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Individuals seeking gender reassignment: marked increase in demand for services

  • Josephine Fielding (a1) and Christopher Bass (a1)

Abstract

Aims and method

To describe the pattern of referrals and characteristics of people aged over 18 seeking gender reassignment in Oxfordshire over a 6-year period (2011–2016).

Results

A total of 153 individuals attended for assessment (of 162 referred); 97 (63.4%) were natal males and 56 (36.6%) were natal females. Mean age at referral was markedly different between the two groups, with females being younger. The number of referral significantly increased over the time period, by an average of 18% per year (95% CI 1.08–1.30). Eighty-seven patients sought transition from male to female, and 46 from female to male, while a smaller group (n = 13) had non-binary presentations. Twelve patients (7.8%) had autism spectrum disorder.

Clinical implications

There are various possible reasons for the increased demand for services for people with gender dysphoria, which we discuss here. When planning services in the UK, both the increase in overall referral rates and the apparent earlier age at referral should be taken into account.

Declaration of interest

None.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike licence (http://creativecommons.org/licenses/by-nc-sa/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the same Creative Commons licence is included and the original work is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use.

Corresponding author

Correspondence to Josephine Fielding (j.fielding2@nhs.net)

References

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Individuals seeking gender reassignment: marked increase in demand for services

  • Josephine Fielding (a1) and Christopher Bass (a1)
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eLetters

Importance of investigating changing patterns across age ranges, and reviewing service provision to best meet the needs of the population

Josephine Fielding
Christopher Bass
23 November 2018

Our paper aimed to highlight the marked increase in referrals seen locally within recent years. We accept that, as Dr Shaw notes, some people, particularly those from the student population who also have families of origin outside Oxfordshire, may have been referred directly to Gender Identity Clinics and so were not captured by the data. This would mean that our findings likely represent an underestimate of the total increase in numbers of people seeking assistance from specialist clinics, which makes the increase we did find even more striking.

We also appreciate Dr Shaw’s points regarding the referral pathway in Oxfordshire and the need to minimise the barriers transgender people experience to accessing services. The clinical pathway has indeed been reviewed and altered since the period described in the study, with service users now being referred directly by GPs, generally to the specialist clinic in Northamptonshire.

The clinic did not assess people under the age of 17, so we did not include data on this age group in our study, but it is certainly notable, as both Dr Shaw and Dr Clyde’s letters highlight, that referrals to gender identity disorder services for children and adolescents have risen dramatically over the last 5 years. Dr Clyde in her letter draws attention to the high rates of referral to the GIDS for children and adolescents since 2010, and in particular the increase in rates of referral of those assigned female at birth [AFAB]. This has also been our experience, although the increase was less marked in our adult population than in the child and adolescent population Dr Clyde describes, and it is interesting to consider possible reasons for this. In our data we found a marked trend towards more natal females being referred over the 6-year period 2011-2016, with a ratio of approximately 1:2 compared to natal males requesting transition. In our previous audit published in 2011 and covering the period 2006-2011 this ratio was 1:3 [Saunders and Bass, 2011]. However this apparent trend did not reach statistical significance in our data. We also identified 8.5% of people presenting with non-binary gender identities, which were not noted in our previous audit. The finding of increased rates of autism spectrum disorder is also of considerable interest, and our finding of 7.8% is almost certainly an underestimate. We agree that clinics are being overwhelmed, and that there is an urgent need for both more research and discussion in this rapidly changing field, in order to best meet the needs of transgender young people and adults.

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Conflict of interest: None declared

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Contrast with referrals to Tavistock and Portman Gender Identity Disorder Service

Katherine Rae Clyde, Consultant in Older Persons' Mental Health, RCPsych
20 November 2018

This article shows a modest increase in referrals year on year approximating 18% with a majority of referrals received being for those assigned male at birth. This is an interesting contrast with data from the Tavistock and Portman Gender Identity Disorder Service (GIDS) for children and adolescents.

