Gender Identity Clinic

Assessment

A diagnosis of gender dysphoria can usually be made after two in-depth assessments carried out by two or more GIC specialist clinicians. However, each person is different and treatment plans vary according to the individual’s needs and circumstances.

Assessment can include:

• Personal history and background
• Exploration of gender identity and gender dysphoria
• History and development of gender dysphoric feelings
• Impact of stigma on mental health
• Availability of support from family, friends, and peers
• Physical health and a physical examination.

The assessment helps determine how someone experiences gender dysphoria and what their needs might be which could include:

• Whether someone has a strong desire to change physical characteristics as a result of gender dysphoria
• How someone manages any difficulties they experience
• How feelings and behaviours have developed over time
• What individualised support and treatment people require.

We recognise that individuals are unique and we would not seek to put service users under pressure to achieve particular arbitrary goals. 

However, we do ask that individuals explore with the clinician they are seeing any barriers to their living in role (typically these would be occupational or relationships with families) so that we may work out an appropriate treatment path and help identify resources for individuals who are experiencing difficulty. 

We generally find clients of this service are living fully in role within a year of presentation, comfortable and able to explore their emotional reaction to change in their appearance and the impact that has on who they meet and whether they feel safe and effective in their new identity. 

If needed we can advise you in applying for changes in your personal details and health service records and there is generally no charge for supporting letters to banks, licensing authorities, passport office etc. Links for further information can be found on on resource and guidance tab.

We also offer a ‘Welcome Workshop’ for people with upcoming initial assessment appointments. The workshop is run on a monthly basis, which people are automatically invited to attend. It is an opportunity to find out more about the gender clinic and to meet others involved. The workshop will include an overview of our service, physical health, and looking after ourselves.

Hormones

Hormone therapy can be part of the process of changing the body, depending on someone’s gender identity and needs. Hormones usually need to be taken indefinitely, even if surgery is undertaken. The aim of hormone therapy is ultimately for someone to feel more comfortable with themselves. Possible changes from taking hormones are listed below.

Hormone treatments to assist with gender transition can only be commenced after two documented diagnoses of Gender Dysphoria/Transsexualism, alongside a satisfactory physical exam and blood results, as per our GIC guidelines.

Each person's treatment is individually tailored to achieve a safe and effective feminisation or masculinisation and is in keeping with national and WPATH guidelines.

Effects of Taking Oestrogen

• Penis and testicles getting smaller
• Less muscle
• More fat on hips
• Breasts becoming lumpy and increasing in size slightly
• Less facial and body hair

Effects of Taking Testosterone

• More body and facial hair
• More muscle
• Clitoris gets bigger
• Periods stop
• Increased sex drive (libido)
• Voice may get slightly deeper, but may not be as deep as other men’s voices.

Most physical changes, whether feminising or masculinising, occur over the course of two years. The amount of physical change and the exact timeline of effects can be highly variable.

Psychology

Meetings with a Clinical Psychologist may help to explore and clarify ideas and feelings, improve relationships, develop strategies to manage health pre- and post-operatively, as well as resolve or manage distress.

This could be for purposes such as:

• Exploring gender identity, role, and expression
• Addressing the negative impact of gender dysphoria and stigma on mental health
• Alleviating internalised transphobia
• Enhancing social and peer support
• Improving body image
• Promoting resilience.

These could be addressed through individual or group work as agreed during consultation.

Surgery

We will discuss the surgical pathway relevant to your individual needs in a very early stage in your attending this service and will be sensitive to someone’s changing ambitions and do not expect or require service users to undergo surgery until they are ready for it, or if not part of their treatment goals.

The Northamptonshire GIC will make referrals endorsing and recommending surgical procedures to appropriately qualified physicians on the basis that it is their clinical opinion that the patient is both eligible and ready to undertake such procedures.

Whilst individual time spans can vary, the following guidelines apply:

• Upper body surgery (Bilateral mastectomy/Breast reconstruction) - Upper body surgery requires one documented clinical recommendation from a GIC Specialists who know the patient. This must be no sooner than 6 months after assessment with Northamptonshire GIC
• Lower Body surgery – Lower body surgery requires two recommendations from a GIC Specialist. This must be no sooner than 12 months after assessment with Northamptonshire GIC.

Not everyone experiencing gender dysphoria will feel they need surgery, or may only require very specific procedures. Individual needs are discussed throughout contact with the clinic.

The aim is to increase someone’s comfort with themselves and reduce gender dysphoria through surgery.

Masculinising surgery may involve

• Bilateral mastectomy (removal of both breasts)
• Hysterectomy (removal of the womb)
• Salpingo-oophorectomy (removal of the fallopian tubes & ovaries)
• Phalloplasty or Metoidioplasty (construction of a penis)
• Scrotoplasty (construction of a scrotum) and testicular implants
• Penile implant.

