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					                         FINAL COMMISSIONING POLICY – OCTOBER 2009



           POLICY ON THE PROVISION OF GENDER
              DYSPHORIA SERVICES (ADULTS)

Report commissioned by:                   Yorkshire and the Humber Specialised
                                          Commissioning Group Priorities Process

On behalf of:                             Primary Care Trusts in the Yorkshire and the
                                          Humber Specialised Commissioning Group area

Produced by:                              Kim Cox and Pia Clinton-Tarestad
                                          Yorkshire and the Humber SCG


Correspondence to:                        Cathy Edwards
                                          Director
                                          Yorkshire and the Humber SCG
                                          c/o Barnsley PCT
                                          Hillder House
                                          49-51 Gawber Road
                                          Barnsley
                                          S75 2PY

Date completed:                           Oct 2009

Review Date:                              April 2011




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CONFLICTS OF INTEREST

None

ACKNOWLEDGEMENTS
Professor Dr Kevan Wylie, Consultant in Sexual Medicine, Sheffield, Maureen
Whittaker, Public Health Specialist Trainee,Dr David Black, Director of Public Health,
Derbyshire County PCT for their significant contributions to the production of the
original policy on which this document is based.

Dr Fiona Day, Locum Consultant in Public Health, NHS Leeds; Tony Nuttall,
Strategy and Specification Manager, NHS Sheffield; Christine Burns, Plain Sense
Ltd; Kate Naylor, Sexual Health Programme Manager, NHS Calderdale; Gill Tait,
Strategic Development Manager, NHS North Lincolnshire; and Carrie Wollerton,
Senior Commissioning Manager, Yorkshire and the Humber SCG for their significant
contributions to the further development of this policy




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                              CONTENTS                               Page

ACKNOWLEDGEMENTS                                                      2

ABBREVIATIONS                                                         4

DEFINITIONS                                                           4

1.    AIM OF POLICY                                                   5

2.    BACKGROUND                                                      5

3.    GENDER DYSPHORIA                                                5

4.    TREATMENT                                                       7

5.    EVIDENCE BASE                                                   9

6.    SERVICE PROVISION                                               11

7.    CRITERIA FOR TREATMENT                                          12

8.    DISCHARGE CRITERIA                                              14

9.    PATIENT NUMBERS                                                 14

10. POLICY STATEMENT                                                  15

11. REFERENCES                                                        16

Appendix A               Routinely Commissioned Treatments            18

Appendix B               Costs/Commissioning Implications             19




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ABBREVIATIONS

GD               Gender Dysphoria
GRS              Gender Reassignment Surgery (also known as Gender Confirmation
                 Surgery)
RLE              Real Life Experience
Y&HSCG           Yorkshire and the Humber SCG




DEFINITIONS


Gender Dysphoria: A condition in which the psychological experience of oneself as male or
female is incongruent with the external sexual characteristics of one’s body.

Gender Identity: The sense of belonging to a particular sex

Gender Identity Service: The staff providing specialist clinical care for patients with
Gender Dysphoria. The service meets and discusses the progress of all clients receiving
care, especially those initiating, receiving hormone therapy and/or those approaching
readiness for surgery.

Transsexualism: The desire to live and be accepted as a member of the opposite gender,
usually accompanied by the wish to make one’s body as congruent as possible with the
preferred sex through surgery and hormone treatment.

Trans man: An individual who was born with a female phenotype, who is seeking to
undergo, in the process of undergoing or having already undergone 'transition' from female
to male.

Trans woman: A individual who was born with a male phenotype, who is seeking to
undergo, in the process of undergoing or having already undergone 'transition' from male to
female.




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1.        AIM OF POLICY

1.1   This paper represents the Commissioning Policy on Gender Dysphoria services for
      adults registered with Primary Care Trusts in the Y&HSCG (Y&HSCG) area, including
      gender reassignment surgery (GRS). The goal of the policy is to assist the service
      user to find a personal accommodation with their sense of gender dysphoria, including
      the provision of clinical interventions to facilitate a transition of social gender role
      where necessary.

1.2   The policy aims to ensure that those most in need and able to benefit are given
      equitable access to the service across the Y&HSCG area.

1.3   The policy does not address GD services for children and adolescents up to the age of
      18. Both adult and children’s providers will be responsible for appropriate transition
      between the services. Commissioning of gender dysphoria services for children and
      adolescents will continue to be considered by the responsible commissioner on a cost
      per case with prior approval basis.


