Sunday, 8 May 2016

The Gender GP

I was browsing one day through Quora. It takes up far too much of my time, though I can’t seem to get away from it. As you might expect, one of the topics I follow on Quora (among plenty of others) is gender, and I was delighted to come across a doctor writing openly about gender issues, in particular trans-gender issues.

Helen Webberley: Gender GP
The doctor is Helen Webberley, a General Practitioner from the UK. Her website, www.gendergp.co.uk, offers amazing access to a sympathetic doctor: “advice on gender issues, counselling and diagnosis, blood tests and monitoring, prescription medication”. And it comes with a plethora of means to get in touch: an email address, a mobile phone number, and the option to do face-to-face video conferencing with Helen. There is also a series of short videos explaining her own views about transgenderism and its treatment, and explaining how Helen can help.

If you’ve read any of this blog at all, you will know how much I am looking for answers to my questions, not just about my own gender, but about the medical treatment of transgender people. You will also know how sceptical I am about the current state of the science behind gender treatment. I have (several times) approached doctors who treat transgender patients (including surgeons who perform sex reassignment surgery ) and also doctors who are themselves transgender, for their own perspectives. They have all quietly declined to be interviewed publicly.

So I wasn’t filled with confidence that Helen would agree, but I got in touch, and she replied immediately and very positively. Here she is, sitting on my virtual couch:

How did you first get interested in treatment of transgender people?

I have always been interested in equality and diversity – it has always appalled me that anyone should be bullied due to their size, colour, hair, gender, preferences, religion etc. I got very interested in Sexual Health in the 90s and did lots of specialist training in this area, and then taught widely on how the medical profession should not judge differing sexual behaviours.

When I became a GP in Wales, I had a transgender person asking me for help, and the nearest clinic was in London. I made it my business to find out more about gender issues and how to treat them, and how to help this person who couldn’t possibly travel to London. It was fascinating, and very rewarding.

What made you decide to pursue it as far as you have (the website, etc)? Why not just treat patients in your own region?

I love technology, and was intrigued as to why healthcare was so far behind the rest of business when providing services online. I made my own website www.mywebdoctor.co.uk offering free advice to those who couldn’t get in to see their GP. I thought it would sit at the bottom of the huge pile of websites in the sky, but I was surprised at how many people asked for help.

I had an idea to offer specific help for transgender people, so I made a special dedicated Transgender page. When I woke up the next morning, I realised just how big a need it was!! From here it has progressed to www.GenderGP.co.uk .

Do you still have a normal GP practice?

Doctor, doctor! Gimme the news!
Until April 2016 I was the senior partner in a GP practice in Wales. My interest and work with the transgender community has meant that I have had to let this go, as I no longer had time to do both. After a brief spell of ill health, I decided to pursue my current interest and now I am a freelance GP and a full-time gender specialist.

What opportunities exist for other doctors who want to specialise in the treatment of transgender people?

There isn't really any official training available in transgender care. But with access to the Internet, there is now endless opportunity for doctors to read policies, guidelines and research to help them to understand more about the needs of the trans community and how best to help them.

I really believe that gender care should be a routine part of General Practice, just as contraception and menopause treatment is. GPs are good at dealing with stress, family issues, workplace problems and hormones. These are the nuts and bolts of gender care and GPs should be offering this routinely.

I have found that a lot of the dysphoria that gender variant people suffer is not due to their variance, but the attitude and responses from society and, ashamedly, the medical profession. If we sort that out, we are a long, long way toward making gender care very simple and easy and less demanding on the doctor and the patient. Trans people are startlingly well-informed: listen to them about their diagnosis and management plans – they have done most of the work for us.

I am presenting a piece of work at the WPATH this year – "Gender dysphoria or medical dysphoria: what causes distress amongst trans patients?"

I find myself concerned about transgender children. How does one determine whether it's ethical to treat children for transgenderism, especially since no long-term studies have been done looking at the outcomes?

The children I have met have been amazing. The diagnosis is often so clear cut, and allowing them to go through a life-changing puberty, that so clearly doesn’t match their true gender, is bordering on inhumane.

By blocking puberty and giving them time to mature and understand what they want and need for their future, you are preventing them from having to have life-threatening surgery in the future, and a life of mismatch and potential humiliation.

I so totally agree with you about the lack of evidence, and that we are guessing and feeling our way, hoping it is right. But we need to prevent transgirls developing into big hairy men, and transboys developing into shapely, delicate females. There is a reason why the suicide rate is so high in this group, and we must stop their bodies developing wrongly.

