Gender Incongruence is classified under ICD11 as a marked and persistent incongruence between an individual’s experienced gender and their assigned sex.
The Chalmers Gender Identity Clinic (GIC) offers an assessment and treatment service for people with gender incongruence. This can include referrals for fertility preservation, facial hair removal, speech and language therapy, hormone advice and referrals for gender affirming surgery.
The GIC team is multidisciplinary team and includes psychiatrists, psychologists, sexual health doctors, endocrinologists, GPs, gender nurses, sexual health nurses, clinical support workers and speech and language therapists.
The team offers clinical advice to other professionals in Lothian either prior to referral, if someone is on the waiting list, or if an issue crops up with a patient already known to the service. Please use SCI Gateway e-advice option for this. The service aims to reply to queries within 5 working days.
Mental health and other support
People who are trans have higher rates of anxiety, depression, self-harm and suicide. They are also more likely to be neurodiverse (ADHD and ASD). It is important that trans people are referred to appropriate mental health services and support services when needed. Please see Resources and Links for further detail.
The Chalmer’s GIC webpage has useful information for patients about what to expect from the service, including a short video about the clinic. There is also information about waiting times and links to organisations that offer support: Gender Identity Clinic | Lothian Sexual Health
Who to refer:
The GIC team is happy to see patients who are aged 17 and over who are considering or want to transition, or those who have already transitioned. Referrals are accepted for someone who is 16 but they will not be seen before they reach their 17th birthday.
If someone is questioning their gender identity, we would advise that they be referred for counselling. LGBT health and wellbeing provide an Edinburgh counselling service: please see LGBT Counselling in Scotland. If after counselling, the patient still wishes to transition then please refer.
For patients under 18 years old the service is not able to prescribe any gender affirming hormones following the CMO’s letter relating to the Cass review. However, those patients can still be seen for assessment and to provide other treatments.
Transfer of Care.
Chalmers GIC will accept transfers of care for new residents of its catchment area who have been treated (or are on the waiting list) of other NHS UK gender clinics. If the GIC is in Scotland the patient should contact their previous clinic and ask the GIC to transfer their care to Chalmers.
Outwith Scotland patients can ask their GIC to transfer care or Chalmers will accept a GP referral along with details of their previous assessment and most recent clinic letters. If someone is on the waiting list at another NHS UK gender clinic, the original date of referral is taken into account when added to the Lothian waiting list.
The GIC is unable to prioritise patients who have accessed private treatment and recommends that they are advised to continue their engagement with their existing provider until the GIC has completed its assessment.
Who not to refer:
Young people under the age of 16: please refer to Gender Service for Young People at Sandyford
How to refer:
Please refer via SCI Gateway to Chalmers Sexual Health Centre à Gender Identity.
There is an e-advice option too.
Changing Names, Gender, Titles and CHI
It is good practice to facilitate people changing their details at a time of their choosing and please see details on how to change CHI numbers.
CHI contains a binary gender marker (the penultimate digit: even for female, odd for male). For non-binary people this is unsatisfactory, and they may not be aware of this. The system is scheduled to be updated but, in the meantime, people may only select male or female as their gender in connection with CHI. If the practice changes someone’s gender on its clinical IT system, Practitioner Services will write to the person to confirm how their details should be updated and issue a new CHI if required.
Practice systems will accept the gender-neutral title ‘Mx’. Please remember to ask the person what title they would prefer and check that all paperwork including prescriptions is updated. People may be upset by being accidentally misgendered.
Support.
Mental health and other support is key: please see Resources and Links for more information.
Screening
If someone has changed their CHI after 14th June 2015 they will be automatically called for screening (cervical, breast, AAA). It is not always possible to identify transgender people who have moved to Scotland or transitioned before 14th June 2015.
Further information on screening for trans people in Scotland can be found at Transgender screening in Scotland (nhsinform.scot).
Confidentiality
Always gain consent when disclosing someone’s gender history, even to other clinicians. In some cases, not doing so can be a criminal offence. Please also be aware of gender identity information being pulled forward automatically through READ codes.
Gender history should not be included in an insurance report, and the recommendation is that patients be encouraged to view such reports before submission.
Contraceptive Choices
Testosterone is not contraceptive and is teratogenic. Therefore transmen and non-binary people using testosterone should be using effective contraception if they are sexually active. Apart from combined hormonal contraception, all methods of hormonal and non-hormonal contraception can be used whilst someone is taking testosterone.
Please see the FSRH Clinical effectiveness Unit guidelines for more detail: Contraceptive Choices and Sexual Health for Transgender.pdf
Prescribing Arrangements.
It has now been recognised that there has been a rapid increase in demand for clinical services in this area and Lothian GPs have received guidance on safe approaches from the Lothian GP Sub-Committee: can only be accessed by NHS staff and is available on the intranet.