2.        BACKGROUND

2.1   Commissioners have, in the past, been asked to make funding available for patients
      requiring GD services. There has been no specific policy for commissioning services
      across Y&HSCG PCTs. As a result Y&HSCG agreed to review the commissioning
      arrangements for GD services with a view to agreeing an SCG wide commissioning
      policy.


3.        GENDER DYSPHORIA (GD)

3.1. The sense of belonging to a particular sex, not only biologically but also
     psychologically and socially, is called gender identity.

3.2. GD is a rare condition in which there is a psychological experience of oneself as male
     or female, which is incongruent with the external sexual characteristics of the body.

3.3   An individual with profound and persistent GD may need clinical intervention to
      facilitate a transition of status, to live in accordance with his or her core gender identity
      rather than with the phenotype1.


3.4   This degree of gender dysphoria is termed transsexualism (ICD10 F64). The ICD-10
                                                                                       2
      diagnosis of transsexualism (F64.0) in an adult requires three criteria to be met :
             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;
             The transsexual identity has been present persistently for at least two years;
             The disorder is not a symptom of another mental disorder or a chromosomal
              abnormality.




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3.5     Gender dysphoria if not treated can lead to mental ill health and severely affect the
        person’s quality of life. The aetiology of the condition is not yet fully
        understood3.Transsexualism cannot be ‘cured’; instead interventions may be
        required to optimise mental health and facilitate transition of status where
        appropriate. The use of aversion or ‘reparative’ therapies is no longer considered
        appropriate practice within the United Kingdom


3.6     Estimation of prevalence

3.6.1   The data available to estimate the prevalence of transsexualism and gender
        dysphoria (GD) is limited due to: research and data quality issues; a wide spectrum
                                                 4
        of diagnosis; stigma and discrimination.

3.6.2   The number of people presenting for treatment is increasing and is currently
        doubling every 5 years, growing at a significantly greater rate that the population as
        a whole (a compund increase of 15% per annum presenting for treatment compared
        to +0.5% population growth per annum)5. This is thought to be due to better social,
        medical and legislative powers coupled with a ‘buddying effect’. Transgender people
        present at any age but the current median age is 42 years.

3.6.3   There are variations in the estimated prevalence of GD. A Scottish primary care
                                              6
        based survey was conducted in 1998 (8.70/ 100,000 population). The prevalence of
        gender dysphoria among patients aged over 15 years was calculated as 8.18 per
        100,000, with an approximate sex ratio of 4:1 in favour of male-to-female patients. A
        more accurate prevalence is that reported in the Gender Identity Research and
        Education Society (GIRES) report commissioned by the Home Office, which
        suggests that current prevalence may be 20 per 100,000. The incidence of new
        cases presenting for treatment is approximately 3/100,000 per year, equating to
        1,500 people in the UK.

3.6.4   An uneven distribution of cases across the country has been documented. There is
        no specific correlation with population density and presentation for GD. The
        distribution is likely to reflect cultural factors, the buddying effect, and the availability
                                7
        of medical services.

3.6.5   The DTI Women and Equality Unit estimated in 2005 that there are currently 5,000
        transsexual people in the UK (including those who are predicted to seek help in the
        future, those undergoing treatment, and those who have completed treatment for
        their gender issues).

3.6.6   The Charing Cross clinic received 771 new referrals in 2008 and is reported to have
        2,000 patients on its books at any one time. It is thought that this service receives
        85% of UK patients, which would approximate to 907 new referrals nationally per
        annum. 99 NHS funded gender reassignment surgical procedures were reported to
        Ministers as being carried out in 2006, notably all of which were male to female
        transformations.

3.6.7   The Gender Recognition Panel reports over 2,350 requests since April 2005 of which
        97% were successful, but many of these reflect a backlog relating to a change in



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        legislation. An average of 25 new applications are currently received every month,
        equating to 300 per year.

3.6.6   From this data, estimating the conversion rate from the general population to referral
        to specialised services to full gender reassignment is problematic but using the
        above data is estimated as approximately 18-51%. It should be noted that these are
        gross estimates. Of note, the majority of people seeking help and undergoing
        specialist intervention are requesting male to female transitions.


4       TREATMENT

4.1     The Care Pathway

4.1.2 Although there is no single model for treatment, the care pathway for individuals with
      gender dysphoria usually includes diagnostic assessment, appropriate psychological
      intervention, the ‘real life experience’, hormone therapy and surgical interventions in
      a patient appropriate but not predefined order. Any clinical support for changing from
      one gender to another, regardless of biological or current gender, must follow extant
      professionally recognized best practice, as recognized by relevant UK clinicians.

