RCPsych Gender Dysphoria guidelines released

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.

7 comments

  1. Aye, the “certificated” thing is weird – I’m assuming it’s just meant as an in-document shorthand to differentiate between the rights of people with a GRC and those of people without one, but it’s not a coinage I’d like to see worming its way into general usage, personally, and lends too much weight to the significance of a GRC.

    They’re also definitely still firmly hanging onto the idea that a period of RLE is a prerequisite for surgical transition, in spite of there being no evidence to support the theory that waiting 1-2 years is helpful to anybody (or makes any difference whatsoever to the very low “regret quotient”).

    And yes, after a brief (though significant and welcome) nod towards non-binary people having an acknowledged need and right to transition in accordance with their experienced (a)gender, the rest of the document is basically all “women and men blah blah”.

    But having said all that, such progress as there is towards transition becoming a patient-centred, informed consent service is very welcome. Now to get our healthcare folk to read it…

  2. I find it extremely concerning that three major trans organisations would sign off on a document that advises genital exams. (That they would fail on NB issues is, sadly, to be expected.)

  3. Ok, so I read a bit of it. They seem to be asking GPs to make an initial diagnosis themselves based on a patient’s medical records. Then there is the initial appt with a psych where the advice is to pay “specific attention to psychosexual history”. The advice regarding when to offer specific procedures may be sensible but the diagnostic process is as fucked as ever. “Recollections of childhood gender-typed behaviours, and childhood and adolescent crossgender dressing with possible erotic accompaniment are elicited.” Ew.

    1. Sigh, so redundant – as Xander says in Buffy the Vampire Slayer (sorry) “I’m 16 – I get turned on looking at *linoleum*.” Sexual arousal is so divorced from gender identity that they only talk to each other through lawyers.

      And this consistent emphasis on validating people who have earlier trans* awareness over people who don’t is very undermining – not to mention very divisive within the trans* community.

      Seriously, they just need to ask “What is your gender identity? And what is it that has led to you being sure enough to be here today in the first place?” and then just listen.

      1. Plus it’s often the case that people thinking of transition, due to the media narrative, have mixed up sexuality with gender in their own head and need to work hard to separate them to figure out transition. Having more people without the necessary training making links between the two is potentially unhelpful.

        1. Bloody right, and especially when the uninformed “experts” are the ones doing the assessing. In the last 3 months, I’ve had 2 consultant psychiatrists who should both know better conflate my sexuality (or lack of same, in that I’m asexual) with my gender identity. They seem to equate being psychologically healthy with having a consistent sexual desire, and therefore if you’re asexual, you’re somehow immediately suspect. At least one of them responded very positively to me drawing him up over this… but the other didn’t – and he used to work in a gender clinic, ferchrissakes. If I have to hear one more of these professionals tell me “Don’t worry, once you’ve completed your transition you’ll have a healthy libido,” I’m going to break furniture.

          I recently did a straw poll of a load of young trans people I’m in touch with, asking them “if you’re young, trans* and live rurally, what are the 3 things most difficult about it?” and high on most people’s lists were rural physical and mental healthcare professionals lacking the training to respond appropriately to young trans* people coming out to them and looking for help transitioning (or just figuring themselves out). It’s pretty shocking when you realise how many GPs in this country don’t know the first thing about even how to correctly gender a trans patient.

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