What can I do while I wait to be seen?
Many people find that going to the GP and asking for a referral to the gender clinic is a huge milestone and that the wait to be seen for the assessment can be a bit of an anti-climax. Everyone is different, and so are their circumstances, but there is no need to wait until you have your assessment at the clinic before embarking on making changes in your life. The life changes that are often described as ‘social transition’ can happen at whatever time is best for you and, for some people, this is something that they feel able to do before starting any medical treatment. In addition to this, making changes to your lifestyle, so that you are fit and healthy, can help you to get access to care and treatment more effectively For many people, relevant changes can include:
- Choosing a name and pronouns that you would prefer to be called
- Changing your name officially through Deed Poll or Statutory Declaration
- Updating your details with banks, passport office, DVLA, National Insurance etc.
- Telling family, friends or colleagues about your gender identity and how they should refer to you.
- Experimenting with your appearance and lifestyle so that they feel more congruent with your gender identity
- Getting fit and healthy, including making sure that you are at a healthy body weight. You can find information and advice about healthy weight, including how to find out if you’re a healthy weight, on the NHS website.
- Giving up smoking and nicotine products. You can find information and advice to help you stop smoking on the NHS website.
- Seeking support for mental or physical health problems. Contact your GP for further information.
- Contacting local or national support groups and making connections with people who can support you and provide safe spaces for you to be yourself.
People on the NRGDS waiting list can access the NRGDS Peer Support Service for help with transition while they wait to be seen.
What will you ask about at assessment?
This usually takes place with one of our nursing or psychology staff. Usually, this member of staff will be the main point of contact for an individual during their care in the service. It lasts up to two hours and covers a wide range of topics relevant to personal experiences of gender dysphoria, gender identity and physical and mental wellbeing. We usually ask about:
- Your gender identity and how your awareness of it has developed over time.
- Your journey through life to get to this point and how you cope day to day at the moment.
- Your experiences of gender dysphoria and how you are affected by it.
- Your mental and physical health now and in the past.
- Your relationships with important people in your life.
Assessment may also cover other topics, depending on your life history. We are aware that there is no such thing as a typical pattern of development or presentation for people with gender dysphoria, and that everyone is different. Therefore, individuals should not feel pressured to provide a “typical” history or life story, under the false premise that this is needed to meet the expectations of staff in the gender clinic or to gain access to essential treatments. It is important to provide all relevant information and be upfront and honest about your situation and experiences. This can include details about delicate or sensitive subjects, including:
Many people will experience some form of mental ill health during their lifetime and periods of change can make this more likely. We understand that untreated gender dysphoria can be a significant cause of mental health problems, such as depression, anxiety and stress and that the people who use our service are often making changes in their life. We ask about your mental health and any risks that you might pose to yourself or others to make sure that you have the support you need, not only from this service but also from other sources available in your area. We are not a mental health service and so, if you tell us that you need extra support or we have concerns that you are not supported well enough, we will ask your GP or local mental health services to support you in their usual way. We are bound by a duty of care to the people in our service and part of this is to communicate clearly with other healthcare professionals involved in looking after you. When we write to your GP or other people involved in your healthcare, we will usually write a short summary of your mental health alongside other relevant medical details. This may include comment on your presentation, because whether someone appears to be looking after themselves or not, can be an indicator of whether they are struggling with their mental health. Monitoring all aspects of your wellbeing also helps us to ensure the care and treatment we provide is beneficial.
We understand that people living with gender dysphoria, or with mental health problems, can sometimes feel so desperate or unhappy that harming themselves can feel like a solution to some of the feelings. We know that untreated gender dysphoria can increase the risks of poor mental health and that self-harm can sometimes be part of that. It is important for us to know about self-harm or thoughts of ending your life, so that we can offer you the support that you need, either in our clinic or in appropriate services in your area. We will always try to work with you to ensure that you can safely receive important treatments for gender dysphoria alongside any treatments that you need to manage self-harm or mental health problems.
The reason that we ask about people’s sexual practices and preferences at assessment is because those who seek to medically transition, through taking medication and/or having surgery, will find that these measures are extremely likely to affect their sex drive, the ways that they might have sex and sexual sensation. It is important that each person has a clear idea of the potential risks and benefits of any treatment on their sex life, as well as on their gender dysphoria. We also ask about people’s sex life within assessment because it can be an area of life that people struggle with, especially if they are experiencing distress related to their physical body. Our assessments are trying to understand the full impact of gender dysphoria on your life.
