Feedback on the Gender Reassignment Pathway Review in Wales

Feedback on the proposals identified from the Welsh Health Specialist Services Committee for the provision of Gender Reassignment Services in Wales.

Introduction The LGBT Excellence Centre was commissioned by the Welsh Health Specialist Commissioning Committee (WHSSC) to organise 4 workshops to input into the review of the Gender Dysphoria referral process in Wales.

The four workshops took place on the following dates and venues: • Sat 9th June, 3.00-5.00pm, Cardiff City Church • Sat 16th June, 3.00-5.00pm, Swansea Council, Committee Room 3 • Fri 22nd June, 3.00-5.00pm, Llandrindod Wells Youth Centre • Sat 23rd June, 3.00-5.00pm, Aberystwyth University

LGBT Excellence Centre Transforming lesbian, gay, bisexual and transgender lives

Objectives of the workshops The workshops followed a similar structure to address the following points: 1. Explain the proposed all-Wales Gender Dysphoria Service, including the time-line for its approval and implementation by WHSCC 2. Identify the major changes (and improvements) compared with the previous Gender Dysphoria Care pathway.

3. Have an “in-depth” discussion with participants so as to explain how the new process is intended to operate throughout Wales.

4. Identify any concerns arising from these discussions for feedback to WHSSC for the pathway to be finalised.

Feedback The feedback from the attendees was collated during the 4 events and summarised as follows: •

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General Generally all participants recognised that the proposed pathway is robust and a significant improvement in the provision of Gender Dysphoria services in Wales. The new pathway seems to address most of the needs and concerns that have previously been identified and reported to WHSSC by individuals and organisations around the inequalities of service provision to transsexual people.

Referral Access A significant number of attendees raised concerns in regards to accessing the pathway referral. Currently, and also under the proposed pathway, the referral to specialist services can only be accessed via a General Practitioner. Attendees were aware that primary care issues around lack of awareness and training, discriminatory practice, or lack of other support services cannot be addressed by WHSSC. However, the referral process could be improved by widening access to a referral via other agencies in

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the 3rd sector, other health professionals, and through self-referral. This would allow individuals that experience difficulties in primary care to be able to access the service and be supported in the process.

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Gender Identity Clinics The establishment of two centres, one in the North and one in the South, for the provision on non surgical services in Wales is welcomed by participants and considered a great improvement on the current requirement for patients having to wait long times and travel to London. A significant number of participants indicated that it would be beneficial for patients to be able to express a preference as to which centre they would be referred to. This would answer some concerns that individuals might have around being potentially “outed” to people they know in the local community or relatives/partners working in the service.

Diagnosis Whilst the proposed pathway suggests that diagnosis will be undergone in Wales, there are concerns around clinics such as Charing Cross expecting a patient to undergo their own assessment. This puts pressure on the individual and creates discomfort in having to prove themselves continually. Furthermore, this also has financial implications for WHSSC with having to fund further unnecessary assessments. Participants consulted with would recommend that the new pathway would rectify this issue in the negotiations for contracts for gender reassignment surgery providers.

Existing Provision Some participants would like to clarify whether patients that have been signposted to Charing Cross under the interim arrangements would be able to transfer to the Welsh Service once this has been implemented.

Whilst it is recognised that some services might be difficult to transfer (such as counselling half-way through the process), it would be preferential and more cost effective if patients were allowed to be treated in Wales.

Integrated Service Provision Whilst the clinics will be providing support in the provision of health services, there is a need to address other support needs that patients might have. These might relate to emotional support, advocacy, social care, housing, community support, etc. Attendees indicate that an integrated approach with other agencies and the local authorities might be beneficial in the identification of issues and available support provision.

The multi-agency approach tested in the provision of support to victims of domestic abuse for example (MARAC/MAPPA) seems a good model for ensuring the wellbeing and care of transsexual patients.

Third Sector Whilst it is recognised by participants that the third or voluntary sector plays a vital role in the provision of support to transsexual people, it has to be acknowledged that there are only a handful of small groups. In particular, there is nothing in West and Mid Wales and in more rural part of Wales. Furthermore, the existing organisations are mostly under-

LGBT Excellence Centre Transforming lesbian, gay, bisexual and transgender lives

Suite 5 Sophia House 28 Cathedral Road Cardiff CF11 9LJ T: 029 20451868 F: 029 20664891 W: www.lgbtec.org.uk E: info@ecwales.org.uk

Company No: 6407962 Charity No: 1123355

Chief Executive Officer Mr Federico Podeschi Chair of Trustees Miss Ceri Harris

resourced and mainly run by volunteers and therefore the expectations placed on their provisions should be realistic and capacity building should be supported.

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Private care A number of participants highlighted the need to manage the process of being referred into the Welsh pathway after having started their transition privately. Some individuals might have undergone some treatment privately due to delays or failures from the public sector. Nevertheless, they might want to be referred into the new pathway and clear guidelines should be identified to ensure that private patients would not have to undergo another assessment or further delays.

Real Life Test The majority of attendees felt that it was still important to maintain the requirement to undergo a test period of living in the other gender to make sure people are supported in the transitioning process and to instil a sense of confidence with the health professionals. However, it was recommended that there should be clear guidance about how and when the real life test happens (i.e. some people might have been living in the role for a number of years before diagnosis – does this count?). Some attendees reported that the real life test can be dangerous for some people that are not given hormones or those that might struggle to pass – as the process could out them. Therefore, a recommendation was made that the 12-month test should include other support services, for example: hormones, emotional support, and third sector referral, and multi-agency support.

Further work Whilst the review of the pathway will address existing difficulties that transsexual patients are experiencing, there are still concerns in addressing problems in the provision of services that fall outside of the remit of WHSSC. A clear set of recommendations should be produced by WHSSC for the work of the committee to drive change in other services. In particular, attendees welcomed the suggestion that WHSSC made already in regards to further work being needed to explore the issues (and support needed) for those people with metal health conditions, people with learning difficulties, people in detention, and young people. A further group that it was felt needed to be taken into consideration is asylum seekers and refugees, who might experience another set of complications in accessing healthcare and gender reassignment support.

Conclusion There was a good sense of satisfaction and support for the proposals put forward by WHSSC amongst the people who attended workshops. Attendees welcomed the recommendations made and expressed an interest in the continuing process of consultation with transgender people. The highlighted feedback should support the strengthening the proposal and it is hoped that this will be considered favourably.

LGBT Excellence Centre Transforming lesbian, gay, bisexual and transgender lives

Suite 5 Sophia House 28 Cathedral Road Cardiff CF11 9LJ T: 029 20451868 F: 029 20664891 W: www.lgbtec.org.uk E: info@ecwales.org.uk

Company No: 6407962 Charity No: 1123355

Chief Executive Officer Mr Federico Podeschi Chair of Trustees Miss Ceri Harris