Summary of NHS England interim guidance for 2013/14 - October 2013
Protocol Notes (section 3.2)
- Transsexualism is the desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment (ICD-10 code F64.0).
- Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristic).1 Trans and gender variant people are not necessarily gender dysphoric.
- Patients with atypical gender identity development but not diagnosed with gender dysphoria will be supported on to a treatment pathway appropriate to their need by the commissioned service.
- See Services for Over 18s and Under 18s below.
- Some, but not all, patients may require formal psychiatric intervention to assist with psychiatric comorbidities and in such cases shared care may be appropriate.
- Assessment, diagnosis and confirmation of gender dysphoria must be by a health professional who specialises in gender dysphoria and has general clinical competence in diagnosis and treatment of mental or emotional disorders, for example psychiatrists and psychologists. (Refer to page 22 of WPATH Standards of Care, V7 for further information)
- NHS England may commission a specialised Gender Identity Clinic (GIC) service from providers able to deliver the range of multi-disciplinary services described in this document, and offer effective and high-quality care for gender dysphoria.
See Services for Over 18s and Under 18s below.
- A period of living in the gender role that is congruent with the individual’s gender identity (sometimes called "real-life experience") before the provision of genital reassignment surgery is required by authoritative guidelines; this is described in Appendix 1 below. The duration of this period is typically 12 to 24 months [UK18.3].
- At the beginning of the period of living in the gender role that is congruent with the individual’s gender identity, the GIC and patient should discuss the practicalities and requirements of the experience and details of patient and family support mechanisms as well as the possible treatments available.
- The period of living in the gender role that is congruent with the individual’s gender identity can be extended if the GIC and / or patient feel that further time is needed or if attendance at the clinic is inconsistent.
- A lead professional will be named on all individualised care plans developed, to provide a link for the patient to the GIC and to ensure follow up of all patients at appropriate intervals. This individual will also ensure that the patient receives appropriate after care.
- Throughout the process of gender reassignment all treatments, procedures, access criteria, associated risks and expectations should be clarified with the patient. An individualised programme of information provision, services, treatment, and surgery as appropriate to the person's individual needs and situation should be discussed and agreed as the patient progresses through the period of living in the gender role that is congruent with the individual’s gender identity. Treatment can be reviewed and modified by agreement of those involved.
- Patients who elect not to have surgery can continue on hormone therapy. This may be supervised by specialist endocrinologists or gynaecologists if this supervision is available. The appropriate clinician should assume responsibility for continued prescribing of hormone therapy (with support as required from the GIC). GICs should ensure that GPs are aware of the hormone management guidelines as detailed in the protocol. In cases where there is uncertainty about the stability of the patient’s gender role, gender specialists should consider offering regular (e.g. annual) review appointments.
- Surgical providers should inform primary care medical and nursing staff of the nature of the procedure, anticipated post-operative care needs, common complications and contact details of the surgical team and associated nursing staff (who provide post-operative care to local patients) as may be clinically appropriate. Good communication is necessary to optimise patient experience and promote a seamless transition from surgical unit to primary care-based care. Hair removal, by laser depilation or electrolysis, at tissue donor sites for genital surgery will be arranged according to guidance from or recommendations of the surgical provider.
- All patients who have surgery should be offered an appointment with the GIC after surgery according to clinical need and within 6 months of surgery to discuss any issues and be provided with a post-operation plan. Information regarding the procedures and post-operation plan should be made available to primary care staff, including district and practicing nursing staff. This should also be provided for the patient’s GP.
Hair Removal for Gender Dysphoria
- Hair Removal for transgender patients is not covered by the Norfolk & Waveney policy / process. It is commissioned by NHS England.
- NHSE have advised that the patient will receive confirmation from their Gender Identity Clinic clinical team, in the form of a letter usually, that they are entitled to hair depilation. Once received, this needs to be shared with the patient’s local team (ie East of England specialised commissioning team if an east of England patient) – email email@example.com, or the patient can call or write to the team, if they prefer.
- There is a list of hair depilation providers already set up with the NHS to provide hair depilation, which will be shared with the patient and they can choose which one they wish to attend. NHSE have confirmed there are several providers within Norfolk for both laser and electrolysis.
Appendix 4 - Hair Reduction
If hair is not adequately removed from areas directly involved in reconstructive genital surgery prior to surgery, it can become a post-operative complication causing risk to the patient and necessitating further surgery to rectify the complication.
