NHS guidelines for transitioning

[Jayne]

At my last visit to the gender clinic in London I discussed the fact that I can't go full time yet, I get bad excema so can only wear makeup occasionaly & sometimes I have to stop shaving for a few days to allow my skin to heal on my top lip, i've also been told I can't have laser treatment due to my skin.
As a result of this the clinic are seeking funding for my electrolosys to be done on the NHS but it is likely that it will take 3 -4 months to recieve approval for funding, I will then have to wait for appointments for treatment so there's no chance i'll have this completed in time for my next appointment in June.

The phsyciatrist has told me that he expects me to be full time by my next appointment but the other week I discovered the NHS guidelines http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_085013.pdf
It states in section 8
Clinicians may encourage, but not oblige, service users to experiment with
androgynous or even cross-gender dressing. Adjustment to the new role is not just
about dress, but also about speech, mannerisms and deportment. For trans
women, there are also issues such as make-up and, sometimes, hair-pieces. It takes
time to achieve a reasonable presentation so it is important that trans service users
do not feel pressured into rushing this stage. It is at the point of transition to the
opposite gender role that trans people are at their most vulnerable to relationship
difficulties, hostility on the street and discrimination in the workplace.

As a result of what was said I feel that the GIC is trying to pressure me into going full time to qualify for HRT regardless of either my personal medical problems or the NHS guidelines.
Has anyone else been put under pressure to start full time by the NHS?

I'm reaching the point where if i'm told at my next appointment that I can't start HRT due to not being full time then i'll start self medicating to force the NHS to help with my treatment as it states in these guidelines in section 7
Those service users who are already self-medicating should be brought into a prescribed
regime as soon as possible. However, insisting that the service user stop hormone
treatment altogether at this point is not necessarily the safest health option, since it
can cause serious stress and have adverse physical and psychological consequences

Does anyone know if these guidelines are the most recent or have they been replaced by new guidelines?

By my next appointment it will have been 2 1/2 years since I saw my GP about transitioning & i'm not willing to wait any longer for HRT to start, right now my life is in limbo & I want to start living again not merely existing

[LilDevilOfPrada]

At my last visit to the gender clinic in London I discussed the fact that I can't go full time yet, I get bad excema so can only wear makeup occasionaly & sometimes I have to stop shaving for a few days to allow my skin to heal on my top lip, i've also been told I can't have laser treatment due to my skin.
As a result of this the clinic are seeking funding for my electrolosys to be done on the NHS but it is likely that it will take 3 -4 months to recieve approval for funding, I will then have to wait for appointments for treatment so there's no chance i'll have this completed in time for my next appointment in June.

The phsyciatrist has told me that he expects me to be full time by my next appointment but the other week I discovered the NHS guidelines http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_085013.pdf
It states in section 8
Clinicians may encourage, but not oblige, service users to experiment with
androgynous or even cross-gender dressing. Adjustment to the new role is not just
about dress, but also about speech, mannerisms and deportment. For trans
women, there are also issues such as make-up and, sometimes, hair-pieces. It takes
time to achieve a reasonable presentation so it is important that trans service users
do not feel pressured into rushing this stage. It is at the point of transition to the
opposite gender role that trans people are at their most vulnerable to relationship
difficulties, hostility on the street and discrimination in the workplace.

As a result of what was said I feel that the GIC is trying to pressure me into going full time to qualify for HRT regardless of either my personal medical problems or the NHS guidelines.
Has anyone else been put under pressure to start full time by the NHS?

I'm reaching the point where if i'm told at my next appointment that I can't start HRT due to not being full time then i'll start self medicating to force the NHS to help with my treatment as it states in these guidelines in section 7
Those service users who are already self-medicating should be brought into a prescribed
regime as soon as possible. However, insisting that the service user stop hormone
treatment altogether at this point is not necessarily the safest health option, since it
can cause serious stress and have adverse physical and psychological consequences

Does anyone know if these guidelines are the most recent or have they been replaced by new guidelines?

By my next appointment it will have been 2 1/2 years since I saw my GP about transitioning & i'm not willing to wait any longer for HRT to start, right now my life is in limbo & I want to start living again not merely existing

Wait this NHS company pays for your transisiton thats amazing!

[Seras]

It is not a company, it is the National Health Service of the UK, free healthcare for all.

