Wednesday, 30 November 2011

Transgender Care Path for Halton & St Helens PCT

A couple of weeks ago, I emailed Halton & St Helen's PCT asking why my GP told me that the PCT had not instructed him to follow the Standards of Care for Transgender people as written by the WPATH.

Today I received an email from the Interim Chief Operating Officer of Halton CCG, located at Victoria House in Runcorn, Cheshire, replying to my inquiry which details the basic care path that Halton & St Helens PCT follows. Here is that email:

There is no single universally accepted pathway for patients with gender dysphoria.  There is a recommended pathway that has been established by the North West Specialised Commissioning Team which we follow locally – work in which I was involved in when I worked with that team.  This is based upon the WPATH Standards of Care, often referred to as the Harry Benjamin criteria.  The recommended pathway can be summarised as follows:
·       Patient sees his/her General Practitioner for assessment and management of gender dysphoria. The GP refers the patient to a local specialist in gender dysphoria where that is available or to the local NHS mental health provider for access to further evaluation.
·       Patient is assessed by the local NHS psychiatrist, who may or may not be an expert in the field of gender dysphoria.  If the local psychiatrist considers the case to merit further evaluation and can rule out the presence of an obvious mental illness that may be the cause of the symptoms of gender dysphoria, the patient is referred on to the Gender Identity Clinic (GIC).
·       Depending on the operational policy of the GIC confirmation of funding may be requested from the patient’s PCT before an outpatient appointment is made. It is important to note that the PCT making the decision need to be aware that there could be a surgical cost at the end of the pathway and that this could be several years in the future.
·       The Gender Identity Clinic - Experts in gender dysphoria assess the patient and initiate Real Life Experience (RLE), prescribing hormones and monitoring the patient, usually in partnership with the patients own GP.  During this period, patients may additionally require psychotherapy, speech therapy, group sessions and other interventions.  After 12-24 months of assessment, the patient is seen by two consultants (one of whom has not previously been involved with the care and treatment of the particular patient, acting as a second opinion) for a final assessment to judge if the patient is suitable for surgery.  If the patient is considered suitable and is personally ready for surgery, a referral is made to the preferred provider for consideration of Gender Reassignment Surgery (GRS). 
·       The provider of GRS requests confirmation of funding for surgery from the patient’s PCT and provides an outpatient surgical consultation appointment once funding is confirmed.
·       The PCT considers the request for funding and once it is ensured that the patient meets the criteria, confirms funding for GRS.
·       Patient undergoes appropriate GRS and returns to follow-up with GIC.
·       Patient discharged from GIC when appropriate and returns to primary care for maintenance hormone therapy and monitoring, if appropriate.
You will have to travel for aspects of this care, such as assessment at a GIC and, should you wish to have surgery, for surgical interventions, as there are no local services due to the specialised nature of the interventions you require.  You should, however, expect support from your GP in terms of arranging ‘shared care’ and local monitoring working in partnership with GIC to minimise travel to and from these centres.
To summate, Halton GPs are following the WPATH Standards of Care and recommended pathways based upon these.  This said, there is clearly a need for improved liaison between the services providing specialised interventions and your GP to enable them to deliver as much care to you locally as possible.

 This path, as outlined above, is missing one thing though. According to my sources, Halton & St Helens PCT refuses to fund the top surgery for both FTMs and MTFs. Knowing this, I emailed a reply back asking if this was true and to be given the PCTs policy on funding for surgery. When/if I get a response, I will post it up here. 

If you have any questions, please comment below and I will either answer them (if I know the answer) or will forward them to my contact in the Halton CCG. 

Sunday, 20 November 2011

International Transgender Day of Remembrance

Today is the 13th Annual Transgender Day of Remembrance. This day was created to memorialise those who were killed due to anti-transgender hatred or prejudice.

In the last year, transphobic crimes have gone up world wide by over 30%. The majority of these have been committed in Latin America, although there have also been murders in the United States of America, Pakistan, and Uganda.  Some sources put the number of murders world wide in last year around 220, which means that there is a transphobic murder approximately every 39 hours. If we add to this number the amount of physical harm crimes against transgender people (transgender people are often physically assaulted for using public restrooms, going into pubs/clubs, or just walking down the street), and the number of transgender people who commit suicide, the numbers would easily quadruple.

The really sad thing is this vast number could easily be drastically reduced by everyone doing just a few things. First of all, family of transgender people, I can not express enough how important it is for you to accept and love your child, sibling, grandchild when they "come out" as transgender. Do not disown them, do not tell them they are going to hell, do not blame their friends or their school. Love them, accept them, and support them. Those three things are so important to transgender people. Stand up for those trans people you may come across out in public, especially if they are being abused or assaulted. Friends of trans people, let them know that you are their friend no matter what and will be there for them, supporting them all the way.

If we all band together, both trans people and trans allies, hopefully transphobic crimes will decrease by next year. At the very least, more people will be educated about the issue. That's where it all starts, with knowledge. The more that people know, the less discrimination there will be.

Monday, 14 November 2011

Name Change and Transitioning Problems

The last few weeks have been full of  "interesting" events and "fun" times with regards to my bank and doctor.

