This paper identifies the challenges of interpreting and implementing appropriate eligibility criteria and assessment processes in adult mental health services, with reference to an inner-city Trust's own protocols. Central guidance, local interpretation and professional judgment are all legitimate contributions, but also confound both the concept and processes of entry to service.
The influence of Primary Care Trusts (PCTs) on the reorganisation of UK health and social care provision is already considerable. As well as challenging institutionalised processes of care, PCTs are encouraging innovation. This article reflects on a service pioneered by a small group of mental health social workers, which has been reconfigured within a new PCT, illuminated by examples of direct therapeutic work and service user feedback. In the new service, the practical application of a social perspective in mental health provision is demonstrated by eligibility criteria based on social context as well as psychological adversity. Possible developments arising from the prospective, multidisciplinary team membership and interface with secondary care are anticipated.
Background: The recent reclassification of gender identity disorder as gender dysphoria (GD) in DSM-5 identifies those seeking to pursue gender transition via specialist services as necessarily 'distressed' and therefore mentally disordered. Distress in gender variant clients may arise from a variety of stressors, external and intra-psychic, many of which may have their roots in childhood experience [E. Bandini et al. (2011)]. Aims: (1) to review current thinking on gender variance and recognition and classification of GD (2) to detail the contribution of childhood adversity to distress in gender variant clients from an audit of 50 such clients (33 assigned/natal males and 17 assigned/natal females) of a mainstream NHS psychosexual service. Methods: Current issues in classification and diagnosis of GD, and debate on the aetiology of gender variance, are reviewed briefly. Audit findings on health, treatment issues and support, and thematic analysis of childhood experiences, provide the basis for a case example of a post-transition client experiencing some common difficulties associated with GD and childhood adversity. Conclusions: Pragmatism of diagnosis and treatment of GD contrasts with the variety of theories of causation of gender variance itself. 'Distress' as a precondition of treatment may reflect childhood experience as much as GD-specific symptoms, and may contribute more to persistent psychological vulnerability. While educational programmes in schools and a better knowledge base in counselling and related training curricula are indicated, gender dysphoric clients, pre-and post-transition, experience common life problems for which generic forms of counselling and therapy are appropriate.
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