Institute of Psychiatry arranges Clinico-Pathological conference

Rawalpindi

The Institute of Psychiatry & WHO Collaborating Centre, Rawalpindi Medical University presented a Clinico-Pathological Conference (CPC) on ‘Where Do I Belong? Mental Health & Sexual Disorders.’

The CPC was the first one carried out under the newly appointed head of the Institute, Dr. Asad Tamizuddin Nizami. In attendance were consultants, residents, house officers, and medical students.

The seminar began with the recitation of the Holy Quran by Dr Yousuf Raza after which Academic Registrar at the Institute Dr. Sundus Fatima set the stage with the presentation of a case of a true hermaphrodite. The patient was born with ambiguous genitalia but predominantly appeared as a male and was raised in that gender role. The patient started developing breasts and menstruating in early teenage and consequently he withdrew from society and started experiencing depression, said Dr. Sundus.

She discussed various psychosocial issues of the patient and results of the psychological assessment. She highlighted the psychiatric management of the patient. Sex reassignment psychological assessment to determine patient’s readiness for the procedures, treatment of co-morbid depression, risk assessment for future psychological complications, social support mobilization and family interventions were discussed.

Head of Surgical Unit-I at Benazir Bhutto Hospital Professor Naeem Zia then presented the surgical aspect of the management. He spoke about the importance of a collaborative effort in the management of this case and the depression, consent, role identification and the required help from psychiatry colleagues.

Gender Assignment, he said, is essential in case of True Hermaphrodites. He spoke about the importance of early intervention and the necessity of consent. He highlighted the challenges of mastectomy in normal individuals which are further compounded in situations such as the case. He showed the audience the difference between the pre-operative and post-operative condition of the patient. The most significant marker of the intervention, he said, was the gratification at seeing the smile and contentment on the face of the patient following the procedure.

Head of Gynaecology Unit at Benazir Bhutto Hospital Professor Shagufta Sial elaborated the disorders of sexual differentiation. She explained the gonadal distribution in these patients. She explained that both testicular and ovarian elements are present in different combinations.

She then described the chromosomal and gonadal characteristics of the case. The dilemma lies in the fact that patient was a female biologically with 46 XX chromosome and had both gonadal tissue while he was always reared as a boy. The difficult moment was when he started having increase in chest size with female like breast and female genitalia, she said.

She highlighted the cultural problems in the management options. Out of three possible options, the patient and his family opted for the one in which his societal role as male was preserved. At this important stage in his life, psychiatric consultation was sought. This evaluation focused on his gender identity before surgery for sex assignment. Also detailed discussions were done with patient and parents to assess their attitudes and inclinations, said Professor Shagufta.

She concluded her talk by describing the hormonal assay and the significance of multidisciplinary approach in the patient’s management which is a perfect example of treatment according to bio-psycho-social model.

Assistant Professor and Head of Child Psychiatry Unit Dr. Ayesha Minhas spoke about the classification of psychosexual disorders. She began with a clarification of the definitions of sex and gender; explaining that the former is a biological indicator of male/female whereas the latter also incorporates social and psychological factors.

Senior Registrar at the Institute Dr. Muhammad Azeem Rao then took stage and presented his research findings associated with transgender population. He spoke about the high incidence of psychiatric co-morbidity particularly depression and self-harm. He showed that 40 per cent of the sampled patients had depressive illness, 23 per cent had suicide ideation while 11 per cent had attempted suicide.

Dr. Asad Tamizuddin Nizami, the Head of the Institute, concluded the seminar highlighting the theme of the seminar further. He congratulated Professor Muhammad Umar, Vice-Chancellor RMU, the faculty and students for the accreditation as a university.

He began his presentation by highlighting the global perspective stating violence against transgender is common (including police abuse, abuse by clients of sex workers and intimate partner violence) and that they may experience family rejection, violation of their rights to education, employment and social protections and as such experience higher rates of unemployment, poverty, housing insecurity and marginalization.

He also said that studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. Especially, he mentioned that depression, suicidal tendency, self-harm and eating disorders are particularly high in this population.

Dr. Asad went on to highlight the legal perspective with how the Supreme Court of Pakistan ruled in favour of a group of transvestites in 2009 followed by granting the ‘Third Gender’ official protection from discrimination. Unfortunately, he added, no civil rights legislation exists to prohibit public or private sector discrimination on the basis of sexual orientation or gender identity. This, he said, naturally leads to the psychiatric illnesses seen.

He concluded with a series of rhetorical questions inspiring the participants to be more caring and empathic towards members of this population. The session concluded with a question and answer session.