If you could wave a magic wand, and change one thing about the treatment of transgender people, what would it be?

Allow them to help shape and dictate their care. If they want to try hormones, take hormones, have an operation, change their bodies – make it easy for them, not the huge struggle they seem to face at the moment.

It seems that transgender issues seem to have burst onto the public stage in the last couple of years. Do you have any thoughts about why this might be? And where it might all lead?

The true prevalence of transgenderism of any degree (remembering that gender is a spectrum on which we all lie, somewhere between 0 and 100%) is massively underestimated, I expect. In the 80s, people felt more confident to come out as gay, and the same is happening now for the trans community. We are about to see the true extent of exactly how common it is to have some variance with your gender. Is ‘male’ and ‘female’ a human generated idea – and have we got it all wrong?

Human X and Y chromosomes
The concept that there are two genders is wrong (in my view). There are two sex-determination systems – XX and XY – and our society has presumed that our gender identity matches those and has made this dictate everything from what you should wear, to what job you should have, to what role you should take in life, to what bathroom you should use, to what gender you should choose to marry.

In the olden days, we also presumed that our sex-determination system also matches our sexual identity (who we are attracted to), but look how wrong we were about that. Again, society dictated that there would only be one sexual identity and we made all the rules about marriage and commitment to fit that. Latterly we have had to re-write the rulebook.

I believe that everyone is on a spectrum of gender (identifying as male or female or somewhere in between) and identity (fancying men or women or anywhere in between) and preference (liking pink or blue or fairies or sport or animals or trains). Society shapes this and suppresses our liberty to express somewhere else along the spectrum. I would love to see what happened in a new society, born without rigid rules and constraints and expectations. Would I have been a very feminine heterosexual?

My video talks about the sphere of diversity, and in that sphere are lots of spectra, and where we lie on each spectrum gives us a unique point within the sphere, unique to you and to me, and excitingly different.

Do you ever refuse to treat someone for gender issues? How do you determine if a person is suitable to be treated or not?

I would be very concerned about someone whose gender issues seemed to stem from a bad experience in earlier life. For example a person who wanted to hide from their genitals and sexuality due to a previous history of sexual abuse.

As my service is a remote service, I do not treat anyone who is shown to have manipulated the system in order to get medication.

Most people are absolutely honest and genuine and so grateful to have the chance to get the care they need, but sometimes I have to signpost people back to their GP.

Have you ever come under criticism from colleagues or the public for what you do?

Oh yes. In one year I have been reported to the GMC twice (but they have found no concerns) and threatened to once – all by leading doctors in this field in the UK.

AMAB? I thought you said...
A transmale counsellor working in the field said I wasn’t qualified. A well-known psychiatrist said that I wasn’t qualified and did not do a comprehensive enough assessment. If the diagnosis of an AMAB who has been cross-dressing for years, and would now like to develop some soft skin, breasts and shapely thighs isn’t a clear enough self-diagnosis, what is? Gay people don’t need a psychiatric evaluation before they are allowed a same-sex marriage. Not all people with abdominal pain are excluded for delusions before taking out their appendix.

Some of these healthcare professionals are supposed to be caring and helping the trans community, but the stories I hear of people’s experiences in their GIC make my toes curl, so I am not surprised that I am not always treated with respect. I wonder whether they are just keeping the GIC waiting list so long to fuel their private practice. I can’t see any other reason that they would not welcome an experienced GP who is helping relieve the burden of their work.

One of them publically wrote about how gender care that is straightforward should be delivered by people’s GPs, and in the same month I received a letter of concern from him via the GMC for doing just that!

Gender care needs to be brought under the auspices of General Practice, and done by good old (modern) GPs who are used to dealing with everyday people, every day. If we don’t start encouraging GPs to embrace this field of medicine, then the waiting lists for the GICs will soon be 10 years, not 2!

The public have been great, I have received so many letters, cards, reviews, testimonials – and every one has been truly complimentary. I have changed many lives for the better, and I expect saved a few desperate lives of people who thought they had nowhere else to turn.

Do you have any thoughts about the autogynephilia model of Bailey and Blanchard?

I had never heard of it so I just looked it up. The majority of transgender patients I have had the pleasure of treating could no way fit into this model. I guess that these ideas could be made to fit some people, but to generalise and say this theory explains gender issues is outright wrong.

I have never really thought about the philosophical arguments so much. I have always concentrated on the physical, psychological and social needs of my patients, so the theory is interesting but a bit mind boggling!

Which famous person would you most like to meet, and why?