4.1.3 There are two groups of individuals with GD; biological males and biological females,
      and the policy identifies specific differences in the care of these two groups.


4.2     The Initial Assessment Period

4.2.1   An initial assessment period of usually three to six months involves diagnostic
        assessment of the patient (including the patient’s history of and current experience of
        gender dysphoria), psychological assessment, general medical examination and
        physiological measurements, including blood tests. Initial assessment should be
        carried out by the professional responsible for the client’s ongoing treatment and
        care, usually a consultant psychiatrist. Assessment should not routinely exceed two
        diagnostic appointments. Where clients are being seen by a range of professionals,
        every effort should be made to minimize visits, using a one-stop approach where
        appropriate. It will be expected that all patients who wish to proceed beyond initial
        assessment will have been through this initial assessment period. The assessment
        of patients who are further down the care pathway or transfer with a complete history
        from another clinician may be shorter.


4.3     Psychological input

4.3.1   All patients will be reviewed at regular intervals in line with best practice guidelines.

4.3.2   Patients may in some cases be offered psychological support as part of their
        individualised package of care.




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4.3.2.1 In some cases, formal psychiatric intervention may be required, particularly for
        patients with psychiatric comorbidities. Shared care may be appropriate in these
        cases.


4.4     The Real Life Experience
                                      8
4.4.1   The Real Life Experience is a period of time, usually one to two years, living in the
        gender role with which the individual identifies, with the aim of assisting the patient to
        fully appraise the practical and social implications of a permanent gender change
        and to assure themselves that it feels right for them and that they can cope with any
        negative implications. During this time the role of the clinician is to advise on coping
        strategies and support the patient to ensure they derive the full benefit of the
        experience. The Real Life Experience is an integral part of any individualised
        treatment plan where gender reassignment surgery is being considered. The quality
        of the real life experience is assessed through the patient’s ability to thrive in their
        acquired gender.

4.4.2   Gender Recognition Certificates should be taken into account at this stage.

4.5     Endocrine Therapy

4.5.1   Endocrine therapy is an important component of treatment for properly selected
        individuals with persistent Gender Dysphoria. Endocrine therapy usually consists of a
        combination of hormone blocking medication (reversible) and the administration of
        cross sex hormones.

4.5.2   The administration of cross sex hormones is only commenced if the patient fulfils
                              89
        the following criteria :
           Competent to consent to receive treatment consistent with safe clinical practice
             and relevant legislation.
           Demonstrable knowledge of what hormones medically can and cannot do, and
             their social benefits and risks;
           Having had a reasonable period between decision between clinician and patient
             to proceed with hormone therapy and the actual administration of hormones,
             allowing time for relevant tests to be carried out where necessary or a cooling off
             period where appropriate.




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4.6     Gender Reassignment Surgery (GRS)

4.6.1   Gender reassignment surgery (GRS) aims to alleviate the psychological discomfort
        of patients with profound GD through changes to the body in line with the individual’s
        gender identity. The criteria for GRS are summarised in section 7.

4.6.2   Surgery for male-to-female patients includes genital surgery such as penectomy,
        orchidectomy, vaginoplasty, clitoroplasty and labiaplasty. Other surgery to assist
        feminisation includes chest reconstruction, thyroid chondroplasty, lipoplasty of the
        waist, rhinoplasty, facial bone reconstruction and blepharoplasty.

4.6.3   Genital surgery for female-to-male patients may involve hysterectomy, vaginectomy,
        salpingo-oophorectomy, metoidoplasty, scrotoplasty, urethroplasty, placement of
        testicular prostheses and phalloplasty. Chest reconstruction with associated bilateral
        mastectomy may be required at an early stage. Masculinisation may be assisted by
        liposuction to reduce fat in hips, thighs and buttocks.


4.7     Other Interventions

4.7.1   Other interventions to assist feminisation and masculinisation during transition, and
        to preserve reproductive potential, include:
              Speech and language therapy.
              Support and advice on style to assist patients in ‘passing’ as a member of the
               opposite gender.
              Hair removal techniques
              Storage of gametes.


5       EVIDENCE BASE

5.1     This is a field in which there are known limitations to the evidence base, owing to a
        history of restricted funding for detailed research, general stigma surrounding the
        subject matter and evidence of difficulties in getting research published in peer
        reviewed journals.4

5.2     The following databases were searched: Cochrane Library (2003, issue 2), and
        MEDLINE, CINAHL, Psychinfo, EMBASE, BNI (published since date of last review)
        using the terms transsexualism and sex reassignment.

