Life in a national gender identity clinic

West London Mental Health Gender Identity Clinic (GIC), also historically known as Charing Cross GIC, is the largest and oldest gender identity clinic in the world and has been in operation since the 1960s (Green, 2008). When many people think of people who transition gender, it is often the idea commonly promoted by the media of the person who was assigned male at birth who joins the army and then later in life lives in a female role. Although we do see people similar to this we also see a wide variety of people who have issues around their gender; those who were assigned male at birth, those who were assigned female, and some people who have intersex conditions. Not everybody who sees us wants or needs to transition to another gender. We are quite happy to accept appropriate referrals before a person has transitioned as we make no assumptions about the best course of action for any given individual. Consequently, there is no expectation that a person will transition after they have been referred to us, but many do come to go through gender reassignment including hormonal treatment, social gender role transition and gender surgeries to construct a body socially and personally appropriate to the patient's reassigned gender. Support around transition, hormones, surgery and counselling psychology services are all possibilities that are discussed when clients come to the GIC.

The counselling psychology service offers additional options to core gender services such as psychological assessment, surgeries, psychiatry and endocrinology. We see people for fortnightly counselling on issues that do not always differ from those found in most general settings, such as bereavement, social anxiety, relationships, sex, etc. For many of our clients these things are flavoured by gender and sex issues, for example concerns about their partner's reactions to them changing sex. Does my transition mean that my wife is now a lesbian? Is there going to be an adverse influence on the children? (not as a direct result of the patient being trans, but possibly for other reasons such as parental tension: Barrett, 2007; Green, 1978).

We also offer therapeutic workshops on different themes, such as sexuality and intimate relationships and the positive aspects of being trans, as well as psychotherapy groups. The expansion of psychological services within the GIC appears to be meeting a need for less explicitly assessment-based services, which are facilitated by psychologists able to bring specialist psychological knowledge to their delivery.

Dr Penny Lenihan, GIC Consultant Psychologist
I am a Consultant Counselling Psychologist and work within the GIC core services as a GIC Consultant as well as developing, managing and supervising GIC counselling psychology. My clinical work requires integrating the traditional role of a psychiatrist in assessments and follow-up appointments with the different training and approaches of a psychologist, as well as a knowledge of endocrine treatment, surgeries and other relevant areas.

Within my clinics I carry out first- and second-opinion assessments of newly referred clients, assessments for endorsement for hormonal therapy and gender surgeries and see clients for regular follow-up appointments, which can range from clinical reviews to psychotherapy and counselling. In addition to 1:1 clinical work I co-facilitate groups and the workshops. One aspect of my work I find really rewarding is seeing clients overcoming challenges that seem overwhelming to them and outsiders. They progress into fulfilling positive lives – often finding support in places they least imagined. Seeing how resilient people can be in this process towards authenticity can be inspiring, and supporting people in grappling with the basic existential issues of what life is about and what it means to be an authentic integrated person is something we to do in our work virtually on a daily basis.

It can be quite challenging dealing with primary care trusts or other funding bodies in the UK. In representing the best clinical interests of our patients we come up against varying protocols and I do spend more time than I would like writing reports supporting appeals for what, to us, appear to be quite unnecessary refusals of care. Unfortunately these frustrations are likely to increase in the current financial climate.

We work closely within a multidisciplinary team, which is essential in this work. GIC counselling psychology has grown substantially and I am extremely pleased to have developed this service with my colleague Christina Richards from the first therapeutic workshop to include the range of services and staffing that exists today. In my career I have varied from being an academic doing some clinical work to being a clinician doing some academic work and for the last eight years it has been the latter. I thoroughly recommend doing both, in whatever proportion, as it makes for a diverse, interesting and constantly challenging work life.

Our training placement programme is a unique opportunity to gain psychological experience and training in working in the field of gender and sexuality in a busy NHS gender identity clinic. I hope trainees reading this with a specific interest in working with LGBT people consider applying to us for a placement. Supervising and mentoring psychologists in training is a very rewarding and inspiring part of my work, particularly as those we have appointed to date have all been of such a high calibre and no doubt will continue to be so. A diversity of approaches are offered within the counselling psychology service and can range from CBT, person-centred, systemic, narrative to existential in the 1:1 service, and our groups are existential and psychodynamic. This provides room for our trainees to develop their experience and skills in their preferred approaches, as well as providing clients with the therapeutic options that may be most appropriate to them.

Christina Richards, Senior Specialist Psychology Associate
My slightly unusual post title is reflective of the fact that I have a master's degree in an associated discipline and many years of publications and associated work in the field. At present I am finishing my doctorate in counselling psychology under the supervision of Dr Lenihan, so part of my day is spent liaising with Dr Lenihan as her clinical supervisee. I find this time invaluable, as no matter what experience one has from the literature, or from personal experience of trans people, the clinical situation is often rather different. Trans people in general are no more likely than the general population to have any psychopathology (Cole et al., 1997); however, like most people, trans people often feel the need not to present their difficulties to others. This can be especially so for trans people who are commonly told by people without the requisite understanding that if they have any difficulties their nascent identity must be wrong for them. Consequently trans people may present one dimension of their experience to their friends, families and communities, and another in the confidentiality of the therapy room – something which I am privileged to witness and endeavour to assist with. In addition, because we are a national clinic, we see not only healthy professional trans people such as doctors, lawyers and the like, but also a reasonable number of patients with forensic histories, sexual difficulties and severe concomitant mental health problems, which makes for an interesting workload.

