Setting the SceneHow we got from there to here in 83 years

Christine Burns MBE

What I’ll Cover

Some historical context

NHS Context

International definitions

What trans people need and want

Challenges to service design

Challenges for today

Historical Context

Trans people have been transitioning for centuries, if not millennia

The modern world brings opportunities but also challenges

Clinical imperialism and voluntary services

Gatekeeping

The UK Clinical Landscape

NHS Care for people with gender identity problems confirmed judicially in 1998/9

GPs -- CMHTs -- Tertiary services

Commissioning until now by 152 PCTs taking policy guidance from 10 Specialist Commissioning Groups

Tertiary services will be commissioned by the NHS Commissioning Board in England after 1st April 2013

Clinical Definitions

The International Classification of Diseases and Health Conditions (ICD)

The Diagnostic and Statistical Manual

Both subject to revision at present

The ICD

The ICD is published by the World Health Organisation, a specialised agency of the United Nations

Ratified by the World Health Assembly(the health ministers of 193 countries)

Always a product of its time

Next edition (ICD-11) 2015/6. Will be part of clinical practice for 15-25 years

The ICD and trans people

Transvestism first added in 1965 (ICD-8) under ‘sexual deviations’

Transsexualism first added in 1975 (ICD-9) under ‘sexual deviations’

And then there was ICD-10...

ICD-10 (1990)F 64.0 - Transsexualism

F 66.1 - Egodystonic Sexual Orientation

F 66.2 - Sexual Relationship Disorder

F 64.2 - Gender Identity of Childhood

F 66.0 - Sexual Maturation Disorder

F 64.8 – Other Gender Identity Disorders

F 64.9 – Gender Identity Disorder, unspecified

F 66.8 – Other Psychosexual Development Disorders

F 66.9 – Psychosexual Development Disorder, Unspecified

F 65.1 – Fetishistic Transvestism

F 64.1 – Dual – Role Transvestism

WPATH DiscussionsF 64.0 - Transsexualism RENAME / MOVE

F 66.1 - Egodystonic Sexual Orientation DELETE

F 66.2 - Sexual Relationship Disorder DELETE

F 64.2 - Gender Identity of Childhood RENAME / KEEP?

F 66.0 - Sexual Maturation Disorder DELETE

F 64.8 – Other Gender Identity Disorders DELETE

F 64.9 – Gender Identity Disorder, unspecified DELETE

F 66.8 – Other Psychosexual Development Disorders DEL

F 66.9 – Psychosexual Development Disorder, Unspecified

F 65.1 – Fetishistic Transvestism DELETE

F 64.1 – Dual – Role Transvestism DELETE

WPATH Don’t Decide

WPATH is a global professional association, involving over 800 clinicians dealing with people with gender identity conditions

Their process is about reaching a consensus recommendation of their own to present to the World Health Organisation

WHO will consult others too

Process takes 2-3 years to secure global consensus for World Health Assembly

Current Thinking

Delete all but two classifications

Rename the adolescent / adult category (“Gender Incongruence?”) and remove from mental health section

Rename the child category (“Gender Incongruence of Children?”) or remove it altogether and use Z-codes

Uses of the ICD

Clinical utility - A common language to describe symptoms and anchor treatments

Common taxonomy for research

Health statistics and funding

Public health and policy

What trans people need and want

In transition

For lifelong wellbeing

In other services

As relatives and carers

In their own old age or disability

Trans care challenges service design

Intensely multidisciplinary. Needs joined up working at a time when NHS is fragmenting

Massive variation in needs

A legacy of stigma and ignorance to be overcome

The Challenge

Don’t accept the asis

Rethink responses around the individual

Slay sacred cows

Listen to the service user