Suffolk Health Authority

Transsexuals and Sex Reassignment Surgery

An internal report produced by Suffolk Health Authority, May 1994

Summary

People who wish to change their sex may be referred to as "Transsexuals" or as people suffering from "Gender Dysphoria" (meaning unhappiness with one’s gender). Transsexualism is regarded as a psychiatric disorder, and it can also be associated with other - and more serious - mental illnesses. Transsexuals usually present to the medical profession with a diagnosis (Transsexualism) and a desired course of treatment (hormone therapy and sex-reassignment surgery). They can have a sophisticated understanding of their condition which may exceed that of a general psychiatrist. Although the transsexual may be certain of their diagnosis, experience in specialist Gender Identity Units has shown that only about 15% of male transsexuals and 90% of female transsexuals are considered suitable for surgery - or still desire it - after specialist psychiatric care and a prolonged period of observation. Unfortunately, lacking insight, some transsexuals may regard such psychiatric care and prolonged observation as being obstructionist.

The determined transsexual can purchase hormone therapy and sex-reassignment surgery in the private sector - without the prior period of psychiatric care and observation. In these circumstances, some transsexuals have been able to undergo hormone therapy and sex-reassignment surgery when - under more considered circumstances - they would have not been considered suitable for surgery, or have no longer wished it. Some transsexuals have thus regretted having had surgery. Suicide is a recognised tragic outcome for transsexuals, and inappropriate surgery will contribute to the strains that transsexuals feel.

Hormone therapy and sex-reassignment surgery are superficial changes in comparison to the major psychological adjustments necessary in changing sex. Treatment should concentrate on the psychological adjustment, with hormone therapy and sex-reassignment surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Psychiatric care may need to be continued for many years after sex-reassignment surgery. The technical success of sex-reassignment surgery is greater for male-to-female transsexuals than female-to-male transsexuals, and continues to improve as new techniques are developed. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the transsexual, and the support from family, friends, employers and the medical profession.

The total cost of treatment for a transsexual, including sex-reassignment surgery, can reach £50,000. Although transsexualism is rare, this health authority has knowledge of 11 people for whom it has been approached for funding. A robust purchasing policy is needed to limit the authority’s exposure to unnecessary costs, to ensure that only effective care is purchased, and to ensure that an undue proportion of its funds are not spent on a few individuals.

It is recommended that the health authority funds the specialist psychiatric assessment, care and prolonged observation of individuals who wish to change their sex. This will take place at the Gender Identity Clinic at Charing Cross Hospital (Riverside Mental Health Trust). Following this, the majority will no longer be considered suitable for surgery, or will no longer wish it. The authority should fund the surgery for those individuals who are considered suitable by the Gender Identity Clinic. A list of purchasing conditions has been developed to ensure that only suitable individuals are referred to the Gender Identity Clinic, and that only suitable individuals undergo hormone therapy and sex-reassignment surgery. Individuals with unusual circumstances will have their case reviewed by the Director of Public Health.

Introduction

Background

At a public meeting of Suffolk Health Authority, the Director of Public Health (DPH) proposed that sex-reassignment surgery (SRS) should no longer be purchased by the authority for residents in Suffolk. After considerable discussion, a decision was deferred to enable a more informed debate at a future meeting.

To assist the authority in its deliberations, it was felt that more detailed information was needed as to the role and outcome of sex-reassignment surgery in the management of transsexuals. This paper provides some of this information.

Scope

This paper covers male-to-female, and female-to-male transsexuals, and the role and outcome of surgery in these two groups. The paper will describe the place of hormone therapy and psychotherapy as these both form part of the full management of a person presenting as a transsexual. It briefly covers the cost implications of the various management options.

This paper does not cover the role of surgery in the treatment of children who are born with indeterminate sex such as occurs in the testicular feminisation syndrome, congenital virilizing adrenal hyperplasia, congenital absence of a penis, Mayer-Rokitansky syndrome, Mullerian failure and other conditions. It is assumed that the health authority will wish to continue to cover the cost of these extremely rare conditions.

Findings

Transsexualism - a definition

A definition has been suggested by Money and Gaskins: Transsexualism is "a disturbance of gender identity in which the person manifests, with constant and persistent conviction, the desire to live as a member of the opposite sex and progressively take steps to live in the opposite sex role full-time."

