Docstoc

Gender Reassignment Paper 10

Document Sample
Gender Reassignment Paper 10 Powered By Docstoc
					Agenda Paper 10

                  SALFORD PCT COMMISSIONING TEAM

       DEVELOPMENT OF COMMISSIONING ARRANGEMENTS FOR

  GENDER REASSIGNMENT SERVICES FOR NORTH WEST PATIENTS


SUMMARY
This paper sets out progress achieved to date in the development of
protocols, pathways and commissioning guidance for the commissioning of
gender reassignment services for north west patients.

The Gender Reassignment Service Development Group with broad
representation from commissioners, both Mental Health and PCT, providers
and patients (Appendix 3) has focused work on clarifying the patient pathway
(Appendix 1), identifying those areas where further work is required and
making recommendations for future service development. This paper
describes each stage of the patient pathway with details of any evidence to
support the provision of and the cost effectiveness of any treatment.
Information on prevalence and contracting numbers is set out in Appendix 2.

The group agreed that highest priority should be given to addressing issues
around accessing local mental health services in order to be able to obtain a
referral to specialist gender identity mental health services. Approval is
therefore sought from collaborative commissioners for the Gender Identity
Service Development Group to undertake a piece of work to scope in detail
the problems and potential solutions around access to both local and
specialist mental health services.




TERMINOLOGY

EUR                   Effective Use of Resources
F2M                   Female to Male
GIC                   Gender Identity Clinic
GRS                   Gender Reassignment Surgery
GRSDG                 Gender Reassignment Service Development Group
HBSOC                 The Harry Benjamin International Gender Dysphoria
                      Association‟s Standards of Care for Gender Identity
                      Disorders
M2F                   Male to Female
RCTs                  Random Controlled Trials
RLE                   Real Life Experience
UCLH                  University College London Hospitals




                                                                                1
                    SALFORD PCT COMMISSIONING TEAM

         DEVELOPMENT OF COMMISSIONING ARRANGEMENTS FOR

     GENDER REASSIGNMENT SERVICES FOR NORTH WEST PATIENTS


1. INTRODUCTION

Salford PCT, as lead commissioner for Gender Reassignment Surgery on
behalf of North West PCTs, presented a paper to Greater Manchester
Collaborative Commissioning Group in May 2005 setting out a proposal to set
up a working group in order to develop protocols, pathways and
commissioning guidance for gender reassignment patients of all of the North
West PCTs. The paper subsequently received the approval of North West
Collaborative Commissioning Groups and a working group was established.
This current paper sets out progress achieved to date against agreed
objectives and the proposed next steps.


2. OUTLINE OF PROGRESS TO DATE

The Gender Reassignment Service Development Group (GRSDG), with
broad representation from commissioners (both PCT and Mental Health),
providers and patient representatives (Appendix 3) met in October 2005. The
timetable set out in the May paper was for the issues in question to have been
scoped in greater detail with a draft policy prepared by end December 2005
and a subsequent implementation plan agreed by the end March 2006. The
development group identified the following key priorities:

        Improve information to inform planning

        ensure consistency of approach across commissioning organisations
         and GPs

        Investigate development of risk share arrangements

In the longer term the group has also identified the need to:

        establish providers of services

        develop quality monitoring framework

Discussions within the group have been wide ranging and a number of other
issues have been considered. The approach the group has taken has been to
clarify the patient pathway (Appendix 1).


3.       BACKGROUND

Specialist Gender Identity Clinics apply The Harry Benjamin International
Gender Dysporia Association‟s Standards of Care For Gender Identity
Disorders (HBSOC). The Royal Colleges of Medicine & Psychiatry are
developing new standards of care for gender dysphoria in the U.K. These
                                                                             2
have been anticipated for some time but have yet to be published and are
unlikely to be so for at least another 6 months.

The Trent Research and Development Support Unit have recently assessed
the evidence associated with key points on the treatment pathways, focusing
on Gender Reassignment Surgery, on behalf of commissioners (Sutcliffe et al,
2005.) They considered 6 earlier reviews which all comment on the poor
quality of the research evidence available; no randomised controlled trials
(RCTs) were available and the studies reflect lower grades of evidence, and
had further problems in their design. Conclusions from the reviews are
understandably tentative, but highlight improvements in patients across most
studies, although 10-15% of transsexuals who undergo GRS having poor
outcomes. They stated no published evidence on cost-effectiveness is
available, nor its derivation possible.