My family and friends laugh at me because I just have no interest in ‘famous’ people. I would like to be famous for really transforming gender care in the UK and the rest of the world. I would like to shake hands with my future self for helping trans people to access safe and easy healthcare without fear of humiliation, prejudice or judgement.

===

As always in my interviews, I like to reflect a little about the answers.

First, Helen seems to be extremely unusual: a doctor who treats trans people and is willing to talk about it openly and willingly. She seems so open, so inviting, in contrast to the attitude of many other (but not all) doctors, which seems to be to be with awkwardness and silence (a vestige, perhaps, of the “shame, secrecy and trauma” which Alice Dreger talked about with intersex children).

Accepting: Webberley
In addition, Helen offers a multitude of ways for people to get in touch with her, which leads me to wonder how she can possibly get any work done. I seem to be forever answering emails, and I don’t have people all over the world asking me about hormones!

I approached a surgeon who performs sex reassignment surgery, and he declined to be interviewed. In fact, he was barely polite with my request. He would not consent to be named publicly. When I offered him an anonymous interview, he was sure that he would be recognised by his answers.

So I guess my point is: so what? If you are a doctor, and you are performing perfectly legal operations, believing in good faith that you are acting for the benefit of your patients, why should you hide? Surely you either believe in what you do, or you don’t. And if you don’t, why are you doing it?

Helen comes across as completely the opposite. Open, friendly, non-judgmental. Willing to discuss some very sensitive issues very freely. I see her very much as a step in the right direction: the direction which says that you don’t need to hide if your gender doesn’t quite fit the slot, but are deserving of sympathy and acceptance and respect. She isn’t hiding; instead she is out there trying to be noticed.

I found myself surprised (read: astonished) that she had never come across the autogynephilia model. I thought everybody knew about that one! But again I find this refreshing: that someone can come to a field (you might say a minefield) like gender, and just apply their own take on it, and be so positive, without being subject to what other people want you to think about it.

I couldn’t help challenging Helen on some of her practices. I believe medicine should be guided by science, and yet the science is lacking in a lot of areas. Again I found her answer refreshing: “guessing, feeling our way, hoping it is right”. How humble, and how different from the dogmatic certainty of people like Paul McHugh.

I am impressed (in case you couldn’t have guessed) with Helen. I find myself hoping that she is in the vanguard of a new wave of doctors: open, receptive, non-judgmental, willing to listen to trans people instead of dictating to them . I wish there were a hundred like her—and perhaps soon there will be.

My thanks, as always, to Helen for her patience, not just with my questions, but with my flurry of emails requesting clarifications on several points. My thanks, too, to her husband Mike for reviewing the final draft.

Form an orderly queue, please. The doctor will see you now.

21 comments:

  1. What an interesting blog- some very informative posts about gender issues. A couple of things that most of the experts seem to leave out is current research into the human genome and basics of human/ animal biology. In the former a fairly recent article about the genome has found that there are at least 17 distinct pointers to human gender. As humans we like things to be laid out easily so lets suppose that at one end is the human male- eats trees fights bears etc and at the other the uber female. In the middle sits the hermaphrodite with the rest of us sitting[ sometimes] uncomfortably between the extremes and the centre.

    Now the biology of mammals [much of which is generally similar] seems to be left out of the gender question. While in the womb the human baby which starts as female recieves a testostereone bang from the mother to start the gender creation of a male. However should this not take fully then a gender confusion arises. Later as the child grows a second testosterone bang happens at the start of puberty. There is also the chance that this may not take properly so through no fault of their own we have young people suffering from gender confusion without the support they really need. Don't the medical profession read Nature ?

    Anyway carry on the good work.

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    1. Hi, and thanks for posting. Since I get a lot of anonymous visitors, would you mind giving some sort of name or avatar to identify yourself?

      Thanks also for your interesting points. I already knew some of that: that the default phenotype for a human fetus is female, and alteration to male requires not just testosterone, but anti-Mullerian hormone as well (which causes regression of some of the female structures).

      In addition to what genetics dictates, environment also plays a part; for example women who take dexamethasone (a steroid with powerful anti-sickness effects) to treat the morning sickness of early pregnancy, have a higher risk of bearing an intersex child, because the dex seems to affect the development of the baby. This is discussed in considerable detail in Alice Dreger's book.

      I didn't know, however, that there were 17 pointers to human biological sex (not gender, which is a societal construct). I don't read Nature routinely, and I would be glad of the reference (if it was in Nature), so that I can check it out.

      This is, of course, a rapidly advancing field, and our current understanding will lag behind a bit, before awareness catches up with the science.

