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Transgender wellbeing and healthcare

  • Aaaaaaaaaaaaaahg it's going backwards.
    Cristine Jennifer Shye.  B/L.  B/Acc
      June 30, 2020 4:51 PM BST
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  • What a waste of time
    Cristine Jennifer Shye.  B/L.  B/Acc
      June 30, 2020 4:50 PM BST
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  • ABOUT THIS DOCUMENT

     

    Produced by COI for the Department of Health
    The text of this document may be reproduced without formal permission
    or charge for personal or in-house use.

     

    Gender variant (trans or transgender) people are relatively rarely seen in GP surgeries. Many GPs say that they lack the knowledge to treat those experiencing
    gender variant conditions and, consequently, they are not confident to do so.
    The first part of this publication provides an overview of care for trans people that is particularly applicable to GPs. Hormone therapy is central to transgender primary
    care, and issues such as assessment and diagnosis are also relevant to general practice. These topics are discussed in greater detail in Annexes C and D. Clinical care for gender variant people should be provided within a framework of good practice that emphasises patient autonomy, allows for the wide variety of needs among trans people and is flexible in its clinical responses to those needs. It should also take account of the social context in which trans people live.   Care should be holistic and may involve a number of different professionals. Accordingly, Annex C also covers a range of information regarding family, social and employment issues that are relevant, not only to GPs, but to a range of health and social care professionals who may be involved in providing a broad spectrum of support and advice to trans people and to their wider families. The information in this publication aims to enable these professionals to respond confidently and
    appropriately when they are approached by trans service users.   The publication is written by a team from the Gender Identity Research and Education Society that includes doctors and trans people. All the team members have specialist knowledge and experience in the transgender field.


    Dr Richard Curtis, BSc, MB, BS, DipBA
    Professor Andrew Levy, PhD, FRCP
    Dr Joyce Martin, MB, ChB, DObstRCOG
    Professor Zoe-Jane Playdon, BA (Hons), PGCE, MA, MEd, PhD, DBA, FRSA
    Dr Kevan Wylie, MB, MMedSc, MD, FRCPsych, DSM
    Terry Reed, BA (Hons), MCSP, SRP, GradDipPhys
    Bernard Reed, MA, MBA

     

     

    Gender variance (sometimes still called gender dysphoria) describes the personal discomfort experienced by individuals whose psychological identification as men or
    as women (the gender identity) is inconsistent with their phenotype and with the gender role typically associated with that phenotype. Both gender role and
    phenotype may, therefore, be sources of distress. The condition may be experienced to varying degrees, and be expressed in a variety of ways. These may
    be intermittent or permanent. Sometimes, gender variance that is initially expressed intermittently, later becomes permanent.
    When gender variance is profound and persistent, it is usually referred to as transsexualism. Since it is a subjective experience, it can only be diagnosed in
    accordance with what is said by the individuals who experience it. There are no tests that provide an absolute diagnosis. Transsexualism is neither a ‘lifestyle’ choice
    nor a mental disorder, but a condition that is now widely recognised to be largely innate and somatic.1 It is one that responds well to medical care.

     

    GPs are usually at the centre of treatment for trans people, often in a shared care arrangement with other clinicians. GPs may prescribe hormones and make referrals
    to other clinicians or services, depending on the needs of the particular service user. Sometimes a GP has, or may develop, a special interest in gender treatment
    and may be able to initiate treatment, making such local referrals as necessary. Otherwise referrals may be made to a specialist Gender Identity Clinic (GIC) where
    there are multidisciplinary teams of professionals. Private treatment with a gender specialist may be preferred by the service user.   Although gender variance is alleviated to a greater or lesser extent by treatment, to the point that many individuals say that they no longer experience any discomfort,
    they may, nonetheless, continue to need hormone therapy and monitoring throughout life. This will usually be the responsibility of the GP.

     

    Whatever their medical needs, trans people (trans men, female to male/FtM; and trans women, male to female/MtF) should be addressed and accommodated
    according to the gender in which they present, unless they specify otherwise.  This applies, as far as possible, to any correspondence. If medical and administrative
    staff are unsure about whether to address an individual as Mr, Miss, Ms or Mrs, it is better to ask, discreetly.

     

    Confidentiality is required for all service users, but this is a particularly sensitive issue for trans people. Reception staff and practice nurses, as well as doctors, need
    to be aware that unnecessary and unwanted disclosure of the transsexual status of service users is bad practice and, in respect of those who are covered by the
    privacy provisions of the Gender Recognition Act, could amount to a criminal
    offence. Furthermore, this information may be irrelevant to their reasons for attending the surgery, since people experiencing gender variance may seek medical
    treatment for conditions that are totally unrelated to transsexualism.


    People are entitled to treatment for transsexualism by law as stated in the case of North West Lancashire Health Authority v A, D & G, Court of Appeal, 1999 (see
    the forthcoming NHS publication A guide to trans service users’ rights). This is not a condition that clinicians may decline to treat. When trans service users present
    for the first time for help with their gender discomfort, it is important that they are treated non-judgementally and sympathetically. Doctors who feel unable to do this,
    should refer them to a colleague who can.