There are three distinct pressures on service development that are pulling in
different directions:

             Lack of available evidence to support the cost effectiveness of
              gender reassignment surgery. This does not support the
              commitment of further resources to the development of the
              service.

             PCTs are legally obliged to make treatment available following
              the decision in North West Lancashire Health Authority v A, D &
              G and the Parliamentary Forum on Transsexualism, chaired by
              Lynne Jones MP, published Guidelines For Health
              Organisations Commissioning Treatment Services For
              Individuals Experiencing Gender Dysphoria and Transsexualism
              in March 2005, recommending a more comprehensive service
              provision than currently available.

             Contact with service users has revealed an underlying feeling
              that there are too many delays along the patient pathway.

Anecdotal evidence from patient representatives has highlighted the ethical
views of some healthcare professionals regarding certain procedures such as
masctetomy for a F2M patient or the provision of hormones. Such issues are
reported to arise when the required service is not being provided by specialist
gender services.

North West Commissioners are not alone in considering service provision for
transgender patients. The Health Commission Wales set out its policy on
Gender Identity Disorder Services in January 2005 and a separate study
considered transgender services for the residents of Sussex in September
2005. Both of these documents identify similar issues regarding care
pathways and local access to services.

Information on prevalence and contracting numbers is set out in Appendix 2. It
has not been possible to identify the number of patients accessing NHS
specialist mental health services, however it has been possible to identify 71
M2F patients and 47 F2M patients who have or who are in the process of
accessing NHS gender reassignment surgical services.


                                                                                3
4. PATIENT PATHWAY

4.1       Overview
          The discussions and work of the GRSDG has culminated in the
          development of a Pathway for Accessing Services for Transgender
          Persons, Appendix 1. This pathway is essentially the same as the
          current pathway for patients who undergo the whole of their gender
          reassignment through the NHS. Where this differs or services are not
          currently provided or where specific criteria/ guidelines are to be
          adhered to is detailed below.

          In broad outline the pathway is as follows:

         A patient sees their GP who refers them to a local psychiatrist.
         Patient sees local psychiatrist and a decision to refer to specialist
          services is made.
         Psychiatrist refers patient to the specialist mental health services.
         Patient is assessed by the specialist services and a diagnosis made.
         If the patient is to continue, a treatment plan is agreed.
         Patient commences reversible treatment including speech therapy if
          required. Male-to-female patients may require facial hair removal at this
          stage prior to commencing Real Life Experience (RLE).
         Patient commences RLE.
         After meeting eligibility and readiness criteria, patient commences
          irreversible treatments: hormone therapy and/or other treatments
          including mastectomy for female-to-male patients.
         Patient completes RLE. If to proceed for genital surgery, a second
          mental health opinion is obtained.
         Patient assessed for surgery.
         Patient undergoes gender reassignment surgery (GRS).
         Patient is monitored for ongoing hormone therapy and receives local
          counselling and support as appropriate.
         Patient receives specialist services as appropriate, e.g. revision
          surgery.
         At all stages of the pathway, information and advice to be available to
          patients, GPs, families, carers and other interested bodies.
         At all stages of the pathway, patient remains under the care of local
          services as appropriate.
         Patients may exit at any stage on the pathway.


4.2       Information and Advice.
          Currently there is great disparity in the information and advice available
          to transgender patients at all stages of their journey. Patient
          representatives have advised that there are a number of registered
          charities that offer support and advice to people who are living with
          gender related problems, ranging from counselling to advice on
          hairdressing, but the quality and nature of this information and advice is
          not regulated and is not available universally. GPs, other clinicians and
          health workers also require information and advice on transgender
          patients.

                                                                                  4
4.3   GP Services
      The patient‟s own GP is the first point of contact on the NHS pathway.
      One of the GRSDG patient representatives undertook a small ad hoc
      survey of 16 transgender service users. This highlighted the disparity of
      information, advice and support patients received from their GP,
      ranging from GPs not willing to help or being obstructive to GPs
      described as totally supportive and extremely helpful, even when not
      very knowledgeable. Wilson et all (1996) noted 31% of trans patients
      had presented to their practice in the last 12 months, however several
      GP respondents to their survey added comments to the effect that they
      lacked knowledge both of the condition itself and of the pathways of
      referral.

      Recommendation:
      Once agreed a mechanism for providing GPs with more
      information about the patient pathway is developed.

4.4   General Mental Health Assessment.
      Gender Identity Clinics (GIC) which North West patients have access
      to (e.g. Leeds Mental Health Trust, West London Mental Health Trust)
      operate as tertiary centres and consequently only accept referral from
      secondary mental health services.