5.3     The search was restricted to reviews and studies in English relating to effectiveness
        and cost-effectiveness of sex reassignment in adults.

5.4     Studies primarily considering surgical techniques were excluded.




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Effectiveness

5.4.1   Five reviews of effectiveness of sex reassignment surgery were identified of which
        three reviewed evidence in male-to-female patients10,11,12 and two reviewed evidence
        in female-to-male patients13,11 and one considered results overall14. The findings of
        these reviews are summarised briefly below.

5.4.2   The Trent Research and Development Support Unit published a report of the risks
        and benefits of gender reassignment surgery (December 2004). It concluded that, in
        comparing two groups (one which had received surgery and the other not) the
        operated group received more benefits in terms of subjective well being, cosmesis
        and sexual function than the non-operated group14.

5.4.3   A recent Tech Brief review carried out in New Zealand11 aimed to identify subgroups
        of transsexual people for whom evidence of effectiveness of GRS exists. It identified
        one systematic review, one prospective controlled study, one retrospective cohort
        study and seven quasi-experimental studies. The review concluded:
               There is insufficient evidence to prove the efficacy of GRS for specific
                subgroups.
               The study designs of the included studies had methodological weaknesses.
               There is limited evidence that early rather than delayed GRS may be of
                greater benefit to carefully selected individuals.
               GRS may be of benefit to carefully assessed and selected transsexual
                people.

5.4.4   A DEC report by the Wessex Institute15, published in 1998 reviewed one prospective
        controlled study, numerous case studies and one cross-sectional study on GRS in
        male-to-female patients. It concluded that:
               A small number of people may experience important benefits from this
                technology.
               The evidence base is limited in that most studies are non-controlled and have
                not collected data prospectively. The overall conclusion of the DEC is that
                the intervention is ‘not proven’.
               Evidence on the incidence of adverse outcomes of GRS is limited due to high
                rates of losses to follow-up.
               Sex reassignment surgery should be available for carefully selected
                transsexual people, and standardised selection criteria should be used.
               There is no comparable alternative to surgery in those eligible for surgery.


5.4.5   A Canadian rapid review on vaginoplasty in male-to-female transsexuals16 in 1997
        aimed to identify criteria for this type of surgery, and concluded that the Harry
        Benjamin standards of care set an appropriate framework for Canada. The review
        includes a brief summary of evidence of effectiveness of vaginoplasty, and
        concludes that despite lack of standardised outcome measures, a high proportion of
        patients benefit from surgery.

5.4.6   A Canadian rapid review of phalloplasty in female-to-male transsexuals13 concluded
        that this remains a highly specialised procedure, requiring high levels of surgical
        expertise, and careful patient selection and follow-up. Limited data on outcome
        measures including patient satisfaction, physiological function and social integration,
        indicate that centres specialising in GRS achieve successful outcomes in a majority
        of patients.

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5.4.7   Two publications have reported the results of GRS (or sex confirmation surgery). For
        male to female surgery at Leicester, the satisfaction rate was 89% at 8 weeks.16 For
        female to male surgery at London, the cosmetic appearance of the phallus was
        considered good in 68% of patients.17



5.5     Cost Effectiveness

5.5.1   The search strategy failed to find any published data on the cost-effectiveness of
        GRS. One of the reviews of effectiveness10 assesses the costs associated with GRS
        for male-to-female transsexuals, but lacks sufficient outcome data to summarise the
        results in terms of QALYs. The review concludes that psychiatric and
        pharmacological cost savings of up to £950 per patient per year may result from
        successful GRS. This calculation is based on a comparison with patients attending
        Gender Dysphoria Clinic four times a year and receiving anti-androgen and
        oestrogen therapy. Post-GRS costs are based on yearly attendance at GD clinic,
        with reduced oestrogen prescription.

5.6.2 The Trent RDSU study considers cost effectiveness and notes the lack of available
      evidence. However, the study considers that such surgery is relatively cheap,
      provides successful outcomes for the majority of patients and is likely to reduce the
      need for psychiatric and hormonal treatments.

5.6.3 No comparison is made with costs for patients on the waiting list for GD services, but
      local experience indicates that some patients require intensive contact with
      community mental health services during their waiting time.

5.6.4 The search for evidence was repeated in June 2009 using Bandolier, Evidence
      Based Reviews, NHS Evidence Specialist Collections, National Library of Guidelines
      (includes NICE Guidance), NICE Guidance (only), and Clinical Knowledge
      Summaries, using search terms ‘transsexual/ism’; ‘gender dysphoria’; and ‘gender
                                                 18
      identity disorder’. One new study was found but it was not readily possible to
      obtain a copy. A decision was made that it was unlikely to change the
      commissioning policy therefore it was not pursued further.

