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Leeds Gender Identity Service - FAQs

 

Leeds Gender Identity Service

Frequently asked questions February 2012

 

Leeds Gender Identity Service is well established, around 20 years old and has evolved over the years.  It is a dynamic process. Below are some frequently asked questions and our answers as they stand in 2012.

 

 

1) What are the team’s views and commitment to the client group?

 

 The service has a very committed multi disciplinary team.  Fortunately all members of the team (Consultant Psychiatrist, Medical Practitioner, Endocrinologist, Clinical Nurse Specialist’s, Occupational Therapist, Prescribing Pharmacist, Clinical Team Manager, Clinical Service Manager and the Team Administrator) share the belief in the bio psycho social model and its application within physical, mental, social and general health and gender identity disorder in particular.  All members of the team believe in the recognition of Gender Identity disorder and the need to facilitate and co ordinate gender reassignment in the safest and most effective manner.

The service believe in mutual respect between service provider and service user, informed consent, capacity , guidelines and a flexible application accordingly to individual needs are paramount to the success of an agreed outcome.

 

2) What standards of care are followed by the service?

 

The Harry Benjamin International Standards of Care have a well established and historical influence on standards of care which are considered worldwide, over recent times these have evolved into the WPATH, version 7, standards of care for the health of transsexual, transgender, and gender nonconforming people. As a team we are mindful of this guidance. The team are aware of the Royal College of Psychiatrist standards; however these are currently in draft format. The Gender Act, ICD10, DSM IV, Nice guidelines, Act of parliament 2004 and the policies of the trust including First Do No Harm all guide our practice.

The service has an active involvement in the development of the National standards of care professionals group. This includes other leading, NHS, Gender Identity Services in the UK. The purpose of the group is to define agreed, UK, baseline standards of care.

 

A proposed DSM V is due for publication; however this is still in draft format.

 

Individuals may be aware of the DOH guidance for GP’s other clinicians and health professionals on the care of gender variant people. The DOH has undertaken to replace this document with a revised guide and work will begin on this guide late October 2011.

 

3)  What is included within the care pathway?

 

The care pathway is guided by the standards of care which are stated above however has the ability to be flexible to meet individual needs.  It includes all the stages of Gender reassignment, assessment, the real life experiences, hormone treatment and surgery.  The service initiates the 2nd opinion and surgical referral but these are completed outside of the Leeds Gender Identity Service therefore any waiting times associated with these are outside of our control.

 

4) What is the assessment?

 

The assessment stage takes up to 6 sessions (6 months) however a minimum of 2-3 sessions completed over a 2-3 month period could be agreed according to individuals needs. 

The criteria of the assessment is confirmation of the diagnosis of gender Dysphoria and exploring aspects of physical, mental and social health.  Issues of eligibility and readiness to move into the next stage would be evidenced based.

 

 

 

5) What is the Real Life Experience?

 

The real life experience in its entirety lasts approximately 2 years however this is broken down to include up to 3-6 sessions (3 to 6 months) in special circumstances; this stage would be shortened to 1-2 sessions, in order to complete an assessment of the real life experience. The information gathered during the initial stage of RLE needs to be evidence based, this would include:

Living in role full time
Change of name
Some form of occupational activity this could include voluntary work, paid employment, further studies or evidence of engagement / daily living in the new role.
The service looks at occupational activity in the most flexible way and will agree with each service user how they will meet this requirement depending on their individual circumstances. If extra support is required by the service user a referral to the occupational therapist is available. 

 

It is the service user responsibility to collect this evidence.  The team’s responsibility is to document it.

 

The hormone stage described in question 6 would also fit into the RLE and will last 12-18 months this would include a surgical referral once a positive 2nd opinion has been received.

 

Leeds Gender Identity Service is keen to learn from our experiences, working safely and flexibly within the care pathway to meet the changing needs of the client group.

For those clients who feel they are unable to live in full time RLE in a specified area of their life e.g. employment ‘special circumstances’ can be discussed with the clinician. If ‘special circumstances’ is agreed the following criteria must be met:

·         The client will be assessed as fitting the diagnostic criteria of Gender Dysphoria with a high level of confidence. (In accordance with ICD 10)

·         The client will be assessed as fitting the diagnostic criteria of primary Transsexualism with a high level of confidence. (In accordance with DSM IV)

·         Psychotherapy opinion / treatment will be accessed and a detailed report provided to the Gender Identity Service supporting a referral for hormone treatment.

·         A 12 month plan will be agreed to identify additional objective evidence for all other aspects of RLE excluding the ‘special circumstance ‘agreed between client and clinician. 

 

 

 

 

6) What is involved in the hormone stage?

