PATHWAY FOR ACCESSING SERVICES FOR TRANSGENDER …



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 |

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 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.

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.

4.3 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. Specialist Mental Health Services – Gender Identity Clinic (GIC)

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.

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”.

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.

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 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.

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.

• 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

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Appendix 1

PATHWAY FOR ACCESSING SERVICES FOR TRANSGENDER PERSONS

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 in treatment |3.27 |0.76 |1.98 |

|Patients with gender dysphoria in psychological / counselling |2.34 |0.53 |1.41 |

|treatment only | | | |

|Patients taking sex hormone therapy but pre-operative |3.33 |0.64 |1.95 |

|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 in treatment |177 |41 |218 |

|Patients with gender dysphoria in psychological / counselling |127 |29 |156 |

|treatment only | | | |

|Patients taking sex hormone therapy but pre-operative |181 |35 |216 |

|Post-operative transsexual patients |244 |69 |313 |

|Total |729 |174 |903 |

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-up appts|TOTAL |

| | |treatment |treatment |operative | | |

|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) |

|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. |

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

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

PATIENTS

NEED FOR FURTHER ASSISTANCE IDENTIFIED

GP

GENERAL MENTAL HEALTH ASSESSMENT

SPECIALIST MENTAL HEALTH SERVICES

GENDER IDENTITY CLINIC

OPINION (S) AND TREATMENT PLAN

ENDOCRINOLOGY

REAL LIFE EXPERIENCE

(RLE)

2ND PSYCHIATRIC OPINION

GENDER REASSIGNMENT SURGERY

(GRS)

COMPLETED GRS

ONGOING LOCAL COUNSELLLING & SUPPORT

ONGOING LOCAL ENDOCRINOLOGY

INFORMATION AND ADVICE

SPEECH THERAPY

(if required alongside endocrinology & RLE)

IRREVERSIBLE TREATMENTS - - - - - - IRREVERSIBLE TREATMENTS

OTHER

TREATMENTS

e.g.

Mastectomy

INFORMATION AND ADVICE

COMPLETED ENDOCRINOLOGY & RLE

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