NHS England Interim Gender Protocol CPAG Approved 12-7-13 (released 15th July 2013)

Key changes to current treatment, and other points of interest:

• GPs may refer patients directly to Gender Identity Clinics (GICs). It is not necessary for GPs to first refer patients to another specialist service (e.g. a psychiatrist). This is important because until now most GICs in England have required patients to be referred by a mental health specialist.
• Facial hair removal will be available on the NHS. The Interim Protocol describes facial hair removal as “essential treatment for MtF patients” (p.10). It is funded by NHS England, rather than CCGs (Clinical Commissioning Groups: these replace Primary Care Trusts). Patients are (in theory) guaranteed nine facial hair removal treatments: one test patch, and nine sessions. Funding can be sought for further treatments but is not guaranteed.
• Hair removal prior to genital surgery will be available on the NHS. Funding for this service is provided through NHS England in a similar manner to facial hair removal for MtF patients.
  
• Adult treatment is available to trans people from the age of 17. The Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust will continue to provide services in London, Exeter and Leeds for trans people under the age of 18, according to its own guidelines. This means that trans people aged 17 may choose between “adult” and “young people’s” services.
• Breast augementation, facial feminisation surgery, lipoplasty and sperm/egg storage may be funded. Breast augementation will only be funded if “there is a clear failure of breast growth in response to adequate hormone treatment”. All of these procedures are funded by CCGs rather than centrally through NHS England, which means that GICs must apply to CCGs for funding. They will be funded (or not) according to CCG policy, which may vary.
• Patients require only one assessment from a GIC team member in order to be referred for psychotherapy or speech therapy. This is important as it has the potential to speed up access to speech therapy and additional psychotherapeutic support.
• Patients must recieve assessment from two GIC team members in order to recieve hormone therapy. This is important because until now, some GICs in England have required assessment from more than two team members. Conversely, it reinforces the position of those clinicians who argue that two opinions is necessary before treatment can begin.
• 12-24 months of “real life experience” is required prior to the provision of genital reassignment surgery. This is important because it means that patients can (in theory) access genital surgery within a year, in line with WPATH guidance. However, it is likely that clinics will continue to demand at least 2 years of “real life experience” prior to surgery.
• A wait of at least 6 months is necessary prior to the provision of chest surgery for FtM patients. The guidance on this is somewhat vague, which should allow flexibility but may be exploited by more conservative GICs. The Interim Protocol states that patients who qualify for chest surgeries “may have engaged in a social role transition” (emphasis mine), and that a referral will “typically” be offered “around 9-12 months, but no less than 6 months, after the patient’s first consultation”.
• Surgical providers are supposed to inform primary care staff (i.e. GPs and nurses) of procedural details and post-operative needs. We’ll see how this one pans out in practice!

Overall, this Protocol should result in a broad improvement in transition-related services for trans people living in England and Wales. If all goes to plan, more services will be available to more people, who will have to do less waiting for them! I offer a more in-depth discussion of these changes – and comparisons to the Scottish Protocol – here (please note that there have been changes since I wrote that post – e.g. GPs should now be able to directly refer to GICs, and facial hair removal should be provided on the NHS in England and Wales, just like Scotland) .

However, GICs may yet resist some of the measures in this document. The protocol was meant to come into force for all trans patients access transition-related services from 1 October 2013, so now is the time to hold medical providers to account.