NW Lancs Health Authority policy on treatment of GID (May 2000)

North West Lancashire Health Authority
16 May 2000

Policy for the Commissioning of Services for People with Gender Identity Problems

1. Introduction.

1.1  This is the Health Authority’s policy to enable it to commission services for people with gender identity problems. It is based on the considerations outlined in the Policy for the Commissioning of Appropriate, Effective and Priority Health Care, and for Commissioning Services from Usual Providers. It will be applied in accordance with the Health Authority’s Procedure for the Application, Amendment and Waiver of Health Authority Policies for the Commissioning of Appropriate, Effective and Priority Health Care, and for Commissioning Services from Usual Providers.

2. Definition.

2.1  Gender identity disorder is a condition in which people have a conflict between their physical and psychological gender. The Authority recognises that this is a health problem in the sense that it can produce a level of distress sufficient to affect the persons level of wellbeing. The condition is also a medical problem in the sense that many of the interventions which may be recommended are ones that require the skills of health professionals. The Authority recognises that gender identity disorder is an illness in the context of the National Health Service Act (1977).

2.2  The illness of gender identity disorder may or may not be present in any particular individual requesting advice on gender identity, and the presence of illness can be determined only by clinical judgement.

2.3  The Health Authority recognises that assessment with a view to possible gender reassignment surgery is the medical strategy for some patients with gender identity disorder illness. Other patients are best managed by techniques leading to psychological adjustment without physical intervention. This is a clinical decision in each individual case, and the Authority will seek and be guided in this respect by the advice of relevant clinicians.

2.4  In considering priority, the Health Authority also recognises the significant pressure under which it is placed to provide additional funds for treatments (or preventive measures) of proven effectiveness for other groups of patients with illnesses which cause physical or mental distress, which shorten life, or which threaten the continuing function of parts or systems of the body. There are many such illnesses which the Authority does not have sufficient resources to address, and it has to make difficult choices about which services represent the best use of its finite resources. In determining its priorities, the Authority gives consideration to all relevant factors including the severity of the condition and the likely outcome of treatment. The basis for commissioning any services for gender identity disorder will, therefore, include evidence of effectiveness which is available at the time and the Health Authority’s then funding and priorities, as well as clinical judgement. Given the competing demands for the limited financial resources available to the Health Authority, the Health Authority’s view is that (subject to careful consideration of the circumstances of the individual case to see whether there is an exceptional reason for adopting a more favourable view) services for the illness of gender identity disorder should not receive as high a priority in the allocation of resources as services of proven effectiveness for illnesses which are life threatening or more severely disabling.

2.5  This policy applies to health care (including out of area treatments) for which this Health Authority is the ultimate source of funds. It also applies to health care commissioned by this Authority for people who reside elsewhere, but who are referred to NHS Trusts in North West Lancashire for out of area treatments.

3. The Policy.

3.1  The Authority will commission services for patients with gender identity problems in accordance with the guidance in appendix 1.

Dr A J Sudell
Consultant in Public Health Medicine
10-May-00.

North West Lancashire Health Authority
January 2000

Policy for the Commissioning of Services for People with Gender Identity Problems.

Appendix I
Guidance for identifying those patients who should receive assessment and treatment commissioned by North West Lancashire Health Authority

1. Introduction.

1.1  This guidance should be used to assess requests for health authority funding, in each individual case:

1. by considering whether the patient is appropriate for funding of treatment to be provided by North West Lancashire Health Authority,
2. by considering any reservations in respect of effectiveness,
3. by considering the level of distress which the treatment seeks to remove,
4. by considering any other groups of patients competing for the same resources of the Health Authority.

2. The process by which this guidance is applied.

2.2  A patient with a gender identity problem has full access to all of the primary and secondary healthcare facilities available within North West Lancashire. The Health Authority expects that the initial assessment of any patient will take place within those facilities.

2.2  A request for funding for assessment or treatment outside of these facilities may be submitted to the Health Authority which will then consider the request. The request should be made by a medical practitioner (GP or consultant) having responsibility for the clinical care of the patient. In the unusual circumstance of a patient being known already by a tertiary centre, the request may come from that centre. (The terms primary, secondary and tertiary healthcare are widely used within the NHS. They are derived from the usual referral pathway, which is from primary care (the General Practitioner who is usually the first point of contact with the healthcare system) to secondary care (usually a provided by a consultant in a local hospital) to tertiary care (usually provided in a centre of expertise serving a population which may be much larger than a single health district).).

