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» Got Questions? Get Answers. » SCARLETEEN CENTRAL » Gender Issues » Worried about NHS transitioning - TRIGGER WARNING: abuse

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Author Topic: Worried about NHS transitioning - TRIGGER WARNING: abuse
oneboikyle
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I’m really sorry, I know that looking down the topics list, my name has come up two times already recently, but this is a different and more specific issue to what I posted before (although, I guess, related, inasmuch as it concerns my own personal gender).

I’ve got an appointment with a psychiatrist to discuss the possibility of medically transitioning. Whilst I am incredibly lucky in that any dysphoria I feel is far from crippling, like some people suffer, I do feel like I would be happier if I medically transitioned, at least to some degree, and the more I think about it, the more sure I am. Especially when it comes to hormones, because I am becoming more and more uncomfortable with my voice. That sounds ridiculous but honestly, aside from my moobs (manageable most of the time with a binder), my voice is the biggest issue I have with myself, because I just can’t lower it enough and strangers on the phone constantly “Ms.” me, or call me Kylie instead of my chosen name Kyle. The rest is relatively disguisable.

Anyway, the appointment is at the very start of June, and I just did a bit of vague research by asking a sort-of friend who’s transitioning about the initial assessments. He mentioned that they ask a lot of probing questions, to ensure that this is what you want, and isn’t the result of multiple personality disorder, or anything else like that. I know that would alarm a lot of people, but as I’ve had a history of depression, I can totally see the point and honestly don’t mind it. He also said that they ask about any abuse in the past, which really worries me because I do remember being sexually abused for a couple of years when I was younger. In fact, it’s some of the only clear memories I have. Can the NHS use this as a reason to not allow me to transition? I honestly believe it isn’t anything to do with my gender, and I am really worried that they might pretend it is, just to save some money.

Relating to that, someone on the live chat (who suggested I post here for more knowledgeable advice than they could give me) said that if I didn’t want to, I didn’t have to tell them. If I chose to lie at that point, but then disclosed about it later on, can they then choose to stop any treatment? For example, could they stop letting me take hormones, or ban me from any surgery I decide I want? I don’t really have a clear idea about this, and am kinda worried about what different outcomes might be.

For any background information, I live quite close to London, UK, and I’ve been questioning my gender for quite a few months now, and have been heading fairly firmly towards accepting myself as a guy. I am 18, so still “very young” in the eyes of a lot of people, it seems, when I talk about being trans, although I personally feel like I’m really late in realising it compared to some people. At the moment, I’m living about 90% of the time as Kyle, although I’m not out to everyone, and I haven’t legally changed my name yet (I’m considering making it a 19th birthday present for myself in October). So yeah, please, some help on this initial psychiatrist appointment would be really appreciated, and maybe any insight from others who have transitioned in the UK about what to expect? Thanks [Smile]

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Redskies
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Kyle, just to clarify, is this appointment with a gender clinic rather than a more generalised mental health service?

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The kyriarchy usually assumes that I am the kind of woman of whom it would approve. I have a peculiar kind of fun showing it just how much I am not.

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oneboikyle
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Not as far as I understand. It's with the local mental health team, who can then refer me to a specialist gender clinic.
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Redskies
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Ah, I see. As far as I know, different authorities do have different routes to accessing these services.

I can't give you any personal insight into the process - hopefully other folk can - but what I do know is that there's information produced by the NHS about what people in your position should expect. It doesn't address everything you're asking about, but it might still help you to have it. Do you already have that information?

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The kyriarchy usually assumes that I am the kind of woman of whom it would approve. I have a peculiar kind of fun showing it just how much I am not.

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Molias
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Hi Kyle,

I do not have personal experience with how the system works with the NHS specifically, but honestly I would be really surprised if someone used a past instance of abuse to deny you treatment. I don't want to say it wouldn't happen, because again I don't know how these clinics work or if a rogue jerk doctor might be hiding out in one, but it seems unlikely.
I did find reference to clinics in the UK following the WPATH Standards of Care, which state:

quote:
Clients presenting with gender dysphoria may struggle with a range of mental health concerns....whether related or unrelated to what is often a long history of gender dysphoria and/or chronic minority stress. Possible concerns include anxiety, depression, self-harm, a history of abuse and neglect.... Mental health professionals should screen for these and other mental health concerns and incorporate the identified concerns into the overall treatment plan. These concerns can be significant sources of distress and, if left untreated, can complicate the process of gender identity exploration and resolution of gender ysphoria....Addressing these concerns can greatly facilitate the resolution of gender dysphoria, possible changes in gender role, the making of informed decisions about medical interventions, and improvements in quality of life.
To me, that says something along the lines of "abuse should be dealt with as needed to understand a patient's overall mental health but isn't a reason to deny medical transition." So assuming that this psychiatrist is following the Standards of Care (and I bet you could call the office and ask, or maybe even find that info online), I think any discussion of abuse, if you were comfortable with that, would be for the purpose of figuring out if it's a part of your history that needs to be talked about as you're discussing the possibility of transition.

