Gender Identity Service

The following information relates to normal service operating conditions

The Leeds Gender Identity Service offers assessment and support to people aged 17 and above with Gender Dysphoria.

Gender Dysphoria is a condition where a person experiences discomfort or distress because there’s a mismatch between their biological sex and gender identity. It’s sometimes known as gender incongruence. You can find out more about this on the NHS website.

Our team will complete a full assessment of people referred to us which includes looking at mental, social and physical health.

Once the assessment stages have been completed and you have a diagnosis, and you are ready to move forward with treatment, we can start you on our care pathway.

The care pathway includes a prescribing clinic that can start hormone treatment. We can refer individuals to voice and communication therapy, discuss surgical opinions and gender reassignment surgery as appropriate.

You can find out more by expanding the different sections on this web page.

Ben’s gender identity journey – a service user story

Ben Brookes is a service user of the Leeds Gender Identity Service. He has kindly volunteered to share both the good and challenging aspects of his continued journey with his gender transitioning. In this video he speaks both about his own gender identity challenges and about how he experienced the NHS system.

Kerry’s gender identity journey – a service user story

When Kerry Bayley first visited the Gender Identity Service in August 2014, she despaired for her life. When we spoke to her three years later, she was happier than ever. In this short video Kerry bravely shares her journey and talks about the support she received from us. We are most grateful to her for allowing us to do this.

 

Our care pathway is quite complicated so we’ve tried to capture it all simply in this document.

In response to feedback from people accessing the service, we have created a document that helps you understand the topics that may be discussed when you attend the service for a first appointment or an assessment. You can What to expect from your appointments – final v1.

The following is an overview of the current waiting times. Please note it is an estimate guide – there are many factors that could affect this, and it will not be the same for everyone.

This information was updated on Friday, 9 February 2024. We will update the referral information on a three-monthly basis. Please note, we are open to referrals.

Referral acknowledgement

When we receive your referral, this will be reviewed and then added to our waiting list if further information is not required. Both you and your GP will receive an acknowledgement letter once this has been completed. This letter will also include forms to be completed and some further useful information. If you have not received an acknowledgement of your referral within 12 weeks, please contact the service.

Waiting times until first appointment

There are currently 5246 people on our standard waiting list to be seen.

There are currently 166 people on our priority waiting list waiting to be seen.

We are currently booking appointments for people who were referred in approximately April 2019. If you were referred before this date and have not been contacted, please contact the service.

If you have been transferred to us from the Child and Young Person’s Gender Service (GIDS), as you have already had an appointment, you will be placed on the priority waiting list and offered an appointment as soon as we can. If you have been transferred to us from this service and you have not yet been seen for an appointment, we will honour your existing waiting times.

Gender Identity Referrals, Discharges, Attendances and DNAs 

The Trust takes the issue of waiting times very seriously. The Leeds Gender Identity Service waiting times are currently reported to our public Trust Board meetings every two months.

Have your say

Since 23 April 2021, as part of a new Leeds and York Partnership NHS Trust (LYPFT) initiative, the Gender Service has started to collect feedback from people accessing our service via ‘Have Your Say’. This is as new way people accessing the service can give feedback on the appointments they attend.  LYPFT have worked with staff and service users  to co-produce the survey.

“Have Your Say” is aligned to the Friends and Family Test, asking about “experience of care”, so provides anonymous patient feedback specifically for the gender service.

• Have your say feedback summary January – March 2023
• Have Your Say Feedback summary April – June 2023
• Have Your Say Feedback July-September 23

 

Supporting trans, non-binary and gender diverse people on the Leeds Gender Identity Service waiting list and care pathway.

You may have questions. You may have heard conflicting information. You might want to talk with someone with lived experience. Gender outreach workers can offer advice and support from the point of your referral to Leeds Gender Identity Service. We can also provide advice and information to people thinking about referral to the service. Gender outreach workers aim to support people accessing Leeds Gender Identity Service across England.

We were shortlisted in the National Diversity Awards 2022: Community Organisation Award LGBT category. We aim to support inclusion and diversity across the support we provide.

Information and advice line

You can call our information and advice Line on 0800 183 1486. We can help with a range of needs related to your transition, including practical advice on name change, document updates, learning more about the Gender Identity Service and signposting to other organisations and support near you. We can arrange a one-to-one session if you need more time to talk.

One to one sessions

We offer one to one support sessions by online video, by telephone or in person. We can provide practical advice and discuss your individual needs and support available. Feel free to ask questions. Contact us to learn more.

Peer support and social groups

People tell us that groups can be a good way of accessing information and support from peers who share similar lived experience. We offer a variety of groups in-person and online. Groups can provide an opportunity to receive support or just listen to other people’s journeys and life experience. This has helped people on their own personal journey. You can take things at your own pace and involve yourself as much as you like.

