This article is about transition in England.
The purpose of this page is to discuss all aspects of the transition process in England, covering the NHS route; the Private Route; the Mixed Route; and the Fourth Way, which is similar to the Mixed Route. Many readers may already be familiar with the existence of the NHS and Private routes to treatment but the Mixed Route is also a common method of getting treatment.
Due to Devolution and the splitting of the NHS by country, treatment routes vary between each country in the UK. This document focuses on England only.
The NHS Route
The NHS route begins with a visit to your GP. Here you will need to explain your situation to a doctor who will most likely already be familiar with any other problems you have been having, such as routine sickness issues and so forth. Your GP has the power to refer you to the local psychiatric team for an initial assessment with a view to forwarding your case to a Gender Identity Clinic (GIC). This is what you need the GP to do.
The local psychiatric team’s role is to facilitate the smooth running of the GIC by assessing potential clients (we are not ‘patients’, we are ‘service users’ or ‘clients’) and identifying any mental and/or physical problems we may have that manifest their selves as transsexuality. This is an important step because treating a non-transsexuality condition as if it is transsexuality can exacerbate the condition, possibly with life-threatening consequences. In the vast majority of cases the local psychiatric team will find there are no other conditions present and they will refer you on to the Gender Identity Clinic with which they have a contract. This may be a local/regional clinic, or it may be Charing Cross in London.
Prior to your first visit to a GIC
There can be a long wait before your first appointment with a GIC because the majority are over-subscribed and under-funded. During this wait it can be tempting to begin self-medication using drugs obtained from friends or the Internet. We cannot condone this course of action but if you do chose to self-medicate we have to recommend informing your doctor about what you are doing and getting regular blood and liver function tests, because hormone therapy can cause many problems if not kept under professional supervision. Many GICs will demand a ‘baseline’ blood work before prescribing hormones, so they know how much of what type of hormone to prescribe, so it is best to not be taking HRT for around six weeks prior to your first visit to a GIC.
You may wish to treat the wait for your first appointment as a time to prepare yourself for the transition process. Several GICs (including Charing Cross, the largest of the clinics) require you to begin the Real Life Test before they will prescribe hormones, which many in the community regard as an affront to decency and common sense. If this is the case, it is best to get yourself prepared as far in advance of your first appointment as you can. You can find out whether your clinic has this policy by either telephoning them (their details should be on our Therapists page) or asking other people on the Internet (our Chat Room may be useful here). The first official day of your Real Life Test will be marked down as the first day they can ‘prove’ you have transitioned so if you can have all this proof ready for your first appointment it makes good sense to do so.
For more information on preparing to transition, see our A guide to transition page. If you are male-to-female, it is worth noting that facial hair removal will not be as effective without an anti-androgen (or the testosterone-blocking effects of high doses of oestrogen), so if you chose to undergo facial hair removal at this stage, discuss a hormone blocker with your GP. They should be able to prescribe these, but some GPs will want approval the GIC (which they may not get until the GIC has seen you for the first time).
The Gender Identity Clinic will facilitate the majority of the transition process. In many cases they will not directly prescribe hormone treatment but will instead direct your GP to prescribe. They will also generally not take blood tests but, again, will instead direct your GP to do this. The GIC will, however, undertake regular psychiatric assessments, to monitor your mental state during transition and determine whether the transition process is working for you. Some GIC doctors will attempt to diagnose transsexuality in you, others will subscribe to the more modern notion that transsexuality cannot be diagnosed and will simply facilitate your transition. In the NHS, the older model is more common, so expect a ‘diagnosis’ at some point.
If you have already begun the Real Life Test (RLT) prior to your first appointment, it is highly likely that the GIC will decide that your RLT ‘officially’ begins on the first day that you see them. This is because many GIC doctors simply don’t believe you unless they see you. There have been instances, in both the NHS and Private routes, of clients lying about the length of their RLT in order to get surgery quicker. By recording the start as the day they first see you ‘in role’, they are simply covering their own backs in case of repercussions at a later date. It’s annoying but in this case we’ve just got to play along.
Some GICs (Charing Cross is the worst offender in this regard) will demand of male-to-female clients that they do not wear jeans, or possibly even any form of trousers. This is unacceptable behaviour and may well constitute an offence. We recommend that you wear what feels right for you, not what anyone says you ‘should’ and we point to the vast differences in dress of the average woman in the street to back us up on this. Some people recommend just going along with the doctor’s demands on the days you have to visit the clinic. It’s your choice. If the doctors give you hassle, remember to complain. Remember that as public servants, they work for you.
The end of the Real Life Test
The Real Life Test generally lasts for two years, from the date it is first ‘officially’ recognised as having begun. At the end of this period, or slightly before if your doctor prefers to have everything sorted in advance, you can expect plans to be put in place for you to undergo gender reassignment surgery (GRS). The NHS does not recognise any form of transgenderism other than transsexuality and transvestism and if you’ve got this far, they will have decided you are a transsexual person. They will therefore want to put you forward for GRS. If you don’t want surgery, make arrangements with your GP to continue hormone treatment and stop going to the GIC. It may be wise to ask the GIC to keep your file open while you ‘consider’ surgery. It is a big step and many people get cold feet or become very nervous about the operation, so most clinics will be happy to give you ‘thinking time’, so you can continue to receive HRT while not having to go through with the final stage if you don’t want to.
Most GICs have a surgeon, or surgeon, that they work with. You should therefore be given a choice of surgeons. Go with whichever seems right for you. Feel free to ask to speak to both surgeons and discuss your wants and needs with them, and also to ask around on the Internet for other peoples’ experiences. It’s unlikely that there will be noone out there who has gone with that surgeon before and each gives different results, so use the option that works best for you.
The date of surgery will always be after the last date of your Real Life Test. In some cases, surgery has been undertaken the day after the RLT has finished; although this is rare and requires very good forward planning on behalf of the doctor, coupled with the surgeon having free time in their calendar. In most cases the surgery will happen a month or two after the RLT officially ends.
You will need to come off HRT prior to undergoing surgery. This is because hormones have a substantial effect on the body and in the case of male-to-female transsexual people, the effects of hormones make you more prone to blood clots while you are bed-ridden after the operation. Just stop taking the pills, the alternatives aren’t worth risking. You can get anti-androgens and anti-oestrogens to help you keep your naturally-occurring hormones under control during this period and it’s recommended that you do this.
It is worth pointing out that a number of myths have grown up surrounding the Charing Cross GIC in London. A number of these myths may have once been based on practices that are now outdated and acknowledged so. A recent piece has appeared online aiming to ‘mythbust’ some of these commonly banded around beliefs, and this can be found here.