Diagnosis and Classification

Transsexualism is considered to be a psychiatric disorder. The "Diagnostic and Statistical Manual of Mental Disorders: Third Edition, Revised" (DSM-III-R) gives the following diagnostic criteria:

Transsexualism: DSM-III-R Criteria

1. A Sense of discomfort and inappropriateness about one’s anatomic sex.
2. Wish to be rid of one’s genitals and to live as a member of the other sex.
3. The disturbance has been continuous (not limited to periods of stress) for at least two years.
4. Absence of physical inter-sex of genetic abnormality.
5. Not due to another mental disorder, such as schizophrenia.

It seems that the DSM-III-R criteria have limited practical use, because they include all people who wish to change their sex, regardless of whether they are ultimately considered suitable for surgery - or still want it after psychiatric treatment. There is a move to use the term "Gender Dysphoria" (meaning unhappiness with one’s own gender) to cover all people who initially wish to change their sex, and to reserve the term "Transsexual" for those who still with to change their sex after psychiatric treatment, and who are considered suitable for sex-reassignment surgery - and for those who have already had surgery.

Whether or not the person fits the above criteria is not so important as whether the person can live as a member of the opposite sex and be accepted in that role by family, friends and employers. The general stability and strength of personality are also not assessed by DSM-III-R, but are vital factors in the outcome.

There is no universally accepted theory to explain the existence of transsexualism. There are cultural differences in the expression of transsexualism, for example none in a series of 200 transsexual males in Singapore had been married, although prior marriage is not uncommon in Caucasian transsexuals (up to 50% in one study). In New Zealand, 9% of the population is Maori, yet 90% of the country’s transsexuals Maori. In Myanmar (formerly Burma), there remain strong animist beliefs in some 37 spirit gods, one of which is a female who takes control of, and imparts femininity on men. Transsexuals are thus recognised in the religion, and, whilst not envied, are respected for their roles as shamans and seers.

People present as transsexuals with a variety of backgrounds and explanations, and it has been felt necessary to sub-classify transsexuals. It will be seen that these classifications can be useful in deciding whether or not sex-reassignment surgery is likely to benefit the transsexual. Several classifications are in use. Most authors divide transsexuals into two groupings, as described below, although they differ in how they place individuals in such groupings. Clinicians may use the person’s main sexual outlet to position people within categories of transsexualism. However, this can be difficult, partly because the patients have a tendency to give a false life history.

Primary (true) Transsexuals

These are people who display the following characteristics, which expand on the DSM-III-R criteria:

1. A sense of belonging to the opposite sex and of having been born into the wrong sex.
2. A sense of estrangement from one’s own body, so that any evidence of one’s own biological sex is regarded as repugnant.
3. A strong desire to resemble physically the opposite sex and to seek treatment, including surgery, towards this.
4. A wish to be accepted in the community as belonging to the opposite sex.
5. Persistence of these feelings and convictions, often since childhood.
6. No evidence of biological or associated psychiatric illness, such as schizophrenia.

These people are very rare, and form a small proportion of all transsexuals, perhaps only 10%. Many pass easily as a member of the opposite sex without the need for hormone therapy or sex-reassignment surgery. It is these transsexuals who are considered suitable for sex-reassignment surgery.

It is one purpose of specialist psychiatric assessment and prolonged observation to identify the relatively rare "true" transsexual from the commoner "secondary" transsexual.

Many primary transsexuals have a limited or absent sex life. They are not sexually aroused by wearing clothes of the opposite sex (as are transvestites). The male transsexual prefers "straight" men. These sexual relationships are explained as "heterosexual" because the transsexual believes he is a female and is naturally attracted to men. Female primary transsexuals similarly explain their preference for women partners.

Despite the unambiguity of the criteria, it appears that even for apparently primary transsexuals, the original gender is capable of unpredictable and sudden re-emergence. A male who was assessed as being a primary transsexual, and who lived life as a woman for 2.5 years, had sex-reassignment surgery cancelled after a hospital policy decision not to undertake such surgery. He returned to the male role, and lived life more happily as a man than he had as a women or as a man prior to that. It is important to note that in this case, the man had refused psychotherapy which could have uncovered a degree of ambivalence. For some clinics, it has been the practise not to provide psychotherapy in cases who are initially felt to be primary transsexuals.

Secondary Transsexuals

In general, these are people who present as transsexuals after a period of living - apparently successfully - in their biological gender role. The desire to change sex can be interpreted as a way of avoiding conflicts caused by failings in their true gender role. The presentation may occur after a crisis, and the desire to change sex may reduce as the crisis is resolved.

This group expresses a sense of discomfort with their biological gender, rather than, as in the "true" transsexual, a belief that they are a member of the opposite sex. This mixed group of transsexuals demonstrate a degree of uncertainty when compared to "true" transsexuals.

