34 | Nursing in Practice | Summer 2022
• Telling their GP / nurse and having their details updated on the practice system .
• Change of personal appearance through clothing changes and make-up .
The next thing may be to medically transition ( although not everyone will ). This may involve :
• Getting a referral from the GP to a gender identity clinic ( GIC ). There are guidelines for GPs and nurses to help with this process on the NHS GIC website ( see resources ). A GIC is a gender-specialist clinic that reviews transgender patients and can initiate hormones and refer for surgeries . This is a long process for patients who choose to go through it , so they will need thorough assessments , mental health checks and counselling before they are prescribed hormone treatments . However , the wait time is very long , and patients should be warned they could wait four to five years for their first appointment ( my husband has so far waited four years ).
• Starting hormone treatment . Hormones should be started at as low a dose as possible for the patient and reviewed with bloods and blood pressure every three months for the first year . If levels are stable , they can move to six-monthly and then annual reviews , according to the World Professional Association for Transgender Health standards . 9 The aim of hormones is to make changes to their body physically to align them with their gender ; bloods should be in the target range for their gender rather than biological sex . The hormones include : – Trans feminine pathway – oestrogen and / or hormone blocker . – Trans masculine pathway – testosterone and / or hormone blocker ( a blocker is not needed for trans men unless they show unwanted symptoms of monthly periods , or puberty for youths , in which case a blocker may be used to stop these ). – Trans non-binary people may also choose to take hormones , depending on which route they wish to align their body with .
Surgical procedures ( surgeries are referred to in the trans community as ‘ top ’ and ‘ bottom ’ surgeries ):
• ‘ Top surgery ’ for trans women – breast augmentation .
• ‘ Top surgery ’ for trans men – double mastectomy .
• ‘ Bottom surgery ’ for trans women – this comes in several forms :
– Removal of the testes ( orchidectomy ).
– Removal of the penis ( penectomy ).
– Construction of a vagina ( vaginoplasty ).
– Construction of a vulva ( vulvoplasty ).
– Construction of a clitoris ( clitoroplasty ).
• Bottom surgery for trans men :
– Construction of a penis ( phalloplasty or metoidioplasty ).
– Construction of a scrotum ( scrotoplasty ) and testicular implants .
– Penile implant .
Other surgery for trans men , removal of the womb ( hysterectomy ) and the ovaries and fallopian tubes ( salpingo-oophorectomy ), may also be considered . 10
Legal considerations of transition How does someone start to transition legally ? A Gender Recognition Certificate ( GRC ) allows a person ’ s gender to be registered legally in the UK . However , people do not need a GRC to change their gender and name on legal documents such as their passport , driving licence , HMRC record or GP record . All that is needed is a deed poll and a letter from a UK-based doctor or psychologist . A GRC is only required to get married , and to die with dignity in the gender they are – people who are transgender need a GRC to legally marry in their current gender , and also
Resources to help your patients
• Gender GP Resources with different guidelines , policies and documents to help you care for your patients . tinyurl . com / GenderGP-docs
• Human Fertilisation and Embryology Authority Information for trans and non-binary people seeking fertility treatment . 2022 . tinyurl . com / HFEA-fertility
• Patient information on how to safely chest bind 2021 . tinyurl . com / safebinding
• CQC Adult transgender care pathway guidelines . 2022 . tinyurl . com / CQCpathway
• What is genital tucking ? tinyurl . com / genital-tucking
for their gender to be applied to their death certificate . If they do not have a GRC in place , then legally their biological sex will be recorded on the certificate by default . If a trans person wishes to marry without a GRC , their birth sex will be on the marriage certificate ; if they have changed their name by deed poll , their new name can be used but must be followed by ‘ formerly known as ’ and their birth name .
A GRC application can be made on the gov . uk website . 11 The person will need evidence to show they have been living in their gender for two or more years prior to the application ; this can be in the form of a deed poll , a statutory declaration , payslips , utility bills or medical letters . They also need two separate statements from UK-registered doctors , or one from a doctor and one from a psychologist . One of these must be a gender specialist . This is all submitted online with an application fee . The government panel will assess the evidence and make a decision ( an application can sometimes be declined ). As of May 2023 , the current wait in the UK was around six months for evidence to be taken to the panel , due to a backlog in applications .
