Gender Identity

Overview

Gender Identity Clinics

In the South of England, Gender identity clinics (GIC) are provided by:

• The Tavistock and Portman NHS foundation Trust (used to be known as Charing Cross gender identity clinic) in London
• Devon Partnership NHS Trust in Exeter.

Other centres are available nationally and patients can be referred to any of them. See NHS Gender Identity Clinics for addresses and contact details.

Prescribing advice for GPs

There is local prescribing advice for gender identity on the BNSSG formulary website. - see the 'BNSSG Transgender prescribing information for GPs' document.

There is currently no commissioned service for prescribing advice within BNSSG and individual practices may have their own policies on prescribing based on the guidance provided. If a GP is considering prescribing while patients are awaiting assessment, then they may want to seek advice from a GIC clinic:

• London GIC Clinic endocrine advice
• Devon Partnership GIC Clinic (Exeter) advice for GPs

GMC advice for doctors

There is GMC Advice for doctors treating trans patients which has information about responsibilities as a doctor and links to policies and educational resources.

BMA advice for doctors

There is also advice from the BMA - Managing Patients with Gender Dysphoria. which includes guidelines on prescribing and bridging prescriptions

Hair removal and other cosmetic procedures

Referrals for hair removal or any other cosmetic or other procedures must be via the gender identity clinic. Referrals outside of this pathway fall under local funding criteria and are likely to be returned. See BNSSG Funding policy page for details.

Referral - London

See the Gender identity clinic website for London for information.

Click on the link for referral criteria and the referral form. A secondary care mental health assessment is no longer required prior to referral but please note that the referral form does request information about any history of physical and mental health problems including a drug and alcohol history and physical health assessment (height, weight, waist circumference, BP, pulse).

Self referrals can be made but still require supporting information from the GP.

How to make a referral

See the GP referrals page on their website. Referrals can be made via eRS or by email or post.

To locate the London Gender Identity Clinic service on eRS, enter the following in the search fields:

• Priority = Routine
• Specialty = Gender Identity Services
• Clinic Type = Gender Identity
• Service name = London Adult Gender Identity Clinic - Tavistock & Portman NHSFT

Referral - Exeter

Click on the link for further information DPT Gender Identity Clinic

The referral form ,including how information on how to refer is on their website.

How to make a referral

Referrals should be made directly by email or post (not via e-RS):

• Secure email: dpn-tr.TheLaurels@nhs.net
• Post: West of England Specialist Gender Identity Clinic,The Laurels, 11-15 Dix’s Field, Exeter, EX1 1QA
• Tel: 01392 677077

Gender identity advice for children

Please see Gender Identity in children and young people page.

Includes latest regulations regards prescription of puberty suppressing hormones for people under 18.

Support for patients whilst on the waiting list for NHS Gender Identity Clinics

The following advice has been supplied by Dr Kimberly Bruce GP (pronouns she/her) and reviewed by Dr Jo Hartland and Dr Anna Sales. This guidance has been co-produced by people with lived experience

(GIC) (NHS waiting times min. 4 years see here)

• Contraception choices – FSRH guideline here.
  • Consider discussing progesterone only contraception for trans men and non-binary people with a uterus, to induce amenorrhoea and ease dysphoria caused by menstruation as supported by WPATH Standards of Care here.
• Sexual health
  • Terrence Higgins Trust guides to sexual health and happy, healthy sex for trans and non-binary people here
  • If having anal sex, refer to Unity sexual health to consider vaccination against hepatitis A & B
• If engaging in high risk sexual behaviours, or patients feel it is appropriate for them and there no contraindications – consider referral to Unity sexual health for PrEP or PEPSE.
  • Gender inclusive PrEP decision tool here
  • PrEP patient leaflet here and PrEP drug interaction tool here
• Consider risk of hormone dependent cancers that may be affected by gender-affirming hormone therapy
  • There is no national prostate screening programme, but consider discussing PSA testing as usual over 50 years (or younger if higher risk for prostate cancer), as per Remedy. There is information on PSA testing written for trans women and non-binary people with a prostate here
  • Check up to date with cervical and breast screening
  • Offer genetic counselling referral as usual if higher risk family history of breast cancer or Lynch Syndrome as per Remedy and NICE guidelines
• Some (but not all) GIC require smoking cessation for hormone therapy initiation and BMI <31 for gender affirmation surgery. Consider when giving lifestyle advice that access to exercise spaces for trans and gender diverse people can be difficult.
• Optimise control of long term conditions as usual e.g. hypertension, T2DM – to reduce risks of hormone therapy
• Mental health support and treatment if needed as usual, see Remedy
• Health safety information on:
  • Binding - LGBT Foundation guide to safe binding here
  • Tucking here
  • Packing here and stand-to-pee devices here
• Local Support Groups
  • List of LGBTQ+ support services (including for young people, their carers and families, people who identify as disabled, Muslims, people of colour, refugees and asylum seekers) here

