Kate Adlington: Without borders—lessons for transinclusive medicine

kate_adlington_picWith a theme of “Psychiatry without Borders,” The Royal College of Psychiatry’s annual International Congress in Edinburgh last week was on trend in a post-Trump, post-Brexit era. Delegates were welcomed to “Auld Reekie” from nearly 50 different countries to discuss the latest advances and issues facing mental health patients and professionals—perhaps a sign of the international academic medical community’s desire to defy isolationist ideologies.

It was not only geographical borders that were on the agenda. Boundaries of gender and sexuality were front and foremost of the keynote talk given by Michael King, Professor of Primary Care Psychiatry at UCL. His talk on “the impact of stigma in psychiatry told through the lens of sexuality and gender” was timely given the upcoming Pride celebrations and anniversary of the Sexual Offences Act 1967 in July—marking 50 years since the decriminalisation of homosexuality in the UK.

The horrors of Nazi-led medical experimentations on homosexual people during World War II are widely documented and taught to new generations of doctors. Instead Professor King examined post-War attitudes towards homosexuality amongst doctors and psychiatrists finding further evidence that medical professionals have not always been on the right side of history.

The Wolfenden Report—published in 1957 and widely believed to have paved the way for the Sexual Offences Act ten years later—was produced by a committee including three doctors and with input from a BMA Special Committee. Whilst the report recommended that “homosexual behaviour between consenting adults in private should no longer be a criminal offence” and that “homosexuality cannot legitimately be regarded as a disease”—King stated that medical opinions taken into consideration remained full of “moral disdain” for gay men, ignored the existence of lesbians and crucially recommended “conversion therapy” as a treatment to “cure” homosexuality. [1]

Such conversion therapy—both religious and behavioural—remained popular in certain settings long after the decriminalisation of homosexuality, partly fuelled by the presence of homosexuality as a diagnosis in the International Classification of Diseases up until 1992. [2] Research published in the UK as recently as 2009 revealed that 1 in 6 contemporary psychologists had engaged clients in efforts to change their sexual orientation. [3]

Not until November 2015 was a cross organisational Memorandum of Understanding on Conversion Therapy in the UK signed by medical, psychological, and commissioning organisations declaring conversion therapy to be unethical. It concluded there is no good evidence that it works, whilst there is evidence to suggest it can cause harm. King asked whether some of these medical organisations might have a responsibility to apologise to those people who had been harmed by such treatments in the past?

Doctors have not been immune from stigma themselves. Famously Dr H Anonymous—later revealed as American Psychiatrist John E Fyer—appeared in disguise at the American Psychiatric Association annual conference in 1972 to discuss the discrimination he and many of his colleagues faced for being gay, including being sacked from medical roles. King also claimed that some doctors were banned from training as psychoanalysts up until the 1990s due to their sexuality.

Geographical borders sometimes create medical boundaries. King ended with a stark warning that global progress is not universal—he stated that Russia recently introduced new legislation that encourages the treatment of homosexual people in ominously-named “sexology clinics,” of which little is known but much feared.

It is boundaries of gender identity that might prove to be the challenge for our current generation of healthcare professionals. A pair of articles published in The BMJ this week—a Practice Pointer on Gender Dysphoria and a What Your Patient Is Thinking written by a group of transpeople—focus on healthcare for transgender patients and highlight that up to 1% of the population is transgender and a higher proportion might be gender nonconforming. Transpeople are more likely to experience anxiety, depression, substance misuse, and violence. And according to the Women and Equalities Parliamentary Select Committee people with gender dysphoria have described their experience of interacting with healthcare services as variable to poor. Anecdotal evidence suggests some GPs are reticent about prescribing hormone therapy to transpeople. Access to specialist services is associated with very long wait times, sometimes years, even though satisfaction rates are “one of the highest of any branch of medicine.” The WYPIT authors emphasise that even the inadvertent misuse of language or incorrect names by healthcare professionals can expose transpeople to harm.

Healthcare professionals have a role in addressing inequalities, fighting discrimination, and supporting society’s most vulnerable. However, history suggests that even when offering well meaning support, our actions may be misguided or even result in harm. Trans inclusive medicine may be a new concept for many healthcare professionals but guidance is available where we need it. An approach of open mindedness, as suggested by the Practice Pointer author James Barrett, combined with an assumption that everyone is an expert in their own identity might be a good place to start.

We are in the midst of our own history and how the healthcare profession cares for transgender people will form the legacy on which we are judged over the next 50 years.

Kate Adlington is a clinical editor, The BMJ


  1. Michael King and A Bartlett (1999). ‘British psychiatry and homosexuality’. BJPsych. 1999, 175:106-113
  2. Annie Bartlett, Glenn Smith, Michael King (2004). ‘Treatments of homosexuality in Britain since the 1950s—an oral history: the experience of professionals’BMJ2004; 328 doi: https://doi.org/10.1136/bmj.328.7437.429.37984.496725.EE (Published 19 February 2004)Cite this as: BMJ 2004;328:429
  3. Annie Bartlett, Glenn Smith, Michael King (2009). ‘The response of mental health professionals to clients seeking help to change or redirect same-sex sexual orientation’. BMC Psychiatry. March 2009, Vol. 9, No. 11. http://discovery.ucl.ac.uk/68888