5.6.5   In addition, the Cochrane database was searched using the above terms, this found
        one additional study from Spain which was discarded as it was not translated into
        English. 19




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5.7 Patient Reported Outcomes
                                                                                          20
5.7.1 An audit carried out by the NHS Audit, Information and Analysis Unit in 2008 found
      that 98% of patients who had undergone gender reassignment surgery (647
      responses) felt it was a positive or mainly positive experience and were happy with
      their outcomes. 49% felt that treatment for trans people at Gender Identity Clinics
      could be improved.


6     SERVICE PROVISION

6.1     The availability of services across the country is very limited21. Specialist services
        available in the Yorkshire area are based in Leeds and Sheffield. There are also
        services in Nottingham, Leicester, Sunderland and London.

6.2     There is currently no provision of surgery for sex reassignment in the Y&HSCG area.
        There are a limited number of surgical units performing GRS procedures.


6.3     Service Delivery

6.3.1 Services for people with GD need to offer a flexible approach to meet the needs of
      individuals at different stages of gender transition. Services will be commissioned
      from designated providers that meet the requirements of the Y&HSCG service
      specification and all relevant legislation.


7     CRITERIA FOR TREATMENT

7.1.1   All referrals to the specialised gender service should be made in conjunction with the
        Community Mental Health Team. General Practitioners making direct referrals will
        be advised by the clinic to refer their patient to a Consultant Psychiatrist for
        assessment. The criteria for referral to the clinic are that the referring clinician
        believes the patient meets the ICD-10 criteria for trans-sexualism (section 3.8.1).
        Where the patient meets the criteria for referral, then this should be made without
        delay.

7.2     Patients should be offered a choice of gender identity service provider wherever
        possible.

7.3     Criteria for referral to the specialist gender identity service will be further explored
        following the publication of the standards of care currently being developed by the
        Inter Collegiate Working Party for Standards of Care for People with Gender
        Dysphoria.




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7.4     Patient Eligibility Criteria for Gender Reassignment Surgery

7.4.1   Not all patients will either choose or be eligible to undergo sex reassignment surgery.
        However, as a point of principle, GRS is an integral part of the treatment of Gender
        Dysphoria and should not be considered separately. Prior approval for GRS should
        not be required for patients who are accepted by the specialised Gender Identity
        Service and who then meet the criteria detailed below. Similarly, gender
        reassignment surgery will not be offered to individuals outside of the care pathway.

7.4.2   The patient eligibility criteria for GRS are adapted from the Harry Benjamin criteria8.
        Eligibility criteria for all patients, regardless of biological or current gender status,
        seeking genital surgery are the same:
          Competent to consent to receive treatment consistent with safe clinical practice
             and relevant legislation.
          Usually 12 months of continuous endocrine therapy (for those without a medical
             contraindication);
          A minimum of 12 months of continuous full-time RLE;
          Regular participation, where required, in some form of psychological input during
             RLE;
          Demonstrable knowledge of the length of hospitalisation, possible complications,
             limitations and post-surgical requirements of the various surgical procedures.
          Gender recognition certificates may be taken into account where appropriate


7.5 Patient Readiness Criteria

7.5.1   In addition to fulfilling the eligibility criteria, the Gender Identity Service must be
        satisfied that the patient meets the readiness criteria8:
           Demonstrable progress in consolidating one’s gender identity role;
           Demonstrable progress in dealing with external social, family and interpersonal
             issues resulting in an improved state of mental health.


7.6     Service and Service Engagement Criteria

7.6.1   The process of identifying patients as eligible and ready for GRS must involve all
        members of the multidisciplinary team and the patient.

7.6.2   The decision to refer a patient to a surgical team must follow extant professionally
        recognized best practice, as recognized by relevant UK clinicians. At present, this
        includes two letters of recommendation prior to initiating genital surgery. One must
        be from a Consultant Psychiatrist from another NHS Strategic Health Authority area,
        who specialises in Gender Dysphoria (second opinion), and the other from the
        Specialist GD clinic. Patients should be offered a choice of surgeon wherever
        possible.

7.6.3   The surgeon should be appropriately qualified and operating within a designated
        service. S/he should personally communicate with the referring GD specialist, to
        verify the referral.




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7.6.4   The patient must be medically fit for surgery and have all medical conditions
        appropriately monitored by their GP.