The groups have sometimes helped people make new connections, increase confidence and provided a sense of wellbeing. Contact a gender outreach worker to learn more or check out our Facebook page.

We are pleased to work in close partnership with Yorkshire MESMAC, Lancashire LGBT and others to bring peer support to you. This is what some people have said about gender outreach:

“It was really good to speak to someone who really understands what you are going through. She was also very informative and pretty much put me at ease”.

“This has all been very helpful because of where I was and where I am now. I feel more confident in myself. The knowledge of the steps and services has increased”.

“I will attend the groups she organises and hopefully will make new friends along the way. I really cannot recommend this enough, especially if you feel all alone like I did”.

“Extremely helpful and relieved some of my anxieties about progressing. Great information. Feeling secure about myself and my future”.

“It’s always difficult for me to meet new people as I can be very shy and lack confidence but I’m glad I attended our meeting. It was really good to speak to someone who really understands what you are going through”.

“When I attended my first session, I felt I was at a low point. As the sessions progressed, my health and wellbeing has improved”.

“It’s easy to bottle things up when they’re floating around in one’s own head. I feel like I made some progress towards me working things out”.

“A very big thank you for all your help and support 😁”.

Give Us Your Feedback

Have you accessed Gender Outreach Worker support?

Please provide us with helpful feedback about our Information and Advice Line, One to One sessions or Peer Support Groups by completing our surveys:

Information and Advice Line – https://www.smartsurvey.co.uk/s/HW00PD/

One to One Sessions – https://www.smartsurvey.co.uk/s/DTBD67/

Peer Support and Social Groups – https://www.smartsurvey.co.uk/s/S52SPO/

For more information

• Download our gender outreach worker leaflet.
• Download our gender outreach worker poster.
• Find out more on our gender outreach worker Facebook page.

Contact our gender outreach workers

Our gender outreach workers aren’t counsellors but sometimes it just helps to talk.

Contact our gender outreach worker information and advice line on 0800 183 1486 (closed weekends, bank holidays and some holiday seasons).

You can also email genderoutreachworker.lypft@nhs.net with your name, date of birth, address and telephone number. Clients of Leeds Gender Identity Service and LYPFT will need to complete an email permissions form if they have not already done so. Find out more in our Get in Touch section.

What is Yorkshire MESMAC?

Yorkshire MESMAC offer services to various communities across Yorkshire including men who have sex with men, African and other BAME people, people misusing drugs, sex workers and LGBT+ young people and adults.

They have bases in Leeds, Bradford, Rotherham and Hull. They also run LGBT groups across the Yorkshire region. Visit the MESMAC website or call 01132 444 209 to learn more.

What is Lancashire LGBT?

Lancashire LGBT are a registered charity and their aim is to support Lesbian, Gay, Bisexual and/or Trans people to be happier, healthier and well connected. Their core work is aimed at improving the health and wellbeing of LGBT people, reducing health inequalities and providing social and support activities to reduce social isolation.

Lancashire LGBT work to improve services for LGBT people as well as reduce the barriers many LGBT people experience accessing services. They regularly deliver awareness training to professionals and work in partnership with health, education and criminal justice sectors. Visit their website or call 07788 295 521 to learn more.

The TranzWiki Directory

If you’re based outside West Yorkshire and Lancashire, check out the TranzWiki Directory. This is a comprehensive directory of groups campaigning for, supporting or assisting trans and gender non-conforming individuals. For more information, visit their website.

Other helpful information 

Please see the below document complied by the service for further resources and information that might be helpful to you.

Service User Information Leaflet 10.01.23

We get a lot of people making enquiries about transgender issues and we sometimes struggle to answer all of these. Therefore we’ve compiled a list of common questions we get from people like yourself and some responses, we hope they are helpful.

Q. If I’ve got to wait a long time to get a prescription for hormones, should I buy them online?

A. We would recommend that people do not obtain medication privately and wait to see our specialist hormone prescribers. They will discuss with you the risks, side effects and benefits of hormone treatment, and will tailor your treatment to your specific needs. You should have blood tests prior to starting hormones, and also regular monitoring blood tests whilst taking hormones. There are potentially life-threatening risks associated with hormone treatment – be aware of these and how to minimise the risks before you start taking hormones.

Drugs bought online can vary enormously in quality and safety. Our hormone specialists prescribe in accordance with the Endocrine Society Guidelines.

Q. What are Testosterone Intramuscular (IM) Injections?

An intramuscular injection delivers medication directly into the muscle. This allows the medication to be quickly absorbed into the bloodstream.