 

The service has an appointed Medical Practitioner, Consultant Endocrinologist and a prescribing pharmacist they are responsible for this stage of the pathway.  The lead professional remains involved throughout the stages including the hormone stage.  Close liaison with General Practioner/other professionals are a must.  This stage could last for 12-18 months or significantly shorter in individual cases. While attending the hormone clinic Clients will receive regular blood test monitoring and appropriate prescriptions. 

 

7) What is the surgical stage?

 

Surgery stage:  2nd opinion is a prerequisite to a surgical referral. Once we receive a positive 2nd opinion a referral to the appropriate surgeon is initiated.  Any delays within this stage would be due to delays in variables totally outside the control of the team.

The service will be responsible for referring clients to an NHS Gender Specialist for a 2nd opinion appointment however if individual clients wish to access private 2nd opinion appointments to speed up waiting times it will be the responsibility of the client to self refer or negotiate this with their GP.

Leeds Gender Identity Service is happy to receive and act upon a positive, private 2nd opinion from a reputable Gender Specialist at the appropriate time within the care pathway.

The service usually refers clients to specific surgeons however will consider referral to other areas if a client has a specific request and the PCT are willing to fund surgery in the requested area. 

 

Clients will need to have completed 12months, full time, RLE before receiving a mastectomy.

18 months before receiving breast augmentation and 24 months before receiving Gender Reassignment surgery.

 

On occasions clients have requested orchidectomy surgery without a penectomy, the service will work collaboratively with clients to ensure the treatment provided is in line with supporting client choice and within the safety of clear clinical boundaries.

This would include:

·         Confirmation from the endocrine clinic that current hormone levels are safe, stable and within range.                     

And

·         A ‘one off’ appointment from an independent NHS gender Specialist is obtained.

 

8) How long will it take me to move through the care pathway?

 

The service follows a care pathway which can be adapted to individual circumstances taking into account transition which has already taken place before attending the service and specifically for those clients holding a Gender Recognition Certificate.  An illustration of the pathway could be represented as follow:

 

The full process from start to finish around 3½-4 years
The shortest flexible process depending on individual needs could be condensed to 18-24 months; this has to be realistic taking into account waiting times for 2nd opinions and surgery which are outside of the services control.
 

9) How do the team keep abreast of new developments and ensure client safety and satisfaction?

 

The service is part of a wider governance group which include most other UK, NHS Gender Identity Service’s. This group meets on a 6 monthly basis and shares views, takes learning’s and discusses standards and guidelines within the area of Gender Identity.

The team are also part of the Specialist Services Clinical governance group within Leeds and York Partnership NHS Foundation Trust who meet on a quarterly basis and also have a team monthly Clinical Governance meeting where issues can be discussed in more detail. Clinical audits, rigorous clinical supervision, evidence based practice are all essential parts of our practice.

Service user feedback is an area which we have worked particularly hard on over the last year. We always provide clients with feedback forms following any new developments and we also ask service users to complete satisfaction questionnaires. Information taken from these forms is used to develop and inform practice in the service.

 

10) Will I get funding to access the service?

 

The team are responsible for the clinical process.  The funding responsibility is in the hand of the PCT’s.

Leeds Gender Identity service has a Service level Agreement with Yorkshire and Humber Specialist Commissioning Group therefore clients from this area will be funded to access assessment and if appropriate the care pathway once a full referral has been accepted. Any funding required for surgical procedures is the responsibility of each individual PCT.

Leeds ad York Partnership NHS Foundation Trust also has a Service Level Agreement with the North West area therefore clients referred from this area would be covered under this agreement.

Any individual outside of these areas are funded on a cost per case basis and PCT’s would need to agree funding on an individual basis before a client can be seen.

 

 

 

11) How will I know what is happening in the service?

 

The team have a specified lead in service user involvement she works alongside service user volunteers to produce a six monthly newsletter. The Newsletter will update all readers on any new developments within the service, will provide feedback on any completed service user feedback form and how this has informed practice and provide service users with an opportunity to display thoughts, feelings, poems or information to others!

The newsletter is posted out to all service users and is available in the waiting area.

You can also access the News letter via Leeds and York Partnership NHS Foundation Trust website.

 

12) What if I am discharged from the service but am experiencing a Gender related problem?

 

The service offers “one off” appointments to clients experiencing an issue they need to explore within the specialist service. To access this you will need support from your GP so they can write to the team and ask for us to see you. Again PCT funding will be needed for this appointment but once we have received a letter the service will request funding for you. The “one off” appointments may cover issues which are stated below:

·         “One off” assessment lasting for an hour in order to advise GP about outstanding problems and submit a medical (psychiatric) opinion.

·          A “one off” assessment lasting for an hour carried out by our Medical practitioner who is able to advise GP’s on endocrinology issues.

GP’s can also request “one off” extended full day assessment in complex referrals where specialist advice / recommendations are required.

 

13) How long will I need to wait to be seen once I have been referred?

The service aims to work within 18weeks once a full referral is received. This is something which is usually achievable when the team are working at a full compliment of staff.