Gender Reassignment Nhs Number Status

Treatment

Treatment for gender dysphoria aims to help people with the condition live the way they want to, in their preferred gender identity.

What this means will vary from person to person, and is different for children, young people and adults. Your specialist care team will work with you on a treatment plan that's tailored to your needs.

Treatment for children and young people

If your child is under 18 and thought to have gender dysphoria, they'll usually be referred to a specialist child and adolescent Gender Identity Clinic (GIC).

Read about how to find an NHS gender identity clinic.

Staff at these clinics can carry out a detailed assessment of your child, to help them determine what support they need.

Depending on the results of this assessment, the options for children and young people with suspected gender dysphoria can include:

  • family therapy
  • individual child psychotherapy
  • parental support or counselling
  • group work for young people and their parents
  • regular reviews to monitor gender identity development
  • hormone therapy (see below)

Your child’s treatment should be arranged with a multi-disciplinary team (MDT). This is a group of different healthcare professionals working together, which may include specialists such as mental health professionals and paediatric endocrinologists (specialists in hormone conditions in children).

Most treatments offered at this stage are psychological, rather than medical or surgical. This is because the majority of children with suspected gender dysphoria don't have the condition once they reach puberty. Psychological support offers young people and their families a chance to discuss their thoughts and receive support to help them cope with the emotional distress of the condition, without rushing into more drastic treatments.

Hormone therapy

If your child has gender dysphoria and they've reached puberty, they could be treated with gonadotrophin-releasing hormone (GnRH) analogues. These are synthetic (man-made) hormones that suppress the hormones naturally produced by the body.

Some of the changes that take place during puberty are driven by hormones. For example, the hormone testosterone, which is produced by the testes in boys, helps stimulate penis growth.

GnRH analogues suppress the hormones produced by your child’s body. They also suppress puberty and can help delay potentially distressing physical changes caused by their body becoming even more like that of their biological sex, until they're old enough for the treatment options discussed below.

GnRH analogues will only be considered for your child if assessments have found they're experiencing clear distress and have a strong desire to live as their gender identity.

The effects of treatment with GnRH analogues are considered to be fully reversible, so treatment can usually be stopped at any time after a discussion between you, your child and your MDT.

Transition to adult services

Teenagers who are 17 years of age or older may be seen in an adult gender clinic. They are entitled to consent to their own treatment and follow the standard adult protocols.

By this age, doctors can be much more confident in making a diagnosis of gender dysphoria and, if desired, steps can be taken towards more permanent hormone or surgical treatments to alter your child’s body further, to fit with their gender identity.

Treatment for adults

Adults with gender dysphoria should be referred to a specialist adult GIC. As with specialist children and young people GICs, these clinics can offer ongoing assessments, treatments, support and advice, including:

  • mental health support, such as counselling
  • cross-sex hormone treatment (see below)
  • speech and language therapy – to help alter your voice, to sound more typical of your gender identity
  • hair removal treatments, particularly facial hair 
  • peer support groups, to meet other people with gender dysphoria
  • relatives' support groups, for your family

For some people, support and advice from a clinic are all they need to feel comfortable in their gender identity. Others will need more extensive treatment, such as a full transition to the opposite sex. The amount of treatment you have is completely up to you.

Hormone therapy

Hormone therapy for adults means taking the hormones of your preferred gender:

  • a trans man (female to male) will take testosterone (masculinising hormones) 
  • a trans woman (male to female) will take oestrogen (feminising hormones)

The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. These hormones start the process of changing your body into one that is more female or more male, depending on your gender identity. They usually need to be taken indefinitely, even if you have genital reconstructive surgery.

Hormone therapy may be all the treatment you need to enable you to live with your gender dysphoria. The hormones may improve how you feel and mean that you don't need to start living in your preferred gender or have surgery.  

Changes in trans women

If you're a trans woman, changes that you may notice from hormone therapy include:

  • your penis and testicles getting smaller
  • less muscle
  • more fat on your hips
  • your breasts becoming lumpy and increasing in size slightly
  • less facial and body hair

Hormone therapy won't affect the voice of a trans woman. To make the voice higher, trans women will need voice therapy and, rarely, voice modifying surgery.