Feminising surgery may involve

• Orchidectomy (removal of the testes)
• Penectomy (removal of the penis)
• Vaginoplasty (construction of a vagina)
• Vulvoplasty (construction of the vulva)
• Clitoroplasty (construction of a clitoris with sensation).

Voice modification

We have a Speech & Language Therapist (SaLT) based within our hospital sites in Northampton and Daventry who can provide sessions for people if required.

The methods used are likely to vary depending on your needs but may involve moderating pitch, intonation, resonance, and articulation as well as non-verbal aspects such as posture and breathing.

Speech and Language Therapy (Voice Modification)

The Speech and Language Therapy – SLT (sometimes referred to as SaLT) department at Northamptonshire Gender Identity Clinic works with individuals who wish to achieve vocal change through voice and communication therapy. Current patients of the GIC can request referral to this service during a GIC appointment or by emailing the clinic.

Content: Voice and communication therapy with us typically involves work on resonance, pitch, articulation, intonation, pacing, volume and projection, as well as other voice and communication aspects. You do not need to have any prior voice knowledge or vocal training. The content of the therapy however is largely guided by the individual and their specific requirements. Voice therapy begins with a 1-on-1 initial session, which is where you will be able to meet your therapist, discuss what you’d like from therapy, your voice and communication objectives and learn more about what therapy entails. It is also a chance for you to ask any voice-related questions.

Format: A course of therapy here usually comprises 1-on-1 sessions. Group sessions may be offered after this, where available and if appropriate for the individual and their voice objectives. Remote voice sessions are often possible via prior agreement with the therapist.

We are committed to working with each patient to establish the most suitable therapy content and format for them to meet their voice goals and support them in developing the right voice for them.

What happens in an initial voice therapy appointment?

The initial appointment is mostly an information-gathering session for the therapist, but also for the patient. The therapist will ask you questions related to your voice. This will include questions like: Have you ever had speech and language therapy before? What is your current voice use like? What would you like from voice therapy? You do not need to prepare anything beforehand. The patient and therapist will set some short term voice goals and suggest aspects you could work on together in order to meet these goals. The therapist will also explain the format and timescale of the sessions. Usually the therapist (with consent) will take one or two very short (< 1 minute) audio recordings of your voice as a baseline.

Is it true that voice modification therapy is for trans women only?

No. We work with any GIC patient to help them develop the right voice for them. This includes non-binary individuals and trans men.

I would prefer to have voice modification therapy closer to where I live. Can I access voice therapy locally?

You can request referral to your local Adult Speech and Language Therapy service via your GP. If the referral is accepted, local voice therapy can be provided closer to your home.

More about our service

We provide a service for people seeking support around their gender diversity, we are commissioned to:

• Undertake diagnostic assessments for Gender Dysphoria
• Offer advice on hormone treatments to GPs with whom clinical responsibility is shared
• Provide specialist interpretation of blood test results that are undertaken by the GP
• Undertake physical examinations to ensure any risks are minimised and controlled
• Provide second opinion assessments for other Gender Identity Clinics
• Undertake assessments and make recommendations for gender reassignment surgeries
• Provide on-going support and monitoring throughout treatment, transition and gender reassignment.

The clinical team aim to provide a high quality gender identity service that:

• Follows NHS England Protocols on gender dysphoria to provide the framework for the clinical pathway through the service
• Is patient centred
• Promotes multidisciplinary working
• Advocates patient and health professional collaboration in formulating individualised care plans
• Supports and advises our primary care colleagues in the safe and effective delivery, monitoring and treatment of patients with gender identity needs
• Offers fair and equal access to the service;
• Signposts patients and other health professionals to appropriate information and support resources;
• Promotes positive awareness of gender issues and the legal rights of people who are transgender, in line with the Equality Act 2010.

Contact with the clinic

Appointments

It is very important that you attend your appointments at the scheduled time, we ask that you present to Reception within the Mental Health Resource Centre so that you can be booked in. If you are not able to attend an appointment please let us know at the earliest opportunity so that we can rearrange your appointment, also your cancelled appointment can be offered to someone else who is waiting to be seen. One further appointment will be offered by the clinic following a DNA (did not attend), but if that second appointment is not attended then you will be discharged from the service and referred back to your GP.  Where appointments are cancelled without notice, contact via the telephone will be made. If you are travelling a long distance to your appointment we recommend that you contact us prior to setting off to ensure your appointment has not been cancelled.

Clinic Letters

Northamptonshire GIC copy all correspondence sent to primary care (GP) colleagues to the service user at their home address, unless requested not to do so. Please let the GIC know how you would like your letter addressed; for instance gender, name, title, address. You can discuss this with your clinician at your appointment. We can also arrange for shortened versions containing just your treatment plan to be sent out if you should wish.

Prior to your first assessment with the GIC it may be that appointment letters or similar are addressed using the details we have on record, which may differ to someone’s preference. This will be due to what is recorded on our system but can be amended following your first contact.