      All of the North West Mental Health Trusts were approached regarding
      the provision of services for patients with suspected gender dysphoria.
      In addition to a waiting time of up to 12 months from GP referral to first
      appointment the following issues were highlighted:

                   lack of psychiatrists with a specific interest/specialism in
                    this area leading to difficulties in accessing an
                    appropriate mental health assessment, and lack of
                    succession planning when existing clinicians cease
                    operating

                   lack of specific arrangements/policies for patients referred
                    due to gender issues. Patients have to compete against
                    other referrals and are not seen as a priority leading to
                    long waiting times. Screening these patients who are
                    unlikely to have mental illness detracts resources from
                    where urgently required.

                   lack of information for clinicians on the requirement for an
                    initial assessment and the onward patient pathway.

                   Difficulties in referring patients into a specialist GIC and
                    the lack of a local GIC for North West patients.

      Recommendation:
      At present patients have to go through local mental health
      services, but this is an area the GRSDG identified as a priority for
      development.



                                                                                   5
4.5   Specialist Mental Health Services – Gender Identity Clinic (GIC)

4.5.1 Diagnosis
      There is debate in relation to the diagnosis. ICD-10 provides five
      diagnoses for gender identity disorders. Transexualism (F64.0) is the
      most relevant, it has three criteria:

          1. 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;
          2. The transsexual identity has been present persistently for
             at least two years;
          3. The disorder is not a symptom of another mental disorder
             or a chromosomal abnormality.

      The other diagnoses are Dual-role Transvestism (F64.1) which relates
      to individuals who have no desire for a permanent change to the
      opposite sex; Gender Identity Disorder of Childhood (F64.2); Gender
      Identity Disorders (F64.8) and Gender Identity Disorder, Unspecified
      (F64.9) which have no specific criteria.

      The HBSOC recommend only mental health professionals who meet
      certain set competencies should diagnose gender identity disorder.
      They list a number of other responsibilities of these professionals
      including diagnosis and arranging treatment of co-morbid psychiatric
      problems, making formal recommendations to medical and surgical
      colleagues in relation to hormonal and surgical treatment, being
      available for follow-up and being part of a team with a special interest
      in gender identity disorders, hence the diagnosis is made by the GIC.

4.5.2 Reversible treatments
      Following an initial assessment and diagnosis by the GIC patients
      continue on the pathway. The first stage of the treatment plan will be
      reversible such as psychotherapy and speech therapy. Sutcliffe et al
      (2005) report there are many studies investigating the use of voice
      therapy for trans patients but highlight the lack of quality evidence
      Examples are de Bruin et al (2000), Gunzburger (1995), Gelfer (1999.)
      However no systematic review of the evidence has been identified.
      The opinion of most authors is that conservative therapeutic
      approaches (i.e. non-surgical) can have positive outcomes. Hormonal
      therapy for female-to-male clients often lowers pitch but some
      therapists seem to consider factors beyond basic pitch (e.g. loudness,
      laughing, gestures.) Most authors agree that speech therapists dealing
      with trans clients should be specialist in voice and many consider that
      they should be specialist in trans patients.

      The HBSOC state there are concerns about the safety and
      effectiveness of voice modification surgery and more follow-up
      research should be done prior to widespread use of this procedure.
      They also recommend that in order to protect their vocal cords, patients
      who elect this procedure should do so after all other surgeries requiring
      general anaesthesia with intubation are completed.


                                                                                 6
4.5.3 Irreversible Treatments

      The point is then reached when continuing along the pathway involves
      irreversible treatment, such as mastectomy and hysterectomy, as well
      as hormone therapy. The HBSOC set out the eligibility and readiness
      criteria for patients to receive the following irreversible treatments:

                           Hormone treatment
                           Breast Surgery
                           Gender Reassignment surgery

      The HBSOC specify what the Mental Health professional‟s
      documentation letter for hormone therapy or irreversible surgery should
      include. One letter is required for instituting hormone therapy or for
      breast surgery but two letters are generally required for genital surgery.
      These letters provide the prescribing physician and/or the surgeon with
      a degree of assurance that the referring mental health professional is
      knowledgeable and competent concerning gender identity disorders.


