Monday, August 17, 2009

Gender Identity Disorder Screening

25 years ago I was one of 20 psychiatrists in a discussion about whether patients with gender identity disorder should have surgery or psychotherapy. The consensus was that surgery was wrong and that the only treatment indicated was therapy. The discussion was being lead by a psychoanalytically trained psychiatrist and we were all junior. I was the only one who argued in favour of a surgical solution. That was as much to do with my community medicine and public health training as anything else. I thought that if 'therapy' didn't work after a reasonable time then clearly consideration of a surgical 'solution' to the 'problem' would be more indicated than continued costly ineffective therapy.
Years later I found myself seeing transgendered patients who had a very negative experience of the process because, quite simply, the basic recommendations for good outcome as laid out by the Harry Benjamin International Gender Dysphoria Association. had not been followed. The Harry Benjamin organization as part of it's 'triadic' approach to GID recommended 'real life experience' ie living full time in the gender to be. Indeed it was early recommended that one spend a year in the role of the perceived gender before or after the introduction of a trial of hormones. Surgery only followed this process. Importantly it was recommended that other psychiatric conditions be excluded before the diagnosis was made. One idea that seemed predominant at the time however was that if you were 'transgendered' this would lead to abuse of drugs and alcohol. This was prior to the present day standard idea of 'dual diagnosis' and the recognition that addiction is a primary disorder and not 'secondary' to other disorders or likely to respond to anything but treatments specific for addiction.
Working in addictions as well it is not uncommon to see people doing drugs and alcohol have many confusions, not surprisingly since the central processing unit is being played around with. One of these confusions is gender identification. Indeed some people on drugs or alcohol believe they are inhabited by aliens or channelling plant life. Yet here were people being lined up for surgical transformation without their drug and alcohol abuse or dependence issues being addressed. The outcome success of the surgical transformation however is directly related to the better pre surgical adaptation. Drug and alcohol dependence predisposed to poor outcome.
Further there are those who are simply delusional. I've met a dozen deities or more in my practice so it's not surprising that psychotic individuals who might otherwise think themselves as not themselves might also think themselves as not their gender. I have treated such individuals with standard antipsychotic medication and they have lost the sense of the otherness of their body almost overnight. In contrast transgendered folk aren't improved with antipsychotics though schizophrenics and manic depressives may be.
The actual diagnosis of Gender Identity Disorder is not fixed in stone. It's easiest if there's a diagnosis made in childhood but mostly the diagnosis is made in an adult who by history gives the criteria as deliniated in the DSMIV. There may or may not be collateral or outside verification of this diagnosis. As for the diagnosis itself it's critical to understand that it fluctuates with symptons of dysphoria waxing and waning at times.
Surgeons and endocrinologists prescribing hormones have commonly established criteria such as requirement for psychiatric assessment principally to rule out the conditions which may mimic GID. Dissociative Identity Disorder or multiple personality disorder is another such condition. While the desired therapy and surgery would have pleased one of the personalities the others would have been sorely displeased for sure. Surgery is clearly not a recommended treatment for DID whereas it is for many GID. Some surgeons recommend anywhere from a half dozen in a year psychiatric visits or reports from over 2 years pre surgery psychiatric therapy before agreeing to do surgery.
In earlier years there wasn't such caution but as more people have had surgery and the procedures become more common and have a better outcome more people are coming forward. However there are those who have sued surgeons and the courts have increasingly become involved.
This is not surprising in this area as there were young women in the sixties and seventies who having decided they didn't want children sought hysterectomies. Unfortunately in their 30's they changed their minds and sued the surgeons. Even more unfortunately the courts found against the surgeons and for a while surgery on female reproductive organs required more than usual consent procedures for women before the age of 25.
Surgeons have generally taken the approach that if they're going to be sued they'd rather not be standing alone. Their favourite companion is usually an internist though as a psychiatrist I've been approached by them for pre cosmetic surgery assessments of those who have unwarranted expectations. This also occurs with GID as some individuals whose personal lives are bereft of relationships believe that overnight a sex change will cause them to have a friendship network and be desirable. This is the sort of matter that should be addressed pre surgery because it clearly can have negative effect on the perceived outcome.
When surgery goes wrong the worst isn't the suing of surgeons. Trans sexual therapies are meant to improve the life of the individual not make it worse. An increase in suicide has been associated with some clinics and that increase has been directly associated with lack of screening. Drug and alcohol addiction in GID is more likely made worse by surgery and certainly psychosis or dissociative disorder and other mental health conditions which can mimic GID or be transitory will not benefit from surgery.