Once you are established on hormones, it may be appropriate for you to self administer hormones with the support and training of the health care provider (doctor or nurse) who normally undertakes your injection.  Your GP surgery may be able to provide the equipment required.  This guidance is suitable for Enantate or Sustanon but NOT for Nebido.

To self administer hormones, please follow our How to give a Testosterone Intramuscular (IM) Injection guidance.

Q. How do I change my name?

A. If you’re transgender and you want to change your name, you’ll need to change your name by deed poll. This can be done for free – simply search free UK deed poll online.

If you’re non-binary and you want to change your name, you’ll also need to change your name by deed poll. However, bear in mind that UK law currently only recognises two legal genders (male and female).

If you haven’t been issued a Gender Recognition Certificate
If you haven’t been issued with a Gender Recognition Certificate (GRC) then you’ll need to change your name by deed poll. In fact, changing your name could be an important step in proving that you’re living in your new gender, before applying for a GRC.

A deed poll will be enough to change your name in your passport. However, if you want your passport to be in your new gender as well, HM Passport Office will need to see:

• your deed poll, showing that you’ve changed your name to one that’s associated with your new gender
• medical evidence showing that your change of gender is “likely to be permanent”. This can be a letter or report from a medical practitioner (such as your consultant or GP), or a chartered psychologist practising in the field of gender dysphoria.

You don’t need a GRC to have your passport updated to show your new gender, and you don’t need to have had gender reassignment surgery.

Please note that changing your passport (or other records) to be in your new name and gender doesn’t give any legal recognition to your change of gender. It’s merely recognition by those record holders that you’ve adopted a new identity. However it does provide supporting evidence to the Gender Recognition Panel (and other record holders) that you’re living in your new gender.

If you want to change your title you don’t need a deed poll. You’re free to use any social title unless it is a restricted title (Princess, HRH, Sir, Lord etc.) and, assuming the new title is part of a change of gender, you simply need to inform record holders of the new title. The important matter is your change of gender. HM Passport Office for example doesn’t list social titles in passports at all, it isn’t considered to be a legal part of your name.

You can use any name or title unless it is to “obtain good or services by deception”.  It’s important that if you change your title or name, you shouldn’t deceive anyone as to your birth gender in order to gain a financial advantage as this would be considered fraud. Once you’ve been issued a GRC you’re under no such obligation and your birth gender is legally considered to be your new gender.

If you have been issued a Gender Recognition Certificate
If you’ve been issued a full GRC, then this will be sufficient evidence of your change of name (and gender, for passport purposes), and you won’t need a deed poll.

If you’ve been issued an interim GRC, then it’ll likewise still be sufficient evidence of your change of name (and gender, for passport purposes) — you won’t need a deed poll.

If your interim GRC has expired (i.e. after six months) and you haven’t been issued a full GRC because your marriage hasn’t been dissolved, HM Passport Office may still accept this as sufficient evidence of your changed name and new gender, because the important point is that you should be living in your new identity for all purposes, not that you’ve been issued a GRC. However, you should check this first with HM Passport Office.

If you’ve been issued a new birth certificate
If you’ve been issued with a new birth certificate, then this is proof of your name change and new gender, for all purposes — you don’t need a deed poll.

Q. How do I change my name on my passport?

A. Once you have a diagnosis of gender dysphoria, we can provide you with a letter to use to change your gender on your passport (see also ‘How do I change my name?)

 

Q. How do I get a gender recognition certificate?

A. The trans charity GIRES has published a guide on this.

 

Q. What services do you provide on the NHS?

A. Hormone treatment, facial hair removal, genital hair removal prior to surgery, voice coaching, speech and language therapy and psychological support.

Q. What services do you NOT provide on the NHS?

A. Breast implants, breast augmentation, voice/laryngeal surgery, facial feminisation surgery.

Q. Can I claim back my travel expenses?

A. You can claim help with the cost of travel if you are on a low income and have made an additional journey to the Leeds Gender Clinic. We can help you with this when you attend for your appointment – ask your Lead Professional.

Q. Who can refer me to the Gender Clinic?

A. Your GP can refer you. There is a GP referral form for them to complete in the “How to refer to the Leeds Gender Identity Service – Information for Professionals” section of this page.

Q. What can I do whilst I wait to be seen?

A. Lots! You can start your social gender transition at any time and you do not need a diagnosis of gender dysphoria to do this. Some people call this ‘coming out’. Your Lead Professional and our support workers can offer advice on this.

There is also a lot of online information about how to do this. Changing your name and pronouns is one way to start. For other people, it’s about getting the right clothes. It is important you do this at your own pace and in a way that you find comfortable. Check out the section called ‘Other Sources of Help’.

