Gender dysphoria is the personal experience of dissonance
between actual and desired gender. When these feelings are
persistent, the person is diagnosed with gender identity
It is a rare disorder, associated with signiﬁcant
psychological distress. Treatment involving hormones and
gender-conﬁrming surgery has been associated with
excellent social, sexual and psychological outcomes.
the UK the Gender Recognition Act 2004 allows individuals
to obtain legal recognition of their post-transition gender.
Lifetime psychiatric comorbidity is high in people with
gender identity disorder,
with 71% reported to have a
current and/or lifetime Axis I disorder.
The outcome of
premorbid psychopathology following gender reassignment
surgery is unclear. Mate-Kole et al
in sexual functioning and neurotic symptoms, whereas
Udeze et al
reported no signiﬁcant effect on psychological
functioning 6 months post-surgery. Following a successful
appeal against a local health authority in 1999,
ban on funding of medical treatment for gender
reassignment was deemed illegal and those diagnosed with
gender identity disorder are entitled to appropriate
treatment in the National Health Service (NHS). The
courts have deemed genital surgery to be an appropriate
treatment in this context. However, there are ongoing
difﬁculties in accessing NHS-funded surgical procedures
and geographical variation is wide.
In Oxfordshire, treatment funding for core gender
reassignment surgery is provided on an individual basis.
The person must fulﬁl the current World Professional
Association for Transgender Health criteria
recommended as suitable for surgery by a specialist NHS
gender identity clinic. Cosmetic surgery and other
procedures, such as breast surgery, larynx reshaping,
rhinoplasty, hair removal, jaw reduction and waist
liposuction, are considered ‘low priority’ and not a core
part of gender reassignment surgery. These are not normally
funded unless in exceptional circumstances, although the
local primary care trust does not deﬁne ‘exceptional’ in this
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. There is currently no provision locally
for ongoing specialist follow-up for those awaiting surgery.
Referrals are received directly from primary care and from
local psychiatric teams. We wanted to review the
characteristics of individuals referred for assessment as
well as the frequency of subsequent requests for surgery and
Individuals referred to C.B. between 2004 and 2009 were
identiﬁed from a referral database kept by the Department
of Psychological Medicine at the John Radcliffe Hospital in
Oxford. Case notes were reviewed by C.B. and K.S. Data were
extracted from the initial assessment notes and recorded
on a form. Comparative analyses were then conducted
using the student t-test for dimensional variables and the
-analysis for categorical variables was performed using
the statistical package SPSS version 17.0 on Windows 7.
The Psychiatrist (2011), 35,325
327, doi: 10.1192/pb.bp.110.032664
Warneford Hospital, Oxford;
Radcliffe Hospital, Oxford
Correspondence to Kate Saunders
First received 23 Sep 2010, ﬁnal
revision 23 Feb 2011, accepted 25 May
Aims and method To evaluate the characteristics of individuals seeking gender
reassignment, the frequency of subsequent referrals to a specialist centre, and funding
approval. Cases were identiﬁed from a local referrals database and data were
extracted from case notes.
Results Fifty-four individuals attended for assessment; 70% were biological males
and 30% were biological females. Mean age at referral was signiﬁcantly different
between the two groups. Over half were taking hormone supplementation and three
had already had surgery. Further, 24% had a current and 30% a past mental illness.
The majority of individuals were referred to a specialist centre for gender
reassignment but only two had funding for surgery approved. Paedophilia was a rare
but concerning ﬁnding.
Clinical implications Psychiatric assessment plays an important role in conﬁrming
transsexualism and in identifying other relevant diagnoses.
Declaration of interest None.
Gender reassignment: 5 years of referrals
Fifty-four individuals from a total of 56 referrals received
attended for assessment. There were signiﬁcantly more
individuals seeking male-to-female transition (70%, n= 39)
than those seeking female-to-male transition (30%, n= 15).
The biological females were signiﬁcantly younger than their
male counterparts at referral (Table 1).
The majority (51%, n= 29) were referred for initial
assessment as opposed to follow-up or re-evaluation of their
eligibility for specialist referral. Eleven males (29%) and
six females (40%) were taking hormone supplementation:
eight males (21%) were taking oestrogens, one was
taking oestrogens and antiandrogen, one was taking a
gonadotropin-releasing hormone (GnRH) analogue, and
one a 5-alpha reductase inhibitor; of females, ﬁve (27%)
were taking testosterone (four depot and 1 gel) and one was
taking a GnRH agonist. Two males (3%) had a penectomy,
orchidectomy and vaginoplasty; two females (13%) had
already had a mastectomy and one a phalloplasty.