This group contains the following, using the example of men to illustrate the categories:

Effeminate homosexuals:

As boys, these are quite effeminate and may cross-dress. The cross-dressing can be quite narcissistic, such as dressing as female film stars. There is no arousal associated with female clothes. In a crisis, they may feel that they were not really a homosexual at all, but a female in a male body.

Heterosexual Transvestites:

As men, they have lived quite successful male lives, often marrying and fathering children. However, they have had a secret side to their lives, in which they cross-dressed as women. The cross-dressing was associated with sexual arousal. In time, as the arousal dissipates, and frequently after a challenge to their masculinity such as after the death of a parent, spouse, or birth of a child, the cross-dressing is replaced by cross-gender desires.

Atypical:

This group is a mixed group of individuals who may have been in and out of a heterosexual, homosexual or asexual world and are trying to find happiness. They are inclined to suddenly realise, "I know why I am so unhappy, I’m really a woman in a man’s body", and proceed to change their gender. Some of these individuals have a major psychiatric illness, and a borderline personality type is a common finding.

The several classifications of transsexualism reflect continuing uncertainty over the use of the term transsexual. This has meant that some transsexuals have been mistakenly classified and as a result, have suffered rather than benefited from treatment, especially from sex-reassignment surgery.

The key to obtaining a successful outcome is the use of diagnostic criteria which will classify transsexuals into those who will, and whose who will not benefit from the various management options.

Assessment Criteria

Criteria which assist clinicians to distinguish primary from secondary transsexuals have been developed by the Harry Benjamin International Dysphoria Association, Inc, who produced guidelines in 1981 for the assessment of people with gender dysphoria "Standards of Care: The Hormonal and Surgical Reassignment of Gender Dysphoric Persons". These guidelines describe 16 minimum standards of care together with 31 philosophical and ethical principles. Key points are summarised below:

1. The patient should show evidence of a stable transsexual orientation, which is evidenced by a desire to rid him/herself of their genitals for at least 2 years.
2. The patient should show insight into his/her condition and should not suffer from any serious psychiatric disorder.
3. The patients must be have been known to a clinical behavioural scientist (or equivalent) for at least 3 months, before this clinician can endorse hormone therapy.
4. The patients must be have been known to a clinical behavioural scientist (or equivalent) for at least 6 months, before this clinician can endorse sex-reassignment surgery.
5. There must be a second concurring opinion by another clinical behavioural scientist.
6. The patient must have been living successfully in the other sex role for at least one year.
7. Improvement in personal and social functioning should be predicted for the individual prior to and after surgery.

How common is Transsexualism?

In England and Wales in 1974, the prevalence of transsexualism was estimated at 1:34,000 males and 1:108,000 females, a male to female ration of about 3:1. When these figures are applied to the county of Suffolk, one would expect there to be about 10 male transsexuals and about 3 female transsexuals. The exact numbers are unknown.

The prevalence of transsexualism appears to depend on the availability of treatment and the tolerance of the condition by society and the medical profession. For example, for people born in Singapore, the prevalence in 1988 was 1:2,900 for males and 1:8,300 in females. This high prevalence was ascribed to the ready availability of sex-reassignment surgery. A similar prevalence in Suffolk would mean that one would expect there to be 112 male and 40 female transsexuals.

Prevalence also rises with time as more people seek treatment and as more have received sex-reassignment surgery. For example, from the records of the only gender treatment centre in the Netherlands, in 1980 the prevalence was 1:45,000 for males and 1:200,000 for females, whereas in 1986 it was 1:18,000 for males and 1:54,000 in females. The change was further ascribed to a lowering of the threshold for treatment.

The male to female ratio was originally thought to be 8:1, however, with the increasing recognition of, and treatment for female-to-male transsexuals, more female transsexuals have come to the attention of the medical profession, such that in one clinic in the USA, equal numbers of both sexes were attending.

Evaluating the Transsexual

Most patients present to a doctor requesting hormones or a sex-change operation. It is not unusual for the male patient to claim he is "a woman trapped in a man’s body" and likens his life-story to that of, for example, Jan Morris (a journalist and author who wrote a popular book describing her experiences changing from a man into a woman). Male patients may come to the interview cross-dressed. Some have already obtained hormones from other sources (e.g.: birth control pill), developed breasts and have undergone electrolysis - and can pass convincingly as women. They may have a female name, and expect to be referred to with female pronouns. Many patients are well read on the subject and their knowledge may surpass that of the general psychiatrist.

