1. Background
Legal obligations and commissioning priority
1.1 The Court of appeal ruled in 1999 that it is unlawful for NHS organisations to
operate anything amounting to a blanket ban on the funding of gender treatment
(Burns, 2008).
1.2 A Primary Care Trust is allowed to accord any treatment ‘low priority’. However, it
is unlawful to use this as a ‘blanket policy’ whereby transsexualism becomes
effectively barred from treatment.
1.3 Principle 3 of the NHS Plan (2000) expresses the need for non-discriminatory
practices and comprehensive involvement of individuals with their own
treatment plans. Implicit in this principle is the overriding need for properly
informed consent of the person concerned before each stage of treatment.
“The National Health Service of the 21st Century must be responsive to
the needs of different groups and individuals within society, and
challenge discrimination on the grounds of age, gender, ethnicity,
religion, disability and sexuality. The NHS will treat patients as
individuals, with respect for their dignity. Patients and citizens will
have greater say in the NHS, and the provision of services will be
centred on patients’ needs” (Principle 3, NHS Plan, 2000).
1.4 It is only relatively recently that the Department of Health has made a specific
commitment to the care of those with gender identity issues who need to
access clinical support.
"The Department of Health is committed to tackling gender inequalities
within the healthcare sector by recognising the specific health needs of
men, women, and transgender people.... The Department's commitment
to create a patient-centred service which extends choice and is
responsive to all patients and users, especially with regards to the gender
perspective, will ensure that any gender differences in treatment and
access are eliminated". (Single Equality Scheme 2007-2010).
1.5 It is clear that NHS commissioners have an obligation to provide services for
people with gender dysphoria and that a policy for this should be formed in
accordance with the normal processes for policy formation and prioritisation.
Referral Criteria
5.1 The Primary Care Trust will only commission Gender Identity Disorder
Services for patients who meet the following referral criteria:
Inclusions
• individuals with an initial diagnosis of transsexualism. A local consultant
psychiatrist who is not part of the gender identity service must have made
the initial diagnosis
• patients who have written clinical support from their GP to ensure possible
future compliance with shared care arrangements if in place
• the transsexual identity has been present persistently for at least two
years
Treatment Pathway (Appendix A)
Initial Assessment
8.1 This period involves the continuation of the diagnostic assessment of the
patient.
8.2 Psycho-social support should be available throughout the pathway.
The Real Life Experience
8.3 This is a period of time of two years, living in the gender role with which the
individual identifies, with the aim of assisting the patient and the professional
in decisions about how to proceed.
8.4 The quality of real life experience is assessed through the patient’s ability to
(Harry Benjamin Association, 2001):
1. maintain employment, voluntary work, or education and training,
2. acquire a legal gender appropriate first name
3. demonstrate that people are aware that they are living in their new
role.
Gender Reassignment Surgery (GRS)
8.5 The treatment process for gender identity disorder includes a variety of
therapeutic options including surgical and non surgical procedures. The
treatment pathway can include any of the following core treatments subject to
external second opinion:
Core Non Surgical Clinical Interventions
• diagnostic assessment
• psycho-social support
• hormone therapy
• pre- and post operative support from a professional with specialist
knowledge of sex reassignment
• voice skills therapy
• Facial hair removal in transwomen, where clinically indicated to
enable the period of real life experience
8.6 The surgical interventions routinely funded under this policy can include one
or more of the following core procedures:
Core Surgical Procedures for Gender Reassignment Surgery in
Transwomen
• penectomy
• orchiectomy
• vaginoplasty
• clitoroplasty
• labiaplasty
• donor site hair removal on surgeon’s recommendation
Any further procedure requested, including those listed below will require prior
approval. Cosmetic procedures require approval from the Restricted
Treatments Panel and are subject to the criteria of “exceptional clinical need”
as defined in the Low Priority Treatments policy. Applications for other
procedures should be made to the Exceptional Treatments Panel.
Cosmetic Procedures
• breast augmentation
• reduction thyroid chondroplasty
• rhinoplasty or other facial bone reduction
• lipoplasty
• blepharoplasty
• face lift
• liposuction
• vocal chord surgery
• Crico-thyroid approximation (only undertaken following speech &
language therapy
• hair removal/electrolysis (except as defined in core procedures)
• procedures to decrease areas of baldness
• skin resurfacing
Post Operative Care
8.8 Trans people are likely to have complex needs, be on lifelong hormone
therapy and may need to be monitored and have the services of a
multidisciplinary team for the long term effects of such treatment such as
thromboembolism, osteoporosis and cancer. Reassignment surgery usually
leads to lower doses of hormones being required. GPs will be advised on
hormone therapy by the tertiary centre, with referral of problems to the local
trust endocrinology services as required. Minor genitourinary tract problems
can be referred to the local urology department, but more complex problems
should be referred to the specialist centre where reassignment surgery took
place. However, both these issues will be part of normal treatment or care
pathways managed by the Primary Care Trust.
Reversal of Gender Reassignment Surgery
8.9 The Primary Care Trust will not routinely provide funding for reversal of
Gender Reassignment Surgery. Gender reassignment therapy/surgery is
provided following rigorous assessment of individual eligibility and readiness.
This is intended to ensure that unsuitable patients are not offered surgery,
leading to post operative regret.
8.10 Revisions or repairs to surgery undertaken outside the NHS, wherever it has
occurred, will not be approved or funded by the Primary Care Trust and this
will include but not be exclusive to:
• surgical revisions for psychological reasons
• surgical revisions for cosmetic reasons
In line with NHS co-funding guidance The Primary Care Trust will not co
fund procedures nor will it support private non-core procedures being carried
out at the same time as core NHS funded procedures. This ensures there is a
clear separation with regards to funding and liability.
____________________________________
Cristine Jennifer Shye B.acc. BL (GS Admin) 
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