Over half of individuals taking hormone supplementation
had purchased it on the internet and were not receiving any
form of physical monitoring for adverse effects. Of the
whole sample, 24% (n= 13) had a current Axis I disorder and
30% (n= 16) had a history of mental illness. No signiﬁcant
differences in past or current mental illness were found
between the biological males and biological females.
Depression was the most common current and past
diagnosis (Fig. 1).
The majority of individuals (80%, n= 45) were referred
to a specialist centre for gender reassignment (Fig. 2),
although only two (4%) have had funding for surgery
approved at the time of the study. Three of the sample had
or were planning to have surgery abroad, on the basis that
services there were more easily accessible and less
expensive than in the UK. Reasons for non-referral to a
specialist centre included being deemed not ready for
transitioning (either determined by the individual or
because the person was not currently living in the desired
gender role), being homosexual but not having gender
identity disorder, having an autism-spectrum disorder with
a signiﬁcant degree of impairment such that the real-life
experience criterion was not met, and seeking gender
reassignment to facilitate or normalise paedophilia. This
latter small group described gender reassignment as a
means by which to increase their intimate contact with
children, which they viewed to be more socially acceptable
in a female role.
The results of our study are broadly consistent with the
current literature. The younger age of those seeking female-
to-male transition has been described in a number of
Levels of psychiatric comorbidity appear to be
lower than those described by Hepp and colleagues.
relationship between autism-spectrum disorders and gender
dysphoria has been described by a number of authors.
It poses a signiﬁcant challenge given the social and
communication difﬁculties associated with this diagnosis.
This becomes a particular issue as living and functioning in
Saunders & Bass Gender reassignment referrals
Table 1 Axis I and II morbidity
Male to female (N=38 ) Female to male (N=16) Total (N=54)
Age, years: mean (s.d.) 35.1 (14.2) 26.9 (9.6)* 32.2 (13.4)
Axis I disorder, n(%)
Current 8 (28) 5 (33) 13 (24)
Past 9 (24) 7 (43) 16 (30)
Affective disorder (
Substance misuse (
Fig 1 Current Axis I disorders in the sample.
Male to female Female to male
Referral to a specialist unit
Fig 2 Referral to a specialist centre.
role are usually prerequisites for referral for surgery. There
are also issues of capacity to consent to treatment,
particularly if the presence of an autism-spectrum disorder
is associated with intellectual disabilities, where it is advised
that psychological and social treatments be pursued.
have been unable to identify any previous literature
describing individuals seeking gender reassignment as a
means of normalising their paedophilia, but this is clearly a
Another worrying ﬁnding is that the internet has
provided a new means by which to acquire drug treatments
without seeing a doctor. Although this allows greater
privacy and ease of access to hormone treatment, the
chemical composition of medications acquired on the
internet is often uncertain and any contraindications,
interactions or side-effects may go unchecked.
The barriers faced by individuals seeking gender
reassignment are considerable. There is widespread
variability in the services funded by local primary care
and the proposed changes to NHS commissioning in
England are likely to complicate this issue further. The
lengthy process is often cited as a contributory factor in the
development of comorbid psychiatric problems, and
untreated gender dysphoria can be associated with
signiﬁcant psychological distress and is a risk factor for
The costs of treatment need to be weighed up
against the ongoing costs of supporting the mental
healthcare needs of those awaiting genital surgery.
This study is retrospective in nature and its primary
objective was not to establish psychiatric diagnoses. None
of the individuals seen by the service had a formal
diagnostic interview so it is likely that Axis II comorbidity
in this sample is underreported. Oxfordshire has a high
student population, with two universities in the city, which
may have introduced some bias.
Future direction of services
Psychiatric comorbidity in the Oxfordshire cohort was
lower than that described in other samples, but despite
many individuals meeting the appropriate criteria, funding
for surgery was rare. In view of this there is a case
for ongoing psychological support to be provided for
individuals awaiting surgery. Doctors should routinely
enquire about where hormones are being bought from,
advise against online purchasing and ensure appropriate
physical health monitoring.
About the authors
Kate Saunders, MRCPsych, is OHSRC Junior Fellow, University Department
of Psychiatry, Warneford Hospital, Oxford, and Christopher Bass,MD,
FRCPsych, is Consultant Liaison Psychiatrist, John Radcliffe Hospital,
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