Frequently asked questions (FAQs) for health professionals

Here are a few suggestions:

• Normalise introducing yourself with your name and pronouns
• If you are not sure how to address someone – ask what pronouns they use
• Do not assume a patient's gender or sexual orientation
• Avoid gendered language eg. sir, ladies and gentlemen
• Use the patient's correct name and gender at all times, regardless of whether or not they are in the room
• Correct others when they use the wrong name/gender – this gets easier with time
• Recognise that gender and sexual orientation are on a spectrum and can be fluid
• Do not ask invasive questions - trans people spend a lot of time answering questions from other people and which can be exhausting.

For further reading check out the GMC guidance on trans healthcare.

Practices should arrange initial training as soon as is practicable by contacting sxicb.primarycare@nhs.net. There is further information here.

SGS is a waiting list initiative and a pilot scheme gender identity clinic (GIC). We are commissioned for two years by NHS England (NHSE) from 2023-2025 and expect to continue after this date. We are currently seeing patients who meet the following criteria:

• Currently registered with a GP in Sussex
• Referred to a GIC before 31st March 2023 by a Sussex GP
• Eligible for NHS treatment.

On this basis, we are not accepting any new referrals nor any transfers.

We are overseen and supervised by Nottingham Centre for Transgender Health (NCTH) and follow their prescribing guidelines. These are available to GPs upon request.

Hopefully, after our two year pilot scheme is completed, SGS will continue independently and can accept transfers and new referrals at this point. We will update GPs and community members when this is decided by NHS England (NHSE), closer to the time.

Sussex Gender Service will:

• provide patients with assessment, diagnosis and discussion about hormone therapy
• screen for contraindications to hormone therapy and discuss side effects
• interpret pre-hormone baseline blood tests 
• discuss fertility including gamete storage and contraception
• refer for gamete storage if requested by patient
• communicate recommended treatment and regimes to GPs using formally agreed collaborative care protocols supported by the Area Prescribing Committee (APC)
• act as a knowledge base for questions and concerns from GP colleagues - please email SGSTeam@spft.nhs.uk and we will aim to get back to you within 2-5 working days
• discuss and refer for surgical interventions in line with the service specification
• discuss and refer for hair reduction therapy, voice therapy, psychological support

GPs are requested to:

• issue prescriptions for the hormones suggested in the patient care plan
• offer contraception as necessary
• offer blood test monitoring in line with the patient care plan and provided prescribing/monitoring guidelines
• offer NHS screening as per these guidelines
• sign up for LCS training if required to build confidence and/or knowledge on prescribing and monitoring hormone therapy for TNBI patients, by contacting sxicb.primarycare@nhs.net 

We are currently seeing patients, in time order, who meet the following criteria:

• Are registered with a GP in Sussex
• Were referred to a GIC before 31st March 2023.

If they meet these criteria, patients are contacted by our admin team by email, telephone, occasionally by mail or via their GP if we suspect their contact details are out of date.

Following contact, patients are invited to 'opt out' of transfer to SGS and continue to wait on their current GIC waiting list. Joining the SGS waiting list is likely to be a shorter waiting time. Once someone comes to the top of the SGS waiting list their assessment, diagnosis, and treatment pathways then begin.

As of November 2023, we were contacting patients who were referred in 2018.
 

Sussex Gender Service (SGS) follows the NHS England service specification.

Here you will find both surgical and non-surgical service specifications for gender identity services for adults.

The SGS pilot is required to follow this service specification, which instructs gender clinics to provide two assessments for new patients (initial assessment for full history taking, and second assessment for diagnosis and to discuss treatment options).

After diagnosis, follow-up appointments are offered as required and individualised to a patient's care plan. Occasionally, extended assessments are offered if further support or discussion is beneficial prior to diagnosis.

To access the treatment pathways, we offer dual diagnoses of 'gender incongruence' and 'gender dysphoria' at the second assessment (or after extended assessments). 

• 'Incongruence' means a mismatch between gender assigned at birth and experienced gender
• 'Dysphoria' means the state of unease, unhappiness or dissatisfaction due to gender incongruence.

Offering both diagnoses means patients can use our clinic letter as evidence of diagnosis, e.g. to access private treatment or to support gender marker changes etc. The diagnosis of gender incongruence is required as per the NHSE service specification to access treatments such as gender-affirming surgery.

Some patients opt only for 'gender incongruence' diagnosis on their clinic letters. One reason for this is that there can be some stigma or negative connotations towards the diagnosis of 'gender dysphoria' due to this label being a psychiatric diagnosis in the fifth edition of DSM (2013).