      Don't be too hard on doctors who don't read Nature. I read somewhere that, if a doctor reads two medical papers a day, then at the end of a year they are two centuries behind the literature. With all that going on, it's effectively impossible for any doctor to read everything. Most doctors read selectively, otherwise they drown.

      Vivienne.

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  2. Hi,

    Thanks for putting the interview together and sharing it. I think it's interesting to read a medical professional's view on trans issues. If Helen is the future, so to speak, I'm hoping this bodes well for us all.

    Lynn

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    1. Hi Lynn. Thanks for dropping by. I really hope so too!

      Vivienne.

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  3. I am sure she is brilliant. You have to be to be a doctor. But does she not see that she contradicts herself?

    She clearly says that there are not simply 2 genders, even though there are indeed only 2 sexes.

    "The concept that there are two genders is wrong (in my view). There are two sex-determination systems – XX and XY."
    "I believe that everyone is on a spectrum of gender (identifying as male or female or somewhere in between) and identity (fancying men or women or anywhere in between) and preference (liking pink or blue or fairies or sport or animals or trains). Society shapes this and suppresses our liberty to express somewhere else along the spectrum."

    Yet, if gender is on a spectrum and has nothing to do with our birth sex, than you would think the solution would be to allow people to be themselves, to express themselves in their true personality and character traits, regardless of whether those traits would be termed masculine or feminine. That seems to be what she is advocating in the quote above. Yet that is the opposite of what she is actually doing. She takes the society's suppression and makes it extreme, saying that it's not okay to be the way that you are, with that body, so let us do radical medical surgery to change your body so that you can be who you are. She is not undoing the gender binary, quite the opposite, she is rigorously enforcing the gender binary.


    Why not encourage the boys and say, "your sex is male, but your gender is on a spectrum, so be a courageous male who likes to do feminine things!" That would be undoing the gender binary (but not sex binary) and allowing people to be who they are.

    Even though she already made clear that sex and gender are two separate issues, she goes on to conflate them together.

    I see this so often from the trans community and it's frustrating that they usually are blind to their irrational arguments. Their own arguments go against their own actions.

    I believe, that those who are pursuing sex change surgeries actually believe deep down in only two genders, masculine and feminine, and they want to change their body to match the gender that they feel they truly are. The people who are truly against the gender binary, and not just using it to argue their position, would not even feel like such a surgery would be necessary. They would truly believe that their sex (their body), and their gender expression would not need to match.

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    1. Hi Thorin, this is interesting indeed. An interesting concept that shows that society dictates these two distinct gender roles whether you are genetically male or female.

      I guess that the patients who come to me for medical help are the ones that need help to change their external features and their internal composure with the use of cross-sex hormones.

      Maybe the ones that are 'courageous males who like to do feminine things' don't need medical help to do that so don't cross my path.

      We all have a lot to learn about this part of humanity. Dr Webberley

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    2. Good points, Thorin, but I think getting the advice "be brave" may be quite insulting to a patient who has fought with their gender dysphoria for years or decades.
      Even if one agrees with the notion that there is nothing wrong with the patient, but with the society they are part of (as I do), then if your goal is to help the patient, but you cannot change society, is it then wrong to do the second best, namely helping the patient find a more comfortable spot in society?

      Personally, I have no plans to transition, but I am no longer able to keep back my needs to step out of the male bubble, and I have not the courage to go against the binary. I did try, it is too scary, for my own and my family's income and life is at stake, and "being brave" about that is too macho an attitude to fit my taste.

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    3. Thanks for dropping by to post your comment, BecomewhoIam.

      I agree that it's very difficult to take on the binary, and that grave societal sanctions can befall people who do. I think if you start off not embracing the binary, you are probably OK. I also think if you happen to belong to part of society where non-conformity is applauded (Grayson Perry, the artist, for example), you can get by. But I suspect there are many, many thousands of unhappy trans people, pretending to live a "normal" life out there, while secretly yearning for more opportunity to express their real selves.

      There are plenty of people in this closet; no wonder it feels so pressurised at times!

      Vivienne.

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  4. I am horrified, but not surprised, at the answer that this GP doesn't believe that the two type model doesn't fit... yet she describes an individual who has been cross-dressing for years? Ummm... what do you think motivated such cross-dressing? And please don't repeat back the standard transsexual narritive. She had to "look it up"? That tells me that she is totally uneducated in this field. No wonder she has been told that she is unqualified... because she is. Any good care giver in any field should KNOW the literature cold. She she have read the research and gotten serious training. But here, she is... no background, and only "looked it up"... and then declares, without actually looking at the science, that none of her patients fit the profile? ALL of them fit one or the other profile. Sad to see such ignorance in medicine...