This presentation is thus fraught with potential difficulties. Nearly all patients will attempt to convince their doctor that they are true transsexuals and, as such, require hormonal and surgical sex-reassignment. The evaluating psychiatrist may naively accept the sophisticated history provided and wrongly conclude that the patient is correct in their self-diagnosis of transsexualism. In fact, true transsexuals form only about 10% of all those presenting as transsexuals. In the Charing Cross Gender Identity Clinic, only 15% of male transsexuals are accepted for surgery.

There are no tests to diagnose transsexualism, and all aspects of the history should be independently evaluated, including interviewing the person’s relatives. However, it has been known for transsexuals to hire surrogate parents to back-up their story. Unfortunately, attempts to formally evaluate the transsexual are perceived as being obstructionist by the transsexual.

The above complexities of the evaluation are such that assessment is better performed by a specialist psychiatric unit.

The Management of a Transsexual

The management of all transsexuals should include psychiatric care and evaluation, a prolonged period of observation - and if considered appropriate - hormone therapy and sex-reassignment surgery. Attention tends to focus on the sex-reassignment surgery which is dramatic and irreversible. However, sex-reassignment surgery should occur only after several years of psychiatric care and hormone treatment. Unfortunately, as psychiatric care takes place over a prolonged period of time, it can be easier for some clinics to offer only hormone therapy and surgery. Furthermore, many transsexuals do not see the relevant of psychiatric care and evaluation. On the other hand, at times of crisis, some transsexuals have benefited from inpatient psychiatric treatment.

A Suggested Management Scheme

This scheme is the one used by the Gender Identity Clinic at the Riverside Mental Health Trust based at the Charing Cross Hospital, and meets the standards of care produced by the Harry Benjamin International Gender Dysphoria Association, Inc.:

1. An initial psychiatric assessment involving (i) a first long interview followed by (ii) a second-opinion interview. Preferably, patients should not have received hormone treatment before this assessment. Subsequent psychiatric care involves four outpatient sessions per year for as long as is considered necessary.
2. Hormone therapy is started when it is thought appropriate. This is usually after the transsexual has benefited from several months (or years) of psychiatric care.
3. A period of psychotherapy in a monthly group sessions.
4. The patient lives full-time as a member of the opposite sex for a period of two years. This should include at least one year of employment as a member of the opposite sex. This is called the "Real Life Test".
5. If this is successful, and a psychiatrist feels that the patient has a good psychological, physical and social well-being, and that this is appropriate for a member of the opposite sex, the patient may be considered for surgery. There is currently a two year waiting list for surgery after referral. Treatment may last for up to five years before surgery is considered.
6. A second opinion is then sought. If this agrees that surgery is appropriate, then a referral for surgery is made. At the Charing Cross Gender Identity Clinic, about 15% of males are ultimately considered suitable for surgery, and about 90% of females.

Psychiatric Care

Psychiatric care should provide a supportive empathic understanding of the problem and help the patient to look at it objectively. It should neither encourage cross-gender desires; nor discourage them. The internal acceptance of a change in sex is a key stage in gender re-assignment. Failure to achieve this will prejudice the success of other forms of treatment.

Psychiatric care can often bring about a resolution of the gender conflict, and some are relieved of the urge for irreversibly surgery. It has been suggested that transsexuals possess rigid gender-role definitions with, for example, males describing a "macho" masculinity. Falling short of this idealised conception of manhood, they assume that they are, therefore, female. Psychotherapy may loosen rigid gender-role definitions and alleviate gender identity problems without sex-reassignment surgery.

Hormone Therapy

Hormone therapy involves taking - life-long - the sex hormones which predominate in the opposite sex. This has the effect of inducing, over a period of a year or two, physical changes resulting in the partial appearance of a member of the opposite sex. In men, for example, taking female sex hormones, brings about the development of breasts and a female fat distribution. In females, taking male sex hormones brings about muscle growth, facial hair growth, and hair growth on the chest, legs and arms, a deepening of the voice, and male pattern baldness. The effects vary from woman to woman.

The physical changes brought about by hormone therapy allow both the patient and psychiatrist to observe the psychological adaptation to a changing appearance. It should be noted that hormones have not only a physical effect, but also a psychological effect, which can encourage some ambivalent transsexuals into having surgery before there is a robust internal acceptance of the change in gender role.

Sex-Reassignment Surgery

Sex-reassignment surgery intends to remove some of the physical characteristics of the biological sex and replace them with those of the opposite sex. Its irreversible effects are additional to changes brought about by hormone therapy. Several surgical techniques have been used - with variable results - and are undergoing continuous evolution and improvement.