Here is a list of TNBI register codes, as per Sussex LCS TNBI training:

Practice TNBI register codes 

  
The following codes are also included in the practice register. Practices should note that the term ‘transsexual’ can sometimes cause offence and is not recommended and should be avoided on problem lists for some patients. However, they may be needed to support national screening requirements. 

• See this link for reference

We offer six main treatment pathways. Patients may opt for none, one or all of them. They can revisit the treatment pathways at their own pace, when they feel ready.

• Hormone therapy
• Surgical recommendation
• Psychological support
• Facial hair reduction
• Voice therapy
• Fertility preservation

Hormone therapy

After a diagnosis is offered, we can discuss gender-affirming hormone therapy. This is either feminising or masculinising hormone therapy, and this can be tailored to an individuals' needs, for example for non-binary people who may not want full-dose cross sex hormones.

We request GPs to kindly organise the baseline blood tests, as we do not have phlebotomy service nor the funding to request blood tests. This is consistent with other national GICs and is an NHS England funding decision. GPs can recoup this cost via Sussex TNBI LCS.
Further Sussex TNBI LCS information here.

When we have received the results, we counsel patients on the expected changes and the risks associated with gender-affirming hormones. Patients read, sign and return a consent form, and we provide a copy to GPs. 

When the hormone regimen has been agreed by the SGS clinician and the patient, we write a recommendation to the GP with the medication name, dosage, form and frequency, and monitoring requirements. We ask for monitoring blood results to be sent to SGS and we follow-up the patient to review their regimen.

Once the patient is settled on their hormone regimen, we discuss discharge to the care of their GP. This is in line with other NHS GICs, and part of our collaborative care agreement. Our A&G line remains open to GPs life-long, and GPs can re-refer patients back to us for soonest appropriate appointment if there is concern. The reason we discharge from our clinic is two-fold: patients will be taking gender-affirming hormone therapy for life, and so primary care is an appropriate location for routine monitoring and annual reviews (Sussex TNBI LCS funds annual reviews, as well as funding for hormone prescribing and monitoring). The other reason is that discharging patients from our care frees up capacity for us to see more patients on the waiting list, and reduce the excessive waiting time for GICs.

Surgical recommendation

Surgery available on the NHS includes:

• Double mastectomy / chest reconstructive surgery
• Feminising genital reconstructive surgery (GRS)
• Masculinising genital reconstructive surgery (GRS)
• Hysterectomy / oophorectomy
• Orchidectomy
• Case-by-case, surgical revision

Surgery not available on the NHS includes:

• Breast augmentation
• Facial feminising surgery
• Glottoplasty
• Tracheal shave.

Following diagnosis, separate appointments are offered to discuss surgical recommendations. Mastectomy/chest surgery requires a recommendation from one gender clinician, and gonadectomies or genital reconstruction surgery requires two recommendations. As SGS is a pilot scheme, the second recommendations will be via video call from our colleagues at Nottingham Centre for Transgender Health.

We are in the process of arranging a direct referral pathways for hysterectomy to the University Hospitals Sussex gynaecology department. (correct as of Jan 2024)

We are currently reaching out to local surgical teams regarding setting up direct referrals for orchidectomies from SGS to local hospitals. We will update the FAQ page when we have more definitive pathways for this.

Surgical referrals are sent by SGS to be processed by Gender Dysphoria National Referral Support Services (GDNRSS). They have a team of dedicated surgical nurse specialists who can support patients with specific surgical advice. More information here.

Approximate waiting times from referral (correct December 2023):

• Chest surgery: 8 months-2 years
• Masculinising genital reconstructive surgery (GRS): 4 years
• Feminising genital reconstructive surgery (GRS): 1-2 years
• Hysterectomy/oophorectomy: 18 months
• Orchidectomy (no current local pathway, referred as GRS): 1-2 years.

Surgical Revision

If a patient had an operation within the last six months, it is the operating surgeon's responsibility to review the patient should there be complications or unexpected outcomes. Patients should be advised to contact their operating surgeon in the first instance.

Some patients have had private gender-affirming surgery, either in the UK or abroad. On a case-by-case basis, SGS can apply to GDNRSS for 'unscheduled aftercare' for consideration of surgical revision. Unfortunately, NHS funding for this is not guaranteed, but we can discuss options with patients during their appointments.

Psychological support

We have a team of experienced psychologists who are trained in first and second assessments, diagnosis, surgical recommendations as well as offering 1:1 sessions for psychological therapy. The therapy includes up to 6 sessions with a psychologist, and aims to support patients using a goal-orientated approach, with a focus on gender-related issues. This treatment pathway is discussed following diagnosis.

