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Dr Az Hakeem is a consultant psychiatrist, medical psychotherapist and a Fellow of the Royal College of Psychiatrists. He is also a qualified Group Analyst who has used this training to develop and facilitate the unique therapeutic practice of mixed group therapy sessions with gender dysphoric patients both pre- and post-transition. He is author of Trans: Exploring Gender Identity and Gender Dysphoria and his website can be found here. We are grateful to Dr Hakeem for writing the following article for us, in response to questions we put to him.

An interview with Dr Az Hakeem

A career in art or a career in psychiatry?

My interest in Gender Dysphoria stemmed from my interest in Art.

I could never decide whether to pursue a career in medicine or Fine Art:  the other version of my life would have been training in Fine Art, and then going on to be an Artist. But growing up in North Wales I was not quite sure how to become a successful Artist and the career path of medicine seemed more straightforward.

I initially came across the idea of Trans through the Andy Warhol Factory of the 1960’s where people were subverting all kinds of norms and changing their appearance and how they portrayed their gender.  It was around this time that “sex changes” were taking place. At the time I thought this was a very exciting part of human sculpture.

I went into medicine with a view to specialising in Psychiatry as I was interested in understanding more about the human mind (much of my interest in art was related to understanding the mind of the person who created the art).

But after I qualified in medicine my first house office surgeon job was in plastic surgery where I helped the plastic surgeons in performing sex change operations. I found the surgical techniques fascinating and was impressed by their work. But I wondered about what was happening in the mind of the person who was wanting to embark on these extensive surgical procedures. I wondered what this indicated about their mental state and the evolution of this trans-reality in their minds.

When I entered psychiatry, I was dismayed to see the lack of thoughtfulness and curiosity in relation to trans patients. My experience of the surgeons was that they were master craftsmen and any questions were outsourced to the Psychiatrist.  But the Psychiatrist merely seemed to be ruling out any evidence of any major psychoses as the root of the person’s decision, and “allowing” the surgeons get on with the requested procedure. There appeared to be a mutual evasion of responsibility and a lack of any analytical curiosity as to how this person found themselves in this situation.

Setting up the first Gender Dysphoria Psychotherapy Clinic

As a higher trainee in forensic psychotherapy, I was lucky to work at a clinic where I was pretty much allowed to pursue any interest I wanted over a luxurious five years of higher training.  I devoted much of this time to setting up and developing the country’s first Gender Dysphoria Psychotherapy Clinic, which I ran single-handedly in the NHS including as a Consultant.

If I had entered psychiatry and found that no one was thinking about Schizophrenia I would probably have wanted to pursue that. But Gender Dysphoria appears to be the one area of psychiatry where no one is, or was, wanting to think in any in-depth way, other than adopting a non- analytic affirmative approach.  This fuelled my interest in the area.

Being a solitary figure doing this sort of work has its problems. Whilst it affords a degree of feeling unique and special it also attracts negativity and on occasion, overt hostility. Colleagues I worked with whilst setting up the clinic were sceptical as to whether there was “any point” in offering psychotherapy for a population who were often assumed to be beyond the remit of a talking therapy. Many colleagues believed that people wanting to change their sex were actually psychotic – these were mainly Psychotherapists who were not trained in diagnosing psychosis but were using the term in a non-psychiatric generic manner.

The fact that I was offering psychotherapy to post-operative regretters – people who had already undergone gender reassignment and had changed their mind – was seen by some as “pointless” because “the irreversible damage had already been done”. I pointed out that the work with regretters was often similar to grief and bereavement work, where someone has been lost.  This is mourned, and reparation and rebuilding is the focus. I suggested that the genital centric focus of my colleagues was a mirror to a genital centric focus these patients presented with.

Indeed there are many similarities between the pathology which we find in Gender Dysphoria and people presenting as Trans and in the situations that Clinicians find themselves in. The very black and white thinking, which is characteristic of a Trans mind (right/wrong, male/female, etc) was often evident in the very for-and-against position in which colleagues often found themselves with this work.

I have always said that I don’t really mind what my patients do as adults, all I want them to do is think about it beforehand, in some depth.

My work has primarily been with adults. I do feel slightly more concerned about allowing children to do things before they really have the capacity and understanding to make decisions or real understanding of what it is to be any gender. With adults I have never attempted to stop anyone from doing anything:  all I ever want to do as a Psychiatrist is to help people think and help them to be happy in a sustained way which makes sense.

Relations with the Gender Identity Clinics

There was hostility from colleagues working in gender identity clinics – often passive aggressive in the form of non-communication. At times there were good relations between ourselves and the gender clinic with patients mutually referred in both directions. But from toward the end of my time in the NHS this collaboration ended and from then to now I have not received any letters from the gender identity clinics regarding mutual patients.

There was a patient who wanted to see a gender identity clinic in the UK alongside my service and so of course I referred them. The receiving Consultant took the patient on but did not respond to any of my letters or consult with me as to how the patient was doing in his therapy. I was surprised that the patient was then offered surgical sex reassignment without any communication with me as his Therapist and treating medical Psychiatrist who had been seeing him regularly.

This refusal to communicate is very rare in mental health, which is generally a field where interdisciplinary communication is seen to be pivotal. Hostility has also been less passive and more overt: patients have alerted me to quite negative comments about me in social media from colleagues working in gender identity, which I have then had to request be taken down.