4.5.4. Hormone Therapy
       Sutcliffe et al (2005) report there are many studies investigating the
       use of hormonal therapy for trans patients but highlight the lack of
       quality evidence. Moore et al (2003) undertook a systematic review of
       the literature relating to hormonal treatment of trans patients. They
       identified a range of both positive (i.e. wanted) and negative
       psychological, biological and anatomical side effects for which there
       was various degrees of statistical, observational or case report
       evidence. They noted significant variation in treatment regimes across
       7 (international) specialist centers. This was particularly in regard to
       estrogen dose in people of older ages, which they describe as
       „alarming‟ in some cases, and in regard to multiple formulations. They
       state “no study has evaluated the degree of desired effects seen with
       these extreme hormonal regimes” and recommend treatment and both
       pre-operative and post-operative monitoring regimes.

      Oriel (2000) describes the management of hormones for trans patients
      as „not difficult‟ and safer than many therapies routinely prescribed by
      the primary care physician, but also emphasises the importance of
      follow-up care after initial prescribing.

      The HBSOC supports the use of hormone therapy stating they are
      “…often medically necessary for successful living in the new gender.
      They improve the quality of life and limit psychiatric co-morbidity, which
      often accompanies lack of treatment.” The HBSOC state that the
      physician providing hormonal treatment and medical monitoring need
      not be a specialist in endocrinology, but should become well-versed in
      the relevant medical and psychological aspects of treating persons with
      gender identity disorders. They also stipulate follow-up regimes for
      people receiving both androgens and estrogens. There appears to be
      a discrepancy between the HBSOC recommending that the prescribing
      clinician need not be a specialist and evidence describing some
      hormonal treatment regimes as “alarming”.


                                                                                7
      Whilst patients are under the care of the GIC, endocrinology should be
      part of the patient‟s package of care with responsibility transferred to a
      patient‟s GP or local services when a patient is discharged from the
      GIC. However not all GICs have been able to confirm being able to
      offer this service to all patients.

      Recommendation:
      This is an area that requires further work.

4.5.5 Real Life Experience (RLE)
      The RLE, during which patients are expected to live and work in their
      desired gender, is the longest stage on the patient pathway being a
      minimum of 12 months, and up to 2 years for some clinics. The
      HBSOC set out the criteria for a successful completion of the RLE.
      During this period patient‟s are commenced on hormone therapy if
      required, are continued to be assessed and are provided with
      psychological support. Patients‟ may also choose to access other
      treatments such as hysterectomy, mastectomy or hair removal by
      electrolysis to enable them to live successfully in their chosen gender.
      Depending which services patients are in touch with, some patients get
      some of these treatments through NHS contracts, some get
      commissioner approval for treatment funding whilst there are some
      patients that do not get these treatments unless they are able to fund
      this themselves via the independent sector.


4.5.6 Other treatments
      The HBSOC state breast augmentation and removal are common
      operations, easily obtainable by the general public for a variety of
      indications. Reasons for these operations range from cosmetic
      indications to cancer. Although breast appearance is definitely
      important as a secondary sex characteristic, breast size or presence
      are not involved in the legal definitions of sex and gender and are not
      important for reproduction. The performance of breast operations
      should be considered with the same reservations as beginning
      hormonal therapy. Both produce relatively irreversible changes to the
      body.

      The approach for M2F patients is different than for F2M patients. For
      F2M patients, a mastectomy procedure is usually the first surgery
      performed for success in gender presentation as a man; and for some
      patients it is the only surgery undertaken. When the amount of breast
      tissue removed requires skin removal, a scar will result and the patient
      should be so informed. F2M patients might have surgery at the same
      time they begin hormones. For M2F patients, augmentation
      mammoplasty may be performed if the physician prescribing hormones
      and the surgeon have documented that breast enlargement after
      undergoing hormone treatment for 18 months is not sufficient for
      comfort in the social gender role.

      The HBSOC state beard density is not significantly slowed by cross-
      sex hormone administration so hair removal is an issue for M2F
      patients. Traditional treatments include shaving, plucking, waxing,
      chemical depilatories and electrolysis. The HBSOC refer to electrolysis

                                                                                8
      stating it does not require formal medical approval, should begin before
      the RLE as many patients will require two years of regular (electrolysis)
      treatments to effectively eradicate their facial hair and it does carry the
      risk of negative side effects. Some authors consider laser treatments
      to be the most efficient method, the HBSOC describe experience of it
      as limited and Haedersdal is to undertake a Cochrane review of Laser
      and photoepilation for unwanted hair growth.

      Recommendation:
      Where PCTs are asked to fund these ‘other treatments’ it should
      be up to individual PCTs to consider the appropriateness of
      patients receiving the treatment on the NHS through the EUR
      policy. It is recommended that PCTs consider the extent to which
      individual patients have followed the pathway when making their
      decision.

