Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697636998271.pdf (Australia)
A SUBMISSION PAPER TO THE SENATE SELECT COMMITTEE ON MENTAL HEALTH FROM: The Gender Identity Awareness Association www.gendermenders.org Date: Monday, February 06, 2006 1 ABOUT THE GENDER IDENTITY AWARENESS ASSOCIATION (GIAA) The Gender Identity Awareness Association provides information and support for those individuals who suffer from gender identity disorders but who, for whatever reason, are unsuitable candidates for gender reassignment procedures.
Internationally, only about 10% of those fronting such clinics with a request for a sex change go on to surgery1.

The percentage of patients presenting at Monash who go on to surgery, however, has increased alarmingly over the years from 29% to approximately 40% at the present time2.
GIAA membership includes a number of persons misdiagnosed as transsexual and mistreated with sex modification procedures, the long term consequences of which have proven to be catastrophic for the person concerned and for their family, friends and significant others.

The purpose of the group is to help protect further patients from being misdiagnosed and mistreated in the same way.
At the present time, the Monash Medical Center Gender Dysphoria Clinic is the only government funded and recognized treatment center in Australia.

Whilst the clinic was originally intended to provide a service for all individuals with gender dysphoria, in fact it is little more than a sex-change treatment center in which only those patients who are considered on brief assessment to be a “true transsexual” are offered a place in their sex-change program.
Members of the group “Gendermenders” share a common belief that gender dysphoric persons require professional care and counselling and that rigorous and comprehensive assessment needs to take place before patients are recommended for irreversible and invasive sex modifying procedures.
We are aware that there are others in the community who believe that individuals have a right to self determination with regard to sex and gender and ought to be provided with unrestricted access to cross-sex hormonal medications and sex modifying surgical procedures as is the case with (other) “cosmetic” procedures.
We believe that such an approach would pose a very real danger to vulnerable individuals whose condition is due to psychological or situational factors that could resolve in time or through psychotherapy and whose distorted self-perception arguably precludes the ability to give a genuine informed consent to such treatment.
We are concerned that an excessive reliance upon sex reassignment procedures, combined with inadequate assessment and care, is presently resulting in the inappropriate administration of gender reassignment to patients who might otherwise have adjusted to a non-surgical solution in time or through psychotherapy.

1 "Surgical gender reassignment for male to female transsexual people", National Health Service UK, September 1998.
2 “Review of people presenting at the Monash Medical Centre Gender Dysphoria Clinic from 1/1/93 to the 31/12/2003”, Mary Samuhel, DHS.

2 We are also concerned about the unproven and experimental nature of sex modifying procedures as a treatment for GID and the lack of long term outcome data on the patients of the Monash Gender Clinic.
We would like to see that every opportunity is given to those who’s condition may be due to psychological or situational factors that could resolve in time or through psychotherapy to resolve their gender conflict by that means and that an independent, long term outcome study is conducted into the patients who have undergone sex- change procedures at the clinic in order to determine the efficacy of those procedures.

This submission is submitted to address the above concerns and to further the above aims.
Ken McGuire GIAA www.gendermenders.org 3 INDEX INTRODUCTION CONCERNS LACK OF GOVERNMENT SUPERVISION RELIANCE ON SEX CHANGE PROCEDURES LACK OF PATIENT OUTCOME DATA APPENDIX 5 8 9 13 SUMMARY OF CONCERNS BY MEMBERS OF GIAA 16 PUBLIC DOCUMENT ATTACHMENTS “SUFFERING FOR THE SAKE OF IDENTITY” “BILLINGS URBAN REPORT” “RECENT DHS REVIEW” 4 INTRODUCTION The demands of transsexual lobby groups for government funded sex modification programs and the concomitant law reforms are being imposed upon Australian citizens with little regard for public opinion or medical and scientific support.
There is an urgent need to review the efficacy of sex modifying procedures as they are presently being practiced and for consideration of the ethical issues and consequences of this practice in order to determine whether or not this is an appropriate or desirable use of medical technology.

How were sex modification procedures introduced?

