Gender Dysphoria: A clinical and legal overview

A report of proceedings at The Royal College of Physicians, on 28 November 2018.

By Lois Rogers for WPA Protocol Plc.

Key points

  • Demand for gender reassignment surgery rising by 15% a year.
  • An estimated 3,500 people a year coming forward for treatment out of an estimated 200,000 to 500,000 transsexual people nationwide.1
  • Recognition of this previously hidden group is expected to have profound social consequences.
  • Lloyds Bank, Goldman Sachs and Netflix are leaders in offering gender reassignment treatment as a healthcare benefit to workers.
  • More employers expected to join these companies at the vanguard of this social change.
  • Other organisations could come under pressure to add the treatment to employee healthcare benefits.
  • Companies should take expert advice and tread carefully in this new era of equality of healthcare provision.
  • Generous offers to cover cosmetic secondary surgery for transgender people could create a legal minefield if the same offer is not available to other employees.
  • Gender reassignment treatment can cost up to £100,000.
  • Studies showing improved well-being, productivity and career progression post gender reassignment, may well justify costs of treatment.

Clinical Overview

One of the UK’s leading gender surgeons based at London’s Charing Cross Hospital, gave the audience a graphic presentation on how surgery can transform a man’s genitals into those of a woman; and the even more complex plastic surgery procedures involved in creating male genitals for a person who grew up as a woman.

Treatment to change gender is protracted and extremely painful both physically and psychologically. It requires commitment and determination that non transsexuals are unlikely to understand.

The condition known as gender dysphoria is defined as profound unhappiness or dissatisfaction with one’s birth assigned gender, leading to the feeling that the genitalia and secondary sexual characteristics are somehow very wrong.

It is now fully accepted that gender identity is distinct from the genitals and cannot be imposed. A graphic example is that of the Canadian baby boy David Reimer, renamed Brenda and brought up as a girl after a botched circumcision removed his penis. Aged 15, he learned he was actually a male but although he underwent surgery to restore his penis he committed suicide in 2004.

Incidence of gender dysphoria is anything between one in 100,000 and one in 60,000. It is not a lifestyle choice and occurs across all populations of the world.

Latest studies indicate the condition can be identified from differences in the brains of affected individuals.

Functional MRI and PET scanning has shown that gender-linked brain structures known as the sexual dimorphic nuclei are more likely to match the non-biological gender in transsexuals.

David Reimer’s death was not an isolated tragedy. The condition causes life-threatening distress and disability. An estimated 20% of affected people commit suicide.

Recognition and acceptance of the problem and the increasing availability of specialist surgery has however, led to a huge increase in the number seeking gender reassignment.

Numbers have risen from a tiny handful to several thousands a year. A new vocabulary has sprung up around this. The Latin prefix ‘cis’ is now used to distinguish those whose gender identity matches the sex assigned to them at birth, from ‘trans’ people who suffer this gender dysphoria.

The surgeon is part of a small group of 13 senior doctors who have set up the British Association of Gender Identity Specialists (BAGIS). They hope that within five years doctors operating in the field will be appropriately assessed and accredited.

Until then he said, there will be a continuing problem of rogue doctors willing to ‘assess’ people who may have all sorts of other psychological problems and offer inappropriate or dangerous surgery. He outlined the multiple processes involved in gender reassignment treatment provided by the NHS, starting with a GP visit. An enlightened GP should after full discussion, refer the patient to a gender identity clinic. Waiting times may run to many months. The patient then embarks on ‘supervised social transition.’ This involves breaking the news of their decision to their employer, and beginning to live and work in their new identity, including a deed poll name change, new bank accounts and driving licence.

Gender reassignment candidates have to live and dress as a member of the opposite sex for a minimum of three months before they start hormone therapy which involves treatment to suppress production of their natural hormones. They receive testosterone injections if they are transitioning to a male identity. Oestrogen tablets, or gels absorbed through the skin are given to transitioning females.

These hormones cause sterility so people should be offered egg or sperm storage. BAGIS is taking the NHS to court to demand this service is funded.

Testosterone will trigger limited outward growth of the clitoris, production of male pattern body hair and muscle development. Oestrogen conversely stimulates some female pattern fat development and limited breast growth.

Despite the considerable pain and suffering involved, many patients then opt for major genital surgery which they are allowed to request after 18 months of hormone treatment.

The operation to fashion a penis involves removing a thick rectangular section of skin and underlying tissue from the forearm. This tissue is then stitched into a tube and attached to the pelvis incorporating the clitoris. The vagina, ovaries and uterus are removed. Spare skin from the vulva may be used to fashion a scrotum including artificial testicles. The possibility of an erection can be offered by the insertion of tiny tubes either side of the penile shaft, which can be pumped full of saline solution from an implanted reservoir between the legs. A valve allows the user to deflate the penis and return the liquid to the reservoir. Repairing the large area of missing skin from the arm involves a major skin graft from the thigh or buttock.

The procedure which involves around three months off work, is far from risk free. There are complications in 85% of cases overall for penis construction, almost half involving urinary problems. The erection pumps also fail after a maximum of ten years and further surgery is needed to replace them.

For male to female transsexuals, the fashioning of a vagina is achieved by dissecting the penis and using the skin to create an internal tube, while again preserving the sensitive nervous tissue previously at the head of the penis, and reproducing it as a clitoris.

For women the complications are rectal fistulas in about one in 20 cases, where tissue breaks down between the new vagina and the rectum causing major infection issues. As soon as the surgical wounds have safely healed the new vagina has to be physically stretched three times a day. Even with the use of this regular process there is a risk of the artificial vagina beginning to close up.

Other sex change processes not covered by the NHS include body hair removal, surgery to tighten vocal cords and speech therapy to produce a more feminine voice; removal of a prominent Adam’s apple, breast implants and surgery to soften jaw line, alter eyebrows, eye sockets and hair line.

The event

This event was organised by WPA Protocol Plc, one of the UK’s leading corporate healthcare trust providers.

This is a summary of the presentations and subsequent discussions. It is the property of WPA Protocol Plc and may not be copied or reproduced without permission.
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Specialist legal advice should be sought if a company is contemplating evolving their healthcare benefits into this area.

About the author: Lois Rogers is an award-winning freelance communicator specialising in healthcare, life sciences and public policy. She was previously health and social affairs editor of The Sunday Times. She also serves on an NHS health research ethics committee. A copy of the report can be downloaded below:

Additional information:

Gender dysphoria overview - NHS.
Gender dysphoria symptoms - NHS.
Gender dysphoria treatment - NHS.