Gender Dysphoria and Primary Care

1. Gender Dysphoria and Primary Care 6th Health and Justice Summit

2. Terminology • Trans* An umbrella term. • Transgender Man: A term for a transgender individual who currently identifies as a man (see also “FTM”). • Transgender Woman: A term for a transgender individual who currently identifies as a woman • Genderfluid/genderqueer • Cis • Pronouns • 'Ask. Listen. Respect'

3. #TransDocFail • This survey builds on the Twitter hashtag #TransDocFail, where hundreds of allegations of discrimination and/or abuse were made by trans people about different aspects of medical care “Uninformed, out of date, potentially dangerous.” • 95% of respondents felt comfortable coming out to their GP but 11% encountered a negative response

4. Prison Specific guidance (PSI) • Choice of estate – generally in line with legal gender, local discretion can be used • Subject to ongoing review (Written Statement made by The Parliamentary Under-Secretary of State for Justice, Minister for Women, Equalities and Family Justice (Caroline Dinenage) 2015) • “An establishment must allow transsexual people access to the items they use to maintain their gender appearance, at all times and regardless of their level on the Incentives and Earned Privileges Scheme or any disciplinary punishment being served.”

5. Legal Aspects The Equality Act 2010The Equality Act, 2010 protects transsexual people from discrimination and harassment in various areas, such as work or the provision of goods and services. Gender Recognition Act 2004Under the Gender Recognition Act of 2004, transsexual men and women can: • apply for and obtain a Gender Recognition Certificate to acknowledge their gender identity • get a new birth certificate, driving licence and passport • marry in their new gender Gender Recognition Certificate • you have or have had gender dysphoria • you have lived as your preferred gender for the last two years • you intend to live permanently in your preferred gender

6. Primary Care: First consultation • Establish Gender Dysphoria history • Mental health inc. substance misuse/risk and a documented mental state examination • Offer UTD health screening: BMI, BP • Health promotion – smoking cessation, sexual health screening as appropriate • Fhx esp. VTE, CVD, Cancer • Offer initial bloods: FBC, U+E, LFT + gamma GT, Lipids, Fasting glucose/hba1c, TFT, SHBG, FSH, LH, vit D, prolactin, testosterone, dihydrotestosterone and oestradiol

7. What happens after you refer? • Long wait times – approx. 2 years • Seen by two psychologists/ psychiatrists before decision to see endocrinologist to discuss hormone treatment is made • Triadic Therapy: real life experience, hormonal therapy of desired gender and genital reconstruction surgery • Gamete storage offered, usually via local fertility service but often not covered by NHS.

8. Primary Care: Monitoring and responsibilities • Ongoing prescribing of endocrine therapy • Organising blood and other diagnostic tests as recommended by the specialist • Monitoring tests (should be specified by their specialist) • Annual medication review • Ongoing screening/ health promotion/ usual GP care

9. What we should expect in a letter from GIC before prescribing • An explanation that the criteria for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy; • A statement about the fact that informed consent has been obtained from the patient; • A statement that the referring health professional is available for coordination of care and welcomes a phone call to establish this

10. GMC position statement • In response, a letter from GMC chief executive Niall Dickson detailed the ‘exceptional circumstances’ when GPs are expected to initiate medication: • The patient is self-prescribing with hormones from an unregulated source. • The bridging prescriptions are intended to mitigate risk of self-harm or suicide. • The GP has sought the advice of a gender specialist and prescribed the lowest acceptable dose.

11. Name Changes • Do not require Gender Identity Certificate • Should require a written statement “statutory declaration” from the patient which needs to be signed. • We write to the registration office at the PCSE: • PCSE.enquires@nhs.net 0333 0142 884 • CCG contact the Personal Demographics Service National Back Office who create a new identity and NHS number • We must discuss the consequences: eg. If not on hormone treatment parameters for bloods may be incorrect, may not be called for national screening programmes. • Confidentiality concerns. Only pass on gender history if clinically relevant and to another health professional. For example, if you refer to ENT for nasal polyps this should be redacted. 

12. Transmen • Testosterone • Usually sustenon 2-4 weekly • Periods usually take a couple of months to stop • Masculinisation takes 2-4 years • Testosterone (25-30nmol/l) post injection and (8-12nmol/l) pre injection (low normal male range)

13. Transmen • Preop: smear annually, USS for endometrial thickness 2 yearly • Post op: lipids, FBC, testosterone, LFT, BP, weight ? Role for DEXA • Common side effects: • Polycythaemia. Once on treatment monitor according to male range. May need to decrease dose/ switch to gel if very raised – liaise with clinic.