Q. Do I have to dress a certain way?

A. Dress how you feel comfortable. Your appearance will not have a bearing on the outcome of your assessments. Wear whatever you feel comfortable wearing. However, it is an opportunity to dress as your preferred gender. We have changing areas onsite if you wish to arrive early and get changed in time for your appointments.

Q. What do I do if I can’t get to my appointment?

A. It’s very important you let us know as soon as possible by calling us on 0113 8556346 or by emailing gid.lypft@nhs.net

If you are more than 15 minutes late for your appointment you will not be seen. This is because your appointments take one hour, and each patient is booked on the hour, every hour. It is not safe to do an assessment in less than one hour, especially given the life-changing treatments on the care pathway.

Q. I have mental health problems. Can I still be seen and treated by the Gender Identity Clinic?

A. Yes. We do require that you are engaging with treatment and that you have been stable for a reasonable period of time. This is again to keep you safe, and ensure that you are able to understand and consent to the life-changing treatments on the care pathway. We have psychologists working within the team who are specialists in gender dysphoria and who are experienced in treating transgender people.

Q. How long does it take to transition?

A. Your physical transition can start with hormone therapy but it doesn’t always. Hormone therapy is not a requirement for chest surgery, for example. Hormone therapy can take up to two years (sometimes longer) to reach its maximum effect. Some surgeons prefer that you have reached this stage but the guidelines for having lower surgery are that you have been on monitored hormone treatment for at least 12 months. Given current NHS waiting times, it is likely that your transition will take 4-5 years.

Q. What can I expect at my first visit to the clinic?

A. Your screening appointment will involve a lot of detailed questions about your life story, particularly relating to your gender. This will involve some personal questions about your body, your sexuality, and your feelings. You will also be asked about your mental and physical health, and your medication. It is important we have a full picture of you as a person in order to make tailored recommendations for your ongoing treatment. All the information you give is confidential.

Questions and answers last updated: 26 February 2019

Frequently asked questions

I cannot get blood tests done during the Covid-19 pandemic, can I still get my hormones?

In some cases, it may not be possible to continue to prescribe safely if you are unable to have routine monitoring blood tests done, particularly if you have had abnormal results previously. Following up abnormal blood tests may be considered urgent, rather than routine, and you should be guided by your GP.  If your GP is concerned they can email us at gid.lypft@nhs.net.

Physical harm is unlikely to occur if your hormone therapy is temporarily reduced or stopped. There may be a slight return of characteristics of birth assigned sex but these should revert when hormone therapy resumes. For people who have had genital reconstructive surgery, physical health complications are unlikely unless you are off hormone therapy for more than two years.

 I am having difficulty arranging an appointment at my GP surgery for my Sustanon / Testosterone Enantate injection, what should I do?

You can ask your GP to consider switching you over to testosterone gel. There is prescribing information to help with this in the Prescribing section on our website.

 I cannot arrange an appointment for my Nebido injection, what should I do?

As Nebido is a long-acting testosterone injection it is unlikely that testosterone levels will drop too low if an injection is delayed by a few weeks. It is not advisable for injections to be given too early.  Again, you can ask your GP to switch you over to testosterone gel.

I cannot arrange an appointment for my blocker injection (e.g Leuprorelin), what should I do?

Blocker injections are long-lasting so even if they have to be delayed your hormone levels will stay suppressed for quite some time.  The longer you have been on the injections, the longer the effect will last.  Try to arrange an injection for as soon as you can after it was due.

Due to the hormone shortages I cannot get my usual prescription, what should I do?

Firstly, you can ask your pharmacist about alternative hormone products.  Your GP may also be able to prescribe generically i.e. with the hormone name, rather than the brand name, then the pharmacist may be able to access a different brand of the same type of drug.  In most cases, the type and dose of your hormones are more important than the brand.

We’re a diverse bunch at the Leeds Gender Identity Service. Our team consists of:

Psychology -Consultant Clinical Psychologists, Clinical Psychologists who assess for a gender dysphoria/incongruence and readiness to progress onto the care pathway. They also provide opinions for surgery. Their team also provide psychology if this is recommended from within the service.

Psychiatry- Consultant Psychiatrists/Psychiatrists who assess for the gender dysphoria/incongruence and the readiness to progress onto the care pathway. They also provide opinions for surgery. Some of our Consultant Psychiatrists can also recommend hormone prescriptions to your GP.

Consultant Endocrinologists (doctors that specialise in hormone treatment) providing hormone assessment/specialist advice and recommendation for hormone prescriptions.

Doctors with Special interest in Endocrinology, who also provide hormone assessment and recommendation/advice for hormone prescriptions.

