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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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FINAL COMMISSIONING POLICY – OCTOBER 2009

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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FINAL COMMISSIONING POLICY – OCTOBER 2009

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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FINAL COMMISSIONING POLICY – OCTOBER 2009

ABBREVIATIONS GD GRS RLE Y&HSCG

Gender Dysphoria Gender Reassignment Surgery (also known as Gender Confirmation Surgery) Real Life Experience 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. 2.1

3.

BACKGROUND 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.

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 5 to +0.5% population growth per annum) . 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 based survey was conducted in 19986 (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

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 the following criteria89: • 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.

8

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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 Zealand 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 17 considered good in 68% of patients.

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 identity disorder’. One new study was found18 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 19 English.

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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 22 guidance produced by GIRES .

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 (MF) and 65 trans men (FM). 22 Using the 1/11,500 prevalence it can be expected that there are 348 trans people. 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

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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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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

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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.ilgaeurope.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:

Barnsley Bradford & Airedale Teaching Calderdale Doncaster East Riding of Yorkshire Hull Teaching Kirklees Leeds North East Lincolnshire North Lincolnshire North Yorkshire & York Rotherham Sheffield Wakefield District

08/09 Actual 09/10 10/11 11/12 12/13 Steady State £ 21,800 £ 19,700 £ 31,200 £ 49,800 £ 38,300 £ 32,800 £ 52,600 £ 52,600 £ 52,600 £ 52,600 £ 52,600 £ 52,600 £ 32,900 £ 32,900 £ 32,900 £ 32,900 £ 32,900 £ 32,900 £ 42,500 £ 51,200 £ 92,300 £ 116,700 £ 75,500 £ 60,700 £ 23,700 £ 23,700 £ 23,700 £ 23,700 £ 23,700 £ 23,700 £ 31,500 £ 31,500 £ 31,500 £ 31,500 £ 31,500 £ 31,500 £ 44,700 £ 44,700 £ 44,700 £ 44,700 £ 44,700 £ 44,700 £ 72,400 £ 72,400 £ 72,400 £ 72,400 £ 72,400 £ 72,400 £ 3,300 £ 7,000 £ 7,000 £ 21,300 £ 7,000 £ 7,000 £ 11,600 £ 11,600 £ 25,900 £ 11,600 £ 11,600 £ 11,600 £ 54,800 £ 86,400 £ 108,400 £ 98,900 £ 76,800 £ 63,400 £ 33,300 £ 33,400 £ 54,000 £ 75,400 £ 52,400 £ 44,800 £ 68,300 £ 105,400 £ 196,300 £ 225,000 £ 148,300 £ 117,700 £ 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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/KPCT-09-210_Gender_dysphoria_po  

http://www.kirklees.nhs.uk/fileadmin/documents/meetings/200911_Nov09/KPCT-09-210_Gender_dysphoria_policy_Oct_09__Final_.pdf

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