Changes in trans men

If you're a trans man, changes you may notice from hormone therapy include:

  • more body and facial hair
  • more muscle
  • your clitoris (a small, sensitive part of the female genitals) getting bigger
  • your periods stopping
  • an increased sex drive (libido)

Your voice may also get slightly deeper, but it may not be as deep as other men’s voices.

Risks

There's some uncertainty about the possible risks of long-term masculinising and feminising hormone treatment. You should be made aware of the potential risks and the importance of regular monitoring before treatment begins.

Some of the potential problems most closely associated with hormone therapy include:

Hormone therapy will also make both trans men and trans women less fertile and, eventually, completely infertile. Your specialist should discuss the implications for fertility before starting treatment, and they may talk to you about the option of storing eggs or sperm (known as gamete storage) in case you want to have children in the future. However, this isn't likely to be available on the NHS.

There's no guarantee that fertility will return to normal if hormones are stopped.

Monitoring

While you're taking these hormones, you'll need to have regular check-ups, either at your GIC or your local GP surgery. You'll be assessed, to check for any signs of possible health problems and to find out if the hormone treatment is working.

If you don't think that hormone treatment is working, talk to the healthcare professionals who are treating you. If necessary, you can stop taking the hormones (although some changes are irreversible, such as a deeper voice in trans men and breast growth in trans women).

Alternatively, you may be frustrated with how long hormone therapy takes to produce results, as it will take a few months for some changes to develop. Hormones can't change the shape of your skeleton, such as how wide your shoulders or your hips are. It also can't change your height.

Hormones for gender dysphoria are also available from other sources, such as the internet, and it may be tempting to get them from here instead of through your clinic. However, hormones from other sources may not be licensed and safe. If you decide to use these hormones, let your doctors know so they can monitor you.

Social gender role transition

If you want to have genital reconstructive surgery, you'll usually first need to live in your preferred gender identity full time for at least a year. This is known as "social gender role transition" (previously known as "real life experience" or "RLE") and it will help in confirming whether permanent surgery is the right option.

You can start your social gender role transition as soon as you're ready, after discussing it with your care team, who can offer support throughout the process.

The length of the transition period recommended can vary, but it's usually one to two years. This will allow enough time for you to have a range of experiences in your preferred gender role, such as work, holidays and family events.

For some types of surgery, such as a bilateral mastectomy (removal of both breasts) in trans men, you may not need to complete the entire transition period before having the operation.

Surgery

Once you've completed your social gender role transition and you and your care team feels you're ready, you may decide to have surgery to permanently alter your sex.

The most common options are discussed below, but you can talk to members of your team and the surgeon at your consultation about the full range available.

Trans man surgery

For trans men, surgery may involve:

  • a bilateral mastectomy (removal of both breasts)
  • a hysterectomy (removal of the womb)
  • a salpingo-oophorectomy (removal of the fallopian tubes and ovaries)
  • phalloplasty or metoidioplasty (construction of a penis)
  • scrotoplasty (construction of a scrotum) and testicular implants
  • a penile implant

A phalloplasty uses the existing vaginal tissue and skin taken from the inner forearm or lower abdominal wall to create a penis. A metoidioplasty involves creating a penis from the clitoris, which has been enlarged through hormone therapy.

The aim of this type of surgery is to create a functioning penis, which allows you to pass urine standing up and to retain sexual sensation. You'll usually need to have more than one operation to achieve this.

Trans woman surgery

For trans women, surgery may involve:

  • an orchidectomy (removal of the testes)
  • a penectomy (removal of the penis)
  • vaginoplasty (construction of a vagina)
  • vulvoplasty (construction of the vulva)
  • clitoroplasty (construction of a clitoris with sensation)
  • breast implants
  • facial feminisation surgery (surgery to make your face a more feminine shape)

The vagina is usually created and lined with skin from the penis, with tissue from the scrotum (the sack that holds the testes) used to create the labia. The urethra (urine tube) is shortened and repositioned. In some cases, a piece of bowel may be used during a vaginoplasty if hormone therapy has caused the penis and scrotum to shrink a significant amount.

The aim of this type of surgery is to create a functioning vagina with an acceptable appearance and retained sexual sensation.

