kaberett: Overlaid Mars & Venus symbols, with Swiss Army knife tools at other positions around the central circle. (swiss army gender)
[personal profile] kaberett
[Twitter hashtag. Zoe's round-up of the lowlights. Sarah's article in the Guardian.]

I'm not reading #TransDocFail because it hurts too much. I am talking about this today because of Julie Burchill; [personal profile] sebastienne has written a fantastic letter and made it easy for you to go to the Press Complaints Commission. I can't stomach doing that, today, but please do consider it.

Here's the background: I'm genderqueer, and I have stage IV endometriosis. The latter means I've got a consultant gynaecologist as part of my medical team. (I am light-headed, hyperventilating and full of adrenaline already at this point in the post. This should give you some indication as to why I'm not reading in more depth.) The first medical professional I ever came out to about my gender was my consultant gynae, way back in, oh, March or April 2010. His reaction was beautiful and perfect: "Oh, so you won't mind if I neuter you, then," he said, grinning - and proceeded to offer me androgens as an option once we'd run through some of the more standard treatments with a lower risk of destroying my liver.

The process for getting a referral to a Gender Identity Clinic (GIC) in the UK is byzantine at best. First you need to go and see your GP, who needs to refer you to your Community Mental Health Team or equivalent for assessment of your overall mental health; from there, you might theoretically - eventually - be referred to a GIC. If your Primary Care Trust (PCT) is willing to provide funding without a fight - which Cambridgeshire PCT is famously bad at doing.

Back in 2010, I felt like taking on the kyriarchy. Back in 2010, I had a consultant who was willing to sort out hysterectomy and androgens for me. I thought it was important for me, in my position of relative privilege, to try getting through the system as a genderqueer person without lying, without claiming to be male, and so on: because if GICs are willing to treat genderqueer people, PCTs should damn well be willing to fund them.

So off I went to my GP, and this, I am afraid, is where it starts to get bad.

[Content notes: nearly three year of sexism, medical paternalism, and suicide.]

I made an appointment with one of the partners at my GP surgery late in 2010: I'd had a very good working relationship with her on the topic of my endometriosis, and I trusted her to be as well-informed - or at least as reasonable - on the subject of trans* healthcare as she had been regarding my experiences self-medicating for the endo.

This was a mistake.

I went in and I sat down, and I told her I thought I was trans*.

After a little to-and-fro, she started pushing anti-depressants.

I explained that I didn't feel they'd be likely to help much with my intense dysphoria about my chest.

She responded that she appreciated that in the information age, self-diagnosis by patients was becoming more usual, but she really didn't think I ought to be rocking up with a treatment plan worked out. (I emphasise that I mentioned dysphoria about my chest only because she wouldn't take "I don't think anti-depressants will fix this".)

Eventually it came down to her saying that she didn't think the PCT looked favourably on funding this type of referral. I responded that I believed she was legally obliged to refer me. And so, extremely grudgingly, she did.

I later discovered that said GP was on the panel that makes funding decisions for the region.

On the 3rd of February 2011, I had an appointment with Dr Fiona Blake, a psychiatrist with the Community Mental Health Team (CMHT). I was nervous, but I went along solo.

I raised eyebrows at some of the things she said, but thought it had fundamentally gone okay. But then - but then. Her follow-up letter was sent to [newinitial] [oldsurname], a name I have never used. Furthermore, it was sent to my parents' address... where my uncle [newinitial] [oldsurname] legitimately gets post. I was at no stage asked how best to address mail.

At this point, I'm going to switch the narrative to the series of letters I've exchanged with the Patient Advice and Liaison Service (PALS). But before I do, please bear in mind while reading this relevant snippets:
  • our consultation opened with FB saying "I don't have any specialist training in this area, but I do have an interest, because my brother - well, sister now, I suppose..."
  • early in the appointment, I stated that my preferred pronouns are they/them/their. I stated this repeatedly throughout the appointment.
  • at one point, FB asked my sexuality. I stated that I did not feel it was relevant to my gender identity. FB insisted that she wanted to know it; I (probably) stated it as "queer, pansexual or bisexual"; "bisexual" was definitely mentioned.
  • on the day of the appointment, I wore: a binder; a close-fitting t-shirt; a plaid shirt as a jacket; corduroy trousers, bought new from the men's section of a clothing store; a pair of boots.