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    1. Steady on, Kay.

      One of my points (which Helen accepts) is that much of the literature out there is misleading, biased, or incorrect. You know that as well as I do. So "knowing the literature cold" isn't always of help.

      The autogynephilia model is just that: a model. It isn't "the truth". It isn't even very close to "the truth": it just happens to be reasonably predictive in some circumstances (and not all, as you suggest).

      We are long overdue for a better model; unfortunately the storm created around Michael Bailey's book has put a lot of people off doing the research. Meanwhile, gender-discongruent people haven't simply gone away, and here is a doctor who is willing to listen to them and help them. Why can't you see that's a good thing?

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  5. Every "Gender GP" should own and read a copy of The Praeger Handbook of Transsexuality – Changing Gender to Match Mindset by Rachel Ann Heath. It covers much of the science, including an explanation of the Fruend / Blanchard two type taxonomy... as well as covering the earlier taxonomies, which once you put the whole of the research corpus together, you can easily see that they too are groping toward the same two type taxonomy, but with different nomenclature and slightly different emphasis on what diagnostic criteria are the most salient to the differential diagnoses. But of the veracity of the two type model and its near universal applicability, there can be no doubt to the careful and thoughtful student of the field. You may read my review of the book at this link.

    https://sillyolme.wordpress.com/2015/03/27/the-more-you-know/

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    1. I am sure Rachel's book is good. I am sure your endorsement of it is sincere. But no matter how good the book is, it does not hold a monopoly on useful information, helpful advice or sensible decision-making.

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  6. re "I found myself surprised (read: astonished) that she had never come across the autogynephilia model. I thought everybody knew about that one!"

    While autogynephilia is not uncommon among cross-dressers -- who may eventually transition, gender-wise, most transgender people don't come out of cross-dressing. Given that, I'm not so surprised that she's not familiar with autogynephilia. And maybe it just doesn't come up in her practice, even if she is sometimes dealing with autogynephiles, simply because it's not necessary for her to understand that in order to do her medical job?

    Have you written about Caitlyn Jenner at all? Seems like she may have gone the route of cross-dressing to transsexual.

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    1. Hi Georgia,

      Please forgive the delay in replying. Your message for some reason was trapped in my spam filter. I get dozens of spam comments a month, so I usually delete them wholesale: just caught yours in time!

      I suppose it's a natural reaction to think that everyone approaches the subject of crossdressing from the same angle as oneself. But of course this isn't necessarily true!

      I did indeed write about Caitlyn Jenner, and you can find the post here: http://bluestockingblue.blogspot.co.nz/2015/07/caitlyn-jenner.html

      Best,

      Vivienne.

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  7. Hey thanks for doing this interview as i was sceptical of the services provided. I still have problems in my own mind with giving children hormones (reproduction/sterility being the main concern).
    For adults though it is great if you can afford the private route. Thanks.

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  8. Thanks for mentioning my book Kay, and especially for your excellent review of it. I had contemplated a new book along similar lines that would include research conducted in the decade after its publication. Your thoughts about varous anomalies in the argument are well-taken.

    I used Helen's unique service to encourage GPs and otger interested professionals in my local area to set up a Medicare clinic with the leadership role being undertaken by the primary care team, i now understand that excellent progress is being made and this will become an example for all of Australia to follow.

    Thanks Helen for being the pioneer in treating gender affirming people with the respect they deserve.

    Rachel Heath, Newcastle, Australia


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  9. Unless you are working with gender dysphoria or suffer from it you cannot possibly understand, it's like trying to describe the reflective nature of water to a blind person, Dr Webberly is helping people experiencing the most traumatic experiences one can as a human being, I for one have had no help with GPs nor other gender specialists and have suffered since a child, this has never changed, DR Webberly gave me hope and is extremely thorough in her approach, Everyone fails to adress what is really happening, we are birthed by life and life is infinite in its diversity, humans are part of that they evolve and are changed just as all things are from mountains to molecules, we try to limit change and evolution but it's impossible we as a species have to change to, one day we will be able to break free from all boxes and modification, of the body and gender will be completely accepted if anything I believe transgender people are that, humans evolving beyond limitations set out by fear ��

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    1. Thanks for dropping by to post your comments, Clarity.

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  10. Hi Rachel, many thanks for that. I would be very interested to shake hands with the Australia team if you could put me in touch? Helen

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