7.6.5   The patient and surgeon must complete informed consent documents in line with the
        guidance produced by GIRES22.


7.7 Gender Reassignment Surgery Procedures

7.7.1   Appendix A details those surgical procedures that will be routinely commissioned for
        patients meeting the criteria detailed in paragraphs 7.4 and 7.5, where the
        procedures are deemed appropriate for the individual.

7.7.2   Any other procedures recommended by a clinician would be considered via PCT
        individual funding requests.


7.8     Reversal Surgery

7.8.1 Patients should be advised that reversal surgery is not routinely commissioned by
      the NHS.


8       DISCHARGE CRITERIA

8.1     Patients will be discharged from the service when:
         They are no longer receiving benefit or
         They have a stable gender identity or
         Following surgery they are medically stable and their care can be transferred to
            their GP or
         They request discharge.


9       PATIENT NUMBERS FOR THE Y&HSCG AREA

9.1     Research-based prevalence estimates have previously been inconsistent with the
        numbers of Y&HSCG residents being referred to the Gender Identity Services. The
        reasons for this are unknown but possible reasons are discussed in 3.6.
        Consequently, it would be unreliable to solely use these estimates to determine the
        level of service to be commissioned.

9.2     Applying the Scottish prevalence estimates, there may be approximately 327 trans
        people in YH, of whom 262 are trans women (MF) and 65 trans men (FM).
        Using the 1/11,500 prevalence it can be expected that there are 348 trans people.22
        The GIRES prevalence of 21 per 100,000 would give an estimated 840 transgender
        individuals in Y&HSCG (672 trans women and 168 trans men).

9.3     A recent survey in Calderdale23 identified 38 trans people currently accessing or
        having recently accessed trans services, equating to approximately 1 in 5000 of the
        population. This estimate is towards the higher end of the range of previous
        estimates of prevalence. The ratio of trans-women to trans-men was exactly 4:1
        which is consistent with previous studies.


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9.4     Of the current estimated 327-800 trans population in YH, some may have received
        treatment already, some may never wish or seek assessment for treatment, and
        there will be a steady stream of new referrals (incident cases) presenting for
        treatment as young people reach adulthood. It is likely that the majority of the trans
        population will require specialised assessment at some stage in their life, especially
        as services become better established and as surgical procedures become more
        advanced. Following assessment, many will progress along the care pathway and it
        can be expected that a percentage of patients will progress to surgical intervention.

9.5     The GIRES study estimates the annual incidence to be 2.6 per 100,000, suggesting
        104 new cases per year in Yorkshire and the Humber. Current referral practice is at
        approximately 2 per 100,000 for specialised services, equating to 80 patients per
        annum.

9.6     It is likely that demand may increase as the service becomes better established as
        described above, therefore it is recommended that these figures should be revised
        as more information becomes available and that services are commissioned at an
        initial level of 2.6/100,000. It should be noted that the number of cases presenting for
        treatment is currently doubling every 5 years. It should also be noted that the
        majority of patients requesting specialised interventions are likely to be for male to
        female transitions, and that not all patients proceed to have a full package of care.


10      POLICY STATEMENT

10.1    The following statement sets out the position of Y&HSCG PCTs in respect of all
        current patients (in treatment and on the waiting list) and future referrals for Gender
        Dysphoria services for patients in the Y&HSCG area.

10.2    A Community Mental Health Team should, in consultation with the patient, make all
        new referrals for GD services for patients from PCTs in the Y&HSCG area, to a
        specialist GD service providing services in accordance with the Y&HSCG service
        specification. The service provider must agree to work to the Y&HSCG policy.

10.3    Referrals for initial assessment should be prioritised according to clinical need and
        placed on a single waiting list. Once accepted for treatment, prior approval should
        not be required for core procedures (see Appendix A) deemed appropriate to any
        individual wishing to undergo them and who meets the criteria detailed in section 7 of
        this policy.

10.4    Progression through the stages of treatment will be based on joint decisions between
        the patient and the multidisciplinary team, via the Gender Identity Service.

10.5    Patients may only be referred for NHS-commissioned GRS when the GD service is
        satisfied that all criteria are met (Section 7). The specialist GD service will be
        responsible for informing commissioners of patients referred for GRS, in line with the
        service specification.

10.6    Only the procedures listed in Appendix A will be routinely commissioned

10.7    The GD service will evaluate its service at least annually and make the results of the
        evaluation available to commissioners.



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10.8    After patients have been discharged from the gender service, they should have
        equal access to health care services in accordance with their physiological needs.