This was the letter I received from Fiona Blake, received by my GP on the 15th of February 2011 (my own copy took much, MUCH longer to get to me due to the screw-up with addressing):
Dear Dr Stephens

Re: E (A) [oldsurname]

Pathway: I&T
Care coordinator:
Fiona Blake
Risk: Low

Diagnosis: "Non-binary gender" status, endometriosis, progesterone intolerance, Migraines with aura, asthma, Renaud's syndrome, possible autistic spectrum traits.
Medication: Inhalers, pain killers as required

Thank you for referring this person for assessment. [Oldname] is about to be renamed Alex and wishes to be referred to with gender neutral pronouns so I will do so in this letter (though there is considerable difficulty avoiding the use of "it" - I did not succeed throughout).

Alex does not feel identified with either gender. Alex has come for assessment of gender dysphoria for access to further treatment at Charing Cross Hospital.

Alex had a well-rehearsed story with nomenclature that is apparently provided by the Transsexual, Gay, Lesbian community. Alex states that they identified with boys in praimary school and felt uncomfortable with the physical changes associated with puberty especially growing breasts.

Alex does not like female-coded dress (especially dresses) and binds her breasts. Alex does not want testosterone-related secondary characteristics (especially facial and body hair) as this would lead to "being read" as male. More male distribution of muscle and body fat would be welcome.

[redacted for privacy of others; the key point is discussion of the fact that I'm not bothered by sex involving my cunt.]

From the first month of periods Alex has suffered both dysmenorrhea and premenstrual mood swings. Since then endometriosis has been diagnosed but treatments other than induction of a medical menopause have been ineffective or problematic. Progesterone is associated with low mood, panic attacks and suicidal thoughts and impulses to self harm (usually only a problem in the day or two before the period) and oestrogen is contra indicated because of a tendency to migraine with aura.

Alex has declined antidepressants because Alex is not depressed the rest of the time.

Alex was born and brought up in Cambridge and has a hostile relationship with her father who is a computer scientist and described as a "text-book emotional abuser". Mother is an editor and "very Roman Catholic".

Alex believes that [stuff about my parents' relationship]. [Father] hit the children and punished them if they did not do as he wished. This came to a head when he found out that [details redacted for privacy of others]. Alex did well academically but life has been blighted by menstrual and domestic problems and Alex was socially isolated at home. Alex got to Cambridge and is reading natural sciences and is in the third year.

Past Psychiatric History
Family counselling Age 16 "Father was not open to anyone else's feelings".
March 2010 College counselling associated with guilt that mother was still unaware of the partner and gender isues.
Autumn 2010 5 sessions further counselling with the University Counselling Service.
Family history-father has had depression.

Drugs/Alcohol/Smoking No drug use. Minimal alcohol. Non-smoker.

Past medical history
Asthma from a child
Raynaud's syndrome
Endometriosis-diagnosed 2009
Migraine with aura in early teens

Mental state examination
Appearance and behaviour- dressed in gender neutral clothing but did not look unusual, made good eye contact and appeared intelligent and articulate and clear about goals. Spoke forcefully and with confidence. Affect - euthymic. No anxiety.
Feels vindicated by others about gender modifying ambitions and the integrity of this sexual relationship. Does not consider that her choice has been influenced by [details redacted for privacy of others].

This is a 21 year old person born a woman but wishing to have breasts removed and have advice about hormone regimes that will reinforce a belief that the correct gender for this person is neuter. I agree that there are strong family dynamics where both female and male role models are unsatisfactory. This belief is not delusional but culturally upheld by the TGL community and [details redact for privacy of others]. Alex is not dysphoric.

Oddly, at the end, Alex said that in consulting the disability resource service about support regarding her asthma and PMS, the officer suggested that Alex may have autistic spectrum disorder. Alex then mentioned various characteristics that suppor this view - Alex says she is "face blind", a perfectionist, rocks when distressed, and is bothered by large groups. I am not convinced by this and am not sure that it is relevant to the gender issue except that it may provide a reason for social discomfort not otherwise explainable and which allows access to a community where all acknowledge their "otherness".

I do not think that she has a mental disorder that would preclude gender reassignment in the form of mastectomies. I note the lack of insight into the potential influence of [a third party] on her choice, her very young age, lack of dysphoria and high functioning. These are factors with may influence the decision about whether this is an appropriate case to fund through the NHS.

Yours sincerely
Dr Fiona Blake FRCPsych
Consultant Psychiatrist

Here are the notes from my first meeting with PALS:

Meeting held 13 April 2011 at [location].
Elizabeth Hartley
Marie McKearney

Alex felt that FB (Fiona Blake) used inappropriate terminology when referring to her own family member early on in their initial consultation. This resulted in Alex feeling that FB was not aware of the preferred terminology used within the LGBT community. Alex said that as the transgender community is not large, through Google it may well be possible to identify the person FB referred to.