Some trans women can't have a full vaginoplasty for medical reasons, or they may not want to have a functioning vagina. In such cases, a cosmetic vulvoplasty and clitoroplasty is an option, as well as removing the testes and penis.

Life after surgery

After surgery, most trans women and men are happy with their new sex and feel comfortable with their gender identity. One review of a number of studies that were carried out over a 20-year period found that 96% of people who had genital reconstructive surgery were satisfied.

Despite high levels of personal satisfaction, people who have had genital reconstructive surgery may face prejudice or discrimination because of their condition. Treatment can sometimes leave people feeling:

  • isolated, if they're not with people who understand what they're going through
  • stressed about or afraid of not being accepted socially
  • discriminated against at work

There are legal safeguards to protect against discrimination (see guidelines for gender dysphoria), but other types of prejudice may be harder to deal with. If you're feeling anxious or depressed since having your treatment, speak to your GP or a healthcare professional at your clinic.

Sexual orientation

Once transition has been completed, it's possible for a trans man or woman to experience a change of sexual orientation. For example, a trans woman who was attracted to women before surgery may be attracted to men after surgery. However, this varies greatly from person to person, and the sexual orientation of many trans people doesn't change.

If you're a trans man or woman going through the process of transition, you may not know what your sexual preference will be until it's complete. However, try not to let this worry you. For many people, the issue of sexual orientation is secondary to the process of transition itself.

Page last reviewed: 12/04/2016
Next review due: 01/04/2019

An increasingly common query on the MPS advice line relates to whether doctors should update and/or change medical records to reflect a patient’s new gender.

‘Transgender’ or ‘gender variant’ are terms given to individuals whose gender identity does not reflect their assigned biological sex. Prevalence of transgender people in the UK was found to be one in 5,000 in a study by the Gender Identity Research and Education Society (GIRES) in 2010.

While many doctors may not have extensive experience with transgender patients, it is an issue which must be treated with upmost care and sensitivity.

It is also important for doctors to understand that failure to address transgender issues appropriately can lead to criminal consequences.

The following questions cover common issues that affect consultations with transgender patients.

Q How can I sensitively raise the issue of gender transition or change with patients?

First, doctors should ensure they are approachable, unbiased and supportive, and have sufficient awareness of transgender issues. Some doctors may feel inexperienced or embarrassed and if this is the case, it may be beneficial for them to complete specific training and/or familiarise themselves with transgender guidance published by the Department of Health.1

While patients will usually raise the issue of gender transition themselves, doctors who consider that it could be an option for one of their patients should raise the issue sensitively. Asking the patient about their preferred name, gender and what term they prefer to use (for example, transgender or gender dysphoria) is likely to go a long way to reassuring them that they have professional support and understanding. It may then become appropriate to offer to refer them to a gender identity clinic.

Q At what point during a transition should I offer to change the gender of a patient’s record?

Under the Gender Recognition Act 2004, transgender people may have their preferred gender recognised by law if they have a Gender Recognition Certificate (GRC). To obtain a GRC, patients must have gender dysphoria, live for two years in their acquired gender and intend to live permanently as such.

Part of living in the acquired gender is likely to involve a change of gender pronoun, plus administrative gender and name changes. Patients going through this transition are entitled to request changes to their existing medical records or have an entirely new medical record created with a new NHS number – and should be supported in this. This request may come at any stage during the gender transition.

Patients may therefore notify practices of their intention to change their gender and those born in the UK do not need to produce any specific documentation. However, if they do produce documentation, it is likely to be a statutory declaration of name and gender change, which are signed on oath and witnessed by a solicitor.

Some patients with a GRC may also choose to have their medical records changed to reflect various details including their new name and gender, without requiring a new record and NHS number.

For requests from patients born outside of the UK, doctors should seek advice from MPS or their medical defence organisation.

Q What should I do if a patient asks me to delete the records from before the change of gender?

If a patient requests administrative changes to their medical records, this should be actioned from the date of the patient’s request. For example, if a patient requests their name and gender to be changed on their records, any reference to their previous name and gender should be removed and their new name and gender should be used going forward.

As doctors are required to keep accurate records, no clinical records created before the change of gender should be changed or deleted. However, patients may request to have factual errors in the records corrected and notes added to reflect their views.