Summary It can be quite daunting to see your first transgender or non-binary person in your surgery or clinic if you have no experience or training in trans health . We will get it wrong from time to time – we are human and we make mistakes . However , it ’ s important that if we do make a mistake , such as misgendering someone , we correct it , apologise and do our best to avoid repeating it in future . The resources listed alongside this article will provide valuable information to anyone wanting to know more . Given all of the above , my main advice is to treat everyone equally and without judgment and to listen to the patient as they are the expert on their own wellbeing and gender . Don ’ t hesitate to ask the person in front of you if you are unsure about something .
If you are a nurse and have concerns , please get your GP involved . If the GP doesn ’ t have the answers the next port of call is the NHS GIC website , which has a lot of resources and advice to support healthcare professionals . Failing that , you can contact NHS GIC directly , via its dedicated email and phone number :
• GIC email for advice : gic . endo @ nhs . net .
• GIC phone number : 020 8938 7590 .
If you do not have any guidelines or policies in place for transgender patients , please think about developing these with your team . Taking the time to do this is likely to be worthwhile for you and your patients in the future . A good starting point might be to share this article with your team at your next practice meeting .
References 1 2021 census : What do we know about the LGBT + population ? tinyurl . com / Census-gender 2 Hudson A . Trans pioneers : Michael Dillon & Roberta Cowell . 2021 . tinyurl . com / Hudson-pioneers 3 Bachmann C and Gooch B . LGBT in Britain – Trans Report . 2017 . tinyurl . com / trans-report 4 Wiepjes C et al . Trends in suicide death risk in transgender people . Acta Psychiatrica Scandinavica 2020 ; 141:6:486- 491 . tinyurl . com / Wiepjes-trends 5 Equality Act 2010 : Protected characteristics . tinyurl . com / EHRC-protected 6 Equality Act 2010 : Gender reassignment discrimination . tinyurl . com / EHCR-gender 7 NMC Code : Being inclusive and challenging discrimination . tinyurl . com / NMC-inclusive 8 Future Learn . Transgender healthcare : Caring for trans patients . tinyurl . com / FL-transgender 9 World Professional Association for Transgender Health standards . 2022 . tinyurl . com / WPATH-standards 10 NHS . Treatment : gender dysphoria . 2020 . tinyurl . com / NHSgender-dysphoria 11 Gov . uk . Apply for a Gender Recognition Certificate . tinyurl . com / GRC-apply 12 Stonewall . A beginner ’ s guide to pronouns and using pronouns in the workplace . 2022 . tinyurl . com / Stonewallpronouns
Additional resources
• Department of Health ( 2009 ) Guidance on NHS patients who wish to pay for additional private care . tinyurl . com / NHS-private
• Endocrine Society . Endocrine treatment of gender-dysphoric / gender incongruent Persons . 2010 . tinyurl . com / endocrinegender
• NHS England . Delivering same sex spaces for transgender people . 2019 . tinyurl . com / NHSE-spaces
• NHS Gender Identity Clinic . Clinical information and guidance for hormone therapy . tinyurl . com / NHSGIC-protocols
• NHS GIC resources . tinyurl . com / NHSGIC-resources
• NHS Sunderland . Guidelines for the use of feminising hormone therapy in gender dysphoria . 2015 . tinyurl . com / Sunderland-guide
• Pride in Practice . Chest binding : A physicians guide . 2019 . tinyurl . com / binding-guide
• Royal College of Physicians . Good practice guidelines for the assessment and treatment of adults with gender dysphoria . 2013 . tinyurl . com / RCPgender-dysphoria
• Time from first onset chest binding related symptoms in transgender youths . tinyurl . com / youth-binding
• Understanding the effects of lung function when using a binder : tinyurl . com / chest-binding
• Understanding the impact of chest binding or genitaltucking . tinyurl . com / Poteat-binding
• World Professional Association of Transgender Health . wpath . org