     

    Those experiencing gender variance have often lived with the discomfort ‘as far back as they can remember’. Many, perhaps most, attempt to repress their feelings
    and to live according to society’s rules for many years. Nevertheless, some may have already embarked on their own solutions, including buying hormones on the
    internet. Some may be experimenting with cross-dressing, or even living full-time in the gender role that is more comfortable than the one assigned at birth. They may have changed their names, and possibly have support from family and employers.   Some have a clear idea about what they want and how they see their future.
    Many, however, have repressed their own needs, often for many years, in order to comply with the demands of society, families, employers and so on, and are only
    just beginning to accept that they are unable to continue their present way of life.   Addressing their gender discomfort may feel urgent, their level of distress may be
    high and they may be feeling suicidal.   Approaching a doctor is often a last resort, and it takes great courage. It is imperative that the GP (or any other professional whom gender variant people may approach) offers support in a holistic way, taking account of personal circumstances. It is also important to reassure service users that treatment is available, and that outcomes can be good.   If trans people themselves wish to have a supportive family member (significant other, close friend) present, then this should be encouraged. Outcomes for trans people have been shown to be better when their families are supportive. This is more likely to be the case if they are involved in the trans person’s treatment process, than if they feel excluded from it. Family members often experience a wide range of uncomfortable emotions: grief and betrayal (especially for partners), embarrassment, anger, guilt, helplessness and, in some cases, revulsion. Support
    for the family as a unit may also be appropriate, and families may be put in touch with voluntary groups and charities working in the field.   Any requirement for a trans person to divorce before medical intervention is not regarded as acceptable practice.

     

    GICs provide several services in-house: mental health support, endocrinology, speech and language therapy and, sometimes, image consultancy. At their best,
    these clinics provide a sensitive and well-rounded approach. Many service users do very well under the GIC regimes, but others have found that these are too
    inflexible to meet their needs. The draft Good practice guidelines for the assessment and treatment of gender dysphoria in the UK (2006) promises a change
    in approach to the treatment of gender variant individuals. It is anticipated that the guidelines, once finalised, will allow greater autonomy, flexibility and choice for
    service users.


    “We herald a new approach to care which has evolved from a linear progressive sequence to multiple pathways of care which recognise the great diversity of
    clinical and presentation needs.” (Kevan Wylie) It is, therefore, desirable that service users are offered the choice of a local service, and are not automatically referred out of area to a specialist GIC unless local provision proves impossible to set up. Although severe gender discomfort raises some complex issues, most elements of the treatment are relatively straightforward and can be sourced locally. GPs, especially those who are regarded as having a special interest in the field and are acknowledged as gender specialists, can make the necessary secondary referrals to ensure that multidisciplinary input
    (endocrinology, mental health, speech and language therapy, facial hair removal and so on) can be provided locally. It is not essential that all services are under one
    roof. This approach to treatment may be less traumatic for the service user since it usually results in more flexibility of treatments, less travelling to appointments, and shorter waiting times.

     

    GPs may also consider that:
    “Private services may be appropriate in individual circumstances and are not necessarily more expensive than National Health services in this field. Services from
    within the private sector which meet contemporaneous standards of care can also be commissioned” (Parliamentary Forum Commissioning Guidelines).6
    This is in accordance with the British Medical Association policy that states:   “Patients who are entitled to NHS funded treatment may opt into or out of NHS
    care at any stage. Patients who have had private consultation for investigations and diagnosis may transfer to the NHS for any subsequent treatment. They should be
    placed directly on the waiting list at the same position as if their original consultation had been within the:- 

     

    NHS.” 7,8GUIDANCE FOR GPs, OTHER CLINICIANS AND HEALTH PROFESSIONALS ON THE CARE OF GENDER VARIANT PEOPLE

     

    Before treatment begins, a thorough assessment should be undertaken of service users’ past and present gender experiences, the anticipated gender development,
    and any historical and current discomfort with the phenotype. This should take place as soon as possible after they first seek medical help for their gender
    concerns. It may take more than one session, but will vary from person to person, and will depend on a number of factors, one of which will be the stage at which
    the individual presents for treatment. As suggested above, this could be anything from an early acknowledgement of the gender discomfort, to an advanced stage
    of physical and psychological transition. A suggested approach to this exploration
    is set out in Annex C.


    The assessment may be carried out by the GP if he or she feels competent to undertake it. If not, then the GP should refer the service user to a local mental
    health or gender specialist. Where the individual expresses a convincing long-term discomfort with their phenotype and with the associated gender role, a provisional
    diagnosis of severe and persistent gender variance may be made, although this may remain open for reconsideration. If the GP has reason to believe that there are
    co-existing conditions that may need prior, or parallel, treatment, those conditions too may require a referral to a relevant local health professional. However,
    treatment for the gender condition should not be delayed unless strictly necessary for clinical reasons.

     

    A Care Plan may be drawn up jointly between the service user and the clinician (GPs are not obliged to do this formally), but it may be necessary to amend or even
    abandon the Care Plan when circumstances change. Trans people often need to ‘feel’ their way forward, in their own time.

     

    To be continued

     

    Cristine Jennifer Shye.  B/L.  B/Acc
      June 30, 2013 1:04 AM BST
    1