Alex asked to be referred to as “Alex” which they felt was ignored by FB.

Alex asked to be referred to as “they” and feels that FB disregarded this request of pronoun preference.

Alex said that FB referred to TGL (trans, gay and lesbian) group, instead of the LBGT (lesbian, bisexual, gay and transgender), which is the proper use of the acronym.

Alex felt “dismissed” as they know more about the subject of Transgender than FB does. Alex felt this was difficult as they would like to see a specialist.

Alex feels the term “female assigned at birth”, rather than “born female”, to be the correct one and this was not used in FB’s letter.

Alex is unhappy with FB’s reference to “the lack of insight into the personal influence of the partner on her choice”. Alex feels that FB should have asked about this and would have been happy to explain why they do not feel the partner is having an influential effect.

Alex feels that the fact they may be on the autistic spectrum should not be seen as irrelevant. Alex feels that transgender people are often diagnosed as being somewhere on the autistic spectrum because of possible social difficulties. [The eventual "neat" version of the complaint included my notes with citations of papers linking autism spectrum conditions and trans* status.]

FB addressed her letter with Alex’s new initial but old sir name to Alex’s parents address. Although Alex acknowledged that this address is the one on the system, it is the same name as an uncle of Alex’s who also has post sent there. This resulted in the letter being opened by the uncle and reading Alex’s private medical information.

MM suggested that the main issue appears to be Alex feeling they are not being listened to, which Alex agreed with.

MM talked through the options of local resolution by PALS, or the formal complaints route. Alex said they would like to go through the formal complaints route and has shown FB’s letter to others for comment, who also agree there are grounds for a formal complaint to be made.

Alex said that the preferred outcome of the investigation would be that the whole spectrum of both sexuality and gender be acknowledged. Alex would like initial transgender referrals in Cambridge to be given to someone who is and expert in the area. Alex would like a second opinion from a specialist.

It was agreed that EH would type up the meeting notes by the end of the week and email them to Alex to check and highlight any information they feel are incorrect or inaccurate. Once Alex is happy with the meeting notes the official complaint investigation will begin.

Alex wanted to note that she would be in America for the summer and would be leaving middle of June 2011.

Meeting closed.

This was the "final response" to my complaint, sent out on the 7th of June 2011:
Dear Alex,

Re: Your complaint regarding the service provided by Cambridgeshire & Peterborough Foundation Trust.

I am writing in response to your formal complaint registered with the Trust on 2 May 2011.

I am very sorry that you have had cause to make a complaint. I would like to thank you for bringing this matter to my attention in order that we can learn from your experiences, and make any necessary changes to ensure that a similar situations be avoided in the future.

Christine Robertson, Investigation Manager and manager for North East Cambridge Intake and Treatment team, has investigated the concerns expressed in your formal complaint thoroughly. I enclose our answers to the matters you have raised, which I hope you will feel has dealt with the issues fully and fairly. In the process of investigating your complaint Christine has reviewed your healthcare records and has interviewed the following members of staff: Dr Fiona Blake, Consultant Psychiatrist, and Claire Warner, Commissioning Service Improvement Manager for mental health, Cambridgeshire NHS.

I would like to thank you and your friend Harry for taking the time to meet with Marie McKearney and Elizabeth Hartley from the PALS and Complaints department on 13 April 2011. This meeting provided a very useful opportunity to fully understand your concerns and to explore with you ways that the Trust might resolve them.

In your email of 24 March and during your meeting with Marie McKearney and Elizabeth Hartley, you explained that there were a number of areas that were of concern to you. Please find below the response to each of the points raised in your complaint:-

1. You would like a second opinion from a specialist

I feel it is helpful to clarify that in the case of Gender Dysphoria, the East of England Strategic Health Authority policy advises general practitioners may wish to refer to a General Consultant Psychiatrist to assist in deciding whether there are any co-existing conditions, or whether any mental health factors need to be determined.

Your GP, Dr Linehan, followed this process and made a referral to the Intake and Treatment team in relation to Gender Dysphoria and in response to your request for referral to Charing Cross. To clarify this was not a referral to a specialist service as you described, and during your consultation it became apparent that your presentation and experience is not typical of Gender Dysphoria.

Christine Robertson has since communicated with the local Commissioning Service Improvement Manager, who was able to clarify that current Gender Dysphoria policies do not accommodate this non-binary gender issue, but will be discussed at a forthcoming meeting with both commissioners and specialist service providers. It is hoped this will give clarity for individuals with circumstances such as yours.

