Excellent discussion, thank you.

Dee, my mention of a psychiatrist is purely from a medically trained area, a qualified equivalent would to my mind be the same - as long as they are fully trained! That BTW is one reason I'm raising the topic. How to ensure therapists are fully trained to deal with us and not just use us as cash cows (or cash bulls Felix!)

A problem I face and others is the diversity of clients, yes many of us are educated, informed and very capable of making a decision and have very clear and obvious GID that is easily treated with support, HRT and surgery (if desired), as Suzi implicated.   Other clients are not, they can have profound problems, how do WE (as a community) tell professionals to deal with such clients? They need and deserve respectful treatment but how do we give it?

A one model system doesn't work, but a split model works to the disadvantage of many. How do we propose models of treatment to resolve that?

I think it should be a case-by-case approach, with the caveat that the initial triage should be conducted by the primary-care physician, provided that he/she has know the patient for a couple of years.

Why you may ask ? Well, in my opinion the primary care physician is the best person to vouch -or not- for the patient health status and cognizant abilities.

So, in this model, it would be up to the primary  care physician to recommend:

1) a quick interview with a physiologist for concurrence with a GO for SRS/HRT,

2) a 4 session with a psychiatrist to make sure patient is emotional and mentally stable before going with a GO for SRS/HRT, and

3) when patient is deemed to have deep undelaying psychiatric issues, the GO will be given after the patient is stabilized.

Quote from: peky on June 14, 2014, 05:52:39 PM
I think it should be a case-by-case approach, with the caveat that the initial triage should be conducted by the primary-care physician, provided that he/she has know the patient for a couple of years.

Why you may ask ? Well, in my opinion the primary care physician is the best person to vouch -or not- for the patient health status and cognizant abilities.

So, in this model, it would be up to the primary  care physician to recommend:

1) a quick interview with a physiologist for concurrence with a GO for SRS/HRT,

2) a 4 session with a psychiatrist to make sure patient is emotional and mentally stable before going with a GO for SRS/HRT, and

3) when patient is deemed to have deep undelaying psychiatric issues, the GO will be given after the patient is stabilized.

Good plan Pecky, probably makes way too much sense for the world we live in today.

I don't think it should be a set number of sessions. I don't think HRT should need any sessions. Surgery on the other hand should need a pass but not a set number. I had one where all we did is stare at each other for an hour, well 55 minutes. That did nothing.

Quote from: LordKAT on June 14, 2014, 08:29:41 PM
I don't think it should be a set number of sessions. I don't think HRT should need any sessions. Surgery on the other hand should need a pass but not a set number. I had one where all we did is stare at each other for an hour, well 55 minutes. That did nothing.

For a lot of healthcare, protocols and set rules are established, especially in areas regarding surgery, and it is for the safety of both patients and doctors.

HRT in some respects, is not readily reversible.  For anything potentially irreversible, treating doctors want to be sure of their diagnosis so the desire for patients to go through some form of therapy prior is understandable.

Some might even say HRT without diagnosis would be the equivalent of someone fronting up to the ER with abdominal pain, requesting their appendix out and refusing to have the actual cause of their pain diagnosed.  I know that sounds like an extreme example, but the principle and philosophy applies.

I went private in the UK for a number of reasons. Primarily the wait times were just too long. I had more or less reached crisis point and going private gave me much quicker access to services. That being said, I had private therapy for 5 months before finding a private psych for an HRT prescription. I had an initial psych appointment were we discussed HRT, and on my second apt a month later had everything i needed for co-care with my GP and to start HRT. I'm glad I was still working with my therapist when the emotional shift of HRT kicked in.

My NHS invitation for my mental health screening, step 1, came after I had already started supervised HRT and was for an appointment still a few months off. Then would have been the GIC referral wait period, and at the time, that was understood to be 6-9 months after the screening. Without self-medding I would have had to wait another year for HRT during RLE (or such was my understanding but this has/had changed). Now with a 3 year wait for SRS up from 7-10 months on the NHS, (and some really bizarre referral rules that seem inconsistent with patient choice rules in the NHS that don't help,) the effective medical transition period is even longer.

I had a chance to talk to Dr. Lorimer at a trans health thing in London a while back and he was saying that cuts were basically slowing things down at the most heavily attended clinic in the NHS. GIC patients tend to rarely if ever skip their appointments and walk away. Numbers of stated regret out of CharX, allegedly attributed to Dr. Barrett were like 2 surgery regrets out of 6000 patients in his career there. Transition and SRS have far lower regret rates it would seem than any other surgery on the NHS.