Course it has strings attached. I am in a similar position, I have my next meeting soon. They told me I had to have made some significant progress by the next one or they may discharge me, luckily I have. I just hope it is enough for them to put me on hormones. I have also been in the system for around 2 years, if they do not respect the significant progress I have made I will be seriously considering going private.

[Beverly]

The phsyciatrist has told me that he expects me to be full time by my next appointment but the other week I discovered the NHS guidelines
...
As a result of what was said I feel that the GIC is trying to pressure me into going full time to qualify for HRT regardless of either my personal medical problems or the NHS guidelines.
Has anyone else been put under pressure to start full time by the NHS?

Some shrinks seem to put a lot of store by RLE, almost to the point of nothing else mattering. From what I can discern it appears that if you do not do RLE then they seem to regard you as a dual-role TV and not as TS. Therefor no hormones.....

For me it was never an issue as I have been RLE for nearly 2 years now but only 'officially' since summer 2012 which was the documented date for my name change.

[Jayne]

At first I thought it was brilliant that I could have this done on the NHS but I would advise anyone who can afford to go private to do so.
I understand that the NHS is underfunded & overworked but transitioning on the NHS has not been a good experience, after 2 years i'm still unable to begin my transition.
No-one should have to put their lives on hold for years at a time due to needing medical treatment, this prolonged waiting has caused me severe depression & insomnia, for the last few months i've considered myself lucky to get 3 hrs sleep for every 2 days going without sleep.

If I had the funds then I would go private in a heartbeat but due to redundancy last year & an estimated 300 people applying for every job in my home town the chances of me finding a job that would enable me to pay for private treatment are close to being zero.

[Jayne]

Are your shrink's initials 'JB'? If so, he seems to put a lot of store by RLE, almost to the point of nothing else mattering. From what I can discern it appears that if you do not do RLE then he seems to regard you as a dual-role TV and not as TS. Therefor no hormones.....

For me it was never an issue as I have been RLE for nearly 2 years now but only 'officially' since summer 2012 which was the documented date for my name change.

The shrink I saw was Dr Davis, it clearly states in the guidelines I found that they should NOT force you to start RLE before HRT but it seems like many of the NHS shrinks ignore the guidelines.
I explained to him in detail that i've been advised that I should wait until i've started HRT before starting electrolosys to reduce the amount of treatment & therefore reduce the chance of complications due to my skin.
I also explained that makeup can often be very painfull when my skins bad, I also explained that on a bad day I may need to moisturise my face every 10 - 15 minutes so wearing make-up is often impractical.
It would seem that he believes that if you don't wear make-up then your not committed to transitioning but i've known more women in my life who barely wear make-up than women who wear lots of make-up.

[BunnyBee]

It states in section 8
Clinicians may encourage, but not oblige, service users to experiment with
androgynous or even cross-gender dressing. Adjustment to the new role is not just
about dress, but also about speech, mannerisms and deportment. For trans
women, there are also issues such as make-up and, sometimes, hair-pieces. It takes
time to achieve a reasonable presentation so it is important that trans service users
do not feel pressured into rushing this stage. It is at the point of transition to the
opposite gender role that trans people are at their most vulnerable to relationship
difficulties, hostility on the street and discrimination in the workplace.

Whoever wrote that is super empathetic or has actually been there.  It's really encouraging for me to see that in an official guidelines document.  Maybe the world is starting to understand.

Some people are really strong and just go out there as themselves day one, but I've always been a wimp and I really take people thinking unpleasant things about me very hard.  It would have been so destructive for me to have had to go out into the world before I could fit at least somewhat well.

I think your doctor is doing real damage to some of his patients, because I'm sure some of them at least are like me.  I'm not British though (I presume that is where you're from) so I don't know anything about your NHS.

[Jayne]

Whoever wrote that is super empathetic or has actually been there.  It's really encouraging for me to see that in an official guidelines document.  Maybe the world is starting to understand.

Some people are really strong and just go out there as themselves day one, but I've always been a wimp and I really take people thinking unpleasant things about me very hard.  It would have been so destructive for me to have had to go out into the world before I could fit at least somewhat well.

I think your doctor is doing real damage to some of his patients, because I'm sure some of them at least are like me.  I'm not British though (I presume that is where you're from) so I don't know anything about your NHS.