Historically, the majority of Australian citizens and medical professionals have opposed the use of sex modification as a treatment for gender dysphoria.
Dr. Herbert Bower, who first started seeing patients with gender dysphoria around 1950’s3, describes the first such surgery performed in Melbourne as follows: “The first male-to-female surgery in Melbourne was cloaked in the deepest secrecy.

It was the late 1960’s and the public would have been in uproar.
The surgeon and his staff operated on Sundays so his colleagues would not know and the whole procedure was kept firmly underground.”4 This highly controversial medical experiment was being conducted in Australian society, without any consultation with the medical profession, government approval or public support.

Keeping the general public and medical colleagues in the dark is firstly deceitful and secondly, suggestive of a lack concern for ethical issues and input from the rest of the medical profession.
How did sex modification obtain government backing?

Psychiatrists involved with “sex-change” procedures eventually managed to persuade responsible authorities to approve of “properly supervised programs”.5 In 1969 Prof. Richard Ball started the Transsexualism Consultative Service6 (TCS).
The University of Melbourne Department of Psychiatry and the Mental Health Authority endorsed this service, which was located at Royal Park Hospital and funded by the Office of Psychiatric Services (OPS) of the Department of Health Victoria (HDV).

In 1975 the Queen Victoria Medical Centre set up its own Gender Dysphoria Clinic under the leadership of Professor W. Walters and their first surgery was performed at the Queen Victoria Hospital the following year.
3 Saji S. Damodaran and Trudy Kennedy “The Monash Gender Dysphoria Clinic: Opportunities and Challenges” Australian Psychiatry Vol 8 No 4 December 2000 4 “Gender Bender” The Age, Saturday Extra 9 Octorber 1999 5 Letter to Robert Coming NHMRC dated 12 January 1984.

6 Briefing Note from Valerie Gerrand, Manager, Client Services DHS dated 27 June 1994 5 During these developments, debate about the appropriateness of such procedures continued within the medical profession.
Many saw transsexualism as a delusion of psychotic proportions requiring psychiatric treatment and viewed sex modification as complicity with the psychosis and therefore both inappropriate and ineffective.7 In 1979 the largest “sex-change” program in the USA at John Hopkins was closed following an outcome study of Meyer And Reter, which concluded that gender reassignment conferred no objective advantage8.
Whilst many medical authorities expressed complete opposition to surgery for the treatment of transsexualism, those involved with the sex modifying programs maintained that surgery was still the best means of coping with a select group of transsexuals.9 The only consensus amongst the medical profession and the Australian government at that time was that there was an urgent need for research10 in order to improve understanding of the aetiology and management of gender dysphoria, and that this was best done in a public setting with a University or research institute association and support11.
In 1988 it was decided that there was to be one government funded Gender Dysphoria Service for Victoria.

It was located at Monash Medical Centre and was made responsible to the board of that hospital.

The Monash Clinic was to be overseen by a government appointed advisory committee who were to monitor the overall running of the program, evaluate its work, and review for the purposes of ratification any decisions made by the Gender Team of doctors in regard to surgery12.
The establishment of the Clinic at Monash Medical Centre represented government sanction of sex modification as a treatment for gender dysphoria and imparted the credibility associated with the public hospital to such surgery.
The clinic was widely promoted and to this day performs the majority of surgeries in Australia, receiving referrals from other states and over seas.13 The general public became more tolerant, even accepting of such operations, primarily based on the misconception that the condition was biological, that patients were being properly assessed and treated and that the administration of “sex-change” operations were justified by outcome studies.
As it turns out, however, the clinic advisory committee provided just two reports to the MMC board of management in its first three years of operation and then dwindled out of existence.

These two reports mentioned a number of major problems with the way in which the Clinic was operating that seem to have been ignored by MMC.

There was no adequate data with respect to the outcome of patients treated by 7 Walters et.

al.
al.

“Transsexualism and Sex Reassignment”, 1986, Oxford University Press Page 55 8 Meyer, J.K>, & Reter, D.J.

