the care pathway at a gender clinic

Note: this document does not necessarily represent current practice.

I have added this document for, at least, historical interest. I understand that the clinic have become far more flexible in their interpretation of policy, since this was issued to me. Seven years is a long time in this field.



(Amended 09.09.2003)

The Standards of Care promulgated by the Harry Benjamin International Gender Dysphoria Association Inc. act as guidelines to clinicians working in the field of gender identity disorders throughout the world, although some clinicians modify these criteria and some even seem to ignore them.

The Gender Identity Clinic at Charing Cross Hospital uses these Standards of Care as firm and ethical guidelines to a great extent.

A typical patient referred to this Clinic by a NHS consultant psychiatrist in their locality might follow the following pathway:

1. An initial consultation with a psychiatrist.

(a) The clinic will accept patients who are taking female hormones without appropriate medical supervision only if they stop. If they refuse to do so at the 1st assessment they are discharged from the clinic.

(b) If the patient has been prescribed hormones by a Psychiatrist and/or Endocrinologist with experience in the management of transsexual patients, the patient will not be required to stop. However the clinic would not endorse the treatment until the patient is sufficiently well known to us that we feel it is appropriate.

2. A second opinion consultation with a different psychiatrist or psychologist.

3. A follow-up appointment with either of the above, who would take over the psychiatric assessment and counselling of the patient. Follow-up appointments might be somewhere between three to six months apart, although we hope to be able to increase the frequency of these in the near future.

4. Some patients might be referred to a monthly group psychotherapy programme.

5. Some patients might be referred for speech therapy.

6. After a suitable period of counselling and probably a further opinion from the alternative clinician initially involved in the assessment process, the patient might be recommended for contra-sex hormone therapy.

7. Either before referral to our clinic or during the process of assessment and counselling described above the patient might make a decision to continue in their transsexual ambitions and to begin to live in the opposite gender role. There are no particular gateway criteria for the patient making this decision, although they would have hopefully been counselled in a relevant manner prior to such a step.

8. A Clinical principal is for reversible social gender reassignment to take place before irreversible biological hormonal or surgical reassignment. Patients are expected to complete a social gender role change prior to having hormones prescribed although it is recognised that this may not always be possible. In addition patients who smoke will be expected to stop completely. No hormone treatment will be authorised by the clinic until three months after the patient has stopped smoking.

9. Married patients are required to have their spouse sign an informed consent describing the effects of hormone treatment on the patient, some of which may impact on the marital relationship.

10. The patient attempts to fulfil a valid “Real Life Experience” living full-time in the chosen gender role. The patient would need to demonstrate acceptance by society in this role and improved social and psychological functioning. For one year of this two-year period the patient would need to demonstrate acceptance and integration in society by being financially independent in employment, or involved in full-time education or training. For some patients of limited psychological or social resources, or in areas of very high unemployment our clinic may accept evidence of significant employment in the voluntary sector.

11. After the managing clinician feels the patient has fulfilled a valid “Real Life Experience” the patient would then have a further consultation with another clinician to obtain a supportive second opinion prior to referral to the clinic surgeon. The clinic surgeon would make his own judgement as to whether to offer the patient surgery, and of course this criteria for acceptance would include whether the physical health of the patient could warrant major surgery.

12. If previously married the patient should present evidence of divorce prior to referral to the surgeon. On some occasions couples decide to stay legally married. In that case a legal affidavit from the wife regarding her understanding of the nature of the surgery and permission for such an operation needs to be obtained.

13. From the surgical aspect all the above is necessary, and after being seen by the surgeon and if suitable and agreeable, the patient’s name is placed on the surgical waiting list. After this it is essential that the patient attend the psychiatric outpatient clinic to maintain regular contact for ongoing assessment until their names reach the top of the waiting list and they are sent for. The waiting list can be approximately eighteen months and this period of ongoing assessment while on the waiting list is of important value to the patient and the supervising clinicians.

14. Mastectomy is done in female-to-male patients who live in Hammersmith catchment area. Female-to-male patients referred to UCLH for phalloplasty and perhaps hysterectomy and ovariectomy.

15. Breast augmentation is offered to some male-to-female patients.

16. It is important to keep outpatient appointments with the surgeon and the psychiatrists after gender reassignment surgery, and obtain advice and management on relevant changes to hormone therapy.

17. Some patients have the need for further psychiatric management and counselling. Such patients may return after surgery for as long as they wish.

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