There is currently no supply of Tostran and no resupply date. Alternative gel preparations are Testogel and Testavan and advice is available at https://www.ngicns.scot.nhs.uk/wp-content/uploads/2020/03/Hormone-Treatment-Alternatives-Covid-Chalmers-Final-190320.pdf.
Please note that Testogel and Testavan gel contain approximately twice the amount of testosterone than Tostran so patients should use half the amount (eg 2 presses of Tostran is equivalent to 1 press of Testogel/Testavan)
Clinical advice is also available by email at gic@nhslothian.scot.nhs.uk
It can be difficult to access treatment preparations – please see
Hormone Treatment Alternatives (18/03/2020).
Gender Identity Clinic (GIC), Chalmers Sexual Health Centre
The Chalmers GIC offers services to people aged 17 and over residing in Borders, Fife and Lothian NHS Board areas. It supports people who may be considering or are undergoing transition in connection with gender incongruence or dysphoria, a condition where there is a marked and persistent incongruence between a person’s experienced gender and assigned sex. This is not a mental disorder and is categorised in the sexual health chapter of ICD-11. For those under 17, please refer to the Gender Service at Sandyford.
The Chalmers multidisciplinary team includes specialists in gender, reproductive endocrinology, mental health, sexual health, pharmacy and speech and language.
The GIC offers assessment and referral for interventions specific to gender identity. These include fertility preservation, facial hair removal, speech and language, endocrine treatment, gender confirmation surgery including some feminising surgeries.
Treatment for people accessing gender services in Scotland is defined by the Scottish Government Gender Reassignment Protocol, CEL 26 (2012). There is a highly effective managed clinical network, the National Gender Identity Clinical Network for Scotland (NGICNS – www.ngicns.scot.nhs.uk).
For those moving into Scotland, please advise about the procedures for changing CHI numbers (please see https://archive.nhsnss.org/foi-disclosure/requirements-for-processing-a-change-of-gender-and-title/).
Prescribing Advice
Please see the primary care management page for more detail and the Lothian prescribing guidance for feminising and masculinising treatment, available on the intranet.
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 here for 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 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
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.
All patients requesting gender dysphoria assessment or treatment should be referred through SCI Gateway to Chalmers or the Gender Identity Clinic. They can also be referred by GP letter if SCI Gateway cannot be accessed (sometimes applies to non-Lothian patients). Please note that referrals from Borders are now direct to the CGIC.
Some people will have been assessed or had treatment by a recognised NHS gender clinic elsewhere and are new to Borders, Lothian or Fife (the areas served by the CGIC). If they have been assessed by a NHS GIC (or equivalent overseas), the CGIC can provide email advice on ongoing treatment or see patients where that is necessary. They are unable to prioritise patients who have accessed private treatment and they recommend they continue their engagement with their existing provider until they have completed the Lothian GIC assessment.
Who to refer:
Anyone aged 17 or over interested in assessment and/or exploration of treatment options connected with their gender identity.
Who not to refer:
People under the age of 17 should be referred to the Gender Service for Young People at Sandyford.
Considerations
- It is common for there to be uncertainty and/or ambivalence. The GIC staff will support someone to explore their experience and would prefer an early referral.
- There can be a long wait to be seen by the GIC. People should be advised to access the GIC website at lothiansexualhealth.scot.nhs.uk/gic for information.
- People considering endocrine treatment should be encouraged to think about fertility preservation (https://www.hfea.gov.uk/treatments/fertility-preservation/information-for-trans-and-non-binary-people-seeking-fertility-treatment/ ). Referral can be offered following assessment and it is helpful for people to have an opportunity to reflect and consider this. Please note referral is made by the GIC not GP. It is likely that people will have access to NHS treatment for fertility preservation. Patients from Lothian and Borders are referred to the fertility centre at Edinburgh, and from Fife to Dundee.
- There is an increased risk of self harm and suicide for people identifying as transgender (‘trans’). Access to and awareness of supportive healthcare interventions are important. Unresolved gender incongruence or dysphoria is associated with significant clinical distress for many people. Please ensure timely and appropriate supportive interventions and management for people experiencing distress.
There is also an increased risk of mental health difficulties. Trans people should be offered referral to mainstream services, where appropriate, and gender considerations should not delay such referrals.
- Please check that people are aware of available support. A current list of organisations is available at http://www.ngicns.scot.nhs.uk/support/.
- There is an excellent short term counselling service based in Edinburgh by LGBT Health & Wellbeing (http://www.lgbthealth.org.uk) to which people can self-refer. (They may be asked to contribute a fee for this, but according to an individual’s means).
The Chalmers Gender Identity Clinic (GIC) maintains that a strong and supportive relationship is vital between the individual, GIC clinicians and those providing the person’s primary care. The Chalmers GIC welcomes questions and is always happy to discuss individuals’ care and to help colleagues. The clinic is supported by Professor Richard Anderson, Consultant Reproductive Endocrinologist.
Guidance is also available at http://www.ngicns.scot.nhs.uk/endocrinology/ and from the GIC (for professionals) by secure email: gic@nhslothian.scot.nhs.uk
Please note that clinical assessment should usually be based on reference values for the gender most aligned to the person’s hormone profile.
Please see Lothian prescribing guidance for feminising and masculinising treatment, available on the intranet. A Scottish working group is reviewing treatment guidance and the Lothian recommendations will be updated subsequently, but it is not thought that this will result in significant changes to clinical advice.
Bridging Prescriptions
For people already established on an endocrine regime by a recognised NHS gender identity clinic, this should normally be continued. Please contact the Chalmers GIC in this situation to discuss.
Some people may choose to self-prescribe hormone treatment. The Chalmers GIC does not make any prescribing recommendation until assessment is completed. Whilst the clinic cautions people against this, specialist staff are happy to discuss in this situation. The GMC has recently updated its guidance which may be helpful: https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare#mental-health-and-bridging-prescriptions.
Health Screening
1. Cervical screening
People changing to a male CHI number in Scotland after 14/06/2015 will continue their enrolment in the cervical screening programme. However, people with a cervix who changed their CHI prior to this or have moved to Scotland may need to be manually enrolled. Please note that the penultimate digit in the CHI number represents gender (even for female, odd for male).
2. Breast screening
Trans women and some trans men may be at risk of breast cancer. For further detail on screening please see: https://www.nhsinform.scot/healthy-living/screening/screening-information-for-the-transgender-community#breast-screening
3. Aortic Aneurysm screening over the age of 65.
This is a gender-specific programme and further details are available on the nhsinform website: https://www.nhsinform.scot/healthy-living/screening/screening-information-for-the-transgender-community#abdominal-aortic-aneurysm-aaa-screening.
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.
Contact Details:
Gender Identity Clinic
NHS Lothian
Chalmers Sexual Health Centre
2A Chalmers Street
Edinburgh
EH3 9ES
0131 536 1570
lothiansexualhealth.scot.nhs.uk/gic
Clinicians can obtain rapid information and support from gic@nhslothian.scot.nhs.uk
Please address your message to the gender team. The clinic will normally respond within two working days. Messages are secure if sent from an NHS address and via an NHS network
Resources
Training
Chalmers GIC staff are happy to visit general practices to offer training and discussion about gender healthcare and attend protected learning time events.
Clinics run at Chalmers every weekday except Friday – clinicians are very welcome to visit, and it is usually possible to sit in clinic. This can form part of CPD, and GP feedback is that it is very helpful.