4.6   Gender Reassignment Surgery
      A second opinion from a suitably qualified mental health expert must
      be obtained before a referral can be made, as detailed above. Sutcliffe
      et al (2005) note the lack of reliable evidence relating to gender
      reassignment surgery - no RCTs are available, only one controlled
      study was identified, various surgical procedures are reported together
      and studies use a variety of different outcome measures (commonly
      the ability to achieve orgasm, to void standing up (F2M) and cosmetic
      factors.) Some studies identify some complications associated with
      surgery. Most authors recognise that many transsexuals experience
      positive outcomes, but the actual magnitude of benefit and harm
      cannot be estimated accurately using current evidence.

      Patients currently appear to wait in the region of 6 - 12 months for
      surgery from referral by the GIC though some patients wait nearly 2
      years. The surgery performed is very specialised and there are a
      limited number of surgeons. Referral pathways restrict patient choice
      with some surgical providers only accepting referrals from a specific
      GIC. In addition not all providers available to North West patients are
      commissioned on a collaborative basis.

      Recommendations:
      1: At present M2F patients who have gone through Leeds are
      funded by individual PCTs for their surgery. Patients who have
      gone through Charing Cross are funded through collaborative
      arrangements relating to the London Post-graduate hospitals.
      F2M patients going through whichever clinic are funded by
      collaborative arrangements either with UCLH or St Peter’s
      Andrology Centre, an independent sector provider. A new F2M
      service is being developed at Leicester. Any patient wishing
      surgery under this service would need to obtain funding approval
      from their PCT.

      2: These arrangements should be reviewed after the work around
      earlier stages in the pathway is completed.




                                                                                9
4.7       Completion of GRS
          Patients are discharged back to their GP by the GIC after completing
          either hormonal reassignment or hormonal and surgical reassignment.
          Post-surgical patients receive follow-up appointment(s) at the GIC for
          up to 1 year post surgery.

          Long-term postoperative follow-up is encouraged in that it is one of the
          factors associated with a good psychosocial outcome. Follow-up is
          important to the patient's subsequent anatomic and medical health and
          to the surgeon's knowledge about the benefits and limitations of
          surgery.

          Long-term follow-up with the surgeon is recommended in all patients to
          ensure an optimal surgical outcome. Surgeons who operate on
          patients who are coming from long distances should include personal
          follow-up in their care plan and attempt to ensure affordable, local,
          long-term aftercare in the patient's geographic region. Postoperative
          patients may also sometimes exclude themselves from follow-up with
          the physician prescribing hormones, not recognizing that these
          physicians are best able to prevent, diagnose and treat possible long
          term medical conditions that are unique to hormonally and surgically
          treated patients. Postoperative patients should undergo regular
          medical screening according to recommended guidelines for their age.
          The need for follow-up extends to the mental health professional, who
          having spent a longer period of time with the patient than any other
          professional, is in an excellent position to assist in any post-operative
          adjustment difficulties.

4.8       Ongoing Local Counselling and Support
          On discharge patients may require ongoing support arranged through
          local services.

4.9       Ongoing Local Endocrinology.
          Surgically gender reassigned patients usually require lifelong
          maintenance hormone therapy and where patients have only
          undergone hormonal reassignment, the maintenance treatment will be
          at higher doses. Transgender males who have undergone
          mastectomies and who have a family history of breast cancer should
          be monitored for this disease.

          Anecdotal evidence provided by the patient representatives on the
          development group indicated that there is a shortage of endocrine
          support services across the North West and that some patients
          experience great difficulty in obtaining the ongoing monitoring that they
          require.

          Moore et al (2003) identifies a number of negative (i.e. unwanted)
          potential side-effects of hormonal treatment of trans people which
          include:

         For M2F treated with oestrogen and progestins: increased propensity
          to blood clotting/venous thrombosis, development of benign pituitary
          prolactinomas, infertility, weight gain, hypertension, diabetes, liver
          disease and gallstone formation.
                                                                                 10
      For F2M Side effects in biologic females treated with testosterone:
       acne, emotional lability, shift of lipid profiles to male patterns and the
       potential to develop benign and malignant liver tumours and hepatic
       dysfunction.


4.10   General Health
       This area should include provision of health screening consistent with a
       persons biological sex. Sobralske (2005) identifies some specific health
       needs to be considered by primary care practitioners that relate to
       hormonal therapy and gender reassignment surgery.

