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What to expect during transition

Transition involves a profound change in your life; this may seem daunting but we are here to help. There are a range of challenges to be addressed during your transition, so we’ve prepared a checklist to help you prepare.

This list is not exhaustive. Transition involves much, much more than the obvious medical interventions of hormone therapy and surgery. You will also need to consider its social and legal implications, from formally changing your name through to dealing with the emotional aspects of informing family and friends.

The West of England Specialist Gender Identity Clinic will support you in all aspects of your transition and will provide you with a personalised file to hold all this information.

Good practice guidelines require people to live in a gender appropriate role for at least a year before they are referred for surgery.

Checklist for transition

  • You will be provided with a great deal of new information about gender identity issues by the clinic. We recommend that you keep it in your personal file for future reference.
  • Living life in your new social role may be very different to your current life and you are likely to have many new experiences; be ready for change and for some challenging situations. Ask for help if you feel overwhelmed by everything; difficult challenges can be overcome with help.
  • Medication and hormone treatment may be offered. We strongly discourage self-medication with irregularly sourced drug treatments. Internet-sourced hormone therapies can be dangerous and are sometimes contaminated. Their use is likely to affect blood test results and, if our medical team are unaware of your self-medication, they may inadvertently offer inappropriate advice or recommend unnecessary investigation. Please, be honest with us. You will experience both physical and emotional changes. Keep notes on how you’re feeling.
  • Gender reassignment surgery (GRS) cannot be provided until you have lived in a social role appropriate to your gender identity for at least twelve months. It is often very helpful to “grow into” your new role in society; rushing in to change without adequate planning and preparation may result in your making mistakes and experiencing preventable suffering.

    We understand that many people feel that they have already been waiting too long to transition, and have hormones and surgery. Just a little more time spent in preparation now may lead to greater happiness and satisfaction for a lifetime. The clinical team are able to discuss with you in detail what is involved in gender reassignment surgery. Not everyone wants surgery, currently, less than half of trans men seek GRS.
  • At some point, you will want to tell other people about your transition. We can advise you on how to carefully and sensitively inform all those who need to know about your transition, from family members to employers. Employers have legal responsibilities to protect you and Unite have written a guide on Trans Equality at Work, click here to view the Trans Equality at Work Guide.
  • Dealing with relationships and, where relevant, maintaining access to your children can be a concern. We recommend that your discuss this with your therapist as soon as possible, particularly if your partner and family are not yet aware of your transition plans. Make notes on your planned course of action.
  • You will need a letter of gender confirmation treatment for use if challenged in using gender-segregated facilities, such as changing rooms or toilets. Ask your consultant or therapist for details.
  • You may be eligible for NHS-funded treatment to reduce your facial hair (epilation).  There is a limit to the amount of treatment funded by the NHS and there is no guarantee that this will reduce your facial hair to your complete satisfaction. If you want additional or future epilation treatment, you will have to pay for this yourself. We can advise you about this.
  • A recent research document identified that 52% of the participants had experienced problems with work due to being trans or having a trans history.  Of concern was the finding that some people had not provided references because of their gender history which may affect the jobs they could apply for, whilst others had left a job due to harassment or discrimination with no job to go to. This could have significant implications should you be reliant on work in order to pay for your accommodation and food. Nevertheless if you’re in transition whilst working for the same employer there is legislation in place to protect your rights. 
  • Your pension and any benefits arrangements might be affected if you’re a transsexual. Seek advice from your private provider and/or the Department of Works and Pensions.  
  • Appropriate use of pronouns may become an issue. Politely advise people of your preferred pronoun.
  • Your entertainment and social activities are likely to change. Here is a link to a list of online resources: Guardian life and style: transgender advice.
  • Transphobic hate incidents may happen and can take many forms including verbal and physical abuse through to threatening behaviour and online abuse.  Transphobic hate crime is a criminal offence.
  • You may require legal support to deal with some issues. It may be beneficial to find a solicitor who has experience in transgender  topics.
  • Counselling is an important part of the transition process, make time to go to these sessions and keep notes of what’s important to you in your personal file.
  • As you prepare for your new life you may require assistance with clothing, footwear, wigs, and cosmetics. You may also need guidance on how to behave and deportment, the clinic’s staff and volunteers will be able to provide advice on all these matters.
  • Voice and communication skills training is provided where required by a specialist speech and language therapist to help particularly with feminising aspects of transition.

Transgender people in some parts of the UK face a wait of nearly three years for appointments on the NHS.

There are seven Gender Identity Clinics across the UK which help people deal with their medical needs around transition. 

All of the clinics have reported an upswing in referrals in the past few years, as more trans people come forward to seek treatment.

However the growth in demand without a significant increase in capacity has led to growing backlog of referrals, leaving transgender people waiting far beyond the NHS 18-week target for all appointments.

Data compiled from NHS transparency releases shows that the Northampton Gender Identity Clinic in Daventry has the longest wait time of all GICs.

Trans people referred to the Northampton clinic face a staggering 30 month wait before their first appointment.