2.3  The Health Authority will consider requests to fund assessment, counselling, advice, psychotherapy, speech therapy, medical (usually hormonal) treatment and follow up. The Authority will give separate consideration to subsequent requests to fund surgical and other procedures. This is consistent with usual practice of regarding each referral as a separate matter. It is also consistent with the Health Authority’s practice in recent years relating to several types of healthcare (both within service agreements and otherwise) that a decision on the funding of definitive treatment is sometimes reserved until the assessment has been completed and its implications have been considered. In such circumstances however the Health Authority recognises that authorisation of further treatment is likely to follow if that treatment is recommended as a result of the appropriate assessment.

2.4  The Health Authority’s enquiries will be made only with the consent of the patient. However the Authority will not fund services if it is unable to confirm eligibility as a result of withheld consent. Reasonable effort will be made to explain to the patient the significance and consequences of any lack of consent.

2.5  The Health Authority expects its residents to be treated only with prior approval. This prior approval may be for the patient to be funded in accordance with Out of Area Treatment arrangements. Alternatively the Health Authority may establish a service agreement for the treatment of patients who satisfy this guidance and these eligibility criteria. That agreement would require prior approval for each individual patient.

2.6  The Health Authority will normally commission services only from NHS Trusts with which it has a service agreement for the purpose. In the absence of any service agreement, and until further notice, the Health Authority recognises the expertise and good clinical practice within the NHS Trusts operating at Charing Cross Hospital (or their successors) and (for children and adolescents only) at the Tavistock and Portman NHS Trust, and currently regards these as its selected tertiary service providers. (In the event of a patient requesting a previous assessment carried out by an alternative provider to be recognised as an expert assessment, the Health Authority will give individual consideration to the matter, and may decide to regard another service provider as having the same status as the current selected tertiary service providers for the patient in question. If a patient has a particularly good reason for requesting referral to a service provider other than the current selected tertiary service providers, then the Authority will consider whether for this patient an alternative service provider should be afforded the status of a selected tertiary service provider.

3. Eligibility criteria for referral for specialist assessment.

3.1  Eligibility criteria for referral for specialist management under psychiatric care, which may include assessment, counselling, advice, psychotherapy, speech therapy, medical (usually hormonal) treatment and follow up, will be as follows:

1. Usually, any funding will be authorised for management at the Gender Identity Clinic in the Health Authority’s selected tertiary service provider.
2. Usually, a local (within portfolio of service agreements) NHS Consultant Psychiatrist will have agreed to make the referral to the Gender Identity Clinic.
3. Usually, the referring psychiatrist will have confirmed to the Health Authority that in his I her opinion the patients problem amounts to an illness, and that the diagnosis of that illness may be gender identity disorder.
4. Usually, the referring psychiatrist will have confirmed to the Health Authority that in his I her opinion the patient is experiencing personal mental suffering and significant adaptive disadvantage as a result of the gender identity disorder.
5. Usually, the referring psychiatrist will have confirmed to the Health Authority that in his / her opinion the patient is not currently suffering from any psychotic condition that is the probable primary diagnosis, or that until adequately controlled would prevent specialist assessment.
6. The referring psychiatrist will have advised the Health Authority whether the patient has ever suffered from serious mental illness (other than gender identity disorder itself) or suicidal tendencies or has made attempts at suicide or genital self mutilation. In the event of such features being present, the Authority will require confirmation that the referral is in the best interests of the health of the patient.
7. The patient’s NHS General Practitioner will be a member of one of the North West Lancashire Primary Care Groups. (or the patient will otherwise be the responsibility of North West Lancashire Health Authority in accordance with NHS guidance in force at the time).
8. Usually, the patients NHS General Practitioner will have confirmed support for the referral.
9. The purpose of the referral will have been defined (e.g. some patients may request assessment with a view to gender reassignment surgery, others may require long term management, but without an expectation of surgery. Others may simply require specialist advice on particular aspects of their condition, without requesting long term care at the clinic).
10. The Director of Public Health and Health Policy will have invited comments from the patient, the General Practitioner and the referring psychiatrist about the severity of the illness, about the probability of a successful outcome, and about any other features that are considered relevant, and will have considered these comments having regard to the Health Authority’s then funding and priorities, and also having regard to competing demands for resources for other patients with the same or different illnesses.

3.2  In the first instance any funding for the patient will be for management in accordance with the defined purposes of the referral, although further consideration may be given to subsequent requests to extend these purposes. At this stage, the authorisation will not include authorisation of surgical interventions, as these are likely to be the subject of an onward referral which will be considered accordingly.

3.3  Usually, authorisation at this stage for funding for hormone medication will be subject to the patient being fully assessed and found suitable in accordance with the relevant Harry Benjamin Criteria^* (unless the Health Authority has been advised and has agreed that there is good reason why those criteria should not be applied for the patient in question). It will also be subject to the patient being aware of the side effects and complications of any medications, of the limits of knowledge about long term side effects and of the status of any unlicensed medication.