       Statements around the general health needs of the trans people arising
       from lifestyle factors run the risk of stereotyping this heterogeneous
       group. Their lifestyles and health needs are as diverse as the rest the
       rest of the population. Whilst there has been a focus within the
       research around health needs resulting from risky behaviour (e.g.
       substance abuse, HIV and STI prevalence) methodological and other
       issues mean firm conclusions cannot be drawn.

       The findings of the GRSDG patient representatives mentioned in 3.3
       highlighted the differing standards of care and support available to
       trans persons from their GP. Trans gender persons need both their
       general health needs and trans-specific health needs to be met without
       discrimination.


5. CONCLUSION

The outcome of work to date has been to make a number of
recommendations as detailed above. The following recommendations are
considered by the GRSDG as a priority:

          1. This paper with appendixes be made available to North West
             Commissioners to inform EUR policy.

          2. There be agreement for further work to scope issues raised in
             the recommendation set out in 4.4 concerning access to local
             Mental Health services.

          3. Other recommendations to be addressed after the work around
             access to local Mental Health services is complete.

Collaborative Commissioning groups are asked for their agreement with the
above priority recommendations


Harry Golby                                Hilary Rothwell
Senior Commissioning Manager               Trainee Commissioning Manager

                                                                      31 May 2006



                                                                                    11
Bibliography
The prevalence of gender dysphoria in Scotland: a primary care study
Wilson P, Sharp C, Carr S
British Journal of General Practice; December 1999; 49; pg.991

An epidemiological and demographic study of transsexuals in the Netherlands
van Kesteren, Paul J; Gooren, Louis J; Megens, Jos A
Archives of Sexual Behavior; Dec 1996; 25, 6; pg. 589

Primary Care Needs of Patients Who Have Undergone Gender Reassignment
Mary Sobralske
Journal of the American Academy of Nurse Practitioners; Apr 2005; 17, 4;
ProQuest Nursing Journals
pg. 133

Substance Use and Abuse in Lesbian, Gay, Bisexual and Transgender
Populations
Tonda L. Hughes; Michele Eliason
Journal of Primary Prevention; Spring 2002; 22, 3; ProQuest Psychology
Journals
pg. 263

HIV prevalence, risk behaviors, health care use, and mental health status of
...
Kristen Clement-Nolle; Rani Marx; Robert Guzman; Mitchell Katz
American Journal of Public Health; Jun 2001; 91, 6; ProQuest Medical Library
pg. 915

Social Work Practice With Gay, Lesbian, Bisexual, and Transgender
Adolescents
Deana F Morrow
Families in Society; Jan-Mar 2004; 85, 1; ProQuest Psychology Journals
pg. 91

On the Incidence and Sex Ratio of Transsexualism in Sweden, 1972-2002
Stig-Eric Olsson; Anders R Möller
Archives of Sexual Behavior; Aug 2003; 32, 4; ProQuest Medical Library
pg. 381

Endocrine Treatment of Transsexual People: A Review of
Treatment Regimens, Outcomes, and Adverse Effects
EVA MOORE, AMY WISNIEWSKI, AND ADRIAN DOBS
The Journal of Clinical Endocrinology & Metabolism 88(8):3467–3473
2003

INVITED REVIEW
A psycho-endocrinological overview of transsexualism
A Michel, C Mormont1 and J J Legros
European Journal of Endocrinology (2001) 145 365±376

Medical care of transsexual patients
Journal of the Gay & Lesbian Medical Assn, Dec 2000, vol. 4, no. 4, p. 185-
194,
Oriel K

                                                                              12
Voice treatment for the male-to-male female transgendered client
Marylou Pausewang Gelfer
American Journal of Speech - Language Pathology; Aug 1999; 8, 3; ProQuest
Medical Library
pg. 201

Acoustic and perceptual implications of the transsexual voice
Gunzburger, Deborah
Archives of Sexual Behavior; Jun 1995; 24, 3; ProQuest Medical Library
pg. 339

Speech therapy in the management of male-to-female transsexuals
M D de Bruin; M J Coerts; A J Greven
Folia Phoniatrica et Logopaedica; Sep/Oct 2000; 52, 5; ProQuest Medical
Library
pg. 220

Haedersdal M, G_tzsche PC, Nielsen M. Laser and photoepilation for
unwanted hair growth. (Protocol) The Cochrane Database of
Systematic Reviews 2004, Issue 1.