“Sex Reassignment”, 1979 Archives of General Psychiatry 36 pp1010- 1015.
9 Transsexualism and Sex Reassignment Page 147 10 Transsexualism and Sex Reassignment Page, p. 131 11 Memorandum from Prof. Smith, Monash University dated 18 July 1988 12 Letter from Prof Sigh dated 31st October 1988 13 Saji S. Damodaran and Trudy Kennedy “The Monash Gender Dysphoria Clinic: Opportunities and Challenges” Australian Psychiatry Vol 8 No 4 December 2000 6 the clinic.
No detailed retrospective research had been carried out, even looking at the overall picture of the patients who had previously been treated.

No other clinical research had been undertaken14.

Furthermore, it does not appear that the committee ever fulfilled its intended function to ratify decisions for surgery, leaving only the opinions of Dr. Bower and Dr. Kennedy to guide the decision to operate15.
These two doctors believe that transsexualism is biologically determined, presupposing sex modification rather than psychotherapy as the treatment of choice – a view, which even they admit, is not held by many in their profession16 nor supported by the available scientific evidence17.

As a consequence, the Clinic seems to have deteriorated into a sex modification centre in which only those patients who are considered on brief assessment to be a true transsexual are offered a place in their program18.
It does not appear that these patients are receiving even the minimal psychotherapeutic assessment required by the standards of care that the clinic claims to abide by.

14 Letter fro Prof. Ball dated 22 November 1990 15 “Gender Bender” Saturday Extra 9 October 1999 16 ibid 17 Transsexualism and Sex Reassignment Page Page 5 18 Document dated 10/12/99 from the clinical secretary outlining the operation of the clinic.
7 LACK OF GOVERNMENT SUPERVISION Patients, who were operated on more than a decade ago, are now starting to recover from their mental illness and to come forward with complaints of inadequate assessment and inappropriate treatment.

Monash Medical Center has acted quickly to distance themselves from responsibility for the treatment of patients at the clinic.
For example, whereas Monash used to claim that they had a clinic for the diagnosis and treatment of gender dysphoria19 they now claim that Monash merely “coordinates the activities of a group of private specialists involved in the treatment of gender Dysphoria.”20 The Department of Human Services have also dissociated themselves from the operation of the clinic, the advisory committee, who were to oversee the clinic, fell apart almost as soon as it was established and no other government agency has assumed any responsibility for the treatment of patients.
No adequate evaluation of the sex modification program provided by Monash Medical Centre has ever been undertaken and the clinic still has no outcome data available 21.

A recent review of the Monash clinic was conducted by the DHS but limited to “discrete service components” being those components that were publicly funded.

The medical records of “private providers associated with the service” were considered to be “outside the purview of the Chief Psychiatrist” and were not examined22.
The DHS review, limited as it was, nevertheless found it necessary to make extensive recommendations many of which reflect the most basic and minimum requirements expected for any kind psychiatric assessment or clinical practice.

The fact that the clinic has simply not been operating at that level is of great concern.

There is an urgent need for recent recommendations set forth by the DHS to be implemented as soon as possible.
There is also a need for a more extensive and comprehensive review of the entire service which includes both private and public components and which takes into account the needs of those who are not treated with sex modification procedures and also the management complications such as post surgical regret.

19 Monash University Guidelines on Gender Transition or Sexual Reassignment for Students and Staff, 2000.
20 Monash University Guidelines on Gender Transition or Sexual Reassignment for Students and Staff, 2003.

