Tim Terry

Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria

The Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria is a publication of the Intercollegiate Committee of the Royal College of Psychiatrists. The overall goal of the Good Practice Guidelines is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynaecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counselling, psychotherapy), and hormonal and surgical treatments. The Good Practice Guidelines are based on the best available science and expert professional consensus. The Good Practice Guidelines articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, the Good Practice Guidelines recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the Good Practice Guidelines to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.

Androgens, health and sexuality in women and men

The importance of good sexual function for individuals is well recognised. Testosterone is contributory to a healthy sex life for both women and men. The British Society for Sexual Medicine (BSSM) has initiated and led the development of these guidelines for the assessment of testosterone deficiency in both women and men, for use within the UK and beyond. Clinical awareness of the possibility of testosterone deficiency and the impact this may have on an individuals sexual and somatic function and the need to make sufficient enquiry about the sex life of patients attending a broad spectrum of clinical services is emphasised. The management of testosterone deficiency is outlined in detail for both women and men.

Current management of male‐to‐female gender identity disorder in the UK

Gender identity disorder (GID), or transsexualism as it is more commonly known, is a highly complex clinical entity. Although the exact aetiology of GID is unknown, several environmental, genetic and anatomical theories have been described. The diagnosis of GID can be a difficult process but is established currently using standards of care as defined by the Harry Benjamin International Gender Dysphoria Association. Patients go through extensive psychiatric assessment, including the Real Life Experience, which entails living in the desired gender role 24 h a day for a minimum period of 12 months. The majority of GID patients will eventually go on to have gender realignment surgery, which includes feminising genitoplasty. The clinical features, diagnostic approach and management of male-to-female GID in the UK are reviewed, including the behavioural, psychological and surgical aspects.

Androgens, health and sexuality in women and men.

The importance of good sexual function for individuals, patients and their general health and well-being is well recognised. Testosterone is contributory to a healthy sexual life for both women and men. The British Society for Sexual Medicine (BSSM) has initiated and led the development of guidelines for the assessment and use of testosterone deficiency in both women and men for use within the UK and beyond. Clinical awareness of the possibility of testosterone deficiency and the impact this may have on an individuals sexual and somatic function and the need to make sufficient enquiry about the sex life of patients attending a broad clinical spectrum is emphasised. The management of testosterone deficiency is outlined in detail for both women and men.

Penile rehabilitation after nerve-sparing prostatectomy: Fact or fiction?

A 65-year-old man is seen in the clinic two months after a robot-assisted bilateral nerve-sparing radical prostatectomy. He is completely continent and has been since the catheter was removed. The main reason for his referral is erectile dysfunction. Pre-operatively his SHIM score was 25 (maximum score 25). He currently experiences some thickening with stimulation, and an erection hardness score of 2. He has a pleasurable sensation of orgasm during which he remains dry. His sex drive remains normal. He has a long-standing history of hypertension and raised LDL cholesterol, managed with amlodipine and simvastatin respectively. He has no other overt cardiovascular or ischaemic heart disease, and he is not a diabetic, but has an elevated fasting glucose of 6.0 mmol per litre. He stopped smoking five years ago, is 5 feet 11 inches tall, a weight of 95 kg, has a waist measurement of 44 inches (BMI 29 – upper end of overweight) (range <18.50 underweight; 18.50–24.99 healthy weight; 25.00–29.99 overweight; >30.00 obese). He performs no regular exercise. His wife is 60. He is keen to try to regain his erectile function.

Caesarean bladder and ureteric injuries in the UK

Lower segment caesarean section (LSCS)-related lower urinary tract injuries are rare. The incidence is rising because of the increasing number of LCSCs being performed. In this review, we classify such injuries into three types and outline their management.