Coventry Health Authority

Policy for Gender Dysphoria

SUMMARY GUIDANCE

FOR THE TREATMENT OF PEOPLE

WITH

GENDER DYSPHORIA

December 1999

1. INTRODUCTION

1.1 This is a summary version of Coventry Health Authority's Commissioning Guidance for people with gender dysphoria.

1.2 People with gender dysphoria have the right to receive treatment.

1.3 The care pathway and approval process is set out below in a brief descriptive format and diagrammatically.

2. CARE PATHWAY AND APPROVAL PROCESSES

2.1 The following gives a brief description of the pathway and approval processes throughout.

2.2 At the GP Surgery

2.2.1 Initial referral to a Specialist

2.2.2 GPs will need to decide whether there are any coexisting conditions or whether any mental health factors need to be determined. A referral to a consultant psychiatrist may be considered for this purpose. Where this is not the case then a referral to a designated specialist in gender dysphoria will be needed. An individual will need two separate independent assessments as part of diagnostic process.

2.3 Local PCT Approval

2.3.1 The local specialist will be expected to advise the Health Authority whether a referral to the Gender Identity Service is advisable. If the Health Authority decide to approve the referral this will be an agreement to commission the complete care pathway (if appropriate and medically supported by the specialist providers), including any referral that may eventually be made for gender reassignment surgery.

2.4 Gender Identity Service Actions

2.4.1 On receipt of the referral the Gender Identity Service will seek formal approval from the Health Authority to proceed with the assessment.

2.5 Initial Assessment and Progress to the Real Life Test

2.5.1 The initial assessment period of three to six months at the tertiary centre involves diagnostic assessment of the person (including the patient's history of and current experience of gender dysphoria), counselling, general medical examination and psychological measurements and blood tests.

2.5.2 Once this has been completed and where it has been resolved that the person wishes to continue with a change of gender they will progress to the `real life test and experience' (RLTE).

2.5.3 Real Life Test Experience (RLTE)

The RLTE will be a minimum of 2 years living continuously in the gender role with which the individual identifies. The aim is to assist the patient and the professionals in decisions about how to proceed. There will be circumstances where the RLTE may need to be extended. The reasons for this must be discussed with the individual.

2.5.4 The quality of the RLTE is assessed through discussions about the patient's ability to consolidate their gender role in areas such as employment, voluntary work, education or training, or some other stable social and domestic lifestyle; formally adopt a gender appropriate first name and to demonstrate that society is aware that they are living in their new role. There may be occasions when clinicians request verifiable documentation or evidence of the gender change.

2.5.5 Treatments provided by the Gender Identity Service

The Gender Identity Service will provide psychological support and the services of an endocrinologist to advise on hormone treatment. Hormone treatment will generally start 3 months after the Real Life Test and Experience (see section below on treatments) has commenced.

2.5.6 Completion of the RLTE and Possible referral for gender Reassignment Surgery

Some individuals may not wish to progress all the way to complete surgical reassignment and there should be some flexibility in the progression from one stage to another. Some individuals may prefer lifelong hormone therapy unless contraindicated.

2.5.7 If gender reassignment surgery is recommended then the Gender Identity Service will ensure that it is recommended by two consultant psychiatrists.

2.5.8 The Gender Identity Service will refer an individual to a specialist centre for reassignment surgery.

2.5.9 Following receipt of the referral from the Gender Identity Service the specialist centre for reassignment surgery will seek approval from The Health Authority to proceed with the surgery.

2.5.10 Following surgery the individual will normally be referred back to local acute and/or mental health services.

Care Pathway Diagram

1

Speech Therapy if necessary

Start 2-year real life test

Follow-up appointments every 3-4 months

Discharge to GP, local Consultant Psychiatrist

2^nd Consultant Psychiatric Assessment if required

1^st Consultant Psychiatric Assessment

Appointment

Referral allocated to Gender Consultant Psychiatrist

Health Authority agrees Consultant Psychiatrist or Specialist refers to Gender Identity Clinic

GP refers to local Consultant Psychiatrist or Health Authority appointed Specialist

Patient visits General Practitioner

Hormone Therapy if necessary

Endocrine Opinion

Referral for surgery if appropriate-requires Health Authority Approval

Gender Reassignment Surgery

Follow-up appointments before referral back to GP/CMHT

1. 1^st and 2^nd assessments by two different GIC Consultant Psychiatrists (if required).

2. Two separate recommendations from Psychiatrists for surgery.