Gender Report; Trent Research and Development Support Unit, Sutcliffe et al,
2005
(http://www.trentrdsu.org.uk/cms/uploads/EBCC%20Gender%20reassignment
%20Final%20report%20240406.pdf)

The Harry Benjamin International Gender Dysphoria Association's
Standards of Care for Gender Identity Disorders, Sixth Version, February,
2001

Guidelines For Health Organisations Treatment Services For Individuals
Experiencing Gender Dysphoria And Transsexualism
Parliamentary Forum on Transexualism – First Version, agreed on March 10th
2005

Transgender Services for the residents of Sussex.
15th September 2005

Policy on Gender Identity Disorder Services
Healthcommission Wales, January 2005




                                                                            13
                                              Appendix 1
PATHWAY FOR ACCESSING SERVICES FOR TRANSGENDER PERSONS
                         INFORMATION AND ADVICE

                        PATIENTS
          NEED FOR FURTHER ASSISTANCE IDENTIFIED



                                 GP

                    GENERAL MENTAL HEALTH
                         ASSESSMENT

 SPECIALIST SERVICES - - - - - - - - - - - - - - - - - SPECIALIST SERVICES


               SPECIALIST MENTAL HEALTH SERVICES
                     GENDER IDENTITY CLINIC


                 OPINION (S) AND TREATMENT PLAN


                           SPEECH THERAPY
             (if required alongside endocrinology & RLE)

 IRREVERSIBLE TREATMENTS - - - - - - IRREVERSIBLE TREATMENTS



    ENDOCRINOLOGY                  REAL LIFE EXPERIENCE               OTHER
                                           (RLE)                   TREATMENTS
                                                                       e.g.
      COMPLETED ENDOCRINOLOGY & RLE                                 Mastectomy

                       2ND PSYCHIATRIC OPINION




                 GENDER REASSIGNMENT SURGERY
                            (GRS)


                          COMPLETED GRS


     ONGOING LOCAL                             ONGOING LOCAL
 COUNSELLLING & SUPPORT                        ENDOCRINOLOGY

                         INFORMATION AND ADVICE                        14
                                                                  Appendix 2


             PREVALENCE AND CONTRACTING NUMBERS

Prevalence
A number of authors have researched prevalence. The most recent British
study is survey of GPs in Scotland (Wilson et al, 1999.) This gave the
following prevalence figures at different stages of the pathway:

                                          Prevalence (per 100,000 population
                                                 aged over 15 years)
                                            M2F          F2M         Total
Patients with gender dysphoria but not      3.27         0.76        1.98
in treatment
Patients with gender dysphoria in            2.34         0.53        1.41
psychological / counselling treatment
only
Patients taking sex hormone therapy          3.33         0.64        1.95
but pre-operative
Post-operative transsexual patients         4.50          1.28        2.85
Total                                       13.44         3.21        8.18

Prevalences (per 100,000 population) from other international studies range
from 0.25 (F2M, America, 1968) to 34 (M2F, Singapore, 1998) (cited in
Mitchell et al, 2002.) Some of these studies only consider prevalence of trans
patients seen at specialist clinics or undergoing gender reassignment surgery
and some authors attribute high prevalence to improvements in surgical
techniques.


The figures for the 2001 Census give the population of the North West of
England as 6,729,800. Using the prevalence figures given above from the
survey of GPs in Scotland, the north west would expect the following number
of patients in each category:

                                          Prevalence (per 100,000 population
                                                 aged over 15 years)
                                            M2F          F2M         Total
Patients with gender dysphoria but not       177          41         218
in treatment
Patients with gender dysphoria in            127           29          156
psychological / counselling treatment
only
Patients taking sex hormone therapy          181           35          216
but pre-operative
Post-operative transsexual patients          244          69           313
Total                                        729          174          903




                                                                             15
Contracting numbers

Specialist Mental Health Assessments
Leeds GIC
Leeds advise specialist commissioners of the number of patients attending
clinic during the year at each stage of treatment. It is not known the actual
number of patients these clinical contacts represent nor how many of the
patients identified during 2004/2005 are within the patient numbers given for
2005/2006. In August 2005 Leeds were able to advise they had 1 F2M and
5M2F north west patients on the waiting list. Activity for January, February
and March 2006 show current activity for 10 identifiable patients at Leeds
GIC.

         Assessments Year 1    Annual    Post-     Follow-             TOTAL
                     treatment treatment operative up
                                                   appts
2004/
2005       2             0          6            1           11        20
2005/
2006*      5             1          5            2           11        24
*figures for 2005/2006 are up to month 10.


