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TransActual response to NHS England’s Stakeholder Consultation on the adult gender dysphoria (non-surgical) service specification

TransActual have now submitted our response to NHS England’s Stakeholder Consultation on the existing adult gender dysphoria (non-surgical) service specification.

Read TransActual’s full response

The consultation was on the existing NHS England service specification for non-surgical gender care. A service specification sets out what NHS services are expected to do and how they’re meant to do it. In this case, they wanted to know what should stay in the specification for NHS gender clinics in England, what should be removed and what should be edited. Everyone registered as a stakeholder on NHS gender dysphoria services was invited to respond to the consultation.

This consultation is part of a wider review into NHS England adult gender services. NHS England have told us that the review consists of:

  • A review of the NHS adult gender dysphoria clinics in England
  • A review of the existing service specification (informed by this consultation and the review of adult gender dysphoria clinics)
  • A consultation on an updated non-surgical service specification.
  • A review of the evidence around hormone therapy for trans people.
  • A consultation on a new national policy on masculinising and feminising hormones.

NHS England tell us that at the end of the review there will be:

  • An updated service specification for NHS non-surgical gender care for adults in England.
  • A national policy on masculinising and feminising hormones.
  • A service improvement plan for NHS England adult gender services.
  • A workforce plan for NHS adult gender services in England.
  • A plan (hopefully) to increase the capacity of NHS adult gender services in England.

TransActual submitted our own response, however we worked closely with other members of the Trans Healthcare Coalition when deciding what to say. The Trans Healthcare Coalition is a group of organisations and individuals all working together on issues related to NHS England’s review of adult gender services.

Our response was informed by:

  • TransActual’s research – thanks again to all the community members that have participated in our research projects so far.
  • The things trans people tell us every day about their experiences of accessing NHS transition-related care.
  • The lived experiences of our team, all of our Directors and staff are trans.
  • Research from other organisations and from academics.
  • Examples of good practice in the UK and around the world.
  • Version 8 of WPATH’s Standards of Care

We were asking to respond to the consultation via an online form, which allowed 1200 characters per section of the service specification. That was far too little space to say all that was needed, so for that reason we submitted a full response via PDF as well as one via the online form.

We have asked NHS England to consider our full document TransActual’s response to the stakeholder consultation and we hope that they do.

Commissioning and funding

  • A national shared care policy – ensuring that GPs have to prescribe and offer blood tests when asked to by a GIC
    Funding GP support for trans people under an enhanced services arrangement.
  • Fully funded training for GPs on trans inclusion, including provision of bridging prescriptions, shared care agreements, blood testing for people who are self-medicating and lifelong care for trans people.
  • Funded trans-specific mental health support for people on waiting lists for transition related care.
  • Commissioning of local GP led services which are able to offer ‘bridging prescriptions’ and blood tests – such as Well-BN, The Bridge.
  • Commissioning of additional local ‘new style’ clinics – such as Indigo, TransPlus, CMAGIC.
  • The full reimbursement of travel and accommodation costs for anybody needing to travel more than 30 miles for an appointment with a gender clinic.

Referral, assessment and care

  • All clinics to allow self-referral, and for trans people without a GP to be supported to find one.
  • 18 to 25s to continue be seen within adult gender services, with improved transfers of care from children and young people’s gender services.
  • Continued recognition that being trans is not a mental illness and that conversion practices are not appropriate.
  • Improved inclusion of non-binary people and non-binary transitions.
  • Trans people be central to planning their own care and not expected to follow a specific transition pathway.
  • Removal of the two appointment requirement to access HRT – it should typically be available after one appointment. Assessments split across two appointments should be only for those who want them to be.
  • A commitment to uphold the principles of the Mental Capacity Act, recognising and respecting the rights of adults to make decisions. Adults (including neurodivergent adults and/or adults with learning disabilities) should be assumed to have capacity unless proven otherwise.
  • Non-judgemental approaches to people who have accessed HRT privately or who are self-medicating.
  • NHS gender specialists to automatically recommend that GPs prescribe if a person appears at their assessment appointment already taking HRT and it’s safe for them to continue.
  • A clear expectation that ICBs will fund fertility preservation.
  • Provision of as many facial hair removal sessions as required, instead of a ‘one size fits all’ package.
  • The policy on physical examinations to remain – they should only take place when absolutely necessary, with trauma informed approaches taken when they are.
  • Surgical referrals to be made after 6 months on HRT and with one letter of referral rather than the current 2 for lower surgery. For the current commitment to provide transition related surgery without HRT if the person doesn’t want it or can’t have it for health reasons.
  • A move away from using BMI as a measure of obesity and providing trans-specific, trauma informed support for those wishing to lose wait and/or stop smoking.
  • Continued access to Speech and Language Therapy for those who want it.
  • Optional access to psychological therapies, with those seeking them to not be unnecessarily delayed in accessing other aspects of transition related care.
  • Clear information for people being discharged from clinics, with easy routes back to support or surgical referral for those who need it.