If you don't feel that your abuse has much of a connection to how you feel about your gender, you're certainly under no obligation to talk about it. You could even decide during the appointment itself if you want to talk about it or not based on how you feel about the person who's asking the questions. And probably you'd be able to just omit that information vs. actively lying about it; I realize that depends on how a question is worded, but if it makes you feel better to not-lie on a technicality, I bet you could manage it.

Also: I don't think it's ridiculous AT ALL that you really want your voice to change; that was a part of hormone therapy I was really excited about too. =)

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Redskies
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Kyle,

I'm very aware that, as a cis person, I can't provide what you were specifically asking for, and so I might be getting in the way. If you feel like I'm getting in the way at all, I'll get out of the way, sharpish, no problem.

I'm replying because I've picked up a small amount of knowledge about trans* people's experiences within the NHS and I know a bit about dealing with the NHS generally, and because I'm not sure if there are any currently active volunteers or users here who've used the NHS for trans-related stuff (although of course there may well be lurkers, in which case, welcome, lurkers, and please share your experiences if you like!) As I said, though, if I'm getting in the way, I'll get out of it.

As far as I know, the NHS guidelines for dealing with trans* patients do not absolutely follow the WPATH Standards of Care which Molias talks about above, though they're definitely something it's a good idea to familiarise yourself with. As far as I can gather, the root problem isn't really money, but that the people deciding on the system are overwhelmingly cis people who are deciding what the best approach to care of trans* folk is rather than what trans* folk actually say works well.

Have you received treatment for depression from the NHS, or discussed it with any NHS medical worker? Is your depression currently fairly successfully managed, and if so, how long since it was a problem? Have you ever mentioned the sexual abuse to anyone within the NHS, or does any child protection or other official agency know about it, and have you ever had any counselling or support for it?

As far as I know, Molias is absolutely right that any history of abuse Shouldn't prevent you from getting referrals and/or medical treatment for gender stuff. However, the NHS is fairly notorious for being very slow in providing gender-related care that people are actually asking for, and plenty of things can slow it down even more for very little good reason. I asked the questions I did above to try to help contribute to a strategy that'll hopefully make your route through no slower than it needs to be.

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The kyriarchy usually assumes that I am the kind of woman of whom it would approve. I have a peculiar kind of fun showing it just how much I am not.

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Molias
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Thanks for that, Redskies. I was able to find a clinic or two that mentioned the SoC on their websites but it didn't look like a universal thing, and I definitely have zero experience dealing with the NHS myself. =)
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oneboikyle
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Thanks a lot guys! Erm, I've not ever read through the standards of care, but I'll be sure to do so, so that I have an arsenal at my disposal if need be [Smile]

Redskies, you're awesome and helpful even if you can't talk from personal experience, so you're definitely not in the way in the slightest. Thanks a lot. I was treated by the youth mental health team around 4 or 5 years ago, and have been referred by my doctor to other councelling services on and off over the years, and so far they've allowed me to be fairly involved in any decisions about me. I really do have an amazing doctor. The last really awful bout of depression was around a year ago, and at the moment I have low days, but enough coping strategies to deal with it myself. But, I've never mentioned the abuse to anyone, except this one time within the family, when I pointed the finger and everyone denied it ever happening. Seeing as I have no evidence of it even occuring, and it's my word against theirs, I've always been loathe to officially report it. Even the worst people can change, and I like to give them the benefit of the doubt. I just don't like the idea of directly lying and denying that it happened.

Molias, your strategy of not-really-lying but not telling them about it definitely sounds like a reasonable middle choice, thanks. I'm not entirely sure how I can manage that, but I'll definitely keep it in mind. Put my brain to use a little, it can only be a good thing.

Thanks a lot, guys. It's definitely made the whole initial assessment a bit less daunting, knowing that my history shouldn't stop the process completely, and I do feel a lot more prepared, now I've got a few things I can do to help myself. Course, if there are any lurkers who want to share their stories still, definitely interested in hearing! The more knowledge I have, the more prepared I can be and therefore the less stressful it will be [Smile]
Thanks a lot!

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Redskies
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Kyle, I'll track down the NHS guidelines for you. I can't remember for the life of me where I came across them, so I'll have to go on a bit of a hunt [Smile] If I remember correctly, the guidelines also cover what you, I and Scarleteen would consider basic respect for your humanity and your gender identity, in any healthcare setting, not just for gender-related care.