The Claybrook Centre (Charing Cross)
The majority of north west patients accessing gender identity services through
the NHS will attend the Claybrook Centre. Activity data is provided for the
number of patient contacts and does not identify the number of individual
patients.

2004/2005         234 patient contacts
2005/2006         201 patient contacts up to end month 8


Gender Reassignment Surgery
Through monitoring information received it has been possible to identify the
following numbers of patients who have or who are in the process of
accessing surgery under the NHS:
       71 M2F
       47 F2M
Due to the format of some of the historic monitoring received it has not been
possible to identify the total number of NHS transgender patients in the north
west who have or wish to, access surgical services.

M2F at Hammersmith Hospitals
The numbers given are for individual patients treated. There have been 4
known instances of repair surgery being undertaken. It has not been possible
to determine if any of the patients requiring repair surgery had their original
gender surgery at the Hammersmith Hospitals. One patient is known to have
undergone their initial surgery at Leicester. It is not known whether the other
patients had their original surgery through the NHS.

2001/2002          5
2002/2003          7
2003/2004          6 (incl. 1 repair)
                                                                             16
2004/2005         11
2005/2006         13 (incl 3 repairs)
2006/2007         17 – forecast figure representing number of patients ready
                  for surgery.


F2M surgery.
Identifying historical actual patient number for F2M patients is complicated by
the number of years it can take for a patient to undergo all 4 stages of
surgery. One F2M patient is currently seeking funding from their PCT to
undergo surgery at Leicester through the new service in development there.

F2M at UCLH
Monitoring information for 2004/2005 at UCLH showed the year when patients
had been a patient at UCLH since as follows:1988(1), 1990(1), 1991(1),
1992(1), 1994(1), 1998(2), 1999(1), 2000(1), 2001(1). Some of these patients
had yet to decide whether they wished further surgery. Using monitoring
information received from UCLH, 18 individual patients have been identified.

2001/2002         4 – contacts, not patient numbers
2002/2003         9 – contacts, not patient numbers
2003/2004         7 – contacts, not patient numbers
2004/2005         6 – contacts though 10 patients on waiting list for treatment
2005/2006         1 – invoiced for 1 patient although were 8 patients who may
                  potentially have received treatment in year.
2006/2007         9 patients on waiting list as at 13/03/2006.


F2M at St Peter‟s Andrology Centre
2005/2006 was the first year of the contract with St Peter‟s Andrology centre.
There are now 28 known patients, although 5 patients do not require any
treatment at present.

2005/2006 – 12 patients received treatment.
2006/2007 – 10 patients are to commence treatment and 10 from 2005/2006
            are to continue treatment.


Leicester
Historically Leicester has performed M2F surgery and other surgical
procedures associated with gender reassignment, such as mastectomy and
hysterectomy. During the last financial year a new service offering F2M
surgery has been commenced,

2004/2005         8 patients – gender reassignment surgery
                  4 „other‟ procedures
2005/2006         8 patients – gender reassignment surgery
                  14 „other‟ procedures up to month 10.




                                                                             17
                                                                  Appendix 3

GENDER REASSIGNMENT SERVICE DEVELOPMENT GROUP


Terms of Reference.
To develop commissioning arrangements to include the whole gender
reassignment patient pathway and all providers for patients of all North West
PCTs.

To draft a policy by winter 2005/2006 and agree an implementation plan by
Spring 2006.


Membership
Harry Golby             Head of Children‟s Services, Salford PCT
Pam Crossland           Press for Change and Patient representative
Dr Raymond E. Goodman Physician with Specialist Interest in Psycho-
                        Sexual Medicine
Janice Snape            Nurse Specialist in Psycho-Sexual Medicine
Sarala Gunawardena      Out of Area Treatments (OATS) Commissioning
                        Manager, Cheshire & Merseyside Specialised
                        Services Commissioning Team
Simon Banks             Specialised Services Commissioning Manager,
                        Cheshire & Merseyside Specialised Services
                        Commissioning Team
Steve Hamer             Service Development Manager – Mental Health,
                        Cumbria & Lancs Specialised Services
                        Commissioning Team
Dr Su Sethi             Consultant in Public Health, Cumbria & Lancs
                        Specialised Commissioning Team
Terry Hevicon-Holland   Continuing Care Programme Manager, Oldham
                        PCT
Hilary Rothwell         Trainee Commissioning Manager, Salford PCT
Elizabeth Anne Caldwell Patient representative




                                                                            18