21 “Statewide & Specialist Mental Health Service Review – The Gender Dysphoria Clinic Monash Medical Centre” (2000).
22 “Clinical Review of Gender Dysphoria Service”, Monash Medical Centre, May 2004 8 RELIANCE ON SEX CHANGE PROCEDURES It is clear from the available literature, some of which is cited below, that gender dysphoria is viewed as a mental illness, and that psychotherapy, not surgery, is the treatment of choice for the vast majority of gender dysphoric patients.
Gender reassignment continues to be a very contentious and experimental means of dealing with a highly selected group of gender dysphoric patients who appear to remain unresponsive to psychotherapy.
The Harry Benjamin Minimum Standards of Care, for example, warns those practitioners who choose to offer gender reassignment procedures that: “A plethora of theories exist regarding the etiology of gender dysphoria and the purposes or goals of hormonal and/or surgical sex reassignment such that the clinical behavioral scientist making the decision to recommend such reassignment for a patient does not enjoy the comfort or security of knowing that his or her decision would be supported by the majority of his or her peers.”23 And the Clinic’s book states that: “Many, such as Stafford-Clark, see transsexualism as a delusion of psychotic proportions requiring psychiatric treatment.
Sex reassignment surgery is seen by this group as complicity with the psychosis and therefore both inappropriate and ineffective.”24 “From within the medical profession a not uncommon view has been expressed that gender reassignment is ethically unacceptable in that it is a form of psychosurgery… while gender reassignment surgery does not involve brain surgery, it could be construed s a form of psychosurgery in that it is a surgical treatment for what appears to be primarily a psychological problem.”25 “Levine suggest that up to 70 per cent of their transsexual patients, following long-term psychotherapy, do not want gender reassignment surgery.
Similarly, Morgan has commented that of presenting transsexuals 10 percent will have a major mental illness, 30 percent will be homophobic (anti- homosexual) homosexuals, and 20-25 per cent will be sexually inadequate individuals with ambiguous gender identity.
The remaining 35 – 40 per cent will probably be individuals with primary gender dysphoria, for whom gender reassignment surgery may be the treatment of choice”26 “A survey of the medical literature suggests that some patients who would otherwise have undergone gender reassignment surgery may adjust to a non-surgical solution through psychotherapy.
Moreover, many misdiagnosed gender dysphoric patients need psychotherapy in the first 23 Harry Benjamin Minimum Standards of Care Jan 1990 (4.7.4 Principle 20) 24 Transsexualism and Sex Reassignment Page 55 25 Transsexualism and Sex Reassignment Page 129 26 Transsexualism and Sex Reassignment Page 5 9 instance, not surgery.
Indeed, gender reassignment surgery should only be considered for a highly selected group of diagnosed gender dysphoric patients.”27 Even when presenting the most favorable view of sex reassignment surgery, the Clinic is forced to recognize that sex reassignment surgery is only appropriate for a select group of transsexuals; “While some medical authorities express complete opposition to surgery for treatment of transsexualism, other workers in the field are of the opinion that surgery is still the best means of coping with a select group of transsexuals.”28 As Dr. Bower himself points out: “Sex reassignment surgery produces irreversible anatomical changes which are of great therapeutic benefit to carefully selected patients.
However, it can be utterly disastrous if the diagnostic evaluation has been incorrect.

It is this element of risk that invests the diagnosis and differential diagnosis of transsexualism with special importance”29 From documents obtained with respect to the operation of the clinic it appears that gender reassignment is being administered as the treatment of choice and that psychotherapy or counseling is not commonly practiced30.
A 1999 document states: “We provide an assessment service for patients with gender identity disorders and in particular we provide supervision and counseling for those who are suitable candidates for sex reassignment surgery.
For those patients who have gender dysphoria but are not ‘true’ transsexuals we also attempt to provide counseling, although it is more difficult as the clinic is extremely short of resources and it is difficult to engage these patients in treatment.” The reason that the clinic relies so heavily on surgical solutions to the illness appears to be due to the team’s belief that it has a genetic cause as their comments below show: “In our clinic all of us have a strong feeling that this is probably a genetic abnormality.
The fact is that we have not been able to find out what genetic abnormality it is and we have tried a few things with various gene probes, none of which has come to anything.
Nevertheless, people seem to be more or less born with the need to be transgendered.”31 “We are convinced it is some sort of biological problem”32 27 Transsexualism and Sex Reassignment Page 146 28 Transsexualism and Sex Reassignment Page 147 29 Transsexualism and Sex Reassignment Page 51 30 Memorandum dated 10/12/99 31 Senate legal and constitutional references committee: sexuality discrimination inquiry transcript of 8/8/96 Page 4 Para 5 32 “Sex Swaps keep injured waiting” Herrald Sun, Tuesday, June 20, 2000 last paragraph.
10 “Bower has sought for many years to gather evidence that transsexuality is caused by subtle genetic changes after birth or by hormonal fluctuations during pregnancy, but admits that no definite data have emerged, and that his belief is not shared by many in his profession”33 “Dr Bower believes that ultimately gender will be explained biologically.
He is currently working with the La Trobe University Genetic Unit on a DNA probe, the DAX gene, which he hopes will explain transsexualism, but he admits the search is fraught, describing it as like 'the proverbial search for a needle in a haystack'.

