Report

Re: Rachel ________ (Zakery _________)

I am writing this letter to inform you that I reviewed this young lady in my clinic at Harplands Hospital Liaison Psychiatry department on the 7th February 2011 at 10am. She attended the appointment alone.

Presenting complaints:
1) Gender issues since the age of 10
2) Occasional periods of depression and anxiety
3) Ongoing gender issues.

History of presenting illness:
Miss __________ informed me that she was well until the age of 10, when she had her first period (menarche). Since then she has been having alot of problems with regards to her identity. She started developing secondary sexual characteristics, which created a problem for her and she feels that this had led her to have low self esteem, poor self image, low mood and occasional anxiety. She reported that she has always felt like a 'boy' and has always been associated with male characteristics, such as playing football, playing with male friends, being attracted to girls etc. She has always dressed like a boy ever since her childhood and she informed me that at the age of 5 when she wore a skirt, she really felt uncomfortable. Her parents split and divorced when she was 8 years of age. She informes me that she told her mother to leave her father, as he had an alcohol problem and was getting aggresive towards them. She is currently living with her mother, who is supposedly working in a special school. She is very supportive.

In terms of her identity issues, she continues to be in the role of a male, which is opposite to her. She has completely made a decision about it. Her parents have accepted her decision. She brought to the clinic today a change of name deed and a couple of letters from her school/college, stating that she was unable to perform very well due to gender identity issues.

The anxiety and depressive symptoms emerged from the age of 10 or 11 and she was referred to CAMHS services, from that I could gather she has received some sort of psychological support and advice. She described symptoms of anxiety and panic attacks, such as palpitations, breathlessness, vomiting, diarrhoea and she also described biological symptoms of depression. The episodes of anxiety and depression have been ongoing on and off since the age of 10. She mentioned that she saw you with regards to her low mood a year ago when she lost her job, and you started her on an antidepressant, which has helped her to a certain extent, but over the past few months things have been deteriorating rapidly and she has been isolating herself, avoiding public places and finding it difficult to cope with her gender identity. She is currently doing a college course and is due to start university; she wants to start the process of gender reassignment in the form of hormone replacement therapy to being before November.

Past medical history:
Psoriasis of the scalp
No other significant medical history.

Past psychiatric history:
At the age of 10 she was referred to CAMHS following episodes of anxiety and depression, for which she received psychological support. She also has a history of deliberate self harm in her teens, mainly due to gender issues in the form of superficial cutting. There is no history of any overdoses or admissions to psychiatric hospitals or other psychiatric services.

Current medication:
1) Dosulepin 150mgs
2) Microgynon 30

She informed me she is allergic to penicillin.

Family history:
Her father is 48 years of age; her parents are divorced and seperated. She is in minimal contact with her father; he apparently has alcohol related behavioural problems. Her mother is 46 and is apparently well, but has a heart murmer. She has a younger brother who is 16, who is living with his dad. There is no history of any mental illness in the family.

Personal history:
Miss ________ reports that she was born from a full term normal delivery. No problems with her developing milestones. She joined school at normal age and there was no history of any seperation anxiety. She was bullied on and off due to her gender issues, but mainly verbally. At the age of 13 she was physically assaulted by a group of girls, which was a random event from what she describes. She was in one relationship with a 19 year old girl. She is not in a current relationship. She is working as a part time cleaner and the moment. She completed her GCSE's and did one year at college, but was not able to sustain this due to problems with her gender, as well as the workload, but has decided to go back to university and currently is doing a course in access.

Psychosexual history:
She was born genetically as a girl, but she described that she has always been a boy. She played with male toys such as cars and never had any dolls. Her mother always thought she was a tomboy and that she would grow out of it. When she reaches her menarche at 10 and had her first period she really had a crisis, and did not know how to deal with it. Ever since then she has always been in the role of a male and continues to be in the role of a male. She is attracted to girls and was in one lesbian relationship, but currently denies any relationship or sexual drive. She is well aware of gender reassignment and has researched this topic on the internet.

Social history:
She is currently living with her mother. Her brother lives with her father. Her mothers accommodation is quite an old house. She is in a part time job. She is trying to claim adult learning grant until joining university. She is not on any benefits and mentioned that she is stressed about her financial situation as she is not able to keep jobs. She drives. She has a few good friends but has a poor social life.

Alcohol and substance history:
Miss _______ denied any significant alcohol or substance use, but I gather from your notes that she had problems with alcohol some time ago, in the form of alcohol dependance for which she was seen by the Addiction services. she denied any current use of alcohol or drugs. She is a non-smoker.

Premorbid personality:
She describes herself to be 'outgoing, confident, masculine and a social person'. She likes football as a hobby.

Mental state examination:
Miss _______ is a 20 year old caucasion woman dressed in male clothes - loose shirt, pullover and jeans, but neatly kempt. Short haired, co-operative and pleasant.

Speech:
She spoke in a slightly deep voice but was relevant and coherent.

Mood:
Her mood was reactive and euthmyic.

Thoughts:
She had negative anxiety cognitions but no formal thought disorder.

Perception:
No evidence of any hallucinations.

Cognition:
She was orientated in time and place and person and had good concentration.

Risk:
She denied any thoughts of self harm, suicide or harm to others.

Insight:
She had good insight with regards to her gender issues and she was keen on getting help for her problems.

Impression:
Miss Rachel ________ is a 20 year old caucasion woman who is presenting with features of gender dysphoria, mainly transsexualism into the opposite gender, that is the male role. She seems to understand the complete process, as she has researched this on the internet. She is settled currently in her male role. She is keen on starting on hormone replacement therapy as she is due to start at university in September. The level of distress caused by her secondary sexual characteristics at the moment is leading her to have depression ans anxiety spells, which are of moderate severity. Even though she has had some issues with alcohol in the past, a bit of self harm and a referral to CAMHS with regards to anxiety and depression, she is currently presenting with no major problems in adjusting to her current role and, in fact, her depression and anxiety episodes are reactive to problems with her gender.

Plan:
1) As he fits the criteria for gender identity disorder I would be greatful if you would please refer him to the gender identity clinic at Charing Cross hospital for futher management.
2) I would be greatful if you could please arrange for routine blood tests.
3) I have reduced her dosulepin to 75mg and I have started her on citalopram 10mg once daily.
4) I have given her information regarding lesbian and gay groups, as well as information from GIRES. I gather she is already known to the IAPT service and is due to start a new session in the near future.
5) I will review her again in 3-4 weeks time.
6) I have asked her to inform me if there are any concerns in the meantime.