‘Suppose it wasn't possible for you to go any further with treatment, what would you do?’ Hypothetical questions in interactions between psychiatrists and transsexual patients

Abstract

Introduction Psychiatrists, like other medical professionals with a diagnosing or prescribing role, control access to a range of forms of treatment, medication and service that their patient, or their patient's carer, may want access to. This ‘gatekeeping’ role is particularly acute in settings where a patient's desire for a certain medicine or treatment (e.g., for the drug methadone, or for ‘cross-sex’ hormones and sex reassignment surgery) may also be interpreted as a symptom of their ‘condition’ (e.g., heroin addiction, or transsexualism). The UK National Health Service (NHS) Gender Identity Clinic (GIC), is one setting where the psychiatrist's gatekeeping role is renowned. Practitioners in a GIC deal primarily with patients who self-identify as ‘transsexual’. Transsexualism is formally designated in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994) as a ‘Gender Identity Disorder’ (GID). Persons diagnosed with GID are said to exhibit ‘a strong and persistent cross-gender identification and a persistent discomfort with their sex or a sense of inappropriateness in the gender role of that sex’ (The Harry Benjamin International Gender Dysphoria Association, 2001: 4). Statistically, transsexualism is thought to affect 1 in 11,900 males and 1 in 30,400 females (ibid., 2001: 2). The treatment for the majority of transsexuals consists of taking high doses of cross-sex hormones (Hormone Replacement Therapy), and undergoing Gender/Sex Reassignment Surgery (GRS/SRS) (Green, 2000). In order to obtain hormones and be referred for surgery, pre-operative transsexuals must be assessed by two psychiatrists at a Gender Identity Clinic.