'The human genome is enormous.

But what other explanations are there, except the purely psychological?

Which I simply cannot believe.


'If by any chance I can determine that transsexualism is a condition that is linked to the new DAX gene on the X chromosome it will radically change things because we can argue with the government that this is a condition which has been present since birth, that the patient can't help it.

It is not a perversion and he or she has got to be helped.
We would have very much stronger arguments to demand free surgery.’”34 “The Monash clinic’s psychiatrists take a rigid approach, arguing vehemently that it has solely a biological genetic cause, sourced to genetic error or an onrush of hormones in utero”35 In contrast, the Clinic’s book points out that there is absolutely no evidence to support their beliefs: “So far there is no evidence for a genetic explanation of transsexualism.”36 “There is no evidence to date that endocrinological factors feature among the causes of gender dysphoria or homosexuality”37 “Symptoms of transsexualism are characteristically psychological in nature rather than biological”38 “It is difficult to see primary gender dysphoria as anything other than a psychological disturbance.
It is of particular interest that, of the many transsexuals presenting for treatment, primary gender dysphoria is not the most common diagnosis nor gender reassignment the most common treatment”39 The Clinic’s own book has this to say about treating gender dysphoria in the belief that it is a biological problem: 33 “Gender Bender” The Age, Saturday Extra 9 October 1999.

34 Saturday Extra 11 July 1998 – Article by Crusader Hills.
35 “Suffering for the Sake of Identity”, The Herald Sun Sunday Extra March 28,2004 36 Transsexualism and Sex Reassignment Page 17 37 Transsexualism and Sex Reassignment Page 19 38 Transsexualism and Sex Reassignment Page 8 39 Transsexualism and Sex Reassignment Page 5 11 “While at present there is no evidence to suggest a biological basis for gender dysphoria, it is premature to rule out completely either a biological- environmental interaction or the fact that there may be some cases or subgroups of transsexuals with biological involvement…The insistence by some individuals, both transsexuals and medical scientists, that gender dysphoria is biologically determined is an entirely different matter.
Such a belief on the part of transsexuals themselves is often an indication that they do not want to question the origins of their condition or explore its causes and development: Such individuals are often unwilling to accept any responsibility for their gender dysphoria and will not entertain any attempts to change it.
Professionals who believe that gender disorders are biological may also be attempting to justify the continuation of gender reassignment surgery without too close an examination of the basis of gender dysphoria in particular patients.
It is important to separate belief and fact in such cases, and to recognize the difference between individuals having a need to believe in biological determinism, on the one hand, and on scientific support for theories of biological causation on the other”40 40 Transsexualism and Sex Reassignment Page 20 12 LACK OF PATIENT OUTCOME DATA Treatment of severe primary gender dysphoria (or Gender Identity Disorder as it is now called) with sex change procedures remains a very controversial treatment despite the fact that it has been practiced for more than fifty years now.
The cause or causes remain unknown by definition and there are no reliable objective means of separating patients whose condition might be improved by the procedures from those who are likely to have a negative outcome.

There have not been any outcome studies conclusively linking gender reassignment to objective measures of improvement in the patient’s mental health and wellbeing or any studies to compare the benefits of gender reassignment to long-term psychotherapy.
Given that sex-change procedures have enormous potential for harm, one would expect that short and long term studies of patients that have undergone sex reassignment surgery would be essential in order to justify the administration of gender reassignment procedures.