Trans-terrorists

Hostility has also come from the trans activists – or the trans-terrorists, as I tend to call them. This is a term I use because the aim of the trans-terrorists is to instil fear and ruin the lives of those who do not fit in with their manifesto and ideals. These are people who have never seen me in a professional capacity, indeed my patients have always found me to be quite open minded, quite thoughtful and quite caring and non-judgemental. The trans- terrorists direct their vitriol towards me because of what they think I represent rather than the actuality. I had the accolade of being referred to as “the most evil dangerous Nazi Psychiatrist in the world” by one particular excitable trans-terrorist. This person has never met me but was reacting to the fact that I was offering psychotherapy for gender dysphoria rather than hormones and surgery. They presumed I was offering some form of conversion therapy, whereas in actual fact all I offer is a neutral exploratory space in which a person can think about their gender confusion without being convinced to do something or not to do something. 

Attempts to silence debate

In 2011 I was invited to be a keynote speaker along with Julie Bindell at a conference “Transgender: time to change” organised by the Royal College of Psychiatrists.  Although I’d never met Julie Bindell, she emailed me and advised me that a 5,000 person demonstration had been proposed by the trans-activists.  As a result the Royal College pulled the plug on the conference.

Conference organisers were braver in Australia, where I was doing a sabbatical. Once again I was invited as a keynote speaker and again the organisers were promised disquiet from trans activists for daring to invite someone who appeared to think differently about trans issues. The organisers on this occasion did not reply but went ahead. Over breakfast in the conference hotel (where I was trying to keep a low profile) someone of an unusual appearance approached and told me that I had not responded to any emails they had sent me.  I proclaimed that this was unlike me, asked for their email address and went back to my room to search my emails. The reason I had not responded was because they were a series of death threats.

My presentation – an overview of my work – was attended by some of the trans activists present at the conference. One trans activist who had presumed that they would have been quite upset by my talk found me to be quite reasonable (I really am quite reasonable) and despite initial apprehensions regarding each other we became quite good friends at the conference and indeed have met for dinner in the UK when they have flown over. I was very pleased that she agreed to write a chapter for my last book.

The value of group therapy for gender dysphoria patients

I trained in both individual analytic psychotherapy and as a group analyst. I found that whilst the individual therapy setting was helpful, the group analytic setting was even more helpful. The risk in the individual setting is that the therapist and patient find themselves in a black and white, yes/no, male/female, I’m right/you’re wrong situation, mirroring the psychopathology of the trans condition itself.

In the group (where all the patients have some form of gender dysphoria) we often found ourselves in a situation where one patient would turn to another and tell them “you sound just like me, but what you’re saying sounds completely mad”. It is often much easier for the group to be challenged in their ideas about gender by others with gender dysphoria. The therapist is there to facilitate and conduct and navigate the discussion and prod and probe at various times, with much of the work being done by the group in true group analytic style. I found these groups to be incredibly valuable for these patients, as did they. Typically I would see a patient for an initial assessment and then meet with them on an individual basis to form a therapeutic relationship so we could gain trust, prior to them then entering my group. Entering an analytic group can be a daunting task for patients but having already formed a therapeutic bond with the therapist they feel safer entering the group where the work can begin.

I typically found that after anything from 6-12 months in the group the initial Gender Dysphoria had been completely resolved. The Gender Dysphoria was a solution that their mind had come up with to make sense of the confusion, which they happened to find in a gender framework. Once they had come to the conclusion that gender was the framework they had stuck with it.

In the world of affirmation or denial, it had rarely been challenged until they entered the group. Often the patients remained in the group long after the Gender Dysphoria had been resolved and found themselves to be in a useful therapeutic role for others coming in.

Pre-operative euphoria and post-operative regretters

There was a common theme of a sense of an initial inauthenticity in relation to their biological sex, which they had hoped would be sorted out by changing sex. There is an initial period of gender euphoria when they felt they had achieved this, but after this had gone they realised that the original sense of not fitting in, or not feeling quite right, persisted, only now in a body that was irreversibly changed and did not make much sense.  Once again, they felt inauthentic but with a new body fraudulence.

I inherited a group of post-operative patients who were mainly depressed and a group of pre-operative patients who are mainly gender euphoric with exciting fantasies of what their life will become. One of the best decisions I made with the service was to integrate these two groups into a heterogeneous group, mixing pre-op and post-op patients. The post-op patients were able to challenge the pre-op idealists with a more reality-based understanding of the limitations of what they were about to pursue and the regrets that they faced.

As I stated in my publications 26% of my patients are post-operative regretters: this 26% of course does not represent the demographic of Gender Dysphoric patents but was the demographic of the people who had been referred to my service. These people were all non- existent data. No one had followed them up from the gender clinic since they had been given their sex changes. They had been free to live their lives as they had wanted to be without anyone asking later whether they had made a mistake. Many of them were too embarrassed to admit that they regretted their decision having persuaded the Doctors and Psychiatrists and gender clinic to give them what they wanted and felt they needed. Many of them were living in a post-operative role which they now felt to be fraudulent but from which they felt there was no return.

The public are often told that relative regret is extremely low. But this of course is a complete fiction. There are no follow-up studies, no one knows what the regret rate actually is and this low rate results from the lack of any information being collected. The patients I saw did not officially exist in any gender identity clinics’ books.

A tool to measure gender dysphoria

When I was living and working in Australia on sabbatical my research team and I developed an outcome measuring tool to both diagnose and measure a change in gender dysphoria which could be used with any treatment be it hormonal, medical, surgical or therapeutic. It measures how unhappy someone is in their gender and how stable they are in that gender identity. It is not limited to how “male or female” someone is:  it can even measure how happy someone is in a non-binary gender identity. It is the only tool of its kind in existence and we made it simple, free to use, and readily available. It is now widely used over the Southern hemisphere.

I have repeatedly written to adult and child gender services at The Tavistock asking whether they would like to discuss using it.  It would not cost them anything and would save them having to invent an outcome measuring tool. I have also repeatedly written to the Chief Executive of The Tavistock. To date I have not had any response from any letters I have sent to them, which to me is somewhat odd.