Facial hair reduction

A referral for facial hair reduction is part of the gender-affirming feminising pathway. People can access up to 8 sessions of laser, or 16 sessions of electrolysis (or a blend of both) for facial hair reduction. This is not available on the NHS for those taking gender-affirming testosterone therapy. 

A referral is offered after diagnosis, and the referral is sent to Gender Dysphoria National Referral Support Services (GDNRSS) who will contact the patient for their preferred location. We are currently in the process of requesting more local providers of facial hair reduction in Sussex.

Voice therapy

We have a speech and language therapist (SALT) within our SGS team, who specialises in gender-affirming voice therapy. We can offer 1:1 sessions or group sessions via video call on in person. Most people are offered 4-6 sessions 1:1 before moving onto group practice.
This treatment pathway is discussed and offered after diagnosis.

Fertility preservation

After the patient is accepted to SGS treatment pathways, SGS can organise gamete storage - if hormones were already prescribed privately or by their GP, this may mean stopping hormones for 3-12 months whilst we wait for fertility to return. The drawback of gamete storage pathway at this stage, is that infertility might be permanent following gender-affirming hormone treatment. Some patients may also find stopping their gender-affirming hormones causes too much dysphoria to continue with fertility preservation.

For more info, please see FAQ titled: 'How can GPs support a patient with fertility preservation?'

In England, Wales and Scotland, a new patient registering with your GP practice may have already been seen and discharged by a gender specialist service. If their previous GP had taken on their prescribing, the patient will expect this to continue at your practice. In this instance, seek to re-establish collaborative/shared care with the original specialist service provider or similar supported prescribing arrangement. 

As SGS is a waiting list incentive and pilot scheme, we are not accepting transfer of care patients. You should instead contact your usual local GIC provider, e.g. London Tavistock, if you wish to transfer care for your patient.

If you have specific questions regarding the patient's treatment, contact the specialist service provider who provides care for your patient.
Avoid referring the patient back to a gender identity clinic as a new referral. This is unnecessary and will lead to a significant delay in the patient's continuing care.

• GMC trans healthcare prescribing.

Sussex Gender Service is an adult service which sees those aged 17 years old and above.

Please refer under 17-year-old patients to one of the 7 national adult gender clinics.

What happens when a young person turns 17 years old on the gender identity developmental service waiting list?

These young people will receive a letter advising them to go to their GP so they can be referred to an adult gender identity clinic. Information on making these referrals can be found here: How to find an NHS gender dysphoria clinic.

Patients with differences in sexual development (DSD), also called intersex, are supported by Sussex Gender Service if they wish to access gender-affirming treatment following prior diagnosis. 

We do not provide investigations or diagnosis for intersex conditions, therefore GPs should investigate and refer as per usual guidance (history, examination, ultrasound, blood tests, refer to Endocrinology or Genetics team as indicated).

Further info here:

• Primary amenorrhoea - e.g. Turner's syndrome, 46XY genotype androgen insensitivity syndrome
• Kleinfelter's syndrome, 47XXY
• Kallman's syndrome.   

Following a diagnosis of DSD, if a patient wishes to access hormone or surgical treatment congruent with their gender assigned at birth, this is often managed by Endocrine and Gynae/Urology teams.

Should a patient wish to be referred to us for gender-affirming transgender care, including genital reconstruction surgery, referrals can be made as usual to local GIC, and the patient will be offered an SGS appointment if they meet our standard criteria. Unfortunately, we cannot expedite appointments for patients due to their medical history.
 

As a waiting list initiative and pilot scheme, we are seeing patients in strict time order and we are unable to expedite appointments for any reason. We hope that the waiting time for patients will gradually decrease as we see patients in the service.

Doctors who manage patients who are considering surgery and/or endocrine treatments should work with those patients to explore whether they may wish to have biological children in the future and options to preserve this capacity, such as whether gamete storage might be considered. The Human Fertilisation and Embryology Authority (HFEA) has useful information for trans and non-binary patients and their doctors on fertility and fertility treatment issues.

We advise that before prescribing bridging prescriptions, gamete storage is discussed and offered to the patient. Funding is on a case-by-case basis via the ICB. Usually evidence needs to be provided that a patient is on the pathway to a diagnosis of gender incongruence/dysphoria.