This sentiment is reflected again and again by many of the doctors who initially supported the establishment and funding of the MMC gender dysphoria clinic.
In 1986 Prof Walters commented in the clinic’s book that: “There is no doubt that there is still a need for a proper long-term follow-up study of patients that have been surgically reassigned… Obviously there is an urgent need for research in this area… because until our knowledge of the condition increases we are not in a position to be dogmatic about the efficacy of gender reassignment as currently practiced.
One might conclude, therefore, that there is indeed an ethical obligation to conduct research into the causes and management of transsexualism.”41 In 1988 Professor G. Smith wrote to Professor Singh in response to Dr. Kennedy’s concerns about the lack of support from the Monash University Department of Psychological Medicine for the continuation of the Gender dysphoria Clinic42.
In this report, Prof. Smith comments: “The attitude of the Department of Psychological Medicine is that gender dysphoria is an important clinical issue which ought to receive special attention in order to improve understanding of the aetiology and management, and that this is best done in a public setting with a University or research institute association and support” And in Prof. Ball’s first report to the MMC Board in 1990, he states: “We consider it vital that the research approach be fostered and incorporated into the program, most specifically with regard to outcome in the short and especially the long term for both individual, sexual and social adjustment.
This we hope will determine and demonstrate the value of this work.” In addition, a letter from the MMC division of Psychiatry in 1991 states: 41 Walters et.

al.

“Transsexualism and Sex Reassignment”, 1986, Oxford University Press, p. 131 42 Memorandum from Prof. Smith, Monash University dated 18 July 1988 13 “The division has required the clinic to develop a secure case file register, assessment protocol, and follow up procedure in consultation with the HDV, Gender Dysphiria Advisory Board.
Finally, in Prof. Ball’s second report to the MMC Board in 1992, he states: “We regard the need for proper collation of all the relevant material vital as is the need for outcome studies relating to all of the patients whatever the ultimate diagnosis or management in order to justify the continuing existence of such work and it’s financial support” It is proposed that the government now reviews its gender dysphoria program and the long-term outcome of patients who have undergone sex modification there.
It is considered that such a review is necessary to enable the Australian government and its citizens to make an informed and appropriate decision with respect to the future medical management of this condition.

It must be determined if sex-modifying procedures are the most appropriate treatment and whether or not this kind of use of medical technology is morally and ethically acceptable.
It is considered that the government can only do this appropriately after long and thorough discussions with a broad section of medical professionals and religious groups.

How should the Monash Medical Program be evaluated?

The Harry Benjamin Standards43 are the controlling guidelines for access to sex modifying procedures.
It is recommended that the government use the relevant standards of care at the time of a patient’s treatment as minimal criteria for the evaluation of the work of the gender reassignment program.

What should be the criteria for determining if sex modification is justified?
Sex modification is considered successful when the transsexual is comfortable and well adapted to the desired sex role, psychologically stable with a well integrated personality44 and is established in some sort of community with a social support network, hopefully with a job and with acceptance from one’s family and one’s friends45.
In order to justify the administration of sex modifying procedures, transsexual lobby groups quote medical professionals stating that hormone treatment and surgical 43 "Standards Of Care For Gender Identity Disorders, Sixth Version", Harry Benjamin Gender Dysphoria Association, February 2001.
44 Transsexualism and Sex Reassignment Page 45 "Senate Legal and Constitutional References Committee Sexuality discrimination inquiry", Australian Government, 8 August 1996 14 reconstruction compares extremely favorably with the outcomes of treatment for other chronic conditions and is 97% successful46 as a treatment for transsexualism.
It is therefore proposed that the sex modification procedures administered in Australia over the past forty years can be considered to be medically justified if more than 97% of the patients prove to be comfortable and well adapted to the desired sex role, psychologically stable with a well integrated personality and are established in the community, are gainfully employed and enjoy acceptance from their family and friends.
It will also be necessary to check the names of any patients who do not respond to the study against records of deaths in order to estimate how many patients committed suicide or died prematurely subsequent to surgery.

Due to the government’s failure to conduct a proper research program in the first instance, the proposed retrospective outcome study lacks a control group.
What this means is that no definite conclusions will be able to be drawn between the sex modification procedures and any perceived or actual improvement in the patients condition.