Informed constent, as in sign on the legal waiver of liability, should be just that. It's the patients choice, and there are consequences for that choice. Anything else, allows for judgement. And who decides what the judgement should be, the prejudices that come with the judges, and etc until we're back to full on gatekeeping. Barrett allegedly said there should be more control for a process that's had 1/3000 or 0.03% reported regret rate. The notion of more gatekeeping is absurd to me.

Pragmatics aside, there are still a huge number of issues that I don't believe are purely the patients responsibility. Why are patients getting into emotional crisis over this? Why is this still so taboo? And why is this the patients responsibility to "fix" or justify this somehow? It feels assimilationist; prove you can be just like the cis folks and we'll let you play. Don't rock the boat. Ever. Finding a therapist, and a community that I could talk about these feelings (and others) was hugely important to my transition. If anything, the emotional side of things was helped with HRT and the world finally "feeling" the way I thought it should.

I guess what I'm slowly rambling towards, is that I had to own my emotional process and accept it for what it was, without blaming, finger pointing, or any sense of entitlement and just get on with it. Having uninhibited access to resources that could support that, is what got me through that, and affirmed me along the way. There were no tests, no milestones, just ownership of my own process. And granting people the dignity of owning their own transition is paramount in my opinion, and something that I've never seen discussed.

Just my experience and my opinions.

ymmv.

Quote from: peky on June 14, 2014, 05:52:39 PM
I think it should be a case-by-case approach, with the caveat that the initial triage should be conducted by the primary-care physician, provided that he/she has know the patient for a couple of years.

Why you may ask ? Well, in my opinion the primary care physician is the best person to vouch -or not- for the patient health status and cognizant abilities.

So, in this model, it would be up to the primary  care physician to recommend:

1) a quick interview with a physiologist for concurrence with a GO for SRS/HRT,

2) a 4 session with a psychiatrist to make sure patient is emotional and mentally stable before going with a GO for SRS/HRT, and

3) when patient is deemed to have deep undelaying psychiatric issues, the GO will be given after the patient is stabilized.

No. Just no.

First off, I don't have a set PCP. And in certain areas(like the Deep South) there's a non-negligible chance of a PCP country doctor reaction to discussing trans issues being along the lines of "LOL get out of my office pervert". Well maybe not stated openly, but I can think of a few that would flat out refuse referrals, so the result is wasting a couple years of your life.

Personally, the optimal choice is true informed consent. At the end of the day we're adults who own our bodies and need to be responsible for ourselves, and it's our responsibility to research and find the help and advice we need. Otherwise you run the risk of having androgynous/gender queer forced into stereotyped roles so they can access the support they need. So I'd vastly prefer to err on the side of looseness versu gate keeping.

One last point (until I think of another). Cindy, you used the term GID (gender identity disorder), which implies that being trans is itself an illness. Since DSM V went active it's GD (gender dysphoria) in which the depression and anxiety which often accompanies being transgendered is what needs to be treated. Sadly when I spoke to my doctor, who admitted that he had no experience, training or knowledge of this, he immediately started talking about antidepressants.

It elf seem that the county / state specific rules seem more powerful in determining how people have to proceed - including the education of "qualified doctors and therapists". Coupled with many peoples complex mental status it seems pretty difficult to make acceptable generalizations

And don't forget Susan's only picks out a handful of views - those without issues or curiousity seem to sail through without opinion and may well represent the larger spectrum of people transitioning.

Yes "regular therapy" sucks - cash mainly - but an experienced therapist can help massively. I had therapy for 3 years (with a year break) to sort out my feelings. But once decided they opened so many doors because the path was clear of obsticals. So I'm an outlier - very lucky - accepted by everyone - and determined. And I can't complain other than silly rules where Swiss Hospitals like you to be in their specific therapy program. But all rules are meant to be broken so I'm going private.

The topic makes me think of the two extremes. People who jump into quick decisions or decisions based on fantasies, and the other extreme of strict gate keeping where a person is over-supervised like a naive child. Either situation is bad. People make dumb decisions all of the time like marrying the wrong person, buying the wrong house, choosing the wrong career. On and on. Maybe the choices are not researched well. Sometimes the realities are way different from the expectations. It might be a career that requires 12 hours a day rather than 8 hours. It might be the way strangers look at you when you speak with them. There are a lot of unknowns. It's hard to tell exactly what a future life would be like. I think we should be allowed to make mistakes. I don't think it should be someone else's responsibility. I like being the captain of my own ship. I'd like passive advice rather than overbearing direction.