2. You were concerned that Dr Blake referred to TGL (Trans, Gay and Lesbian) Group instead of LBGT (Lesbian, Bisexual, Gay and Transgender), thus excluding bisexual identities.

I accept that by using TGL rather than the full LBGT term this excludes those with bisexual identities. I apologise that the former term was incorrectly used and for the offence it caused you.

3. You felt ‘dismissed’ and felt that Dr Blake regarded your being well informed as a bad thing. You felt Dr Blake was ill informed or perhaps un-accepting of trans identities.

I am very sorry if you felt dismissed. Dr Blake stated that at no point did she feel you being well informed was a bad thing. In a psychiatric assessment it is important that individuals are encouraged to describe their experiences and associated emotions in detail. It was not an indication of disbelieving your statements, just a desire to understand them in more detail. I am sorry that you felt that Dr Blake was insufficiently informed. As I previously clarified, her non specialist role does not require her to have extensive levels of expertise in trans identities but to have expert skills in psychiatric conditions.

4. You felt the term ‘female assigned at birth’, rather than ‘born female’ would be more correct.

I appreciate you are expressing your preference for language and I am sorry if the use of the phrase ‘born female’ was in your view incorrect in any way. It is necessary that your biological sex at birth was clearly stated for those considering your ongoing needs.

5. [redacted for privacy of others]

6. You felt that during your consultation with Dr Fiona Blake, Consultant Psychiatrist, inappropriate terminology was used.

I apologise that the terminology used was offensive to you, that was certainly not the intention. Dr Blake acknowledged that she was clumsy in her communications and is very sorry for the distress this clearly caused you.

7. You felt that the disclosure of Dr Blake’s family members experience may be a breech of their confidentiality.

I appreciate your concern that Dr Blake may have breeched her relatives confidentially, and this was discussed with her. Dr Blake explained this was done in order to try and indicate some empathy for people with gender identity issues, and in the knowledge that the family member is not readily traceable. I am sorry this caused concern and Dr Blake appreciates that this was not helpful.

8. You requested to be referred to as ‘Alex’ or ‘they’, which you felt was ignored.

Christine Robertson reviewed the letter you were copied in on
5 February 2011, and noted that despite Dr Blake reiterating your request for gender neutral pronouns, she did proceed to refer to you in female i.e. her. I am very sorry that despite your specific request this was not adhered to throughout the correspondence.

9. You felt your possible characteristics of autistic spectrum disorder should not be regarded as irrelevant. You indicated that transgender people are often diagnosed as being somewhere on the autistic spectrum.

Dr Blake did include that this diagnosis was suggested to you by a lay person, though it has not been formally diagnosed. In her letter Dr Blake indicated the characteristics you spoke of but did not necessarily agree or confirm with the diagnosis. Dr Blake did indicate that this could be an alternative reason for the social discomfort you described, but did not feel it should be a barrier to or indicator of your gender identity issue.

10. The copied correspondence was addressed to ‘A. [oldsurname]’ at your family home address, resulting in an uncle opening the letter. You felt Dr Blake should have clarified this issue.

I am very sorry that this regrettable mix up occurred. It is unfortunate that having acknowledged your preference to be referred to as Alex, this initial was used with your surname at the time, which led to the unfortunate and distressing breech of your confidentiality. Having studied your notes there was no record nor recollection of an alternative address being provided. You have since confirmed your change of surname to Brett and provided an alternative address. We have changed our records accordingly.

11. You gained the impression the Dr Blake held prejudice against bisexual and transgender individuals, leading to Dr Blake giving an incorrect diagnosis.

I am sorry if you have gained this impression, during the investigation the Trust could find no evidence to suggest this is the case. The diagnosis given in the letter is ‘Non binary gender,’ and is the terminology you used in your consultation. This was not a formal diagnosis by Dr Blake as a general psychiatrist, but an indication for further consideration by a specialist service, thus why it remained in quotation marks.

12. You felt that reference to your ‘young age’ was a reason you may be mistaken about your gender identity, and indicated a lack of awareness regarding developing treatment for the condition in puberty.

Dr Blake is aware of Gender Identity Disorder both in children and young adulthood. Dr Blake was not proposing you had not considered this carefully or been ‘mistaken’ as you have clearly researched the subject, and referred to your age as part of the context of your situation. I am sorry if you felt this was inappropriate.

13. You felt Dr Blake was unaware of non-binary-gendered trans people, and were concerned by the phrase ‘lack of dysphoria’, used in the copied correspondence.