A prescribing Shared Care Agreement is being finalised in Lothian and should be available soon: practices will be informed when this is available.
Medication Shortages
There are occasional shortages of hormone treatments. Any shortages and recommended substitutions are posted on the GIC section of Lothian sexual health website: Gender Identity Clinic | Lothian Sexual Health.
Topical testosterone safety warning.
Premature puberty and genital enlargement have been reported in children who were in close physical contact with an adult using topical testosterone and who were repeatedly accidentally exposed to this medicine. To reduce these risks, advise patients to wash their hands after application of topical testosterone, cover the application site with clothing once the product has dried, and wash the application site before physical contact with another adult or child.
Further information can be found at: Jan-2023-DSU-PDF.pdf (publishing.service.gov.uk)
Cyproterone acetate and risk of meningioma
Some patients prefer cyproterone acetate as an antiandrogen and some private providers may recommend using it. There is a dose-dependent association with cyproterone acetate and meningioma. The risk increases with increasing cumulative dose. It is contraindicated in patients with a meningioma or a history of meningioma. If someone treated with cyproterone acetate develops a meningioma it must be permanently stopped.
GPs are not be expected to undertake any monitoring.
Further information can be found here:
Cyproterone acetate: new advice to minimise risk of meningioma – GOV.UK (www.gov.uk)
Frequently Asked Questions:
The service is always happy to provide advice and can be contacted via Chalmers Gender Identity SCI Gateway advice.
Will the NHS provide fertility preservation for patients who have obtained treatment privately?
Patients are entitled to NHS fertility preservation once they have been assessed by the clinic as suitable for hormone treatment. The specialist service can make a referral after discussion with patients. If people want to preserve their fertility before being seen at the gender clinic they need to do it privately.
It is helpful to give patients link to information about fertility preservation for trans people: Information for trans and non-binary people seeking fertility treatment | HFEA
My patient is self-prescribing; how can I support them?
It is well-established that at their first gender clinic visit, a significant number of transgender people will already be taking hormones bought online or from someone else. In the UK surveys suggest that the main reason for doing so is the long wait for assessment and treatment. The dangers of DIY hormones range from minor to serious. Even buying hormones from an online pharmacy is risky.
We recommend that you explore your patients understanding of hormone use and the safety issues round them.
Should I prescribe progesterone as requested by my patient who is a trans woman?
Chalmers GIC follows the guidance from NHS National services Scotland ‘Endocrine and fertility preservation guidance’. This states that progesterone is not recommended for transwomen. There is only anecdotal evidence and a few opinion pieces recommending it. There are risks including possible increased risk of breast cancer and cardiovascular disease and side effects including mood changes.
How do I stop periods in transmen and non-binary people before they start testosterone?
Often transmen are distressed by their periods and may require medical intervention to reduce or stop menstruation whilst they are awaiting their initial assessment. The investigation and management of abnormal uterine bleeding in transmen not on testosterone is the same as for cis females. However, transmen may find pelvic examinations and transvaginal ultrasound scans distressing and clinicians should be sensitive to this. Although combined hormonal contraception can be effective at managing bleeding problems, some transmen may not wish to use this method as it contains oestrogen.
The progesterone only pill is often used (desogestrel 75 micrograms once daily) but there
is a risk of unpredictable bleeding. Depot or implant progestogens (usual contraceptive doses) and the IUS are also options, but bleeding may take 3 – 6 months to settle down.
Once someone is established on testosterone, periods should stop, usually within 6 -12 months.
NHS Lothian gender-specific reference ranges for blood tests.
The Cass Review
Gender Identity Clinic | Lothian Sexual Health
Number 6 –is a support service for people who have an ASD diagnosis. They provide individual and group support and also run a trans and non-binary support group. https://www.number6.org.uk
LGBT health and wellbeing – provide social support, individual support, and a counselling service for trans people. https://www.lgbthealth.org.uk
Beyond Gender – a group for 16 – 25-year-olds trans and non-binary people. It runs every Tuesday 6 – 8 pm in central Edinburgh and is run by LGBT youth. https://www.lgbtyouth.org.uk
Glitter Cannons – a LGBTQ+ youth group run by West Lothian Council based in Boghall, Bathgate. It provides a safe space for 12 – 25 years old and runs on a Thursday 6.30 – 8.30. Instagram page: Glitter Cannons (@wlglittercannons)
Support for relatives:
There are no in-person support services locally for family members but there is some online/ phone support:
The Beaumont Society – have a National 24 hr helpline supporting trans people and their families (01582 412220) www.beaumontsociety.org.uk.
Depend – provides free confidential advice, information and support for all family members, spouses, partners and friends of trans people in UK. Depend – Supporting the families and friends of trans people in the UK.