Quote from: ErinS on June 15, 2014, 10:03:08 AM
At the end of the day we're adults who own our bodies and need to be responsible for ourselves

Yes..... and no.

The trans world is full of "damaged goods", people who have developed conditions because of GD or come with conditions along with GD. There are also people in the general population with all sorts of conditions who are not capable of deciding what to pick from the supermarket shelf for dinner yet will walk into a police station and confess to crimes they never committed. It is so common that the police hold back details of crimes so they can sort out the "confessors" from those who are truly 'fessing up.

In a world like that you just cannot throw someone a piece of paper and ask them to sign it and say "Well everything is all right!!"

Quote from: Monkeymel on June 15, 2014, 10:44:46 AM
And don't forget Susan's only picks out a handful of views - those without issues or curiousity seem to sail through without opinion and may well represent the larger spectrum of people transitioning.

Indeed. I think that what you say is actually the case. It certainly mirrors what I have come across.

Quote from: Gina_Z on June 15, 2014, 10:55:13 AM
The topic makes me think of the two extremes. People who jump into quick decisions or decisions based on fantasies, and the other extreme of strict gate keeping where a person is over-supervised like a naive child. Either situation is bad. People make dumb decisions all of the time like marrying the wrong person, buying the wrong house, choosing the wrong career. On and on. Maybe the choices are not researched well. Sometimes the realities are way different from the expectations. It might be a career that requires 12 hours a day rather than 8 hours. It might be the way strangers look at you when you speak with them. There are a lot of unknowns. It's hard to tell exactly what a future life would be like. I think we should be allowed to make mistakes. I don't think it should be someone else's responsibility. I like being the captain of my own ship. I'd like passive advice rather than overbearing direction.

Same here.

Informed consent.... blah, blah, blah.....

This conversation is, so far, one sided. What about the doctors and medical people? Believe it or not, some of them have a conscience and actually care about their patients and want the best for them. Whether or not "informed consent" is the way to go, does anyone ever think about the medics?

They may just get you to sign on a piece of paper and it ma absolve them legally, but what about their conscience? What will happen to them if they see patients getting worse outcomes because they embarked on the wrong course of treatment?

And how robust is that legal waiver? If they simply consented to everything and hid behind a piece of paper, how long would it be until someone decided that the waiver was no protection? That factor "x" or circumstance "y" should have been picked up and treatment refused?

We, on the trans side, may want untrammalled access to whatever drugs we want, on demand with no restrictions, but what about the people who have to hand them out? And clean up the mess of ones gone wrong? They have to look at themselves in the mirror each morning. Do they deserve no consideration or protection?

Quote from: yvvrvt on June 15, 2014, 11:18:20 AM

The trans world is full of "damaged goods", people who have developed conditions because of GD or come with conditions along with GD. There are also people in the general population with all sorts of conditions who are not capable of deciding what to pick from the supermarket shelf for dinner yet will walk into a police station and confess to crimes they never committed. It is so common that the police hold back details of crimes so they can sort out the "confessors" from those who are truly 'fessing up.

In a world like that you just cannot throw someone a piece of paper and ask them to sign it and say "Well everything is all right!!"

My point as well and is the reason why it's incumbent on the provider to ascertain that the transition wannabe fully understands the ramifications before allowing them to sign an informed consent agreement. It needn't be a protracted or extremely expensive process driving them to take alternative routes and possibly harming themselves as a result.

Quote from: yvvrvt on June 15, 2014, 11:25:58 AM
Informed consent.... blah, blah, blah.....

This conversation is, so far, one sided. What about the doctors and medical people? Believe it or not, some of them have a conscience and actually care about their patients and want the best for them. Whether or not "informed consent" is the way to go, does anyone ever think about the medics?

They may just get you to sign on a piece of paper and it ma absolve them legally, but what about their conscience? What will happen to them if they see patients getting worse outcomes because they embarked on the wrong course of treatment?

And how robust is that legal waiver? If they simply consented to everything and hid behind a piece of paper, how long would it be until someone decided that the waiver was no protection? That factor "x" or circumstance "y" should have been picked up and treatment refused?

We, on the trans side, may want untrammalled access to whatever drugs we want, on demand with no restrictions, but what about the people who have to hand them out? And clean up the mess of ones gone wrong? They have to look at themselves in the mirror each morning. Do they deserve no consideration or protection?

Simple. They need to do what, in their personal opinion and experience, is right. There are reputable therapists and endos working in informed consent models, and some that aren't. I prefer IC, but understand some(both patients and treatment personnel) may need/want something different.