Dr Blake has not had experience of non-binary-gendered trans people in the past and whilst not unique, it is uncommon and was not the presentation she had anticipated given the referral from your GP. Dr Blake felt it was important to be open about the limit of her knowledge. The phrase ‘lack of dysphoria,’ when using the word ‘dysphoria’ to describe disquiet, restlessness or malaise, was felt by Dr Blake in her professional opinion to differ from your presentation as an individual who was very clear about their needs.

14. You indicated your wish for the whole spectrum of both sexuality and gender to be acknowledged, and would like referrals in Cambridge to be given to someone who is expert in the area.

As previously indicated NHS Cambridgeshire do not commission local specialist services, and both GP and General Psychiatrist are asked to make careful consideration before progressing individuals for assessment at the London based service.

15. You were unclear if Dr Blake was applying Harry Benjamin Standards of Care.

Dr Blake is aware of the Harry Benjamin standards of care, much of which are focused around the delivery of specialist psychological, medical, and physical interventions.

Thank you for raising your concerns and complaints with us and for your willingness to work with the Trust to improve the services we provide, and I can assure you that we will learn from this experience.

I would like to express my regret that you have found it necessary to make a complaint. I do hope that meeting with Marie and Elizabeth, and my subsequent response has provided you with some reassurance that we have taken your feedback seriously. If this is not the case and you feel there are further questions you would like answered, please do not hesitate to contact the Complaint Department on 0800 376 0775, who will discuss further options for resolution with you.

Yours sincerely

Chief Executive

c.c. Christine Robertson, Investigation Manager
Annette Newton, Director of Operations
Neil Winstone, General Manager
Irfann Arif, Equality and Diversity Officer

This is the response I sent them on the 17th of April, 2012:
Dear Mrs Raine,

Re: Your letter dated 7th June 2011

Thank you for your detailed response. I apologise for the delay in my reply; the apparent unavailability of NHS care for my dysphoria combined with the death of two friends in close succession and followed by pneumonia triggered a serious depressive episode. I do appreciate the thorough and unreserved apologies you made in response to points 2, 6 and 8.

Nonetheless I would at this stage like to question some of the points you raise.

1. East of England SCG Policy for the commissioning and treatment of people with gender dysphoria

You state that my “presentation and experience is not typical of Gender Dysphoria.” Among trans* communities it is commonly held that when seeking treatment one must stick very closely to a “standard narrative” or risk failing to receive care, as has occurred in my case. The WLMHT GIC website addresses this issue in its FAQ: “Do I have to dress/act a certain way? No. Everyone is different. Dress and act as you feel most comfortable. This is a safe space and anything that people generally wear in public is fine.” Their recognition of the diversity of gender experience does not seem to be reflected in the way my case has been managed. Additionally, please see section 15, with particular respect to the WPATH guidelines regarding “cultural competence” and “current community … issues”. The WLMHT does appear to regard my gender identity and presentation as consistent with a standard diagnosis of gender dysphoria; it is not clear to me why a non-specialist has been trusted to make a judgment in this matter given the commissioning policy (see bulletpoints below).

You further state that “the local Commissioning Service Improvement Manager […] was able to clarify that current Gender Dysphoria policies do not accommodate this non-binary gender issue, but will be discussed at a forthcoming meeting with both commissioners and specialist service providers.” I have now read the East of England Specialised Commissioning Group Policy for the commissioning and treatment of people with gender dysphoria1 (as of August 2010: I was not able to locate the January 2011 revisions) and am not clear on how this decision was reached. I would appreciate knowing the results of the discussion in the meeting you mention. In any case my specific concerns are:
  • In §5.7, the commissioning policy states that “[t]here are two groups of individuals with Gender Dysphoria:- Trans women and Trans men.” This is not in line with the beliefs of the WLMHT, the standard GIC for referrals made within Cambridgeshire: the WLMHT recognises and supports transition to non-binary genders.
  • In §5.9, the policy states “[i]n line with this commissioning policy, local PCTs are encouraged to source professional advice from a local Consultant Psychiatrist who has training and is experienced in Gender Dysphoria. This may be supplemented, possibly, by the opinion of a Consultant specialist within mental health or from another clinical discipline”, in addition to §5.11 “It is expected that Consultants engaged as local specialists will hold suitable post graduate specialist training in Gender Dysphoria as well as being registered with their respective accreditation bodies e.g. the GMC and the Royal College of Psychiatrists.” Dr Blake expressed to me during my appointment that she had no training in “gender issues”, and therefore according to this policy she is not a suitable candidate for the role she was carrying out.
  • In section §5.25, you state “[...] Where a Consultant Specialist has not been sourced by the PCT the GP will have to consider whether it is appropriate make a referral direct to the GIC.” As described elsewhere in this document, I do not believe Dr Blake meets the criteria of a “Consultant Specialist”. An initial attempt to refer me directly to the WLMHT GIC did not contain this information and as such I was redirected for assessment by Dr Blake. This is not a satisfactory state of affairs.
  • In section §5.27 the policy states, “[i]f necessary, the local Consultant Psychiatrist may make a referral to the GIC to provide or confirm a diagnosis of Gender Dysphoria.” As described here and in section 15, I do not believe Dr Blake to be a Consultant Specialist capable of making a diagnosis, and as such a referral to the GIC was surely indicated in order to, as your policy states, “provide or confirm a diagnosis”.