Our pharmacist works alongside the prescribing clinic in a non-medical prescribing role, seeing individuals in the prescribing clinic for the recommendation of hormone prescriptions.

Clinical nurses who see people through the assessment process and act in the role as a Named Professional providing support and six-monthly appointments to those people accessing the service care pathway. Some of our clinical nurses can also recommend hormone prescriptions.

Speech and Language Therapists who provide group and individual therapy sessions with the goal of being a voice that reflects who you are.

Gender Outreach Workers who provide peer support and advice primarily to those people waiting to access the service via one-to-one appointments and groups either online or in person.

We accept referrals from your GP or NHS healthcare professional. We also accept self-referrals to the service. Referrals can be made using the referral form found on the link below. Please note that we only accept referrals for people aged 17 and above. If you are self-referring we would ask that you discuss this referral with your GP as if they are not in agreement with long-term prescribing and monitoring this may affect future care.

Download a copy of our Gender Identity Service referral form.

The completed referral forms should be emailed to gid.lypft@nhs.net.

If you are emailing from outside of the NHS, please note that we cannot guarantee the security of any communication sent to us via email, and that communication via email is entirely at your own risk. There is a postal address on the referral form should you prefer to send by post due to this reason.

Welcome to the Healthcare Professional Hormone Support Hub.

We understand that there are challenges for primary care health professionals in prescribing hormones for transgender, non-binary and gender diverse people.  The aim of the content of the website is to support and guide health professionals through common queries and presentations in this group.  We want to work in collaboration with GPs and are committed to supporting GPs develop expertise and confidence in hormone prescribing.

 

Primary care responsibilities: GMC guidance; Trans healthcare – ethical topic – GMC (gmc-uk.org)

The GMC website has some great information on how to make your practice more inclusive and considerations of the health inequalities and challenges faced by gender diverse people.  They say:

“GPs must co-operate with GICs (Gender Identity Clinics) and gender specialists in the same way as they would other specialists, collaborating with them to provide effective and timely treatment for trans and non-binary people. This includes:

–             Prescribing medicines recommended by a gender specialist for the treatment of gender dysphoria;

–             Following recommendations for safety and treatment monitoring

–             Making referrals to NHS services that have been recommended by a specialist.” With regard to the prescribing of off licence medication.

–             Most of the medications used for the treatment of gender dysphoria are not licensed for this specific indication, although GPs will be familiar with their use in primary care for other purposes.”

 

Primary care responsibilities: Information from the BMA; https://www.bma.org.uk/advice-and-support/gp-practices/gp-service-provision/managing-patients-with-gender-dysphoria

“Collaboration with gender specialists

The GMC advice states that GPs must co-operate with gender identity clinics and specialists to provide effective and timely treatment for trans and non-binary people.

NHS England’s guidance states that when clinical responsibility for prescribing is transferred to general practice, it is important that the GP is confident to prescribe the necessary medicines.

In our view, this advice reaffirms that GPs should approach shared care and collaboration with gender identity specialists in the same way as they would any other specialist.”

 

Gender Identity Toolkit for General Practice;  https://igpm.org.uk/wp-content/uploads/2022/03/Gender-Identity-Toolkit-for-General-Practice.pdf

The above toolkit has fantastic information on terms, treatment pathways and the administrative processing that might be required from a General Practice perspective.

 

Leeds Gender Identity Service Hormone Clinic

At the Leeds Gender Identity Service, we aim to review our patients in the hormone clinic after they have had a diagnosis made of Gender Dysphoria.  The waiting list for the hormone clinic is lengthy.  Patients are seen by one of our hormone clinicians, counselled and provide full written consent to hormone treatment.  Here is a copy of our detailed consent forms which also has information regarding what to expect from cross sex hormones, common side-effects and complications:

–             Informed Consent Estradiol

–             Informed Consent Testosterone

In line with the NHS England service specifications (Appendix J) we are required to provide the GP with patient-specific written ‘prescribing guidance’ and advice around hormone care.  We are not commissioned to provide or arrange any investigations.  We will offer advice on dose titration, administration, initiation, duration of treatment, monitoring, advice on the interpretation of laboratory results and likely treatment effects. To support this process, we review our patients in clinic until they are well established on hormones, but require GP’s to prescribe, request blood testing and send on the results to us, whilst the patient is under our care.

https://www.engage.england.nhs.uk/survey/gender-identity-services-for-adults/user_uploads/specialised-gender-dysphoria-service-specifications.pdf

We will see patients, stabilise their hormone regimen then discharge the patient back to primary care with further information regarding monitoring and ongoing care.