The shortest advertised waiting time is at Northern Region Gender Dysphoria Service, Newcastle, but even there transgender people are left waiting for 12 months to see a doctor – far in excess of the NHS targets.

London’s central Charing Cross Gender Identity Clinic has a 14-month wait time. All other GICs have a waiting time between one and two years.

The extensive wait to even start the medical transition process is compounded by further backlogs in specific services, with trans people facing further waiting periods if they choose to have surgery.

In a statement to PinkNews, a spokesperson for Northamptonshire Healthcare NHS Foundation Trust admitted that its clinic was unlikely to meet the “extremely ambitious” NHS 18-week target.

It said: “We know that the most important aim for patients is to commence medicinal treatments or have a referral for surgery as soon as possible.

“With the exception of a ‘Welcome Workshop’ provided to explain the pathway of transition through our service, we want to ensure that the first clinician the patient sees will be one that can complete a diagnostic assessment to start the treatment pathway.

“Unfortunately there is a lengthy wait time between initial referral and first diagnostic appointment, at all times we are open and honest about this to avoid setting unrealistic expectations.”

It added: “We saw an unprecedented demand for services in mid-2015 which reached a peak of over 80 referrals per month. Even now, we receive an average of 45 referrals per month.

“Given the relatively small size of our GIC, demand outstrips supply. We must also factor in that once people are accepted by our clinic we need to allocate our clinical resource accordingly, to progress their treatment in line with NHS England guidelines.

“The current NHS target of an 18 week referral to treatment (RTT) is extremely ambitious in the face of such high demand and this is also the case for the other GIC’s operational in England.”

The clinic continued: “The 30 month wait time displayed on our website is a ‘worst case’ scenario based on the number of clinicians, who are sufficiently competent to provide diagnostic assessments and recommendations for treatment of the service, remaining at the current rate.

“One of our aims is to grow our workforce however there is a national shortage of these specialised clinicians which has meant external recruitment has proven ineffective.

“We are in the process of providing supervised professional development in-house as a form of ‘growing our own’ capable clinicians.

“To this end, we have been successful in recruiting additional psychology and nursing posts to provide this broader range of supportive and diagnostic interventions, which we believe will ultimately result in reducing waiting times.”

An NHS spokesperson added: “‘Demand for gender identity services has risen sharply in recent years as more people feel able to come forward for support and funding for services has been increased to reflect this.

“The NHS continues to work with those who provide gender identity services to reduce their waiting times as quickly as possible.”

Trans activists took to Twitter to condemn the growing waiting times.

Fox Fisher of My Genderation said: “As you can see, waiting times are too long. This can have major effects on the well-being of a trans person.

“For me, the wait was also too long. I ended up taking hormones that weren’t prescribed. I longed to be under the wing of the NHS.

“I ended up spending money I didn’t have, after a really long wait, for a private appointment.

“Is it any surprise that self harm / suicide rates are so high in the UK when waiting times are so long?”

The UK’s health watchdog last year recommended an urgent expansion of London’s gender identity services, warning that patients were being let down by limited capacity.

The Care Quality Commission praised the standard of care available at the clinic, it warned that waiting lists were well in excess of the NHS-wide statutory targets.

The report said: “There were long delays between people being referred to the service and having an assessment and treatment.

“The target timescale was 18 weeks but people were waiting 10-14 months. Action plans had been developed with commissioners but these were still being implemented.”

The CQC inspectors also warned that a number of administrative shortcomings have made things more difficult for trans people accessing the service.

The report added: “Administrative systems were causing problems for people who used the service. There were delays in
letters being sent to people who used the service and to other professionals.

“Appointments were being cancelled, sometimes at the last minute when people were already travelling to the clinic.

“People using the service were not always told why appointments were cancelled and would sometimes have to wait long periods of time for appointments to be re-arranged.”

“The trust must ensure they follow through the action plan agreed with commissioners so that patients are assessed within 18 weeks of being referred to the service. This includes the recruitment of staff.”

Many NHS services relating to gender identity have seen a rapid upswing of people seeking treatment in the past few years as a growing number of trans people seek help.

The only clinic to deal with transgender young people has seen a 500% rise in people seeking treatment, while adult services have seen a similar rise.

Dr John Dean, chair of the National Clinical Reference Group for Gender Identity Services, warned previously that waiting lists must not be allowed to spiral out of control.

He said: “Not treating people is not a neutral act – it will do harm.

“There are a number of studies that report evidence of suicide and self harm among trans people who are unable to access care.

“It is an intensely demeaning and frustrating experience to have to live in a social role in a body that is incompatible with your deepest inner sense of self.”

Parliament’s Women and Equalities Select Committee also sounded the alarm on the issue last year, warning that services with year-long waiting lists were in violation of statutory limits.

However, little has changed about the waiting time backlog despite the repeated warnings.

The surgeon who previously performed the majority of the NHS’s gender reassignment surgery previously warned that backlogs for surgery are ‘spiralling out of control’.

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