Sex-reassignment surgery involves multiple procedures which take place over a number of years. Unsuccessful first attempts may need repairing later.

Surgery in the Male

For the male-to-female, this involves many procedures over a number of years. It may involve:

• Amputating the penis and removal of the testes.
• Increasing the size of the breasts - beyond that achieved by hormone treatment.

Electrolysis of facial hair is undertaken separately. Sex-reassignment surgery can also include the following:

• Construction of a vagina, using a section of bowel, or the inverted skin of the penis. Such a vagina will allow sexual intercourse. (The patient will be infertile.)
• Shortening of the vocal chords in order to raise the pitch of the voice.
• Re-contouring the facial bones to create a more feminine face, for example by changing the shape of the nose. (Rhinoplasty.)

Surgery in the Female

Similarly surgery for the female-to-male involves many procedures over several years. These may involve:

• Reducing the size of the breasts, nipples and areolae and, in other ways, re-shaping the chest wall.
• Removal of the uterus and ovaries
• Removal of the vagina
• Construction of a phallus from a tube of skin - phalloplasty. The clitoris is usually retained in its usual position in order to allow orgasm. Depending on the method, the new phallus may allow the passage of urine, may be fitted with a stiffener to allow sexual intercourse, and may be supplied with nerves in order to allow sensation.
• Construction of a scrotum and implant of artificial testes.
• The conversion of the clitoris into a small penis. (Metaidoioplasty).

Outcomes after Surgery

Introduction

Outcomes after sex-re-assignment surgery should be considered in two dimensions: one dimension is whether or not the surgery has achieved its aim of replacing biological sexual characteristics with those of the opposite sex. The other, more important dimension, is whether this change in physical appearance - when combined with the other treatment options - has benefited the patient.

The final outcome of treatment should be regarded as the cumulative effect of the suitable selection of patients, the support of family, friends and employers, the psychiatric care, hormone therapy, and - finally - the sex-reassignment surgery. Deficiencies in any component of the management can lead to a poor outcome.

Surgery should not be regarded as a cure for transsexualism. One author found that all his patients had psychological problems including family rejection, difficulty at work, problems with sexual adjustment, depressive ideas and suicidal behaviour despite being satisfied with the surgical outcome. It should therefore be expected that some patients will continue to need psychiatric care after sex-re-assignment surgery.

Gender identity conflict can be an intolerable strain. In one study, 24% of transsexuals undergoing assessment, or on a waiting list for sex-reassignment surgery, had a history of attempted suicide. Another study found that 12% of transsexuals had had inpatient psychiatric treatment during their lifetimes. It is perhaps not surprising that suicide after surgery is a tragic, but recognised, outcome. Rates of up to 2% have been reported.

The Technical Success of Surgery

The technical success of surgery has an impact on the overall outcome of the change-of-sex treatment package - people who have had technically unsuccessful operations are less satisfied with their change of sex. On the other hand, a change in the physical appearance of a patient does not resolve the internal psychological confusion over gender identity - it may even intensify it. Sex-reassignment surgery cannot be expected to solve problems of personal instability and social adjustment.

The purpose of sex-reassignment surgery is to imitate the physical characteristics of the other sex. The degree of success depends on the closeness of the imitation both in appearance and function. No operation will be completely successful as full functioning is never achieved.

Based on a few small case series, it appears that male-to-female surgery achieves a greater technical success than female-to-male surgery. Males can expect a good physical resemblance and a vagina which allows sexual intercourse.

Studies of Outcome after Surgery

Research into the effects of the treatment on transsexuals - including sex-reassignment surgery - has been complicated by the following factors:

• An estimated 90% of all patients treated are unavailable for long-term follow-up.
• Different researchers have used different criteria for diagnosing transsexualism and for deciding which people are suitable for surgery.
• Studies which have followed people up for many years after surgery, are following up people who were diagnosed and treated at a time when out-dated criteria and surgical techniques were in use. Conclusions drawn from these studies are rarely applicable to today’s transsexuals and surgical techniques.
• Studies which evaluate transsexuals after surgery do not always describe the complete treatment package (psychiatric care, support from friends and relatives, hormone therapy, etc) which may vary between patients

The Gender Identity Clinic at the Charing Cross Hospital (Riverside Mental Health Trust) has recently appointed a new American consultant with a particular interest in researching the effects of treatment of transsexuals. The new consultant is taking advantage of the large number of transsexuals which attend the unit which enables statistically valid research to be undertaken. In this way useful up-to-date information on outcomes will become available which will guide future purchasing policies.