Bank Problems

My bank is Santander, previously known as Abbey National, and is based in Spain. When I changed my name via Deed Poll back in August 2011, I contacted all of the businesses and organizations that I am involved with to inform them of the change. All of them changed my details without any hassle, except for Santander. The branch manager said that because my chosen title (Ser - a gender neutral version of Sir) is not available on their drop-down list they could not change my name in their systems. The manager was very nice and sympathetic and informed me that she would contact someone higher up to see what could be done about it.

Fast forward a few weeks and I went back to my branch to get an update. Unsurprisingly, there wasn't one. My next course of action was to contact Santander's Customer Complaint Department. On the 30th of September, 2011, I received a letter from Sarah Nielsen, the Service and Control Manager in my new name informing me that "unfortunately your change of detail request is not compatible on our system, so therefore we are unable to complete your requests".

Under the advice of a retired police officer friend, on the 11th of October, 2011, I sent a letter to Santander's Customer Complaints Department informing them that "under the Data Protection Act, as you are holding personal data about me, you are legally obliged to ensure that all data you hold about me is correct and up-to-date," and that since their "current systems may not have the option for Ser..., then I will accept the use of Reverend as my religion believes that everyone is a reverend or pastor; alternatively, I will accept the use of no title. However, please note that I would prefer a change in your system to allow gender-neutral forms of address in the near future so that all of my correspondence between myself and different companies are the same."  Their reply, which I received on the 7th of November, 2011, reiterated that they are unable to change my records to reflect my new name and title. 

Today I contacted the Financial Ombudsman Service to ask for their help to resolve this matter. The lady I spoke with was very nice and understood my unhappiness about the situation. She agreed with me that Santander should update their systems to allow titles to be typed in and to allow "other" as a gender choice. She told me that they have until the New Year to contact me. If they don't contact me by then or they still refuse to change my records to reflect my name change, then we will be taking it to the next stage. 

Transitioning - Conventional Care vs Informed Consent

At the end of September, 2011, the World Professional Association for Transgender Health (WPATH) published the 7th edition of  their Standards of Care (SOC). This version of the SOC strongly encourages a GP-centred local care path and the use of Informed Consent. Yet when I approached the topic to my GP, he dismissed the idea, saying that Halton's PCT and the NHS instructed medical providers to use the Conventional care path. 
The conventional care path follows a very rigid procedure - the patient sees their GP, the GP refers to a local psychiatrist who then refers to a Gender Identity Clinic and the patient goes to the GIC for everything transition related. This may not seem like a bad path, and for many it works fine, but for those of us who live hours away from the nearest GIC, it can be very stressful and time consuming. 

The GP-centred local care path with informed consent is much better for those of us who don't have a GIC near by. It allows us to access everything locally with the GP acting as a gateway to all the services which the patient needs. This path is less stressful because it entails less time off work, less time away from family, and less travel time for the trans* person.

Not being happy with my GP's dismissal of my preferences, I asked some transgender friends about their care path. Several of them, both in America and in England, have gone the GP-centred local care path, so I know it can be done.
After doing some searching online, I found the name of the chairman of Widnes practice based commissioning (PBC) and his email and sent him the following email:

Dear Dr. Schofield,

As a resident of Widnes and a transgender person, I would like to ask you why it appears that Halton PCT is not updating their policies and ensuring providers follow significantly updated guidelines regarding the Standards of Care for transgender people.

My current GP is Dr. Gunaseelan who is located at the Widnes Health Resource Centre on Caldwell Road. When I approached him for help in starting my transition, I expressed a preference to having GP-centred local care using the Informed Consent method as suggested in the 6th and 7th Editions of the WPATH Standards of Care. (Information on these methods can be found on (section 3) and (starting on page 14).)

My reasoning behind this is simple - I am a single parent and travelling to either Charing Cross or Leeds Gender Identity Clinic would be very difficult for me. Having my treatment GP-centred, using local care and Informed Consent would make my transitioning process easier and less stressful for me and my son. However, my GP dismissed my wishes and has insisted on following the conventional care path which includes a diagnosis of Gender Identity Disorder by a Psychiatrist (which is highly discouraged in the 7th Edition of the WPATH SOC) and a referral to a Gender Identity Clinic.

When I asked him why he is insistent on going down the conventional path, he said it is because Halton PCT and the NHS has not instructed the GPs to use the WPATH SOC.

Is this true? And if so, why have Halton's GPs not been encouraged to follow these new standards? Doctors are expected to keep their knowledge up to date regarding new insights/advances, as I'm certain you know.

Please, if you could let me know what Halton PCT's views are about this, I would be greatly appreciative.

Thank you for your time and attention to this matter.

Sincerely yours,

Hopefully I will receive a reply from Dr. Schofield or one of his associates in the next few days. When I do, I will post it in a new entry.

It isn't my goal to get any one in trouble in either of these matters. I do however, hope that by pressing the issue I get help not only for me, but for others who may be going through similar circumstances either now or in the future. I don't want anyone to have to go through all of this if they don't have to.