3.4  In authorising funding at this stage, the Health Authority acknowledges that assessment and medication treatment will, in appropriate cases, be followed by surgical and other treatments, and will make that assumption when considering its priorities and available funding. Conversely if a patient reaches a stage at which the expert advice and skill of the selected tertiary service provider is no longer required, the Authority will expect the patient to be referred back to local services.

3.5  Eligibility criteria for surgical and other treatments will be as follows:

1. Usually, the patient will have been assessed at the Gender Identity Clinic in the Health Authority’s selected tertiary service provider and found to be in clinical need of the treatment.
2. Usually, the patient will have been referred initially to the Health Authority’s selected tertiary service provider in accordance with this guidance, or will have satisfied the requirements of section 4 of this appendix.
3. The package of treatment, including any treatment deferred for further consideration, will have been defined and agreed by the Health Authority in accordance with its policies.
4. Usually, a consultant at the Health Authority’s selected tertiary service provider will have confirmed to the Health Authority that:
   1. the patient is aware that there is no guarantee of satisfaction with the anatomical result,
   2. the patient is aware that there is evidence that some patients do not adapt well to their new gender after reassignment surgery,
   3. the patient is aware that reversal of the procedure may not be possible, and that Health Authority funding for reversal might not be available,
   4. the patient is aware of the extent to which any procedure will affect his/her reproductive capacity.
5. Usually, the Health Authority will have received confirmation from two consultants at the Health Authority’s selected tertiary service provider that the patient satisfies relevant Harry Benjamin Criteria^* (or the Authority will have been persuaded that the Harry Benjamin Criteria^* should be waived).

3.6  In addition to the eligibility criteria listed above, the Health Authority may, at each stage, consider any other relevant issues, and may make appropriate enquiries, and may decide to provide or not to provide funding for the individual patient under consideration. The Authority may seek to confirm that a decision to approve funding will be in the best interests of the health of the patient.

4. Patients who have already been referred to a specialist centre or had otherwise commenced gender reassignment before seeking authorisation.

4.1  Patients who had been referred to the Health Authority’s selected tertiary service provider as NHS patients before becoming the responsibility of North West Lancashire Health Authority will be funded for continuing treatment provided that they satisfy the eligibility criteria in this policy. The Director of Public Health and Health Policy may take into account the additional distress that may be caused by a withdrawal (rather than an initial refusal) of NHS funding. The psychiatric advice required to satisfy criteria in section 3.1 may come from a psychiatrist at the Health Authority’s selected tertiary service provider, or from a psychiatrist in the previous district of residence.

4.2  Patients who had been referred to the Health Authority’s selected tertiary service provider as private patients may be funded for continuing treatment provided that they satisfy the eligibility criteria in this policy. The time from referral to commencement on medication, and from referral to surgery should be no less than for patients treated throughout under the National Health Service.

4.3  Patients who had been referred to tertiary centres other than the Health Authority’s selected tertiary service provider will need to be considered fully in accordance with this policy applied in accordance with the Health Authority’s Procedure for the Application, Amendment and Waiver of Health Authority Policies for the Commissioning of Appropriate, Effective and Priority Health Care, and for Commissioning Services from Usual Providers. The advice of psychiatrists from such tertiary centres may be considered in lieu of the advice of local psychiatrists in section 3.1, but not normally in view of the expert assessment required from consultants at the Health Authority’s selected tertiary service provider. Until a decision can be reached and advice obtained, funding will be offered on an interim basis to continue any medication considered to be clinically essential, but not to introduce new therapeutic objectives.

4.4  Patients who have earlier attempted gender reassignment techniques outside of the recognised healthcare system will be subject to the normal provisions of this policy in all respects. Local surgical and endocrinological advice may be sought within the directory of service agreements to correct any medical complications of such attempts. Until a decision can be reached and advice obtained, funding will be offered on an interim basis to continue any medication considered to be clinically essential, but not to introduce new therapeutic objectives.

4.5  Retrospective authorisation of funding will not usually be given either for patients treated as if they were NHS patients, or to patients who, having funded treatment privately, seek reimbursement.

* The Harry Benjamin Criteria constitute a series of guidelines for the evaluation and treatment of gender identity disordered persons. They are produced by the Harry Benjamin International Gender Dysphoria Association, which is a professional organisation of health professionals who treat patients with Gender Identity Disorder. The guidelines were initially written in 1985, with the fifth revision being written in June 1998. References in this policy are to the revision that is in force at any time.