Review of Selected Published Studies

In a British study, 50 selected transsexuals were studied during assessment, 50 after acceptance for surgery, and a further 50 between 6 months and 2 years after surgery. Their psychological profile was assessed in sex dimensions: Somatic anxiety, Phobic anxiety, free-floating anxiety, depression, obsessionality, and hysteria. Transsexuals who had surgery scored significantly lower than those awaiting surgery and those undergoing assessment in all six dimensions. Those accepted for surgery had significantly lower scores than those undergoing assessment in somatic anxiety and depression. This indicates an improvement in the psychological state of transsexuals as they progress from initial assessment to surgery.

In a comprehensive review of reviews (1984), for between 10 and 15% of patients who undergo sex-reassignment surgery, the results "end up in failure" - and up to 7% having a "tragic" outcome (suicide, request for reversal, psychotic episode), but up to 90% of patients benefiting from the treatment. In general females fare better than males. In a 1987 Swedish study, notable for the prolonged duration of the follow-up, of 13 transsexuals between 6 and 25 years after surgery, 5 (38%) were felt to have regretted having had surgery.

Summary: Overall Benefit After Treatment

• There is little good, relevant and up-to-date research evidence on the effectiveness of the various components of the treatment process.
• The final outcome after treatment is dependant on the whole treatment process, not only sex-reassignment surgery.
• The overall benefit after treatment - including surgery - is "good" for most patients.
• Failures must be expected, including some suicides, but better patient selection should improve the outcome.
• Surgery is not the "cure" for transsexualism nor should it be seen as an end-point of treatment, as some will require continued support.
• Some transsexuals will require further surgery to correct or improve the technical results of initial surgery.

Factors Associated with a Good Outcome

In general sex-reassignment surgery is deemed appropriate for primary transsexuals, but not for secondary transsexuals. One study found that criminality, an unstable personality and a personality lacking in self-support was associated with a poor outcome. Further to this, a long-term follow-up study of 13 transsexuals found the following statistically significant prognostic factors:

For a good outcome:

• "Fair" mental health and a "fair" relationship with a partner.
• A history of an overprotective mother and distant father.
• A degree of hesitancy or caution as to the value of sex-reassignment surgery during the assessment - to be compared to a fixed belief that surgery, and only surgery, will help.
• High sexual activity with partner and/or a strong libido.
• Bisexual experience and biological heterosexual experience - indicating flexibility of sexual outlets.

For a poor outcome:

• Aged over 32 at first request for sex-reassignment or for starting cross-dressing.
• A history of having had "hard" jobs, for example, heavy industrial work or forestry.
• A history of early separation from parents in infancy.

Based on trial-and-error experiences over the past 20 years, other authors have suggested the following criteria:

Good Candidates: Life-long cross-gender identification. Inability to adopt or live in assigned biological gender role. Capacity to pass effortlessly and convincingly in society. Not considered to gain sexual arousal from cross-dressing. First heterosexual experience, if any, was in early adulthood rather than in adolescence. Some higher education. Demonstration of stability, holding the same job for years, long-term relationships, etc. Willingness to accept and actively participate in psychotherapy before and after surgery. Presence of adequate social and family support. Completion of a programme at a recognised gender identity clinic. Living and working for at least 2 years as a member of the opposite sex. At least one year of medically supervised hormone treatment. After a long-term relationship, the psychotherapist feels relatively comfortable in referring the patient for surgery. Absence of any characteristics of poor candidates.

Poor Candidates: Absence of characteristics of good candidates Active or recent thought disorder. Exclusively uses cross-dressing for sexual arousal. Recent major loss or emotional crisis. History of significant anti-social behaviour. Multiple suicide attempts, including self-mutilation of genitals. Substance misuse. Unrealistic expectations of surgery. By-passing normal channels of care, such as obtaining hormones illicitly, or obtaining surgery elsewhere. After a long-term relationship, the psychotherapist resists referral for surgery.

Service Provision

NHS

There are three NHS Gender Identity Clinics in the UK. The one at St James’ Hospital, Leeds, accepts only patients from the Yorkshire and Humberside area. The one at the Royal Victoria Infirmary, Newcastle, currently only has patients in the Northern Region and is unlikely to take on patients from outside this area because of the practical difficulties over travel.