• NHS population screening. breast, cervical, AAA
  • National screening invitations are based on the gender marker on the patient’s GP records rather than their organs/tissues.
  • This means that transgender and non-binary people (independently of whether they have changed their gender marker on their NHS records), may not get the national invitations for the screening that they need and are entitled to.
  • Give patients NHS England “population screening: information for trans and non-binary people” here
• Speech and language therapy helps ease dysphoria and build confidence – the Voice Team at St. Michael’s Hospital accept referrals for trans voices for around 4 therapy sessions see here.
• Facial hair removal - NHS GICs refer their patients directly, see here
  • The ICB does not routinely commission treatments for permanent or hair removal, including electrolysis and laser therapy. Please see the Hair Removal (Including electrolysis and laser therapy, also covering complex pilonidal sinus disease and para stomal disease) Policy - Prior Approval.
  • If people choose to seek private treatment, recommend practitioners registered with the British Institute and Association of Electrolysis (https://www.electrolysis.co.uk/ and NHS advice here

Patients on hormonal therapy (See Overview section above for BNSSG transgender prescribing information for GPs)

• Contraception - FSRH guideline here.
  • Combined hormonal contraception containing oestrogen is not recommended if taking testosterone as it interferes with testosterone
  • Cessation of menses takes about 2-6 months once taking testosterone
  • Gender-affirming hormone therapy (including oestrogen, testosterone and GnRH analogues) cannot be relied on for contraception.
  • Testosterone is teratogenic and contraindicated in pregnancy.
• Gamete storage
  • Gender-affirming hormone treatments have been shown to impact fertility, although their degree of impact on fertility may vary between individuals see here
  • There is criteria based access (CBA) in BNSSG for gamete storage for “those prescribed testosterone on a NHS gender dysphoria pathway” or any other drug a clinician feels is likely to compromise fertility”. See here. N.B.Gender affirming hormone therapy may need to be stopped for a few months to allow gamete collection.
    • For NHS funded assisted conception and IVF following gamete storage, they still have to meet the usual BNSSG CBA for infertility assessment and treatment see here

Referral to Secondary care

• Gender Identity is a protected characteristic - only include information about gender identity on the referral letter if clinically relevant and only with the patient’s permission e.g.
  • Adaptions – discuss adding information on gender identity (with the patient’s consent) and requests for reasonable appointment adaptions E.g. when referring to gynaecology or urology asking about the possibility of being seen in a general department, side room, or have an appointment at the beginning or end of clinic.
• Think about pregnancy risk in someone with a uterus and a male gender marker on their NHS notes when referring to radiology for x-rays/CT scans
• Colonoscopy/sigmoidoscopy – may be more uncomfortable if a trans woman’s neovagina is constructed from colon tissue. Discuss with the patient about including this information on the referral form.
• Breast – top surgery/chest surgery – usually does not remove all the breast/chest tissue and breast/chest tissue often remains in the axilla and nipple area. Patients should discuss with their surgeon about whether they would need national breast/chest screening in the future. Chest changes during transition and checking guidance for trans and non-binary people here
• Vaginal/ovarian ultrasounds – transvaginal scans (TVS) may cause dysphoria for trans men and non-binary people with a vagina so consider the following:
  • Abnormal vaginal bleeding on testosterone needs an urgent ultrasound (see below) and endometrial biopsy to check for endometrial hyperplasia. Some GIC also recommend regular endometrial ultrasound monitoring every 2-5 years whilst taking testosterone. (however this is not core GP work).
  • Transabdominal scans of the uterus/ovaries
    • require a full bladder
    • are less accurate if someone has a high BMI
    • can assess for ovarian pathology but are not as sensitive as TVS for endometrial thickness. (N.B. after around 6 months of testosterone, the ovaries may take on a polycystic appearance).
    • On ICE request consider writing e.g. “trans masculine/non-binary patient with a uterus. Prefers full bladder transabdominal rather than transvaginal ultrasound initially. If possible please see in a general rather than gynae department”.
    • If radiology feel at the point of scan that the quality is sub-optimal, they will discuss further options with the patient e.g. would they consider TVS.
  • Currently transrectal ultrasounds are not available in BNSSG
  • Other options may include hysteroscopy under general anaesthetic or MRI.
• Urology
  • For trans women who have had bottom surgery (gender affirming surgery), the prostate is usually retained. It is easiest to examine the prostate via the anterior wall of the neovagina (see picture below from Prostate Cancer UK) and here
  • If they are taking feminising hormone therapy (including testosterone suppression with GnRH analogues) the prostate will be smaller on examination and you should have a lower threshold for referral to urology of PSA >1ng/ml see here 

Resources

The NHS England Gender Dysphoria Clinical Program page  has links to Service Specifications for Gender Identity for adults and children.

Gender Identity Support line - (provided by the Gendered Intelligence charity) - this has been recommended but the Exeter GIC clinic and may be useful to support patients during the long wait for an appointment.

Gender Identity Toolkit For General Practice (March 2023) - template clinical guidance document for Gender Identity policies within NHS organisations (produced by Indigo, Pride in Practice, THhe IGPM and Practice Index).

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.