Written evidence submitted by Gender Identity
Research Education Society (GIRES) (LOCO 30)
PROPOSALS TO
THE CLG COMMITTEE
We propose that local social and psychological
support be provided for trans people and their families, in line
with equality law, and the government White Paper on the new NHS.
THE LAW
¾ Those
who propose to undergo, are undergoing or have undergone a process
(or part of a process) for the purpose of reassigning their sex
by changing physiological or other attributes of sex, are protected
in the provision of goods and services; those perceived to have
the characteristic of gender reassignment; and those associated
with people who have the characteristic, are also protected from
discrimination by:
¾ the
Equality Act 2010;1 and by
¾ the
Human Rights Act, 1998 (Articles 8 and 14).2
¾ European
law protects users of health services from experiencing "undue"
delay in accessing treatment.3
¾ There
will be a "requirement for GP consortia to have a 'duty to
promote equalities.'"4
¾ Present
treatment protocols for trans people risk breaching these laws
by:
¾ providing
discriminatory treatment; causing
¾ undue
delay, and
¾ failing
to provide adequate holistic, therapeutic support for trans people
and their families that is locally accessible.
¾ Decentralising
social and mental health care under the GP consortia provides
an opportunity to reassess the delivery of care and support to
this marginalized group.
¾ Although
the numbers are still low, 20 per 100,000 (subject to regional
variation), the numbers presenting for treatment are doubling
every five years. Existing tertiary services are already overburdened.
If no supplementary provision is available, even longer delays
will ensue.
¾ This
will be reflected in the significant deterioration in mental health
of many trans people and their family members, frequently resulting
in family breakdown.
PROPOSED LOCAL
COMPLEMENTARY SERVICES
In the treatment of trans people it has become customary
to follow inflexible protocols and pathways, encompassing primary,
secondary and tertiary providers; these pathways are applied to
all trans people, regardless of their individual needs and circumstances.
This suggests stereotyping, so the protocols are, therefore, discriminatory
in their application with regard to some service users.5
Some local expertise already exists and a few trans
people are benefiting from services delivered in their area. However,
many are having to wait for long periods of time to be given appointments,
and then are obliged to travel long distances to Gender Identity
Clinics, at personal expense or, in some cases, funded by the
Local Authority.
The Department of Health's recent Procurement document
invites us to challenge existing service provision, by securing
delivery of service that is:
¾ Innovative;and
¾ more
cost-effective.
It is proposed that a new approach, running in parallel
with existing tertiary provision, will be cost effective because
it is supplied locally under the auspices of primary care; it
will be less stressful and expensive for the service users themselves;
it will help to avoid the collateral damage to trans people's
lives and those of their families by providing holistic psychotherapeutic
support; and it will be likely to secure better mental health
outcomes. Consequently, the ongoing cost to the NHS is likely
to be less, and the service users are more likely to be making
a contribution in the work place because of associated improvements
to their mental health and wellbeing.
"A model for such locally accessed treatment
is the Trans Care Project in Vancouver, Canada. When the centralised
hospital gender dysphoria programme was closed in 2002, a dispersed
community-based model of care was set up. Care for the trans population
became the responsibility of clinicians with varying degrees of
trans experience out in the community.6, 7, 8 Training
was provided where needed.
GP CONSORTIA
"GPs are well-placed to design care packages
for patients, which should lead to improved health outcomes and
tighter financial control".9
The establishment of 450 GP consortia provides an
opportunity to follow a similar model in the UK. It is not suggested
that the existing model involving tertiary Gender Identity Clinics
be discontinued, but that complementary services be provided locally
that would be used in conjunction with, and perhaps, sometimes
instead of, tertiary services. Each consortium may expect to be
caring for approximately 45-50 trans service users; there may
be around six to eight new cases a year.
TRAINING OF
LOCAL CLINICIANS
AND HEALTH
PRACTITIONERS
It is proposed that five regional two-day training
events are undertaken, which one GP and one mental health provider
from each consortium attends. This would provide a level of expertise
at primary care level which would be capable of initiating local
mental health support that would be independent of the "gatekeeper"
function currently undertaken by psychiatrists, usually as part
of the GIC provision.
"It is quite difficult to develop an authentic
therapeutic relationship with a client when the initial diagnostic
evaluation casts the clinician in the role of a gatekeeper who
controls access to medical treatments."10
The "gatekeeper" has the power to delay
or deny treatment, which severely inhibits open and transparent
communication with service users, who often feel obliged to present
with an acceptable "script", which omits or minimises
the real difficulties experienced in their lives. The dual role
of the GIC clinicians in providing psychological support, as well
as undertaking the "gatekeeper" function is inherently
contradictory and less able to provide the therapeutic support
needed by service users.
Training would be provided by a mixture of professionals
and voluntary groups with expertise in the field. In addition
an e-learning package would be developed to assist further training.
This would be provided to all consortia.
Three main aims to be met by the local provision
of services:
1. psychotherapeutic support for trans people
at local level;
2. provision of local support for families of
trans people, which is currently unavailable in most GICs; and
3. provision of an alternative way of meeting
eligibility criterion 3 (Harry Benjamin standards of care)11
for accessing hormones, by enabling three months psychotherapy.
MENTAL HEALTH
AND SOCIAL
SUPPORT FOR
TRANS PEOPLE
AND THEIR
FAMILIES
1. Psychotherapeutic support for trans people
themselves is currently not provided by some GICs, and even where
it is, it cannot be accessed on a regular basis, partly because
GICs don't have the human resources and, partly, because the travelling
involved would be totally impractical.