10.8    This policy will be reviewed in 2011, taking into account the findings of the service
        evaluation and/or when further significant information becomes available, either from
        clinical trials, NICE or the Inter Collegiate Working Party for Standards of Care for
        People with Gender Dysphoria. The policy complies with the Gender Recognition
        Act, 2004.




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11         REFERENCES

1
  GIRES Guidelines for Primary Care Trusts [PCTs] & Strategic Health Authorities [SHAs], (Annex A, Standards
of Care in the Treatment of Gender Dysphoria & Transsexualism, Annex B, Informed Consent forms)
http://www.gires.org.uk/Text_Assets/Guidelines.pdf
2
    International Classification of Disease
3
    Wylie, K. Gender Related Disorders. BMJ. 2004 Nov 27;329(7477):1270
4
 Meads C, Pennant M, McManus J, Bayliss S. A systematic review of lesbian, gay, bisexual and transgender
health in the West Midlands region of the UK compared to published UK research. Report number 71, March
2009. WMHTAC, Department of Public Health and Epidemiology, University of Birmingham. 2009
5
 Gender Identity Research and Education Society. Gender Variance in the UK: prevalence, incidence, growth
and geographic distribution. June 2009
6
 P Wilson, C Sharp, and S Carr. The prevalence of gender dysphoria in Scotland: a primary care study. Br J
Gen Pract. 1999 December; 49(449): 991–992.
7
 Gender Identity Research and Education Society. Gender Variance in the UK: prevalence, incidence, growth
and geographic distribution. June 2009
8
 Harry Benjamin International Gender Dysphoria Association. Standards of Care for Gender Identity Disorders,
Sixth edition 2001. Düsseldorf: Symposium Press
9
 Guidance for GPs, other clinicians and health professionals on the care of gender variant people; Department
of Health [Prolog #286109]
10
   Best l, Stein K. Surgical gender reassignment for male to female transsexual people. Southampton: Wessex
Institute for Health and Development. 1998. 25.
11
  Day P. Trans-gender reassignment surgery. Christchurch: New Zealand Health Technology Assessment
(NZHTA). 2002. 25.
12
  Alberta Heritage Foundation for Medical Reasearch. Vaginoplasty in male-female transsexuals and criteria for
sex reassignment surgery. Alberta Heritage Foundation for Medical Reasearch. 1997. 25.
13
  Alberta Heritage Foundation for Medical Reasearch. Phalloplasty in female-male transsexuals. Alberta
Heritage Foundation for Medical Reasearch. 1996. 9.
14
  Pfäfflin and Junge (1998); Sex Reassignment. Thirty Years of International Follow-up Studies After Sex
Reassignment Surgery: A Comprehensive Review, 1961-1991; English Ed. by Jacobson and Meier
15
   Best l, Stein K. Surgical gender reassignment for male to female transsexual people. Southampton: Wessex
Institute for Health and Development. 1998. 25.
16
  Goddard JC, Qureshi A & Terry TR. Feminizing genitoplasty in male transsexuals – early follow up. Sexual &
Relationship Therapy, 19, Suppl 1, S85. 2004
17
  Bettocchi C, Ralph DJ & Pryor JP. Pedicled pubic phalloplasty in females with gender dysphoria. BJUI, 95,
120-124. 2005
18
  HAYES, Inc.. Sex reassignment surgery and associated therapies for the treatment of gender identity
disorder. Lansdale, PA: HAYES, Inc 2004:42
19
   Andalusian Agency for Health Technology Assessment. Gender dysphoria: possible interventions and
coverage in Andalusian Health System – systematic review, economic evaluation. Sevilla: Andalusian Agency
for Health Technology Assessment (AETSA), 1999.
20
     NHS AIAU. Survey of Patient Satisfaction with Transgender Services, June 2008




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21
   Murjan S, Shepherd M and Ferguson BG. What services are available for the treatment of
transsexuals in Great Britain? Psychiatric Bulletin 2002 26:210-212
22
 Based on 2001 census data for the population of those aged over 15 years and registered with Y&HSCG
PCTs.
23
     NHS Calderdale. Survey of the trans population in Calderdale. March 2009




Additional Reading

Trans: A Practical guide for the NHS; Department of Health [Prolog # 289748]

Guidelines for Commissioners; The Parliamentary Forum on Gender Identity;
http://www.gires.org.uk/assets/Medpro-Assets/parlimentary-guidelines.pdf

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and
Discrimination; The Equalities Review http://www.pfc.org.uk/files/EngenderedPenalties.pdf

Endocrine Society of America: Guidelines on hormone treatment;
http://jcem.endojournals.org/cgi/content/abstract/jc.2009-0345v1?papet

Transgender EuroStudy: Legal Survey and Focus on the Transgender Experience of Health Care
(April 2008); Whittle, S.W et al; ILGA-Europe; http://www.ilga-
europe.org/europe/publications/non_periodical/transgender_eurostudy_legal_survey_and_focus_on_t
he_transgender_experience_of_health_care_april_2008




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                                           Appendix A
                PROCEDURES THAT WILL BE ROUTINELY COMMISSIONED

Sex reassignment involves a variety of therapeutic options, including surgical procedures
and other clinical interventions summarised in Section 3.

