Keynote presentation delivered at the "Trans Health Matters" conference at the London Lighthouse on 12th Mar 2013

1. Setting the Scene
How we got from there to here in 83 years
Christine Burns MBE

2. What I’ll Cover
Some historical context
NHS Context
International definitions
What trans people need and want
Challenges to service design
Challenges for today

3. Historical Context
Trans people have been transitioning for
centuries, if not millennia
The modern world brings opportunities but
also challenges
Clinical imperialism and voluntary services
Gatekeeping

4. The UK Clinical
Landscape
NHS Care for people with gender identity
problems confirmed judicially in 1998/9
GPs -- CMHTs -- Tertiary services
Commissioning until now by 152 PCTs taking
policy guidance from 10 Specialist
Commissioning Groups
Tertiary services will be commissioned by the
NHS Commissioning Board in England after
1st April 2013

7. Clinical Definitions
The International Classification of Diseases
and Health Conditions (ICD)
The Diagnostic and Statistical Manual
Both subject to revision at present

8. The ICD
The ICD is published by the World Health
Organisation, a specialised agency of the
United Nations
Ratified by the World Health Assembly
(the health ministers of 193 countries)
Always a product of its time
Next edition (ICD-11) 2015/6. Will be part of
clinical practice for 15-25 years

9. The ICD and trans
people
Transvestism first added in 1965 (ICD-8)
under ‘sexual deviations’
Transsexualism first added in 1975 (ICD-9)
under ‘sexual deviations’
And then there was ICD-10...

10. ICD-10 (1990)
F 64.0 - Transsexualism
F 66.1 - Egodystonic Sexual Orientation
F 66.2 - Sexual Relationship Disorder
F 64.2 - Gender Identity of Childhood
F 66.0 - Sexual Maturation Disorder
F 64.8 – Other Gender Identity Disorders
F 64.9 – Gender Identity Disorder, unspecified
F 66.8 – Other Psychosexual Development Disorders
F 66.9 – Psychosexual Development Disorder, Unspecified
F 65.1 – Fetishistic Transvestism
F 64.1 – Dual – Role Transvestism

11. WPATH Discussions
F 64.0 - Transsexualism RENAME / MOVE
F 66.1 - Egodystonic Sexual Orientation DELETE
F 66.2 - Sexual Relationship Disorder DELETE
F 64.2 - Gender Identity of Childhood RENAME / KEEP?
F 66.0 - Sexual Maturation Disorder DELETE
F 64.8 – Other Gender Identity Disorders DELETE
F 64.9 – Gender Identity Disorder, unspecified DELETE
F 66.8 – Other Psychosexual Development Disorders DEL
F 66.9 – Psychosexual Development Disorder, Unspecified
F 65.1 – Fetishistic Transvestism DELETE
F 64.1 – Dual – Role Transvestism DELETE

12. WPATH Don’t Decide
WPATH is a global professional association,
involving over 800 clinicians dealing with
people with gender identity conditions
Their process is about reaching a consensus
recommendation of their own to present to the
World Health Organisation
WHO will consult others too
Process takes 2-3 years to secure global
consensus for World Health Assembly

13. Current Thinking
Delete all but two classifications
Rename the adolescent / adult category
(“Gender Incongruence?”) and remove from
mental health section
Rename the child category (“Gender
Incongruence of Children?”) or remove it
altogether and use Z-codes

14. Uses of the ICD
Clinical utility - A common language to
describe symptoms and anchor treatments
Common taxonomy for research
Health statistics and funding
Public health and policy

15. What trans people need
and want
In transition
For lifelong wellbeing
In other services
As relatives and carers
In their own old age or disability

16. Trans care challenges
service design
Intensely multidisciplinary. Needs joined up
working at a time when NHS is fragmenting
Massive variation in needs
A legacy of stigma and ignorance to be
overcome

17. The Challenge
Don’t accept the asis
Rethink responses around the individual
Slay sacred cows
Listen to the service user