Having the misfortune of knowing transexuals who have killed themselves after surgery, a colleague in one case, and patients who came to the emergency suicidal, it is readily apparent to those working in this field that there is a need for screening out those who are clearly not GID or at least recognising that psychiatric issues that need to be addressed first before surgery if a good outcome is to be expected. Because of the better outcome for surgery in non smokers for instance some surgeons have said that quitting smoking is a criteria for them doing a variety of surgeries including gender reassignment surgery. Certainly this is good medically but it also seems to be a way of assessing motivation for surgeons natually wanting good outcomes.
The actual surgery is only a part of the care and post operatively there is a regimen that needs to be followed carefully for good results. Willingness to follow recommendations before surgery is the best indications of likelihood to follow recommendations post surgery.
The other factor in terms of screening is that these procedures are often paid by insurance agencies who are committed to cost saving. State or provincial or federal health plans want the best cost outcome. As I originally argued if surgery could replace a lifetime of inadequate therapy then clearly from a community medicine and public health and funding basis surgery was superior. However more than one major university affiliated transgender surgical clinic has shut down when the 'cost' in human life and suffering did not show improvement. Lack of adequate screening and pre surgical preparation was seen to be the principal reason for the poor outcomes.
Screening in this sense is not limited to GID. As a surgical resident I screened alcoholics for heart valve replacement. Because of the problems of liver disease and bleeding in alcoholics they were not candidates for mechanical heart valves but were given the less long lasting 'pig' valves because these were associated with fewer complications in alcoholics.
Finally the treatment for GID is not solely surgery and hormones as many with GID opt to lead a life in the gender of their orientation without medical or surgical assistance. There are also increasingly those among the young people who view themselves as 'gender queer' and work to having society change to accept this third alternative. Politically they view medications and surgery as evidence of the rigidity and lack of enlightenment of society and see indeed the need to educate society that there is more than binary code in nature and humans. Rather than 'pass' or 'fit in' to existing society they want society to grow up and accept the existing variety so that individuals who are 'intersex' will not feel the need for 'sexual mutilation' as they describe this process.
Alternatively, sex reassignment surgery can be acquired privately and paid for individually without need of insurance or third party involvement where one makes an individual contract with a surgeon who feels sufficiently comfortable with the individual as to not require any mental health assessment in contrast to the Harry Benjamin recommendations. International surgical units provide this service and may have very good physical results.
Finally it is clear that sex reassignment surgery is beneficial for many in ameliorating symptons and correcting a mismatch between internal perception of self and external presentation. Individually I have seen many cases where this is the case. However, in the process of screening I have had to say 'no' or appear to 'deny' patients obsessed with the idea of a surgical solution to their mental health or addiction issue. This has resulted in threats and intense anger that causes few to want to work in the process of screening especially when the individuals seeking this service may have heavy duty drug addiction, psychosis, severe personality disorders and/or criminal sociopathic backgrounds. There is a desire among doctors to to be appreciated for their more often than not underpaid work. In this field the tendency is for individuals to be angry with the system that doesn't understand their 'need' and therefore not appreciate what they feel 'entitled' to or to feel extreme rage if they feel entitled to a treatment that is denied them until they address their mental health or addiction needs. It's rather a no win situation for the psychiatrist in contrast to the surgeon or endocrinologist who commonly are truly appreciated for providing the desired therapy
One of the simplest recommendations for good outcome has been for involvement in the transgender community support resources. There are several in which transgendered folk can get together and discuss their experience and care. This has proven as effective for good out come as pre natal classes proved for obstetrics.
In those who have addictions not surprisingly a year after abstinence treatment there are those who remain committed to surgery and those who have changed their minds or want more time to consider the options available to them.
It remains too that surgery is a life threatening procedure with the morbidity and mortality that surgery and anesthesia does carry, though relatively speaking the risks decrease each year. Finally the surgical procedures are relatively irreversible so that like any life long decision it's worthy of patience and deep consideration. Those who are fully informed also have the greatest likelihood of the best medical and surgical outcome. In Canada screening remains the best medical and psychiatric practice.

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