Alternatively, after the patient is accepted to SGS treatment pathways, SGS can organise gamete storage - if hormones were already prescribed privately or by their GP, this may mean stopping hormones for 3-12 months whilst we wait for fertility to return. The drawback of gamete storage pathway at this stage, is that infertility might be permanent following gender-affirming hormone treatment. Some patients may also find stopping their gender-affirming hormones causes too much dysphoria to continue with fertility preservation.

This may vary due to your role, but there are a number of ways you can support someone who is waiting to access a gender service.

Firstly, it is important not to assume that any difficulties your patient is experiencing are due to gender. While some things may be related, for example low mood due to a wait for gender-specific healthcare, others may not be. Worrying that presenting difficulties will be connected to gender diversity by professionals can be a barrier to accessing mental health services for trans and gender-diverse people. Be led by your patient in considering what type of support they need, which in many cases will be support that you are experienced in delivering.
It is important to think integratively about your patient's needs, considering intersectionality - this is how different parts of a person's identity and life experiences interact to form their individual experience. This will help you to be able to work alongside them to work out the best care plan.

Intersectionality: the complex, cumulative way in which the effects of multiple forms of discrimination (such as racism, sexism, and classism) combine, overlap, or intersect especially in the experiences of marginalised individuals or groups.

Trans and gender-diverse people often worry that they will have to educate their doctors or clinicians about gender, which can again pose a barrier to seeking care. Educating yourself about gender-diversity, and trans, non-binary, and intersex lives will help you approach the support you offer from an informed perspective and help to build a good therapeutic alliance. There are lots of great resources on the Clare Project website via www.clareproject.org.uk/resources/ and books such as 'Gender: A Graphic Guide' by Dr Meg-John Barker and illustrator Jules Scheele, and 'How to Understand your Gender' by Dr Alex Iantaffi and Dr Meg-John Barker provide a good introduction to thinking about gender.

For many people, waiting to be seen by a gender service can be distressing and damaging to wellbeing, especially as the access to the healthcare which they need and the amount of time they wait is completely out of their control. Maintaining hope and general wellbeing can be protective and is particularly important during this time. Some good tips for wellbeing and self-care can be found on the LBGT Foundation website, the 'Rewriting the Rules' website (Zines - Rewriting The Rules), and the TransActual website.

Your patient may find it useful to be linked in with other trans, non-binary or gender-diverse people, especially if they do not have much in the way of a support network. Visit this page for links to local LGBTQ+ support organisations.

If your client thinks that it would be helpful to have a joint meeting with you and someone from our psychology team we would be happy to facilitate this, however we would only be able to do this after your client has completed their initial 2 assessments within our service and been offered an NHS diagnosis of gender incongruence. At this point they can request to be seen by our psychology team, and we can triage this request to think about what will be most helpful. 

GMC guidance says: 

“You must co-operate with Gender Identity Clinics and gender specialists in the same way that you would co-operate with other specialists, collaborating with them to provide effective and timely treatment for trans and non-binary people. This includes: prescribing medicines recommended by a gender specialist for the treatment of gender dysphoria; following recommendations for safety and treatment monitoring; making referrals to NHS services that have been recommended by a specialist.

"Once the patient has been discharged by a Gender Identity Clinic or gender specialist, the prescribing and monitoring of hormone therapy can be carried out successfully in primary care without further specialist input. From the patient’s perspective, management in primary care is far easier, and there is no specific expertise necessary to prescribe for and monitor patients on hormone therapy. 

"It is not necessary to refer trans people back to their gender specialist before referring them to other secondary or tertiary providers, for matters unrelated to their gender history. 

"If you feel you lack knowledge about the healthcare needs of trans people, you should, in the short term, ask for advice from a gender specialist. In the longer term, you should address your learning need as a part of your continuing professional development which will enable you to provide treatment to meet your patients’ needs. E-learning is freely available on the Royal College of General Practitioners’ website and carries CPD points”.

Guidance for doctors treating transgender patients. General Medical Council, March 2016.

There have been many discussions between stakeholders regarding prescribing for patients. The SGS currently follows the Nottingham Guidelines for hormone prescribing. This is due to the fact that we are being trained and supervised by the Nottingham Centre For Transgender Healthcare clinic. We are following the process of the other UK GICs and requesting GPs to undertake the prescribing of medication, under a collaborative care agreement (CCA).

A CCA allows SGS to discharge patients from our service after they have been stabilised on their medication. This means SGS will not be a life-long clinic, and allows the team to see more patients and reduce the waiting time for patients coming through the service.

Should you have any questions for your patients whilst they are under our care or after discharge, then please contact us via our Advice and Guidance email address SGSTeam@spft.nhs.uk (for professionals only).

