There have been discussions on a number of trans groups recently with regard to Gender Identity Clinic (GIC approaches) to top surgery without testosterone for people assigned female at birth. The WPATH international standards of care, which all clinics in the UK work towards, make it clear that hormones are not a prerequisite to surgery. The NHS England interim protocol says that, for patients having chest surgery: “in most circumstances, they will also have commenced treatment with masculinising hormones.” Therefore both the WPATH standards of care, and NHS England protocols clearly allow for circumstances where patients can have top surgery without hormones.
However, at present there is no concrete information available to patients on the issue of top surgery without hormones. Anecdotal reports suggested that some clinics have working practices of assuming patients will take testosterone for a set amount of time before chest surgery, and may be resistant to patients who wish to access chest surgery without testosterone. It also appears that some clinics have more experience with supporting patients in this situation than others. A lack of previous experience does not necessarily mean clinics would not be prepared to consider such referrals in the future, but being the first such patient seen by a clinic may present additional challenges.
Accordingly the seven adult English Gender Identity Clinics were contacted and asked by Freedom of Information request:
- Whether they had any protocols with regard to making referrals for top surgery without testosterone for trans men and non-binary people assigned female at birth
- Whether they had made any such referrals in the last 5 years
- The approximate number of such referrals over the last 5 years
- Whether they would treat a patient with a clear male identity differently to a patient with a clear non-binary identity
No clinics had any written policy on the principle of offering top surgery without testosterone. Most stated that they would take decisions on a case by case basis, in line with the interim NHS policy on gender identity services. Charing Cross referred to a working practice of “complex cases” being discussed at a Multi-Disciplinary Team meeting, at which a treatment plan would be agreed on an individual needs basis. Leeds referred to such cases being discussed at a clinical supervision meeting. No other clinic provided any additional detail on their decision-making process.
Northamptonshire, alone of all the GICs, stated that they believed that there was no funding for surgical referrals for non-binary patients, and therefore no treatment could be provided to someone not identifying as male or female. This was in marked contrast to all other GICs, who answered this question by stating something along the lines that they would take decisions according to the individual needs of the patient. Exeter and Nottingham explicitly confirmed that non-binary patients would not be treated differently to male patients. Given that funding and commissioning is undertaken on a national basis by NHS England, it is unclear why Northamptonshire’s response to this issue was inconsistent to all other GICs, to the evident detriment of some potential patients. This issue requires urgent clarification and addressing for the benefit of non-binary patients currently attending or waiting to attend Northamptonshire GIC.
Several GICs were unable to extract data as to the number of such referrals within the last 5 years without conducting a manual search of records, and thus exceeding FOI time and cost limits. Newcastle, Leeds and Exeter stated that they were not able to extract any data on this issue at all. Nottingham and Northamptonshire stated positively that they had made no such referrals. Sheffield had made one such referral. London had made at least one such referral, but were not able to extract a total number.
Exeter (The Laurels)
The Laurels did not have a written policy regarding offering top surgery without testosterone. They stated that establishing whether they had made any such referrals would require a manual search of files, and as such would take them over the time/cost limits for a Freedom of Information request. With regard to offering top surgery without testosterone to non-binary people, they stated: “No we would not treat them any differently but we would look at their individual clinical need”
There is some footage of John Dean, clinical director at the Laurels, discussing this issue at an NHS symposium, where he seems to be open to allowing non-binary people to proceed with these kinds of treatment on an “informed consent” basis http://www.nhsengland.public-i.tv/core/portal/trans-non-binary – from about 2hours and 40 minutes onwards.
Leeds did not have a written policy, and stated that they would interpret the NHS interim protocol and apply it on an individual basis. For both non-binary people and trans men, such cases would be considered at clinical supervision meetings. They were unable to extract any information as to whether they had made referrals in the past.
London (Charing Cross)
Charing Cross did not have a written policy. However, they stated that: “Patients who present with complex needs are discussed at the Multi-Disciplinary Team meeting whereby the best course of treatment and treatment plan is agreed. This is done on an individual needs basis.” They were unable to extract the number of referrals for top surgery without testosterone they had made in the last 5 years, but stated that they had made at least one. With regard to offering top surgery without testosterone to non-binary people, they stated that all patients would be treated according to individual needs.
They do not have any specific policies, and would be unable to extract information from their files as to whether they have done this in the past. With regard to offering top surgery without testosterone to non-binary people, they stated: “The Trust has no recordable documentation regarding this specific scenario and therefore, within the context of the FOIA, does not hold the information. We can say, however, that there is no ‘blanket’ answer to this as all individuals are treated differently, depending on their circumstances, as we provide person-centred care.”
Northamptonshire does not believe that funding is available to provide surgery for patients who identify as non-binary rather than male: “If not identifying as male then there is no pathway funded”. They were the only clinic to state that they would not offer medical treatment to non-binary people, or to refer to a supposed funding barrier to supporting non-binary patients. (NHS England have now stated that they have told Northamptonshire that this is incorrect)
Northamptonshire stated that they would consider offering top surgery without testosterone in some circumstances, although it would depend on the reasons why the patient was not taking testosterone. They provided the example of an older patient who could not take testosterone for medical reasons, who might still qualify for chest surgery. They have not however referred any patient for top surgery without testosterone in the last 5 years.
Nottingham stated that they do not have any specific protocols – they would follow existing WPATH and UK standards of care guidance. They have not made any such referrals in the last 5 years. When asked whether patients with a clear male identity would be treated any differently from patients with a clear non-binary identity, they stated “no”.
Sheffield stated that they do not have any specific protocols and would make decisions on a case by case basis. They have made a referral for top surgery without testosterone on one occasion in the last 5 years. With regard to offering top surgery without testosterone to non-binary people, they stated: “Each service user is assessed on an individual basis a formulation is agreed and a care plan is proposed to meet the individual service users needs going forward.”