The gender identity clinic at Charing Cross Hospital, under the care of Dr D.H. Montgomery (Consultant Psychiatrist), is the clinic where patients from Suffolk attend if they receive treatment paid for by Suffolk Health Authority. Psychiatric treatment and group psychotherapy sessions are undertaken at the clinic. Hormone therapy, if recommended, is prescribed by the patient’s GP in Suffolk. Surgical treatment (male-to-female) is mostly undertaken at the Charing Cross Hospital, although surgery to the vocal cords may be undertaken elsewhere. The rarer female-to-male surgery is most often undertaken by Mr J. Prior, a Consultant Andrologist at the Institute of Urology and St Peter’s Hospital Mastectomies (surgical removal of the breasts) are performed by another surgeon.

Private

There are a few private psychiatrists and plastic surgeons who will accept referrals, and possibly self-referrals for gender identity treatment. Some of these are perceived by NHS practitioners to be offering a sub-standard service. A particular concern is that hormone therapy may be started before adequate psychiatric assessment has been completed, and sometimes in error. There is a risk that surgery may also be undertaken in error. The often persuasive story of transsexuals and the difficulty of evaluating it has already been noted.

Sex-reassignment operations may also be purchased overseas. In the earliest days of sex-reassignment surgery, clinics in Morocco and Mexico were the only one’s performing surgery, and the results were known to be technically poor.

Current Purchasing by Suffolk Health Authority

There is no information on the number of people treated for gender identity problems prior to the introduction of the internal market in 1991. Costs will have been borne by the hospitals undertaking the management and surgery.

A recent review of extra-contractual referrals (ECRs) has shown that the authority has been approached for the funding of gender re-assignment care for 10 people. It is not always clear from the data which of these are male-to-female or female-to-male patients.

In the last two years, two people have received care purchased by the health authority at a total cost of £4,528. Three people are awaiting treatment which will be purchased by the authority at an expected total cost of £8,531. Agreed funding has not been taken up by two people. One person is now the responsibility of a general practitioner fundholder (GPFH), and a decision is pending on two people. Since the merger with Waveney district on 1st April 1994, information has been received about a further one person for whom the former Great Yarmouth & Waveney Health Authority was approached for funding.

GPFH can purchase psychiatric care, but as the cost of any subsequent surgery is excluded from the operations which GPFHs can purchase, the authority will be approached to fund these operations. No such approaches have been made yet. Unfortunately, no reliable data exist to inform the health authority about the current purchasing activities of GPFHs outside the county of Suffolk.

Purchasing Policies of Districts in East Anglia

Cambridge Health Authority

There is a written policy statement, developed recently and agreed between local psychiatrists and the health authority. Under this policy, referrals to the gender identity clinic at the Charing Cross Hospital, directly by GPs, are notified to the health authority. These patients are then examined locally by psychiatrists under existing contracts. If these psychiatrists feel that referral to the gender identity clinic is appropriate, then a tertiary referral is made. A review of the case is undertaken by local psychiatrists before surgery is undertaken. Any patients initially referred to local psychiatrists are handled in the same way.

Huntingdon

No contracts, the authority responds to ECRs which are reviewed on an individual basis. Currently there is a request for an ECR which the authority is considering.

Norwich

No particular policy, but a policy is being considered.

North-West Anglia

No particular policy. The authority has had no requests or referrals.

Great Yarmouth and Waveney

Policy reviewed in March 1994. A working party recommended that funding should continue for those patients currently undergoing treatment at a Gender Identity Clinic. Funding of future requests will not necessarily be agreed and will be limited to a financial ceiling (unspecified), and will be restricted to residents of 5 years standing. Where possible, psychiatric care and surgical procedures should be performed within the district, in consultation with the Gender Identity Clinic.

Purchasing Considerations

Priority Status

"The Health of the Nation" identifies five key areas which should receive priority attention. One of these areas is Mental Illness for which there are three primary targets:

1. To improve significantly the health and social functioning of mentally ill people.
2. To reduce the overall suicide rate by at least 15% by the year 2000.
3. To reduce the suicide rate of severely mentally ill people by at least 33% by the year 2000.

Most transsexuals would not be classified as being severely mentally ill, but some will have crises during which they are severely ill and require inpatient treatment. As a group transsexuals have a high rate of suicide. However, because transsexuals are

so uncommon, their suicides form a small proportion of all suicides. Proper attention to the psychiatric care of transsexuals will make a marginal contribution to the achievement of all three targets.

Economic Considerations

A full economic analysis would compare the costs of providing full treatment for transsexuals with the cost of not providing treatment. It would also compare the relative benefits - to the population of Suffolk - of providing treatment for transsexuals with other purchasing options. The data do not exist which would enable such an analysis.