The GMC guidance:

“Once the patient has been discharged by a GIC or gender specialist, the prescribing and monitoring of hormone therapy can be carried out in primary care without specialist input. From the patient’s perspective, management in primary care is far easier, and there is no specific expertise necessary to prescribe for and monitor patients on hormone therapy.”

The following guidelines are here to support you with making decisions around hormones:

• Shared care Interim Guidance
• Information about hormone regimens
• Initiating Feminising Hormone Treatment
• Initiating Masculinising Hormone Treatment
• Information about treatment with Leuprorelin for transwomen
• Self Injection Testosterone

Hormones are off license use and unlikely to be licensed for this indication in the future. Prescribing off license medication GMC Guidance;

“Most of the medications used for the treatment of gender dysphoria are not licensed for this specific indication, although GPs will be familiar with their use in primary care for other purposes.”

Close liaison with the specialist clinical team and the GP is essential, and we thank you for your support with this.

Fertility Preservation / Gamete Storage:

We would advise that patients should be offered the choice of referral to a provider to store gametes before they engage in any self-prescribed, private or NHS prescribed hormone treatment.  This referral can be made directly by the GP.  Further information can be found here at the Human Fertilisation and Embryology Authority: https://www.hfea.gov.uk/treatments/fertility-preservation/information-for-trans-and-non-binary-people-seeking-fertility-treatment/

Other Commonly Encountered Hormone Dilemmas:

GPs are faced with difficult clinical decisions when trans people request a prescription of hormone treatment outside of NHS specialist pathways or while facing a long wait for assessment within an NHS specialist pathway.  The main challenges arise when there is no documented specialist NHS assessment and gender dysphoria related diagnosis.   We have a number of documents to help support you with these difficult clinical decisions:

–             Info Re Bridging Prescriptions Leeds GIS

–             Info Re Prescribing on the Request of a Private Provider Leeds GIS

–             Info Re Self Prescribing Leeds GIS

–             Info Re Progesterone Leeds GIS

–            Info Re Restarting hormones Leeds GIS

– An approach for primary care when encountering a new patient with Gender Dysphoria v5

 

Hormone Equivalent Doses and Shortages:

We are told that there is not a shortage of Sustanon at present but we do seem to have multiple parties contacting us with difficulty obtaining this.  We would recommend a switch to Testosterone Enanthate at the same dose and frequency that you were receiving Sustanon.

–             Switching between testosterone

–             Conversion table for Estradiol

Troubleshooting and FAQ for hormones:

Vaginal Atrophy: 

Testosterone changes the vaginal epithelium in a similar way to post-menopausal changes in cis gender women.  The proliferation of the epithelial cells slows and becomes thinner and more fragile causing bleeding, discomfort, pain with intercourse, vaginal discharge or recurrent UTIs.  As a result, vaginal examinations can be distressing not just due to dysphoria but also due to discomfort and pain.  Consideration can be given to using vaginal estrogens to treat the atrophy.

The recommendations are not limited to the below.  If atrophy is suspected and the individual is unable to tolerate a full examination, we would suggest treatment for 4-6 weeks before another attempt at vaginal examination is made.  In some severe cases it may necessitate more frequent and prolonged application of topical Estradiol than in post-menopausal females.

• Vagifem/Vagirux: 10mcg tablet daily for 2 weeks then 1 tablet twice per week (if still symptomatic at 2 weeks it would be appropriate to continue with application for 4-6 weeks before titrating down to 1 tablet twice per week).
• Ovestin cream 0.1%: 1 application per day for 2-4 weeks then reduction based on symptoms down to a maintenance dose of one application twice per week.

Occasionally a combination of a vaginal preparation and a vulval preparation are also required along with vaginal moisturizers such as coconut oil.  We would also recommend lubricants for penetrative intercourse.

If vaginal bleeding is a problem, please see our separate advice above on: ‘How to Approach Vaginal Bleeding for Transmen and Non-Binary Individuals on Testosterone Treatment’

 

–             How to Approach Vaginal Bleeding in Transmen on Testosterone Treatment

Topical testosterone (Testogel): risk of harm to children following accidental exposure.

–             Requests for HSBO (Hysterectomy and salpingo oophorectomy – historically transmen receiving testosterone were advised to have this surgery.   There is currently no evidence for an increased risk of endometrial or ovarian cancer with testosterone treatment, but any symptoms which could suggest a problem with these organs, particularly vaginal bleeding, pelvic pain or abdominal bloating should be investigated further. The WPATH (World Professional Association for Transgender Health) recommend against routine oophorectomy or hysterectomy solely for the purpose of preventing ovarian or uterine cancer for transgender and gender diverse people undergoing testosterone treatment and who have an otherwise average risk of malignancy.