I find forcing everyone to use the same system as distasteful as forcing someone to bake a cake for individuals they don't agree with.

Quote from: yvvrvt on June 15, 2014, 11:18:20 AM

In a world like that you just cannot throw someone a piece of paper and ask them to sign it and say "Well everything is all right!!"

Well yes, actually you can. It comes down to fundamentally how you view the human experience, and whether or not people are responsible beings or wards of a nanny state.

I suspect our backgrounds and life experiences are so different we may never see eye to eye on this matter.

Quote from: kira21 ♡♡♡ on June 14, 2014, 12:55:13 PM
That's really good to hear that some people are getting more out of the process from the gic.  Unfortunately my experience with the gic (notts) is that they have not identified any councilling groups or anything like that for me.  They have not even mentioned it and I think that should be part of the process. 

I would still really like to talk about issues with a trained professional and I have not been offered the opportunity to do that with the gic and it should be a requirement.

I am not sure if you are blaming the person being treated when you say they find problems everywhere,  but if you are then I,  having spoken to the people I was referring to would not find that very fair,  but I could be misreading what you mean. 

I would not say the 'horror stories'  are not true (unless you think they are all lying - myself included.  I wouldn't really even describe mine as a horror story and if I had to do it again it would not put me off transition, it's just a disappointment and not how it should work. What I think it might be better to say is mixed bag.

That's the trouble with the nhs, its a medically focussed postcode lottery,
I have had a waiting period, of eight months,  but according to my letter, things will be moving very quickly come august. 1.5 years. seem like a long time, but ill be receiving 6 therapist appointments, once monthly (and if I can provide proof of name change ill have hormones the first visit, not having done this will result in having them the second, unless you wish to keep your name ), After that ill have to provide a proof of being active in my preferred roll. (voluntary work counts) this for a year and I can go in for srs. and as a further point, time scales can be reduced and it says, "depending on the level of transition the patient has already" accomplished. So what this looks like is, IF I have already been working and can provide proof of activity in the preferred roll, this time will be reduced from time needed to provide. and could result in srs eligibility after 6 months or even during that six months.

I don't think I would change anything, SO far. But im in leeds. But the processes for trans seem to be much the same as they are for everything ells. Excellent in some areas, ok in some, and completely disappointing In others.


BTW I'm certain we have informed consent in conjunction with practitioner evaluations. E.g The practitioner goes through everything with you, everything that will be on the letter, then askes you to read and sign, but no matter how many signatures you write they can still refuse if they have a recognised and/or valid reason why. And no matter how much they might like to, they still cant if you don't sign.

Yes I am a regretter but in favor of informed consent. I guess just make sure it is informed and that more emphasis is put on a. transition is not all or nothing and b. question and discussion why each individual procedure is desired and what are the potential outcomes. Ie why do you want SRS/HRT/FFS/beard removal/social transition... have you considered not doing it and doing ___? Do you have to have it now or can you wait? What if you don't like the results or you have complications? And so on.

EDIT: wanted to add many trans health "professionals" view in a cookie cutter sense.

I really have no problem with the process I went through. That included about 45 therapy sessions total so far. Honestly probably 30 of those were discussing exactly how to disclose to family and work on familial relationships, four were dedicated letters advocating my treatment, a few on course of treatment, a few on tangent therapy subjects(dealing with my ex) etc.

If one were to refine things down it could be done in a lot fewer sessions. All that work on disclosure didn't change a thing as far as I had guessed it would go.

A few scattered thoughts:

- Well, I've heard about the gatekeeping done in the UK and I agree with the person who said it was cruel. I know so many people who wait YEARS before even being able to start. That's just wrong, being made to suffer with dysphoria like that is really horrible.
- But I really don't know how I feel about informed consent. I've seen it happen so often where people are on HRT, experience a well-documented effect, and are shocked and have no idea why this is happening to them. So clearly, their consent was not all that well-informed.
- One big problem I see is the lack of knowledge on the part of therapists. It's not entirely their fault, as our knowledge is limited, but there are some people being approved for transition who later regret it and really never should have been given the OK. I see a lot of common denominators in the detransition stories popping up (won't get into them here), and those may need to start being addressed more closely in therapy.
- Then there are detransitioners who were really, absolutely certain they were trans and seemed to make a very well-informed, well thought out decision, and met all the criteria that we have established for GD. I don't see it often, but I have seen a few, enough to make me consider this. That's something that I can't really speak a lot on. Just noting that there are some detransitioners who have big, obvious signs that transition was wrong for them, and then others who seemed to be the ideal candidate for transition but it didn't work out.