Patients that request a new medical record may understandably be concerned about the confidentiality of their previous records under their old NHS number. Unless an alternative has been discussed and agreed with the patient, previous medical records should be filed with the CCG (or the BSC if in Wales). No reference to the old NHS number should be made on the new record.

Q What should I do if I cannot find a way to change the record (eg, if the IT system doesn’t offer that option)?

In England and Wales, if a patient has requested a new NHS number, doctors should write to the Personal Demographics Service (PDS) to request a new record. NHS Connecting for Health has published guidance to assist with this process.2 Practices which use the PDS’s National Health Applications and Infrastructure Services (NHAIS) interactive software should update the new details electronically, and once a new NHS number has been allocated, old patient records should be filed with the Clinical Commissioning Group (CCG) (or the Business Services Centre (BSC) in Wales) and the patient then re-registered with the new details. In some instances, a patient may request that their old records be filed at the practice. If this is the case, the old NHS number should not be recorded on any new records.

In Scotland, the process is slightly different. Doctors are required to input a patient’s new name and gender details into their practice management computer system. Practitioner services will then contact the patient to confirm that they wish to be issued with a new Community Health Index (CHI) and NHS number. Once agreed, the previous medical record will be transferred electronically to the new record.

If problems are experienced when attempting to change the gender of a patient on a practice’s internal system, doctors should contact their IT provider for further advice.

Q Are there any other changes I should make apart from to the patient record? (eg, informing other doctors)

It is important for doctors to clarify with patients how they would like details relating to their gender change and previous gender represented going forward. Many screening programmes are gender-specific and doctors should therefore discuss the risks and benefits of screening both in biological gender and acquired gender. If screening is requested, doctors should discuss and agree with the patient on an individual recall approach which preserves their dignity and privacy without disclosing their gender history. Documentation of the discussion should be accompanied with the date and the patient’s signature.

Doctors should not discuss a change in a patient’s gender with anyone else within the healthcare team unless they have the patient’s express consent.

Q Are there any approaches or terms that should not be used in consultation with transgender patients?

The General Medical Council (GMC) is very clear that doctors should treat patients fairly and with respect – whatever their lifestyle choices or beliefs – and must not allow their personal views on gender reassignment to affect a patient’s care. GPs should only use medically recognised terms when treating transgender patients and avoid using jargon to keep the consultation clear and polite.

Q What notes should I make on a patient’s sex if they are transitioning?

The GMC (in Good Medical Practice) advises that clinical records must be clear, accurate, legible and contemporaneous.

As doctors may be involved in arranging blood tests and prescribing hormonal medications prior to gender reassignment surgery, it is important to document all care and treatment provided. Whilst it is important to document relevant clinical information, the records should not contain any administrative reference to previous gender or name.

Reassurance should be given to patients that any medical records relating to gender transition are sensitive information and will be treated confidentially.

Q Why would doctors face criminal charges over mis-recording gender?

The Gender Recognition Act 2004 outlines the rights of patients who have legally changed their gender and presented a GRC.

It is an offence under Section 22 of the Act for doctors to disclose information relating to the patient’s former gender to any third party without the explicit consent from the patient. Consent should be obtained prior to sharing information with any other party (including to another person within the practice), even if considered necessary for the provision of care.

An exception might be if disclosure were justified in the public interest (for example, if the patient was displaying violent characteristics as a result of hormone changes).

However, doctors in this situation are advised to seek advice from MPS or their medical defence organisation first.

Rachel Birch is a medicolegal consultant at MPS.

The answer to, ‘What should I do if a patient asks me to delete the records from before the change of gender?’, was updated on 11 November.

References

1 Department of Health. Trans: a practical guide for the NHS. 2008; Gender Identity Research and Education Society (GIRES) for the Department of Health. Guidance for GPs, other clinicians and health professionals on the care of gender variant people. 2008; Department of Health. Gender dysphoria services. Aguide for general practitioners and other healthcare staff. 2012. http://www.nhs.uk/Livewell/Transhealth/Documents/gender-dysphoria-guide-for-gps-and-other-health-care-staff.pdf

2 NHS Connecting for Health. PDS NHAIS Interaction Procedures Guide, Chapter 7.

3 NHS West London Medical Health. Your information leaflet.

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