Referrals to GIDS have increased from 97 in 2009/2010 to 2016 in 2016/17. From 2014/15 to 2015/16 referrals increased by over 100% and from 2015/16 to 2016/17 increased by 41%. Ages at referral seen by the service ranged from a very few at 3 to 17 years old.

Also in contrast to this much larger increase in referral rates, is a marked change in the proportion of those assigned female at birth (AFAB). Up until 2011 there were more referrals of those assigned male at birth (AMAB). Since then the number of those AFAB referred has grown steadily and in 2016/17 more than twice as many referrals were made for those AFAB as those AMAB (data available on GIDS website).

We need to be looking as a profession at these striking differences, and more research is required into the reasons for this. It may be that reducing stigma has led to higher referral rates, particularly amongst teenage girls but it could also be that the characteristics of those being referred are changing. This links with the finding that there seems to be a higher prevalence of autistic spectrum conditions (ASC) in clinically referred, gender dysphoric adolescents than in the general adolescent population. Holt, Skagerberg & Dunsford (2014) found that 13.3% of referrals to the GIDS service in 2012 mentioned comorbid ASC (although this is likely to be an underestimate).

In this context, it is alarming that referral rates are increasing at a rate that services and research cannot keep up with. Both the American Academy of Pediatrics and the Australian Standards of Care and Treatment for Transgender and Gender Diverse Children and Adolescents appear to support both medical and surgical transition in adolescents. And yet long term outcomes in this group are not known. We know that adults who have Gender Dysphoria and who transition report the dysphoria beginning in early childhood. We do not know yet know that those experiencing dysphoria in childhood will go onto experience dysphoria in adulthood. Indeed, we know that 80% of individuals referred to GIDS do not proceed to transition.

In the UK we are fortunate to have a national service for children who follow best available evidence, but there is an urgent need for both research and discussion. This is not always easy in a highly emotionally charged atmosphere.
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Conflict of interest: None declared

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The requirement for a general psychiatric assessment risks psychopathologising the experience of transgender people.

Michael Shaw, Consultant in Gender Dysphoria, Northern Region Gender Dysphoria Service
12 October 2018

This paper and the service from which the statistics are drawn appear concerning on a number of levels. It appears unlikely that the fundamental assertion which underpins the statistics in this paper is accurate, namely that “our case note review was able to capture all patients referred within a certain time period in this geographical area.”

The authors state that: “All individuals who request treatment for gender dysphoria in Oxfordshire are referred to a single clinician (C.B.) for psychiatric assessment and subsequent referral to a specialist centre,” and later, “there is a single point of access in Oxfordshire for onward referral to specialist gender clinics”.

This referral pathway is not consistent with mainstream practice in other areas of England and is not supported by current protocols and guidelines representing best practice. The 2013 College Report “Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria” emphasises referral by or via a GP with no other gatekeeping requirement.

The requirement for a general psychiatric assessment is at best unnecessary and at worst risks psychopathologising the experience of transgender people who are presenting with gender dysphoria, an experience of discomfort or distress which is not psychiatric in nature.

There is local awareness of the unusual nature of the arrangement in Oxfordshire. The Oxford University LGBTQ+ society advises on its website: “N.B. A lot of GPs will seek to refer trans customers to psychiatrists (in Oxford, this is usually Dr Chris Bass), but this is a completely unnecessary procedure. If you’re seeking referral to a Gender Identity Clinic to receive hormone treatment or surgery, this will only lengthen the process. Psychiatric assessments are not required by Gender Identity Clinics, and your GP is qualified to make the referral.”

Given the high proportion of students who will have families of origin outside Oxfordshire and the high level of awareness within Oxford University that a psychiatric assessment is unnecessary, it appears likely that a significant number are bypassing the service.

Another factor not considered by the authors is the almost exponential rise in people presenting to gender identity services who are under the age of 17. Provision is via a centralised national service for young people. At 17, their care is then transferred to an appropriate GIC. Transfers of care now comprise an increasing proportion of referrals to the Northern Region Gender Dysphoria Service. As this is the case nationally, such patients will also bypass Dr Bass and will not feature in the statistics presented.

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Conflict of interest: None declared

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