FtM patients require hair removal prior to radial artery phalloplasty or radial artery urethroplasty; otherwise the patient would have hair-bearing skin on the inside of the neourethra. MtF patients require hair removal prior to vaginoplasty and labiaplasty.
Hair removal from the donor site can be performed with a surgeon’s recommendation prior to completion of the period of living in the gender role that is congruent with the individual’s gender identity before genital reassignment surgery, in order to reduce delays in surgery.
Facial hair reduction
The reduction of facial hair is seen as an essential part of gender reassignment for a trans-woman to facilitate the period of living in the gender role that is congruent with the individual’s gender identity before genital reassignment surgery. The absence of facial hair is of psychological benefit and will produce a greater well-being for the patient as there should be little or no need to remove hair on a constant basis.
It is recommended that facial hair removal should commence prior to social gender role transition, as the beard must grow to visible lengths to be removed.
Laser and Intense Pulse Light (IPL) treatment for facial hair reduction is most effective on those with dark hair and fair skin and is unsuitable for treating non-pigmented hairs such as grey, white, blonde and red; the latter may require reduction by electrolysis. Some modern lasers are able to effectively treat racially pigmented skin.
A fixed number of sessions (one site test and eight sessions), will be funded for facial hair reduction for trans-women.
Service for over 18 year olds
There are 7 gender specialist clinics for adults in NHS England and referrals can be made to these clinics to explore with the patient the options available to them.
Exeter (The Laurels)
Lead Clinician: Dr John Dean
|Devon Partnership NHS Trust
The Laurels Gender and Sexual Medicine Clinic
11-15 Dix’s Field
|Leeds (Newsome Centre)
Lead Clinician: Dr Amal Beaini
|Leeds and York Partnership NHS Foundation Trust
Leeds Gender Identity Service
Outpatient’s Suite, 1st Floor, Newsome Centre
|London (Charing Cross)
Lead Clinician: Dr James Barrett
> Referral (form) to WLMHT Gender Identity Clinic
|West London Mental Health Trust
Gender Identity Clinic
179 – 183 Fulham Palace Road
Lead Clinician: Dr Byran Timmins
|Northamptonshire Healthcare NHS Foundation Trust
Northants NN11 4DY
Lead Clinician: Dr Walter Bouman
|Nottinghamshire Healthcare Trust
Nottingham Gender Clinic
Lead Clinician: Prof. Kevan Wylie
|Sheffield Health and Social Care NHS Foundation Trust
75 Osbourne Road
Nether Edge Hospital
Lead Clinician: Dr Helen Greener
|Northumberland, Tyne & Wear NHS Foundation Trust
Northern Region Gender Dysphoria Service
Walkergate Park Hospital
Newcastle Upon Tyne
Services for children and under 18s (Appendix 5)
Children and young people experiencing gender dysphoria will access treatment and support via the gender reassignment protocol. Each patient will be considered on an individual basis by their gender identity clinic.
At present specialist gender identity development services for children and young people under 18 are available through the Gender Identity Development Service at The Tavistock and Portman NHS Foundation Trust, London, and their satellite clinics in Exeter and Leeds. Children and young people should contact their GP in the first instance and thereafter may be referred to the Gender Identity Development Service at The Tavistock and Portman NHS Foundation Trust, London.
Other professionals in Health, Social Services and Education departments as well as young people and their families can contact the Service directly to discuss a possible referral. Further information can be found at https://gic.nhs.uk/
Teenagers who are 17 years of age or older may be seen in Adult Gender Clinic.
They are entitled to consent to their own treatment and follow the standard adult protocol, and this consent cannot be overruled by their parents.
Additional contact details:
Gender Identity Development Service
The Tavistock and Portman NHS Foundation Trust
120 Belsize Lane
Tel: 020 8938 2030
Fax: 020 7431 8320
Web: Gender Identity Development Service
The Gender Identity Development Service at The Tavistock and Portman NHS Foundation Trust is part of the NHS Camden Child and Adolescent Mental Health Service (CAMHS) which offers help to children and adolescents from birth until their 19th birthday, their families and carers as well as offering advice and consultation to other professionals working with children, adolescents and their families.
Further information on assessment and treatment of children and young people under 16 with gender dysphoria can also be found in the WPATH Standards of Care, 7th version (page 10, http://www.wpath.org
is available for health professionals.
For more information please visit http://gids.nhs.uk/referrals