Data, governance and staffing

  • A commitment to ongoing service improvement, with trans people’s voices at the centre of that.
  • Public data on waiting times, times between appointment, appointments offered per month, a clinic’s budgets, service user outcomes and evaluations.
  • All gender clinic staff to be trained in health inequalities, particularly in relation to multiple marginalisation.
  • To ensure that there are people with lived experience of medical transition working in every gender clinic.
  • Each clinic to have care navigators and/or peer supporters.
  • Gender clinic staff to take a non-pathologising approach to intersex people.
  • Admin capacity and processes to improve at gender clinics, making better use of digital tools and systems.
  • A digital portal to provide GPs and trans people with quicker ways to get information from a gender clinic – including after discharge.

TransActual have always advocated for a Primary-care based affirmative informed consent model of care.

By that we mean:

  • Trans people should be believed when we say who we are.
  • Most of us shouldn’t need to see a specialist to get the transition related care we need.
  • A trans person’s GP should prescribe their hormones after following an informed consent process.
  • A trans person’s GP should refer them for transition-related surgery, specialist mental health support, hair removal and Speech and Language therapy if asked to.
  • There would be a role for gender specialists, but they would be for people who want or need access to them.

However, there is still a lot of work to be done before that can become a reality in the UK. Systems and attitudes need to change before there is a total reform of the NHS gender clinic system.

In particular:

  • Trans inclusion training for all healthcare staff, with training on prescribing and monitoring hormones for GPs.
  • An improvement to GP working conditions.
  • A change to the political and media rhetoric that is contributing to GP nervousness around prescribing hormones to trans people with a letter from an NHS gender clinic, let alone anyone else.

The stakeholder consultation closed on 25th November 2024, so we expect that NHS England will analyse the data and write a report based on responses to it. Stakeholder consultation reports are not always released immediately after they’re written . Sometimes they’re released when a public consultation goes live – in this case, that would be the consultation on a reviewed service specification – but sometimes they’re released later than that still.

As we understand it, NHS England staff will draft a revised version of the current non-surgical service specification using:

  1. The feedback from this stakeholder consultation
  2. The findings of the review of the NHS adult gender dysphoria clinics in England

Drafting processes can differ, but before NHS England publish the updated non-surgical service specification, we expect that they will:

  1. Hold a public consultation on the draft.
  2. Analyse the consultation responses.
  3. Write a consultation response report.
  4. (Potentially) amend the draft based on responses to the consultation.

If you’ve got questions about TransActual’s approach to the review into transition related care for adults in England (or anything else), you’re welcome to get in touch. Email info@transactual.org.uk.

We appreciate that the review into transition related care for adults in England has made some people extremely anxious.

We can’t take away your worries completely but there are three things we can tell you:

  1. In a meeting with trans and/or LGBTQ+ organisations (including TransActual), NHS England stated that they do not plan to remove access to HRT for trans people. We intend to hold them to this.
  2. The Trans Healthcare Coalition is working to provide a collective and coordinated effort to engage with and respond to the recent NHS review of its Adult Gender Dysphoria Services.
  3. Trans people have always managed to access transition related care and always will.

If you’re struggling with your mental health, please seek support. You’ll find mental health and wellbeing resources and support lines on the Mental Health and Wellbeing Hub.

TransActual’s work around the review of transition related care is currently funded entirely by your donations. You can support our efforts to protect and improve trans people’s care by donating – either on a monthly basis or even as a one off.

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