46 “Transsexualism.

The Current Medical Viewpoint”, The Gender Centre Website (http://www.gendercentre.org.au/currentmedicalviewpoint.htm) 15 APPENDIX – SUMMARY OF CONCERNS BY MEMBERS OF GIAA 1.
Duty of care in arriving at a correct diagnosis: Our members have expressed their feeling of having been diagnosed as a "genuine" or "true" transsexual and placed on the clinical sex-change program prematurely, in many cases after just one or two sessions with a clinical psychiatrist.

We would like to see appropriate minimal assessment requirements put into place as well as safeguards to ensure that a diagnosis and recommendation for treatment by gender reassignment is not made "too quickly."

2.
2.

Elimination of psychological or situational factors contributing prior to initiation of hormones and surgery.

Our members express the feeling that they were not provided with an adequate opportunity to explore or resolve background issues contributing prior to initiation of gender reassignment.

They feel that the "psychotherapy" was directed towards supporting the gender reassignment process rather than to the question as to whether or not it was an appropriate treatment option for them.
We would like to see a requirement for establishing a psychotherapeutic relationship with patients with the goals of (1) eliminating any possible (psychological or situational) contributing factors and (2) exploring the patients understanding of and commitment to gender reassignment.

3.

Informed Consent – diagnosis.

Our members do not feel that they were provided with truthful or complete information about their condition.
They feel that treatment decisions were made "behind closed doors" in clinical meetings and that the true results of psychometric testing were withheld from them etceteras.

We would like to see an assessment process which is more transparent to the patient and that the patient is given full, true and accurate information on the nature of their condition and any uncertainties in their diagnosis that might benefit from psychotherapeutic exploration, for example.

4.
4.

Informed Consent - information about transsexualism: Our members express that they were not informed about the various professional views on transsexualism or about the controversial and experimental nature of sex reassignment as a treatment option.

They feel that they were led to believe that their condition was biological and irreversible and that only hormones and surgery could provide relief to their distress.
We would like to see that patients are provided with true and accurate information about the various theories and professional views on the cause of and treatments for transsexualism.

5.

Informed Consent – consequences 16 Our members express the opinion that they were not provided with adequate information about the limitations, possible risks and consequences of sex modifying procedures.
They were not informed, for example, that there was a "significant" chance that they would wish to cease hormones and go back to their original situation sometime during the "real life test" or that there were individuals who reverted to living in their biological gender again some time after surgery.
We would like to see that patients are given true, accurate and complete information about the limitations, risks and consequences of gender reassignment and that some efforts are made to ensure that the patient does not entertain unrealistic expectations of what hormones and surgery will achieve for them.

6.
6.

Alternative Therapies Our members regret that they were not offered psychotherapy as a treatment option nor given any indication that their condition could be managed with anything other than sex modifying procedures and living continuously in the opposite gender role.

We would like to see that those who's condition may be secondary to psychological or situational factors that could resolve in time or through psychotherapy be given adequate opportunity to resolve their issues by that means.

7.
7.

Securing second opinions: Our members feel that they were denied any opportunity to obtain an independent second opinion on their diagnoses but were instead informed that the clinical doctors were the only experts in the field within Australia and that no one else was qualified to treat their condition.
We would like to see that patients have the opportunity for independent assessment by general psychiatrists or psychologists who are not necessarily proponents of the position that Gender Identity Disorder is biological and irreversible and who may consider that a psychotherapeutic approach to management is more appropriate than gender reassignment.

8.
8.

Follow-up and management of "complications" Our members complain that they were not provided with adequate follow-up or support, especially after expressing continued confusion in regard to their gender identity, regret of surgery or a desire to resume living in their natal gender again.
We would like to see that the clinic protocols incorporate some means of managing "complications" such as support for patients who regret hormones and/or surgery and wish to resume living in their natal gender again, including: (a) Psychological support in coming to terms with any irreversible effects of sex change hormones and surgery suffered by the patient.

(b) Medical support in reversing, as much as possible, any reversible effects of the hormone therapy or surgery.

17