4. 'Female assigned at birth' versus 'born female'
I appreciate the necessity for a clear statement of the sex I was assigned at birth. I dispute that “biological sex” is a useful term: as I am sure you are aware there are a wide variety of biological sex markers, including but not limited to chromosomes, gonads, primary and secondary sex characteristics, and endocrine system. I note that the Department of Health publication “Trans: A practical guide for the NHS”2 uses exclusively the “assigned at birth” terminology I suggested was preferable, as does the GIRES report “Gender Variance in the UK”3 and the internationally-recognised WPATH/Harry Benjamin Standards of Care.4

7. Dr Blake's sister
My concern was not simply that Dr Blake's sister's confidentiality was breached – it was the terminology Dr Blake used in referring to her. Using the phrase “brother – well, sister now, I suppose” does not indicate any empathy for trans* people: on the contrary, it implies that Dr Blake does not consider her sister's gender valid. Most people with an awareness of trans* issues, if they misgender someone so blatantly, fall over themselves apologising, rather than adding the appropriate gender descriptors apparently as an afterthought. Dr Blake's apparent inability to respect binary trans* people's gender identity did not make me feel that I had much hope of having non-binary identities understood or respected.

10. The address to which my correspondence was sent
I appreciate your apology in this matter. I strongly suggest that relevant care providers are in future advised to explicitly check the preferred form of address with the patient.

11. Dr Blake's prejudice towards bisexual and trans* people
I acknowledge your statement that you “find no evidence to suggest [Dr Blake holds these prejudices]”. I do not, however, accept it: someone who refers to a trans* individual using their sex assigned at birth (see section 7); who deliberately chooses to leave “bisexual” out of the acronym LGBT, despite having insisted I disclose my sexuality (queer/pansexual/bisexual); who claims that “it” is the only gender-neutral pronoun, despite my explicit request at the beginning of the consultation that I be referred to as “they” (and in the process ignores the existence of the Spivak and ze/hir sets, which a consultant dealing with trans* people ought to be aware of); and who uses the phraseology “born male” and “born female” (see section 4) is at the very least behaving disrespectfully towards people's stated identifications, in a fashion that runs directly contrary to equality law. Ignorance is not an excuse – and if Dr Blake claims ignorance of these issues, then I argue that she is not fit to practise in this area (see section 15 regarding “cultural competence”, and note that she was apparently incapable of paying attention to important information obtained during my assessment).

12. Dr Blake's reference to my 'young age'
I did indeed feel that Dr Blake emphasising my 'young age' was intended to imply that I am easily influenced and 'might change my mind'. I do not accept that referring to me in those terms, as opposed to stating my age in years, was simply to give 'context' – the phrasing that she used is infantilising and does call my judgment into question, especially given the phrase's proximity to “lack of insight”. This level of language analysis is taught in secondary-level courses. I hold a GCSE in English Literature; I assume that Dr Blake holds an equivalent qualification.

13. Use of 'dysphoria'
Within the WPATH standards of care, “gender dysphoria” is defined as “discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics).5 I do indeed feel discomfort and distress caused by such a discrepancy, and by my secondary sex characteristics. The fact that I am able to articulate this clearly and calmly to a gatekeeping medical professional is not an indication that I feel no distress: rather, it's an indication that I have done my preparation, and that as someone with numerous chronic conditions (including severe endometriosis, for which the average diagnostic delay worldwide is 8 years6, rising to over a decade where onset of symptoms occurs as a teenager) I have become extremely capable of self-advocating in situations where the medical profession is reluctant to provide appropriate care. I strongly dispute the assertion that 'clarity about my needs' is identical to a lack of 'disquiet, restlessness or malaise', especially given my clearly-expressed discomfort with aspects of my body.

