which is permitted at the time of transition, noting that binding can potentially be harmful.
- Anyone with an intersex condition should have equal access to gender services.
- On an administrative front, all GP etc records should be fully updated from the moment someone transitions, including name and title, and this does not require a deed poll or statutory declaration. Information that a patient has gender dysphoria or has transitioned should never be disclosed to other healthcare professionals unless strictly necessary.
The document has a brief discussion of, but does not fully address, treatment of adolescents with Gender Dysphoria. It also does not attempt to set any age limit at which “adult” services should be accessible which will disappoint some people.
Of course, it’s impossible to compile a guidance document like this without some areas which people will feel are negative, or do not go far enough. Some of the more obvious ones include:
- A full physical exam, to include a genital exam (Which may be refused) is recommended when a patient first approaches to a GP. No evidence is presented as to why this should be clinically helpful and given the distress such procedures can cause, it’s inclusion here is somewhat surprising and is likely to put people off approaching their doctors. Inappropriate handling of physical exams were the source of some of the most serious complaints in the recent #transdocfail saga, so this advice may be as harmful for GPs as it is for trans folk.
- Discussion of non-binary/genderqueer identities is lacking. There is more on this on the nonbinary.org forums.
- Some very odd language around “certificated” men and women, meaning holders of GRCs.
Finally, two points that appear to be older portions of the document from it’s original decade-old draft incarnation that were missed in later updates:
- An uncited line on page 40 states “progesterone is not usually indicated since no biologically
significant progesterone receptor sites exist for biological males“. This is inaccurate, as well as misusing the term “biological males”. The line appears to have been lifted from another paper coauthored by Wylie, who chaired the working group that produced the RCPsych guidelines.
- The section on male-to-female genital surgery is somewhat gloomy and does not reflect the current state of the art.
Overall, it’s a welcome document and certainly one that can be used by those in the process of medical transition to persuade their GPs and other medical and administrative staff to do the right thing.