The full cost of treating a transsexual from the initial psychiatric assessment at a specialist clinic through to the last episode of surgery, can cost up to ?50,000 - spread over a number of years. Clearly a robust purchasing policy needs to be developed to limit the unnecessary exposure of the health authority to such large costs, to ensure that only effective treatment is purchased, and to ensure than an unreasonable proportion of the authorities’ funds are not spent on a few individuals.

Purchasing Options

1) No specialist psychiatric care or sex-reassignment surgery

Under this option, no care at a specialist gender identity clinic would be purchased nor any sex-reassignment surgery. Transsexuals would receive psychiatric care in Suffolk under existing contracts. The complexity of evaluating the transsexual has already been noted, and limited local experience may make this option a difficult one to implement. Some transsexuals have purchased sex-reassignment surgery privately. However, it is possible that these transsexuals would not have wished to undergo surgery, or would not have been considered suitable for surgery if they had had specialist psychiatric care and counselling.

2) Specialist psychiatric care, but no sex-reassignment surgery

Under this option, the evaluation and psychiatric care of the transsexual is carried out at a gender identity clinic, but the authority would not purchase any recommended surgery. It is likely that about 85% of males and 10% of females would not require surgery after attending a gender identity clinic. However, the prior knowledge that the authority would not purchase surgery even if it was considered appropriate could jeopardise the period of psychiatric care and observation. Patients may plan means of paying for surgery early on in the assessment which may conflict with the objective assessment process. Patients may not see the point of attending psychiatric clinics and inappropriately seek surgery and hormone therapy elsewhere.

3) Conditional purchase of both specialist psychiatric care and sex-reassignment

The health authority would purchase psychiatric care at a gender identity clinic and sex-reassignment surgery and hormone therapy for those individuals considered suitable. This option is likely to provide the best care for the population of transsexuals in Suffolk. Purchasing conditions would limit health authority exposure to the significant costs involved and ensure that only appropriate care was purchased.

* This option is the recommended option.

4) Unconditional purchase of specialist psychiatric care and sex-reassignment surgery

This liberal purchasing policy could lead to a situation whereby the ECR budget was exceeded, and unsatisfactory ad hoc temporising decisions being made. In the absence of scrutiny, unnecessary referrals could be made. It is conceivable that individuals may wish to become residents of Suffolk in order to benefit from this purchasing policy.

Purchasing Conditions

• Transsexuals are seen at the Gender Identity Clinic based at the Charing Cross Hospital. This clinic has adopted the guidelines produced by the Harry Benjamin International Gender Dysphoria Association Inc.
• All referrals to this Gender Identity Clinic are made by a local consultant psychiatrist (under existing contracts) as a "tertiary referral". This would allow clearly unsuitable candidates to be screened out early on. GPs should be notified of this decision. It should be possible to come to an agreement with the Gender Identity Clinic such that direct referrals to the clinic are identified, and the GP asked to re-refer to a local consultant psychiatrist.
• In order to limit the possibility that people may have moved into Suffolk in order to take advantage of the health authority’s purchasing policy, a residency condition may be applied.
• The patient should undergo a period of assessment, psychiatric care and counselling as recommended by the Gender Identity Clinic. If felt appropriate, this may involve some therapy undertaken locally under existing contracts.
• Hormone therapy should be prescribed only on the recommendation of the Gender Identity Clinic.
• If sex-reassignment surgery is recommended by the Gender Identity Clinic, the Director of Public Health should be sent - early on - a full clinical progress report. This will assist in the evaluation of the ECR request and the scheduling of surgery within the limits of the ECR budget.
• Each recommended episode of surgery should generate a new ECR request. Each ECR request will be considered in the usual manner taking into consideration the current financial status of the ECR budget. The surgery would normally be expected to be undertaken by units experienced in the specialised nature of sex-reassignment surgery. However, if felt appropriate, certain operations may be performed locally under existing contracts.
• Patients currently undergoing assessment, receiving psychiatric care or hormone treatment at the Gender Identity Clinic funded by the health authority, should continue to have their treatment funded by the health authority.
• Patients part-way through sex-reassignment surgery funded by the health authority, should continue to have their surgery funded by the health authority, subject to each episode of surgery generating a fresh ECR request which will be considered in the usual manner taking into consideration the current financial status of the ECR budget.
• Patients with unusual circumstances will have their case reviewed by the Director of Public Health who may wish to take into consideration an assessment by the Gender Identity Clinic.