The reason I asked if anyone in the NHS has ever known about the abuse is because, if they had, chances are high it would be in your medical records, and in that case it would probably be a bad idea not to mention it if someone specifically asked. As you've never mentioned it, it is your choice whether to disclose or not. Generally, it's better to share as much as we feel able to with medical professionals, but I do think that no-one should ever feel pushed into disclosing past abuse if they don't want to. There's an added complexity with it being gender-related care that you want to access, as sometimes these kinds of "extra" things can add more time to the process, depending on the individual medic; and of course, for some trans* folk, getting access to the gender-related care is more urgent than the NHS currently caters for.

Somewhat as an aside to the rest of this conversation, please know that if you ever want or need support or just to talk about anything to do with the abuse, there are services where you can access that without involving official institutions or reporting in any way, particularly now you're over 18. Evidence or proof or what-not won't matter in the slightest to those organisations; they simply want to support people in the way that each person needs and will be most helped by.

Obviously I hope that the psychiatrist you have the assessment with will be clued up and supportive. Just so you're fully prepared, though, as it's with a general mental health service, exactly how suitable this psychiatrist is is a bit of an unknown. They Should have at least basic training and awareness around gender identity, but it wouldn't surprise me if they weren't a specialist in gender things and if you knew more about gender stuff than they did. From your first post, I'm understanding that what you're looking for isn't help in figuring out what's going on with your gender, but rather medical input for at least some aspects of transitioning? If that's the case, then your likely goal from the assessment with this psychiatrist is a referral to a gender clinic. As you can't be sure exactly what level of knowledge and understanding this psychiatrist is going to have, it might be a good strategy to keep that goal in mind and to make sure you communicate your gender clearly and consistently. This appointment might not be the best time for deeply complex thoughts about gender identities, presentation, femininity/masculinity, etc! Obviously, see how it goes with the psychiatrist. I imagine that you can get a good "feel" very quickly for how much people grasp and respect trans* identities.

As far as I know, there's almost nothing that would permanently close the door on accessing gender-related care, so that's not something you need to worry about. The reason I'm saying some of this is that waiting times for both mental health services and especially gender clinics are usually months, so even getting held up by one extra unnecessary mental health appointment is a long delay that most folk would rather avoid if possible.

I'm glad to hear you've had such good care for your mental health stuff. I think it's very likely that the psychiatrist will bring up the mental health stuff with you and be assessing where you're at. Quite apart from the fact that it's generally in our interest to be managing our mental health well [Smile] , it'll help for you to make sure you're managing your mental health as well as you can (and that includes getting any support you need, I certainly don't mean that struggling by oneself is a good strategy!), so that that's apparent to the psychiatrist. As the psychiatrist will have access to your medical notes, definitely don't lie or leave out big things about your treatment and care with this, as that's likely to come back to bite you. I'm not suggesting that you have to share every grim thought that's ever gone through your head, but what you say about your mental health history should match the facts.

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The kyriarchy usually assumes that I am the kind of woman of whom it would approve. I have a peculiar kind of fun showing it just how much I am not.

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oneboikyle
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That's very kind of you Redskies, thank you. I found the international WPATH SoC by googling it, but I've had no luck with the NHS guidelines specifically.

Of course I plan to be fairly open with the dear Doctor (I kinda wish they were a professor, so I could call them Prof, but never mind) with regards my past mental health issues. I definitely believe that it's nothing to be ashamed about, any more than having hayfever each summer, so... Plus, I'm getting a sneaking suspicion that my gender issues were possibly a reason for my low self esteem (one of the factors in my depression), before I realised what the problem was, so it's quite possibly very relevant.

Also, as much as I love debating about different nuances regarding gender, I already figured that's better left until I get referred to Charing Cross or wherever. I mean, I'll be fairly open with the fact I still have slight doubts every now and then with most people, but I get the impression that's not a thing to share immediately with the person controlling access to medical care for me. Especially seeing as the doubts only really surface when I'm around fairly transphobic people, and are more centred on not being "man enough" to count as trans. It's almost like internalised transphobia. So, not something to discuss until I'm talking to an expert, I think lol.

Thanks for the heads up about support with my past. I doubt I'll ever choose to access anything like that, because honestly I've come to the point that, although I don't accept what happened as okay, I accept that it did happen and I can't change that now. Talking more about it, won't change anything, and it doesn't really affect my life now, so I don't see the point.

Anyways, thanks a lot, and if you do happen to find a copy of the NHS guidelines, I'd definitely be interested to read them. Thanks [Smile]

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Redskies
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Got it! Also, I've dug up the thing I was remembering, and come up with a couple more helpful things.