In addition to supervision Dr Lenihan and I work together on funding bids and research. We are also writing a book to be published by Sage later this year with Dr Meg Barker at the Open University, on sexuality and gender for psychologists, psychotherapists and other helping professionals. We also liaise with a range of other health and legal professionals, both nationally and internationally, who wish to have specialist psychological assistance on matters that pertain to sex and gender.

In addition to my psychotherapeutic and assessment work I also work closely with the multidisciplinary team. We have frequent meetings and often wander into one another's offices for a consult – something which is invaluable in a field as underresearched as trans care (although I should note that the evidence that surgery is beneficial for carefully selected patients is overwhelming, see Gijs & Brewaeys, 2007). In particular,

I seem to have become the clinic statistician and reference repository, which is nice as, while we all identify as gender specialists first and foremost, we have complementary skills we can share and bring to an individual's care.

One of the biggest professional challenges facing me at the moment is overcoming some of the myths about what it is that we do. Non-clinical academics writing about the field often refer to the 'psycho-medical' discourse, as if there was only one, and speak about 'gatekeeping' services, as if we are power-mad oligarchs rather than clinicians trying to use what resources we have to the best effect. In the field of trans, clinicians are often reduced to a stereotype of their role, without an understanding that we too are people who go to the movies, eat sandwiches and read books and grab a latte on the way to work. I find it difficult to be reduced to the stereotype of a 1950s psychiatrist when much of my work involves advocacy as well as writing on poly and kink, in addition to trans, from an affirmative angle. I'm aware that my colleagues and I have a wide variety of different views drawing on a variety of different discourses – they too are not 1950s psychiatrists. The work in much of the non-clinical literature seems to be aimed at shooting that straw man. While this saddens me personally, what concerns me most is 18-year-old clients who are being caught in the crossfire. They come in to see me literally shaking having heard these stories. It is only after some time that they realise the stories are not true and so they can engage with the process of becoming themselves.

Felicity Adams, Psychologist in Doctoral Training
I have been working at the Gender Identity Clinic on a placement as part of my counselling psychology doctorate. I am currently in my second year, working at the GIC one day a week. I was drawn to this placement as it offered me the chance to gain specialist experience working within the gender and sexuality field whilst also gaining experience in common psychological problems within a consultant-based multidisciplinary team.

One of the things I love most about this placement is that it allows me to adapt psychological interventions based on individual need, which is exciting and pretty challenging. For example, when working with social phobia one must be mindful that for some clients the fear of victimisation is sadly a reality (Hill, 2005). The behavioural experiments one plans for must therefore take this potential danger into account.

In addition, this placement has allowed me to become familiar with issues more commonly found within this client group than others; such as the feelings of inauthenticity, guilt, and issues around disclosure. This placement has certainly made me much more confident in discussing issues around sexuality and sexual practices; I learnt pretty quickly to get over any embarrassment I felt discussing these issues!

The GIC team offers a fantastic peer support network; we meet up regularly for group supervision, which allows us to discuss cases of interest, and since we come from a range of modalities we can share ideas of how to work best with our clients across these approaches. This has been a wonderful way for me to see theory jump to life when we formulate within these frameworks. We also have the opportunity to discuss relevant literature, forthcoming publications and events; all of which helps me keep abreast with the latest issues.

Working in this clinic has challenged my preconceptions of gender, and it has opened my eyes to how the binary nature of gender has become so ingrained in our society. This placement has encouraged me to have a far more fluid concept of gender and to question the norms we might place on ourselves and others.

References

Barrett, J. (2007). Transsexual and other disorders of gender identity. Oxford: Radcliffe.
Cole, C.M., O'Boyle, M., Emory, L.E. & Meyer III, W.J. (1997). Comorbidity of gender dysphoria and other major psychiatric diagnoses. Archives of Sexual Behavior, 26(1), 13–26.
Gijs, L. & Brewaeys, A. (2007). Surgical treatment of gender dysphoria in adults and adolescents: Recent developments, effectiveness, and challenges. Annual Review of Sex Research, 18, 178–224.
Green, R. (1978). Sexual identity of 37 children raised by homosexual or transsexual parents. American Journal of Psychiatry, 135, 692–697.
Green, R. (2008). Potholes in the road with gender dysphoric patients: Contentious areas of clinical practice. Sexologies, 17(4), 254–257.
Hill, D.B. (2005). Trans/gender/sexuality. Journal of Gay and Lesbian Social Services. 18, 101–109.
Richards. C., Barker, M. & Lenihan, P. (in press). Sexuality and gender for psychologists, psychotherapists and other helping professionals:
A practical guide. London: Sage.