14. Transwomen • Standard regimen: oestrogen valerate 2mg od. • Aim for oestrogen of 350-600 pmol/l (normal female follicular range) • Feminisation takes up to 2 years. Higher doses are counter productive – abnormal breast development and excess oestrogen is converted back into testosterone. • GNRH analogues added if testosterone remains high. • Increase in erections/ sexual thoughts in first two weeks after initial injection – cyproterone acetate given to counteract this • Aim to get testosterone into female range (<3) • Nausea and headaches relatively frequent

15. Transwomen • DVT risk: 2.6% (x20 that of people not on Tx), mostly during first 2 years. Highest risk with ethinyl oestradiol. • Breast Cancer: no studies in transwomen but only 4 case reports. • Hyperprolactinaemia. Raised in 10-14% of patients. • LFTs: raised in 3%. Usually mild and just require monitoring.

16. Transwomen • Pre-op monitoring: LH, FSH, testosterone, oestradiol, SHBG, prolactin, dihydrotestosterone, PSA, weight BP, lipids, glucose. • Post-op:oestradiol, prolactin, LFT, BP, weight. • >50 years olds: can consider stopping HRT, mammogram every 5 years, PSA. Consider DEXA.

18. Some Key Messages • Life expectancy no different for transmen/women • Generally an improvement in mental health conditions such as depression is seen.

19. NHS England expects GPs to co-operate with their commissioned GICs and to prescribe hormone therapy recommended for their patients by the GIC. They are also expected to co-operate with GICs in patient safety monitoring, by providing basic physical examinations (within the competence of GPs) and blood tests recommended by the GIC. The GIC is expected to assist GPs by providing relevant information and support, including the interpretation of blood test results. Hormone therapy should be monitored at least 6 monthly in the first 3 years and yearly thereafter, dependant on clinical need.

20. Importance of GPs • Given the multidisciplinary needs of transsexual, transgender, and gender-nonconforming people seeking hormone therapy, as well as the difficulties associated with fragmentation of care in general (World Health Organization, 2008), WPATH strongly encourages the increased training and involvement of primary care providers in the area of feminizing/masculinizing hormone therapy.

21. Support networks for patients • http://transbareall.co.uk/ • We are a trans led, voluntary organisation that works with trans people to explore feelings and decisions around bodies, sexual health and intimacy. • http://genderedintelligence.co.uk/ (young people) • http://www.mermaidsuk.org.uk/ (young people) • http://gendertrust.org.uk/ • Articles, legal advice • http://www.bristol-crossroads.org.uk/ • Website for the transgender community, partners and family. • http://www.gires.org.uk/ • Gender Identity Research & Education Society • GIRES is a UK wide organisation whose purpose is to improve the lives of trans and gender non-conforming people of all ages, including those who are non-binary and non-gender.

22. References Ministry of Justice. Review on the Care and Management of Transgender Offenders. November 2016. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/566828/transgender-review-findings-web.PDF NHS England. 2018. Interim Gender Dysphoria Protocol and Service Guideline 2013/14. https://www.england.nhs.uk/wp-content/uploads/2013/10/int-gend-proto.pdf. NHS UK. Gender dysphoria services: a guide for general practitioners and other healthcare staff. https://www.nhs.uk/Livewell/Transhealth/Documents/gender-dysphoria-guide-for-gps-and-other-health-care-staff.pdf World Professional Association of Transgender Health (WPATH). (2011). Standards of care for the health of transsexual, transgender, and gender nonconforming people. http://www.wpath.org/publications_standards.cfm Royal College of General Practice. Guidelines for the Care of Trans Patients in Primary Care. 2017. http://transiness.co.uk/wp-content/uploads/2013/12/GP-trans-care-guidelines.pdf Gender identity and Research Education Society. http://www.gires.org.uk/terminology RCGP module on Gender Variance. http://elearning.rcgp.org.uk/course/info.php?popup=0&id=169 General Medical Council. Trans healthcare and bridging prescriptions. https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare#mental-health-and-bridging-prescriptions Ministry of Justice. National Offender Management Service Annual Offender Equalities Report 2016/17 Ministry of Justice Statistics Bulletin Published 30 November 2017. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/663390/noms-offender-equalities-annual-report-2016-2017.pdf

23. UK Services