After the first assessment, a decision is made by the team regarding next steps. This will either be a recommendation for an extended first assessment or a second assessment.
What is an extended assessment?
Where there is a need identified for additional psychological or medical support to make decisions about the best approach to assessment or treatment, the team might offer an extended assessment process. Service users might use this to explore their requirements for treatment, raise questions or reflect on their needs. The extended assessment will be with the person that team feels can best meet this need.
Why are there two assessments?
The second assessment appointment takes place after a period of at least three months, but in reality the waiting time is much longer at present. In many respects, it covers similar topics to the first assessment, but it also has some elements which are new. The second assessment is usually one appointment which lasts up to two hours and is with the member of the medical team. The second assessment explores whether thoughts, feelings and aspirations remain the same and/or what may have changed in the interim period. At the end of the second assessment, a plan of care is agreed and staff make the necessary arrangements for the next stage of treatment, if required.
Will you take into account my assessment in another service?
We will always read information sent to us by referrers, including other gender specialists in the NHS or working privately before making a decision on whether an individual needs to be assessed by NRGDS staff. In some cases, people will have been assessed some time ago and it will be important for us to review the assessment with them in order to hear the most up to date information about how they are. Some assessments come to us missing important and necessary information or with information that is not of sufficient quality. In these circumstances, we will need to undertake a longer assessment to make sure that we have all the information that we need to offer you the best healthcare. People who have been assessed in the Gender Identity Development Service (or those who have received a diagnosis of gender dysphoria in the past) may need a longer assessment to confirm that they meet the necessary diagnostic criteria.
Further information The following documents provide further information on diagnostic criteria and the guidelines that govern assessment:
Can I take progesterone, or extra oestrogen, to increase my breast size?
Hormones work by changing the way certain parts of the body grow and function. This process takes time. The dose of hormone alone does not determine how fast these changes occur. It is more important to have the right amount of hormone at the right time. If you feel that your hormone regime is not working well for you it is important that you discuss this with your doctor in the team before making any changes to how you take it. Taking more hormones than you are prescribed can damage your physical development in the longer term.
Taking large amounts of oestrogen at the beginning of medical transition can cause poor breast development in the longer term. It may be more effective to add an anti-testosterone medication to your treatment, to help increase feminising effects by reducing testosterone. Whatever the issue, you should discuss this with your doctor in the service before making any changes.
Oestrogen and progesterone
Taking progesterone as well as oestrogen will not result in more feminising effects.
It doesn’t help to increase breast size: Some people believe that taking progesterone will increase their breast size. This is because people who have a cycle of hormones that includes progesterone get larger breasts during phases in their hormonal cycle when there is more progesterone. In reality the increase in breast size comes from water stored in the breast tissue (not an increase in the fat that makes up most of breast tissue) and is only a short-lived, temporary increase in size, lasting a few days. There has been some limited research evidence in the past that progesterone increases breast size. In fact, it just increases the size of the milk ducts very slightly and this is of no benefit in increasing the size of the breast overall. Almost all breast growth in birth assigned females happens before they start to produce progesterone so it plays almost no part in breast development.
It interferes with oestrogen: Progesterone can interfere with the work of oestrogen in the body. It can make your liver more effective at breaking down oestrogen so that it can’t be used by your body. Progesterone can also stop your breasts developing oestrogen receptors, so that however much oestrogen you take afterwards, your breast tissue can’t take it up and use it to increase the size of your breasts. Progesterone is a hormone that your body can use to make its own testosterone. This means that taking progesterone can cause unwanted side effects such as loss of head hair, increase in body hair growth, acne and weight gain.
Taking it carries risks: In addition to interfering with feminising effects of oestrogen, taking progesterone can have its own potential risks, such as an increase in risk of cardiovascular problems (such as having a stroke, heart attack or blood clot in your heart or lungs) and a possible increased risk of developing breast cancer.
What if I want a different treatment from what you describe?
We recognise that each person attending the service will want different things from treatment and that some will not want medical interventions of any kind. Part of your assessment will include the opportunity to explore what types of treatment you feel you want with your clinician, then a treatment plan will be agreed. This plan is reviewed and often altered throughout your time with the service. Staff in the NRGDS can only refer the people they work with for treatments that are available within currently agreed NHS pathways. There are a variety of treatments that some people may wish to access, which are not available. For example, there is no provision under current NHS funding for gender clinics to provide access to feminising chest (breast augmentation) surgery, facial surgery or voice surgery.