We recommend you undertake the LCS TNBI online training, which is designed for post-GIC assessment GP prescribing and monitoring. The training is RCGP accredited. The GP practice will receive funding as laid out in the LCS service specification.
For further details or to book your place, please email sxicb.primarycare@nhs.net. 

Patients can request a change to their gender marker at any time and do not need a Gender Recognition Certificate or have undergone any gender affirming medical treatment.

PCSE must be informed when a patient wishes to change their gender marker. The GP practice needs to include the patient’s name as it is currently registered and their NHS number. You must also confirm that you have discussed the change with the patient and they are aware this will involve the creation of the new NHS number. 

PCSE will then send the GP instructions of how to proceed as well as a deduction.

Once the GP has accepted the deduction, they will then register the patient’s new details provided by the PCSE.

PCSE will send the new medical record envelope with the patients updated details. Information from the patient’s previous record must then be included in the new record, although the patient’s previous identity should be redacted. A black mark pen can be used to adapt physical notes and electronic records should be printed, redacted with a black marker, then scanned back into the system.

If the gender is being re-assigned from male to female, the screening team will contact the practice for no cervix confirmation.

If the gender is being re-assigned from female to male, screening will become the responsibility of the practice.

Please see the PCSE webpages below for full information:

• Adoption and gender reassignment processes
• Process for registering a patient gender re-assignment.

There are many resources online to instruct how people can change their name or gender marker on official documentation such as passports, driving licences, or NHS records. We can offer supportive documentation for patients following diagnosis, if requested.

Here are some resources you can signpost people to:

• Change your name by deed poll
• Gender Construction Kit - the UK guide to changing documentation that are linked to gender
• Change your name or personal details on your passport
• Change the name or gender on your driving licence
• Apply for a Gender Recognition Certificate.

There is currently no provision within SGS for requesting or taking blood tests, we request these are done by patients' GP practices. The blood tests are to establish basic good health (in terms of liver function etc.) and to obtain a baseline hormone screen. 

We request that blood tests are completed around three weeks before appointments to ensure we have the results ready when they attend. If any concerns arise from the blood test, we will contact the patient and their GP.

If you are worried about acutely deranged blood results, please contact the on-call hospital team (haematology, endocrinology, medics).

SGS does not run an on-call service nor deal with emergencies relating to hormone or surgical complications.

If you have general routine queries regarding abnormal blood results, please get in touch via SGSTeam@spft.nhs.uk. We aim to respond within 2-5 days.

We recommend you undertake the LCS TNBI online training, which is designed for post-GIC assessment GP prescribing and blood monitoring. The training is RCGP accredited. The GP practice will receive funding as laid out in the LCS service specification.

For further details or to book your place, please email sxicb.primarycare@nhs.net.

If you assess that prescribing for a transgender patient who is self-medicating is in the patient's best interests and is likely to mitigate risks, you can contact us for advice regarding the lowest acceptable dose and monitoring required. If you want to contact us for advice in those situations, we recommend contacting us by email via SGSTeam@spft.nhs.uk.

We can provide you an information sheet with SGS prescribing guidelines, hormone consent form, and GMC guidance, should this be of interest to you.

We recommend you undertake the Sussex LCS TNBI online training, which although not designed for bridging hormone support, contains lots of important information regarding blood monitoring and reviews. The training is RCGP accredited.

For further details or to book your place, please email sxicb.primarycare@nhs.net. 

Please email SGSTeam@spft.nhs.uk for professional support (please note, this email address is for professional use only).

Patients wanting to contact SGS, please email sussexgenderserviceinfo@spft.nhs.uk.

Although we will endeavour to answer any queries from GPs, our email is primarily for patients who will be seen by us (i.e. meet the following criteria: registered with a GP in Sussex; referred to a GIC before 31 March 2023; eligible for NHS treatment), are being seen by us, or have been seen by us.

We are an adult service, so will be unable to provide advice and guidance for children and young people under 17 years old. 

We advise you to contact London Tavistock or another GIC for all other queries, via gic@nhs.net.

Website links below:

• The Tavistock and Portman NHS Foundation Trust - Gender Identity Clinic
• The Tavistock and Portman NHS Foundation Trust - Gender Identity Development Service
• National Referral Support Service, managed by NHS Arden and Greater East Midlands Commissioning Support Unit.

The Standards of Care version 8 details the guidance issued by the World Professional Association of Transgender Healthcare Professionals. It is free to download and contains all the latest guidelines for gender affirming treatment.