2. Where family breakdown occurs, outcomes for
trans people may be predicted to be less good.12 An
holistic view that has due regard for the trans person's situation
in the family setting, can be very beneficial, by helping families
to support their trans family member, and to process their own
grief and anger.
3. Also, at the moment, in some GICs, the eligibility
criterion for obtaining a prescription of hormones, is a prolonged
period of real-life-experience. This involves a complete change
of gender role in all circumstances: work, home, on the street,
in leisure pursuits without benefit of hormones. This is not possible
for all service users and unsafe for many. The alternative offered
in the International Harry Benjamin standards of care,13
is a three month period of psychotherapy. For the reasons outlined
above, this option is not offered to many trans people. Such a
period of psychotherapy can only usefully be done at local level.
The training programme proposed would enable independent counsellors
to offer this service in reasonable travelling distance from service
users' homes.
OVERCOMING DELAY
GPs, in "shared care" arrangements, currently
provide hormone treatment: prescriptions and monitoring, following
a diagnosis usually obtained at the GIC. This is typically preceded
by an initial "differential diagnosis" by a local psychiatrist
to establish that no "co-existing psychopathology exists".
This model presupposes that all trans people need to be
declared free of psychiatric illness before a further assessment
and diagnosis can take place. This presumption means that all
trans people are subject to this element in the treatment pathway,
regardless of need. This stereotyping creates a barrier to treatment
and a delay, neither of which is appropriate in all cases.
The European Court of Justice v NHS
(2006) defined the concept of "undue delay" as being
delay based on an arbitrary timeframe, rather than a medical decision.
The result, in this case, was that the PCT had to repay the costs
of the private treatment undertaken by the patient.
Better training for GPs will enable them to make
well-documented direct referrals either to GICs or to other gender
specialists, in all cases where there are no psychiatric disorders.
It also facilitates the development of local expertise in providing
psychological support and oversight of the care pathway for trans
people.
This ability would also be applicable when access
to private care is sought. This may also be commissioned so long
as comparable standards of treatment are provided; it is often
less expensive than the GIC treatment. This approach is endorsed
by the NHS Audit, Information and Advisory Unit's report,14
and the British Medical Association15 and the new NHS
approach to health service provision.
REFERENCES
1 Equality Act,
2010 provides protection against discrimination in the provision
of "goods and services" to those having the "protected
characteristic" of "gender reassignment". The Act
replaces the Sex Discrimination Act (1999 regulations, and 2001
amendment of legislation.
2 Human Rights
Act, 1989, Article 8 Everyone has the right to respect for his
private and family life, his home and his correspondence. There
shall be no interference by a public authority with the exercise
of this right (includes those who are providing a public health
service)
Article 14, engaged with Article 8, protects against discrimination
and "provides compelling protection for trans people, respecting
their autonomy and dignity"
"General application of rules, that may be applicable to
individuals, but cannot otherwise be shown to have clinical justification,
would be disproportionate."
3 European Court
of Justice versus the NHS (2006): the concept of "undue delay"
means that delay may be regarded as "undue" if it is
based on an arbitrary timeframe, rather than a medical decision.
4 Department of
health Equality Impact Assessment of NHS White Paper.
5 Legal Opinion
(not available) in regard to the Draft UK Guidance for treatment
of Gender Dysphoria,
www.rcpsych.ac.uk/pdf/Standards%20of%20Care%20Draft%20v8%203b%20final.pdf
6 Bockting, W
O, Goldberg, J M (2006) Introduction: Transgender primary medical
care. International Journal of Transgenderism 9(3/4):1.
7 Feldman, J,
Goldberg, J, (2006) Introduction: Transgender primary medical
care. International Journal of Transgenderism 9(3/4):1.
This programme is supported by a comprehensive website at www.vch.ca/transhealth/
8 Dahl, M, Feldman,
J L, Goldberg, J, Jaberi, A (2006) Transgender primary medical
care . International Journal of Transgenderism 9 (3/4):1.
See also:
http://transhealth.vch.ca/resources/library/tcpdocs/guidelines-primcare.pdf
Recommended reading.
9 Department of
Health Strategy (2010).
10 Lev, A I, (2004)
Transgender Emergence: Therapeutic guidelines for working with
gender variant people and their families. Ed. Terry Trepper,
The Haworth Clinical Practice Press, New York, London, Oxford
p 47-51.
11 Harry Benjamin
International Gender Dysphoria Associations standards of care,
sixth version, 2001(now renamed World Professional Association
of Transgender Health).
12 Landén,
M, Wålinder, J, Hambert, G, Lundstrum, B (1999) Factors
predictive of regret in sex reassignment. Acta Psychiatrica
Scandinavica 97(4):284-289.
13 Harry Benjamin
International Gender Dysphoria Association's The standards of
care for the treatment of gender identity disorders—sixth
version (2001) Symposion, Düsseldorf.
14 Schonfield,
S (2008) Audit, Information and Analysis Unit: Audit
of patient satisfaction with transgender services. The mean
waiting time from specialist referral to first appointment at
a GIC was 30 weeks and the median was 22 weeks. When looking only
at those who attended a NHS GIC however the mean waiting time
was 34 weeks and the median was 26 weeks. (N.B. waiting times
vary from Clinic to Clinic and from year to year).
15 British Medical
Association policy that states:
"patients who are entitled to NHS funded treatment may opt
into or out of NHS care at any stage. Patients who have had private
consultation for investigations and diagnosis may transfer to
the NHS for any subsequent treatment. They should be placed directly
on the waiting list at the same position as if their original
consultation had been within the NHS."
October 2010
| 