14. 'NHS Cambridgeshire do not commission local specialist services'
Please refer to the second bulletpoint in my response to section 1, with particular reference to the East of England SCG policy §5.11, and my detailed explanation in section 15 regarding the fact that Dr Blake did/does not meet the WPATH's minimum requirements for competency to carry out a suitable assessment. Should the local authority wish to argue that Dr Blake was not acting as a specialist, I again direct you to section 15 of this letter, and in particular the extracts from the WPATH standards of care. I find it highly concerning that local services have blocked my care pathway, especially as relevant experts have expressed a willingness and desire to treat me (personal communication with staff at the WLMHT).

Given Cambridgeshire PCT's history of an actively unhelpful approach to commissioning,7 and Dr Linehan's initial statement to me that Cambridgeshire PCT “doesn't tend to like funding this kind of thing” (she only made the referral when I stated my belief that she was legally obliged to do so), the picture painted of the PCT's attitude to providing appropriate care for trans* people is deeply concerning.

15. Harry Benjamin Standards of Care
The fact that Dr Blake is aware of the HBSoC does not mean that she is applying them – which was my originally stated concern. In particular:

  • the WPATH standards of care list, as minimum requirements for “competency of mental health professionals working with adults who present with gender dysphoria”:8
    • Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria.
    • Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.
    • In addition to the minimum credentials above, it is recommended that mental health professionals develop and maintain cultural competence to facilitate their work with transsexual, transgender, and gender nonconforming clients. This may involve, for example, becoming knowledgeable about current community, advocacy, and public policy issues relevant to these clients and their families.

  • In reference to the role of mental health professionals carrying out assessment and referral, the WPATH guidelines say: “The role of mental health professionals includes making reasonably sure that the gender dysphoria is not secondary to, or better accounted for by, other diagnoses. Mental health professionals with the competencies described above (hereafter called “a qualified mental health professional”) are best prepared to conduct this assessment of gender dysphoria.9

By her own admission, Dr Blake is not “knowledgeable about gender nonconforming identities and expressions”, nor had she (at the time of my assessment) accessed “continuing education”: in my appointment, she explained to me that she had no specialist training in “gender issues”. She therefore does not meet the minimum requirements for competence laid out by the WPATH, and displays absolutely no concern or modesty about the impact of this fact on her ability to make suitable clinical assessments.

Furthermore, the WPATH states that “[i]f mental health professionals are uncomfortable with, or inexperienced in, working with transsexual, transgender, and gender nonconforming individuals and their families, they should refer clients to a competent provider or, at minimum, consult with an expert peer. If no local practitioners are available, consultation may be done via telehealth methods, assuming local requirements for distance consultation are met.10 Dr Blake, someone unfamiliar with “current community issues... relevant to clients”, and who has clearly not “maintain[ed] cultural competency” - otherwise she would have been familiar with, for example, the Charing Cross GIC's recognition of and respect for non-binary identities11 - should, if she were complying with the WPATH standards of care, have consulted someone more senior. She did not.

I therefore feel that my concerns regarding her compliance with the WPATH/Harry Benjamin standards of care have not been adequately addressed.

At this point, my chief concerns are that
(a) Dr Blake is no longer the psychologist used to assess patients presenting with gender dysphoria, which I understand may already have been achieved via her moving to another post;
(b) provision of treatment for trans* people by Cambridgeshire PCT is made significantly more accessible and transparent; and
(c) having undergone social transition I am given some practical means of progressing along the care pathway. “We will make necessary changes to ensure that similar situations be avoided in the future” is unfortunately of limited use to me and my mental and physical health going forward.

Yours sincerely,

Since sending them that last letter, I heard nothing for many months until I e-mailed to enquire about follow-up. I've since been assured, several times, by an actually-lovely receptionist, that a response is "being finalised" and will "go in the post any day now"; so far, I've seen neither hide nor hair of it.

Given the above, I'm not actually expecting it to improve matters, either.

And that, ladies and gentlemen and everyone else, is why I haven't been reading about Julie Burchill, and why I haven't been keeping up to date with #TransDocFail, because my ongoing personal experiences in this area are too much of a disaster for me to face reading more about mistreatment of other trans* people.

(no subject)

Date: 2013-01-13 06:28 pm (UTC)
tim: Tim with short hair, smiling, wearing a black jacket over a white T-shirt (Default)
From: [personal profile] tim
Do you want this to be linked to? (Ordinarily I'd just link to public posts, but since this is so personal I thought I'd ask first.)

(no subject)

Date: 2013-01-13 06:37 pm (UTC)
tim: Tim with short hair, smiling, wearing a black jacket over a white T-shirt (Default)
From: [personal profile] tim
I gave it a second read-through and didn't see anything (obvs. I don't know your former names and don't want to, but I didn't see anything other than "Alex" used for you).