 

Considerations of other aspects of long term care for Transgender Non-binary individuals:

Feminising Treatment:

• Blood tests: Estradiol, SHBG, testosterone, U&E’s, LFT’s, Lipid profile including Triglycerides, and Prolactin should be done six monthly for a year and then annually.  Estradiol levels are ideally between 350-750 pmol/l if aged < 40; 300-600 pmol/l if aged 40-50; 200-400 pmol/l if aged > 50 or younger with significant CV risk factors particularly smoking or high BMI (> 40 kg/m²).
• Hormones: If starting Estradiol over the age of 40 we would recommend conventional treatment for 10 years then reducing dosing down.  If started under the age of 40 we would recommend a dose reduction between 40-50 with an aim to tailing off and potentially stopping treatment between 60 and 70.  However, we would recommend an individualised approach should be employed after discussion with the individual regarding the risks and benefits.  If lower gender affirming surgery is not performed, we would recommend continuing a hormone blocker.
• Mammograms: transwomen become eligible when they turn 50 for mammography on the breast screening programme.  If she continues to take estradiol after the age of 70, she should continue to attend the breast screening programme.  In addition, she should remain ‘breast aware’.
• Prostate: If the patient develops any urological symptoms, consideration should also be given to the fact that she still has a prostate gland in situ.
• Osteoporosis: There is no evidence for routine DEXA scanning in trans-feminine individuals. Trans-feminine individuals may have lower bone density than matched cis-males, but they are at no greater risk of osteoporosis than matched cis-females, provided that they have not had androgen blockade or gonadectomy without estradiol treatment. We would encourage an individualised approach to DEXA scanning based on the presence of other risk factors such as low BMI, corticosteroid use, alcohol excess or medical conditions associated with reduced BMD in line with national guidelines.

 

Masculinising Treatment:

• Blood tests: Testosterone, Estradiol, LFTs, FBC, Lipid profile including Triglycerides, to be done six monthly for a year and then annually.  Testosterone levels should be in the lower third of the reference range immediately before Sustanon or Nebido injections (trough levels), middle third of the reference range on Nebido (for samples taken mid-way between injections) and testosterone gel (taken 4 to 10 hours after application).  The lower third of the male reference range is usually around 8-12 nmol/L and the middle third of the male reference range is usually around 15-22 nmol/L but does depend on the normal range for the local assay as these vary.
• Hormones: There is no recommendation of an upper age limit to stop masculinising treatment and we would recommend a pragmatic and individualised approach after an analysis of the risks and benefits.
• Uterus and Ovaries: There is currently no evidence for an increased risk of endometrial or ovarian cancer with testosterone treatment, but any symptoms which could suggest a problem with these organs, particularly vaginal bleeding, pelvic pain or abdominal bloating should be investigated further.
• Cervical Screening: Attendance for routine cervical screening tests should remain the same as per the NHS Cervical Screening Programme recommendations, however the invitation process and informing of results are outside the NHS Cervical Screening Programme process and should now be organised within your GP practice.  If you have not already done so and your patient is registered as male, with a new NHS number, you should liaise directly with the screening lead for cervical screening who will advise on further action.
• There are challenges regarding recalls for cervical screening and we know that there is poor uptake of cervical screening in this group.  Consideration should be made of what may make the individual more comfortable and less concerned about this procedure including the use of vaginal Estradiol.  There is further information on our website for health care professionals regarding cervical screening.
• Testosterone treatment is not contraceptive and is a teratogen.  Contraceptive needs should be considered if required.
• Osteoporosis: There is no evidence for routine DEXA scanning in trans-masculine & non binary individuals and typically they show no change or an increase in BMD as a result of testosterone hormone treatment. We would encourage an individualised approach to DEXA scanning based on the presence of other risk factors such as low BMI, corticosteroid use, alcohol excess or medical conditions associated with reduced BMD in line with national guidelines.

 

Advice and Guidance Service:

We understand that GPs may feel that they have limited experience with cross sex hormones and feel uncertain about prescribing them.   There are long waits for our hormone appointments, and we aim to offer support, advice and guidance for GPs who are looking after patients who have been discharged from the hormone clinic.

If you have a clinical query that is not answered by the above information, we are happy to respond to these on receipt of a written email or letter from yourselves to our inbox at gid.lypft@nhs.net .  In order for us to respond to this in a safe and timely fashion, please include an update on the problem the person is experiencing with their hormones, your query, an up-to-date medical summary including patient details, what hormones they are receiving, medications, allergies, their most recent blood tests (and how this was times in relation to their hormones) as well as a BMI and blood pressure reading.  We cannot arrange to review these patients in clinic, but we can offer further advice and support.