We recognise that postal services can be unpredictable and clients who fail to attend appointments sometimes have informed us they had not received their appointment letter. We are aware that clinic letters following appointments are not always received as quickly as would be preferred. Unfortunately the length of time can vary due to staff capacity and number of appointments within a given period.

If you are expecting a clinic letter and have not received this within the expected time frame, please contact us via email/telephone.

GIC Emails/Telephone

The GIC can also be contact by email genderclinic@nhft.nhs.uk. This way of communicating with the clinic can be used for queries such as appointments, letters, emailing blood results, GP queries, etc. Emails sent to the GIC will be responded to as quickly as feasible, but due to limited administrative support, the complexity of a matter, or advice required, this may take some time.

We would ask if the matter is urgent that you communicate by telephone on 03000 272858, and follow up with an email. If the matter is more urgent, typically this will concern prescriptions of hormones or blood results etc., it is likely that one of staff in the clinic will ring you directly and we would be grateful if you would keep the clinic informed of your current mobile number. This also speeds up communication about appointments, which unfortunately from time to time might need to be changed.

The role of the GP

Your GP is pivotal in the provision of your treatment pathway, hormone treatment and referral to other services, including secondary care services when there are co-morbid health concerns. Typically this might include unstable diabetes or hypertension, mental health and communication difficulties.

We recognise however that GPs from the wider referral base may have no knowledge of the field and from time to time GPs are reluctant to initiate treatment as they are unfamiliar with the use of this drug in particular outside of its licensed indications. GPs can seek guidance on our website with the information and links provided or contact us by phone/email found in the Contact Us section.

We will provide individual support to GPs by phone if required, particularly in the use of gonadorelin analogues such as Prostap.  We would ask that any GPs with concerns get in touch directly with the clinic, by phone or email and we are able to provide copies of the National Standards of Care and reference to relevant commissioning documents.

GPs should ensure they are involved in the referral process, particularly if another clinician or healthcare provider is referring (e.g. Tavistock GIDS, CMHT). In particular, it should be checked that the GIC’s referral form has been completed for agreement to collaborate on prescribing and monitoring.

In the case of self referral – we will advise in writing that a service user has self-referred to make the GP aware and request support and collaboration.

Why we require GP involvement

Terminology

Diagnosis 

Northamptonshire Gender Clinic uses the ICD-10 classification system and you may see the term "Transsexual F64.0 - male to female" or "Transsexual F64.0 - “female to male” in the diagnosis section of clinic letters.

We recognise that terminology changes and classifications often lag considerably behind and that many service users object to the term "transsexualism" or "gender identity disorder". We are however obligated to use these terms until there is an official change in the classification system. Clinicians will be happy to discuss any particular wish you may have regarding how your condition is referred to in formal correspondence and wherever possible we will attempt to correspond with you in accordance with those wishes. From Jan 2022 the ICD 11 term will be “Gender Incongruence of adolescence or adulthood” (HA60).  When ICD 11 is incorporated into the NHS, this will be reflected in the team’s terminology

This service recognises that people undergoing treatment may not wish to be referred to as "patients" or "clients" and may have already had experience elsewhere in the UK or overseas and may have strong views, for example, of the role of professionals as gatekeepers of service and the relevance of counselling or psychological interventions and what they regard as a normal emotional state. We welcome your views and will seek to reflect that in your individual treatment plan.

Confirming and expressing gender identity should be a positive and empowering experience for everyone.

Gender Dysphoria

In recent years the needs of individuals identifying as transgender and experiencing gender dysphoria has become increasingly highlighted, raising their profile both within the NHS and in wider society through the media. For transgender people, the sex they were assigned at birth and their own internal gender identity do not match.

This incongruence can be a source of significant distress. Indeed, the DSM-5 identifies this distress as ‘gender dysphoria’, where up to 1% of the population reportedly experience ‘Gender Variance’ (WPATH 2011). This highlights an increasing demand for support for individuals experiencing gender dysphoria.

For some individuals who experience gender dysphoria, medical interventions alone, such as hormone therapy and gender reassignment surgery, can alleviate associated distress. Others may need more in depth support around their psychological wellbeing and mental health.

Non-Binary

We recognise that there are identities other than the traditional binary identities. People who identify as non-binary may think of themselves as both man and woman (bigender, pangender, androgyne); neither man nor woman (genderless, gender neutral, neutrois, agender); moving between genders (genderfluid); or embodying a third gender.

The Northamptonshire GIC accepts referrals for people who identify as non-binary and this is in line with the guidance given to us by NHS East Midlands, who commission our service.

Non-binary individuals may have different goals to binary transgender individuals. This can lead to challenges regarding the treatments offered. Medical treatments and surgical procedures can create physiological changes that are not yet sophisticated enough to tailor to individual desires. The GIC always aims to explore, and cater to, someone’s goals and aspirations as fully as possible.