And yeah, this is awful :-( Among other things after reading a blog comment yesterday (in response to a blog post from a fellow American about how to help suicidal friends) saying smugly "well I suppose it would be different in a country where anyone who needed it could get counseling/therapy"). I asked if there are any countries where that care is open to everyone regardless of gender, trans or cis-ness, neurotypicality or lack thereof, and so on, and got no response. Sorry you had to go through this shit, nobody deserves to be treated this way.

(no subject)

Date: 2013-01-13 07:08 pm (UTC)
such_heights: amy and rory looking at a pile of post (stock: books)
From: [personal profile] such_heights
Argh. There's nothing helpful I can say in response to this, but thank you so much for sharing it. It's fucking terrible, and I'm sorry, and I heart you. *squish*

(no subject)

Date: 2013-01-13 10:56 pm (UTC)
sebastienne: (notebook)
From: [personal profile] sebastienne
This comment made me smile.

I'm sorry about the rest of it. <3

(no subject)

Date: 2013-01-13 09:34 pm (UTC)
littlebutfierce: (atla iroh bullshit)
From: [personal profile] littlebutfierce
Ugh. :/ I'm so sorry. ♥ ♥

(no subject)

Date: 2013-01-13 11:07 pm (UTC)
ludy: a painting i did looking in a mirror (Default)
From: [personal profile] ludy
i'm sorry you've had to go through all this

(no subject)

Date: 2013-01-14 02:27 am (UTC)
inoru_no_hoshi: The most ridiculous chandelier ever: shaped like a penis. Text: Sparklepeen. (Default)
From: [personal profile] inoru_no_hoshi
That is amazing crappy care, and I'm so sorry. <333 *hugs*

I hope it gets better, slowly but surely! <333333

(no subject)

Date: 2013-01-14 03:46 am (UTC)
stormerider: (Default)
From: [personal profile] stormerider
Ugh... *smashes head against a wall* I'm so sorry that you're having to deal with all of that. *offers hugs if desired*

I'm still coming to terms with being GQ as opposed to being an "unconventional man" and I've got a lot to sort out, especially with my health limitations. I would like to slide towards androgyny, but I'm really not sure if there's enough that I can do with my body that will allow me to be "read" as androgynous. Specifically, I have facial hair, and I haven't not had facial hair since something like 1996. I'm not sure that shaving it wouldn't make my body dysphoria worse (even if it made my gender dysphoria better? since I... don't recognize myself in the mirror. I have to specifically remind myself that it's a mirror, what I see is what is in front of it, I'm in front of it, ergo what I see is my own body. There's just... no sense of personal recognition there).

And even if that worked out ok, my health makes general hygiene somewhat problematic in the first place, and scent sensitivity is a big problem for dealing with shaving cream. (The last time I was around our ex-housemate when he was using shaving cream, it gave me a migraine from hell. He had to switch to using shampoo, but I can't personally use the shampoo that the others use, because it will give me a migraine. I use a honey beer shampoo bar that has a very neutral scent to it, because it's the only thing that doesn't cause me massive problems.) So not only am I faced with needing to shave regularly, but risk a migraine every day just to do so, and... ugh, I just can't deal with the thought of facing that.

I do want to work on acquiring some different clothes that fit my personality better, like poet shirts and such, possibly with lace, possibly with cravats. But that's not necessarily going to be "read" as androgynous, either; I might just be read as a fop instead.

And while I do have long hair, I'm also balding significantly, which bothers the hell out of me, and "reads" as male (not that women don't have to deal with balding, but it's a lot less common and most people read "balding" as "male"). I may end up playing around with some wigs; I don't know. Something else to investigate.

(no subject)

Date: 2013-01-14 09:48 am (UTC)
naath: (Default)
From: [personal profile] naath
Cripes, that's beyond shit.

I was aware things were bad, but not how bad :( :(

(no subject)

Date: 2013-04-26 08:27 pm (UTC)
thefairymelusine: line drawing of a knight lying by a bank of flowers (Default)
From: [personal profile] thefairymelusine
Christ dude. Also, hallo.

I also feel we have a LOT in common. I also have a very intelligent professional father (journo), and an EXTREMELY Roman Catholic mother (who is a textbook emotional abuser). AND OH HOLY FUCK do I hate how I have to fucking neuter my vocabulary, intelligence, articulacy and identity to access any trans related healthcare and sometimes space. (I am gay, and a particularly binary trans high camp trans male dom, who currently is forced to live as non-binary owing to mental health issues)

And hugs, if you would like them.


kaberett: Overlaid Mars & Venus symbols, with Swiss Army knife tools at other positions around the central circle. (Default)

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