The following procedures, if appropriate for the individual undergoing sex reassignment,
should be routinely commissioned. The particular order in which interventions are carried
out may vary, subject to the eligibility criteria set out within the policy, but are routinely
funded only once.

Non-surgical interventions include:
   Diagnostic assessment
   Psychotherapy during all stages of active progression, including RLE
   Hormone therapy, including endocrinology assessment
   Speech and language therapy
   Support and advice on style
   Pre and post operative wound management support from a District Nurse with a
      specialist knowledge of sex reassignment
   Facial hair removal in trans-women, where clinically required

Routinely funded surgical interventions are different for trans-men and trans-women, as
follows.

Surgical procedures for sex reassignment in trans-women are:
    Penectomy
    Orchiectomy
    Vaginoplasty
    Clitoroplasty
    Labiaplasty
    Chest reconstruction, where clinically indicated
    Donor site hair removal on surgeon’s recommendation

Surgical procedures for sex reassignment in trans-men are:
    Mastectomy
    Hysterectomy
    Vaginectomy
    Salpingo-oophorectomy
    Metoidoplasty or phalloplasty
    Urethroplasty
    Scrotoplasty and placement of testicular prostheses
    Donor site hair removal on surgeon’s recommendation




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                                                 Appendix B

                                COSTS / COMMISSIONING IMPLICATIONS

        The current cost of the specialist gender identity service is approximately £4,000 per
         patient per annum. The service cost is based on current clinic prices, averaged out
         to include the costs of assessment and treatment, but excluding surgery.

        The cost of male to female GRS, dependent upon the procedures carried out is
         approximately £14,300. Female to male GRS costs between £25,000 and £65,000
         dependent upon which of the 4 surgical stages are carried out.

        The table below models the anticipated commissioning implications of this policy (at
         08/09 prices), including the clearance of any backlog of patients meeting the criteria
         within this policy:

                                08/09 Actual 09/10         10/11         11/12         12/13         Steady State
Barnsley                         £     21,800 £     19,700 £      31,200 £      49,800 £      38,300 £      32,800
Bradford & Airedale Teaching     £     52,600 £     52,600 £      52,600 £      52,600 £      52,600 £      52,600
Calderdale                       £     32,900 £     32,900 £      32,900 £      32,900 £      32,900 £      32,900
Doncaster                        £     42,500 £     51,200 £      92,300 £     116,700 £      75,500 £      60,700
East Riding of Yorkshire         £     23,700 £     23,700 £      23,700 £      23,700 £      23,700 £      23,700
Hull Teaching                    £     31,500 £     31,500 £      31,500 £      31,500 £      31,500 £      31,500
Kirklees                         £     44,700 £     44,700 £      44,700 £      44,700 £      44,700 £      44,700
Leeds                            £     72,400 £     72,400 £      72,400 £      72,400 £      72,400 £      72,400
North East Lincolnshire          £      3,300 £      7,000 £       7,000 £      21,300 £       7,000 £       7,000
North Lincolnshire               £     11,600 £     11,600 £      25,900 £      11,600 £      11,600 £      11,600
North Yorkshire & York           £     54,800 £     86,400 £     108,400 £      98,900 £      76,800 £      63,400
Rotherham                        £     33,300 £     33,400 £      54,000 £      75,400 £      52,400 £      44,800
Sheffield                        £     68,300 £    105,400 £     196,300 £     225,000 £     148,300 £    117,700
Wakefield District               £     52,200 £     35,600 £      35,600 £      49,900 £      35,600 £      35,600


   (Shaded PCTs are where information has not been received regarding treatments outside of the
                                 Leeds and Sheffield services)


        It is important to note that the commissioning implications set out above assume a
         10-15% conversion rate to surgery, based on experience to date. There is no
         evidence available regarding conversion rates, but clinical estimates vary from 5% to
         35%. This is therefore an area of risk in financial planning.




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