Okay, first things first. As far as I understand, what's in this publication is not binding on NHS staff. It's "best practice guidance", and, quoting from the document itself, "This document gives practical best practice advice for NHS organisations to address their responsibilities relating to trans employment and healthcare delivery." So, it's aimed at NHS workers, but I reckon it's very handy for you to know what they're told is best practice. If I were in your position, I think I might print or otherwise acquire a copy of the document and take it with me in a bag to appointments, just in case. Here's the link: http://www.gires.org.uk/assets/DOH-Assets/pdf/doh-trans-practical-guide.pdf (Apologies to anyone using screen-readers that this is a pdf file. I'm not sure if this is available online in any other format, but if anyone needs that, I would figure out a solution.)

There's also this, which is a similar publication: http://www.qahc.org.au/files/shared/docs/GP_trans_UK.pdf I'm a little confused as to why the link I've found for that appears to be an Australian url, but as far as I can tell, the document is for and about the UK NHS.

How access to gender-related care is arranged and run is really very localised in England, and will be according to your own local healthy authority (until a few months ago, I would've said "Primary Care Trust", but I don't know if the NHS is still structured like that or if the local bits are still called that since the recent re-structuring). Anyway, your local healthy authority: that should be whatever local health authority runs your local hospital/s and GP surgery. I can't be sure which one you're in to find you the relevant info, but if you google the name of your local health authority and "gender reassignment protocol" or "gender dysphoria policy" or a combination like that, hopefully it'll turn up their information.

I suggest you ask your GP (I assume the doctor you wrote about above is a GP) about how the whole process of getting referred to a gender clinic in your local healthy authority works, even the parts that don't directly involve you or the GP, just so you know what to expect. It sounds like your GP has served you very well in the past and was supportive and acted immediately about your gender query, so it sounds like they'd be a good person to ask who would find out and tell you accurate information. A GP is unlikely to know all the details unless they've recently assisted another patient through the system, but they should be able to find out.

What I'd come across for England is actually a draft protocol. I can't find anything that looks like a "proper", final one. So, services in England won't be required to adhere to the draft protocol, but still, it might fill you in on the sorts of things the system currently thinks are appropriate. I first found this via a trans person's blog, and there's some smart-looking analysis of it on that blog too, so I'll drop you those links. Do remember, of course, that the analysis is people's personal opinions. This blog post http://transactivist.wordpress.com/2012/07/26/have-your-say-on-england-gender-dysphoria-services/ is less helpful in itself, but it seems to have a copy of the protocol document ("A copy of the document is available below: Gender Dysphoria Services – An English Protocol") when other links to the document don't seem to work any more. Analysis is here http://transactivist.wordpress.com/2012/07/31/business-as-usual-a-look-at-the-draft-english-protocol-for-gender-dysphoria/ and here http://transactivist.wordpress.com/2012/08/21/guest-post-draft-protocol-review/

Some of the stuff within and about the draft protocol (and maybe your local authority one, I don't know) is, sadly, not for the faint-hearted, and not for when you're having a rough day. Take it easy and take your time if you want to go reading around this stuff. The NHS is an imperfect thing, and more imperfect than usual with regards gender-related care. Don't lose heart or be overwhelmed, though; the overall picture is not that every person has a bad or difficult experience, but that the NHS is not currently doing well enough overall with regards gender-related care. You're immediately in a better position if you have a supportive GP, and if Charing Cross is indeed your relevant GIC, that's probably overall good, as it seems they're one of the more progressive ones in England.

I completely agree that mental health stuff is nothing to be ashamed of. I know, though, that the world in general's attitude is sometimes not helpful, so I don't assume that people are going to disclose mental health stuff as if the world was always fine with it. As someone who often chooses not to disclose my own mental health stuff, great respect to you and thank you for being as open and outspoken about it as you are.

quote:
I still have slight doubts every now and then with most people, but I get the impression that's not a thing to share immediately with the person controlling access to medical care for me.
That's exactly what I was driving at, but I wasn't sure I'm in an appropriate position, only having second-hand knowledge, to say so quite so directly.

[ 05-03-2013, 12:08 PM: Message edited by: Redskies ]

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The kyriarchy usually assumes that I am the kind of woman of whom it would approve. I have a peculiar kind of fun showing it just how much I am not.

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oneboikyle
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Thanks a lot; I'm slowly working through all the articles, bit by bit. Some of it is a bit confusing, but I'll get there slowly [Smile]
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Redskies
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You're very welcome. If you need a hand with any of it, or to discuss any of it, do feel very free to ask, and I'm sure Molias or me or someone else - depending on what you're asking - will be happy to help.

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The kyriarchy usually assumes that I am the kind of woman of whom it would approve. I have a peculiar kind of fun showing it just how much I am not.

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Heather
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I also want to make sure you know about CliniQ, Kyle.

They're here: https://www.facebook.com/cliniQlondon

Even though it's a sexual health clinic for trans* patients, my impression of them over there is that they do offer help a bit more broadly, and could be a good place to talk to someone in the NHS system about all of these concerns.

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