If you would like to organise further training for your practice to improve your knowledge and confidence with hormone prescribing, please contact Leeds GIS and we will do our best to facilitate this.

Screening:

–  How to Approach Cervical Screening for TGNB individuals – Info For Health Professionals

–  Screening information for transgender people: https://www.gov.uk/government/publications/nhs-population-screening-information-for-transgender-people/nhs-population-screening-information-for-trans-people

–             Cancer research UK screening information: https://www.cancerresearchuk.org/about-cancer/cancer-symptoms/spot-cancer-early/screening/trans-and-non-binary-cancer-screening

–             Live through this Cancer Charity supporting and advocating for LGBTIQ+ people affected by cancer: cervical screening campaign: https://livethroughthis.co.uk/removethedoubt/

–             Endometrial Screening: There are no clear guidelines for management of abnormal uterine bleeding or endometrial surveillance in this population.  There is a theoretical concern of endometrial pathology based on data of increased risk with increased serum androgens in cis post-menopausal women.  Current data from a trans male population suggests trans men are at no increased risk of endometrial cancer.  Longer term studies are lacking.  The WPATH (World Professional Association for Transgender Health) recommend health care professionals apply the same respective local screening guidelines (including the recommendation not to screen) developed for cisgender women at average and elevated risk for developing ovarian or endometrial cancer in their care of transgender and gender diverse people who have the same risks.  Some UK services undertake a 2 yearly transvaginal ultrasound to assess endometrial thickness, but the Leeds service does not recommend routine screening only prompt investigation if concern.

Sexual health and Contraception:

–             FSRH: Contraceptive Choices and Sexual Health for Transgender and Non-Binary People: https://www.fsrh.org/documents/fsrh-ceu-statement-contraceptive-choices-and-sexual-health-for/

General health:

–             Cancer in Trans and Non-Binary Individuals – UK Cancer and Transition Service: https://www.wearetransplus.co.uk/uk-cancer-and-transition-service-for-professionals/

–             Macmillan – https://www.macmillan.org.uk/cancer-information-and-support/impacts-of-cancer/transgender

–             Bone Health – Consider BMD/DXA if additional osteoporosis risk factors

Thank you for your support and continuing to work with us.

If you have any additional feedback or would like to see some further information, please contact the hormone team via gid.lypft@nhs.net

When you and your clinical team agree that you are ready for surgery, the Gender Dysphoria National Referral Support Service (GDNRSS) will process your referral to your chosen surgical provider. The GDNRSS team have Clinical Nurse Advisors who can provide information on the following:

• Surgical techniques used by various providers and surgeon teams
• Typical recovery times following surgery
• Potential post-surgical complications
• Surgical eligibility criteria, where providers have these in place
• Waiting times for surgical providers
• Supporting patients to change provider

They can provide virtual consultations and also have a Single Point of Access support line that you can call for information about your referral, the status of your chosen provider and practical information such as travel and parking, who can accompany you, what to take with you and where to report to when you get there. For more information about this service, download this leaflet. 

You can contact the Gender Dysphoria National Referral Support Service by calling 01522 857799 or by emailing agem.gdnrss@nhs.net.

The Leeds Gender Identity Clinic has students and health care professionals who attend to gain experience and knowledge about the service. Unfortunately we are limited as to how many health care professionals can access the service due to capacity and time available.

We have an established relationship with a number of universities in Leeds and York and have allocated placements each year for occupational therapy students, nursing students and medical students.

If you are part of a healthcare professional body and would like the opportunity to spend a day with the service we would ask that your course tutor or professional manager write to our service outlining the reasons for your visit and the benefits you will gain.  We will try to accommodate day visits where appropriate however this may not always be possible.

If you are interested please email gid.lypft@nhs.net

The Leeds Gender Identity Service is based at The Newsam Centre and can be contacted by Calling 0113 8556346.

This number is answered between 10am and 2pm Monday to Friday. Unfortunately we are unable to respond to voicemail messages.

We do also have our email address gid.lypft@nhs.net.

Please do not send personal information through this email address without completing a permission form, which can be attached to your email. If you choose to not complete this form, you need to be aware that, if your email address is outside of the NHS that we cannot guarantee the security of any communication sent to us via email, and that communication via email is entirely at your own risk.

Follow us

You can join our Facebook communities to find out more about what our Gender Outreach workers are doing in your area:

• www.facebook.com/LeedsGenderOutreachWorkers
• www.facebook.com/GenderOutreachWorker
• www.facebook.com/YorkshireMESMAC/
• www.facebook.com/lancashirelgbt/

If you come to us for a face-to-face appointment, you might be wondering where we are and how you get to us.

This video will help you find us and familiarise yourself with our location and the area.