Reading through the entire report is very encouraging but dealing with the reality of the shrinks is something else entirely, when I have my next session I will be printing of the guidelines & taking them with me so that if i'm told I cant start HRT then I will have some ammo to fight back with.
If i'm denied HRT then i'll make it perfectly clear that I will start self medicating immediately & I will be asking about the complaints procedure to put a proverbial bomb under them.
after all what's the point in guidelines when the shrinks seem to make up their own rules?

[Elspeth]

Whoever wrote that is super empathetic or has actually been there.  It's really encouraging for me to see that in an official guidelines document.  Maybe the world is starting to understand.

Pretty sure that section is a paraphrase or even a quote from the Benjamin Standards. I'm sure you can find endless debate about the Benjamin Standards in trans dialogues... it's been a subject of heated debate now for at least several decades.

In practical terms, I wonder whether it might be productive to discuss Lana Wachowski's speech at the HRC visibility awards with your therapist, if you're having some issues with those pressures to present in a form your therapist is willing to view as female?  I don't know how much you've discussed this, and I'm also not very informed about what your practical options are if there's bad chemistry between you and someone that NHS is paying for. My impression is that, given the limits and restrictions to access, there is a potential for problems with therapists who many not yet have entered the 21st century.

I'm hesitant to say this after such a short reading, but I can really sympathize with the temptation to offer an ultimatum about self-medicating. Granted, it would be better to strategize with someone who has already managed to negotiate the rat maze that the NHS system often sounds like it has become.

One afterthought that is probably painfully comical to you at best: What you describe about skin conditions, could they be expected to improve with HRT? Is there any way to get a dermatology consult and treatment that would address the issues that make using make-up painful and require an impractical skin care regimen? In short, is there any way to improve the skin condition, putting aside your entirely valid point that at this point in time very few cisgendered women wear that much make-up, and that one could make a case that wearing make up in this day and age, beyond something very subtle, tends to get one identified as a drag queen, not as a contemporary woman in one's own age cohort?

[Isabelle]

Complain. I don't know who you complain to in the UK. In NZ we have the Health and Disabilities Commisioner. Your psych is clearly not following the guidelines. His job is to help you transition. Not block you by inventing his own rules.

[Padma]

How straightforward transitioning on the NHS is very much depends on where in the country you are, and who you get - and, well, to some extent on the client, too, and what they've got going on. For some people it can really stretch out, and I don't know why that is - but for others it can be very straightforward indeed.

[Beverly]

Complain. I don't know who you complain to in the UK. In NZ

There are a lot of NHS complaint mechanisms (too many probably) but a good starting point would be the local PCT (Primary Care Trust) or CCG (Care Commissioning Group). The GP responsible for the initial referral should know which of these would be the best starting point as they are changing in April 2013

[Bex80]

Is there a PALS (patient advice liaison service) for the nhs trust you can contact for guidance? We have used this for my wife when we werent happy with treatment timescales and they really helped, even if its just advice. A second opinion is your medical right  well. X

[muuu]

.

[Elspeth]

How straightforward transitioning on the NHS is very much depends on where in the country you are, and who you get - and, well, to some extent on the client, too, and what they've got going on. For some people it can really stretch out, and I don't know why that is - but for others it can be very straightforward indeed.

How much do you sense this is because of arbitrary factors like resistant or obstructive care givers, as opposed to some sort of patterns of active defiance from clients? I hate to frame it in these terms when I realize it's so much more complicated than that, but some of the stories I've read often have me thinking that the clients might have been resisting giving the caregivers the sort of assurances they might have wanted to have to feel that RLT was going well enough to be predictive of a good outcome once they started someone along on some of the unalterable parts of the process?

I guess part of why I'm asking too has to do with my ex's ambivalencies about my son's will to transition, particularly because he's not identifying at all as a more conventional guy. (Then again, when I came out to him in the most direct terms, he mentioned that he had not really been aware that I was trans... I had been masking myself that well, apparently, as part of taking misguided advice to wait to transition until the kids were old enough to understand what I was saying by coming out.)

[Jayne]

One afterthought that is probably painfully comical to you at best: What you describe about skin conditions, could they be expected to improve with HRT? Is there any way to get a dermatology consult and treatment that would address the issues that make using make-up painful and require an impractical skin care regimen? In short, is there any way to improve the skin condition

There is a chance that HRT could improve my skin but an equal chance that it could make it worse.
I've been in hospital 3 times, one time I had no skin left on 75% of my body & another time I had so much extra skin that I could barely move. I have been offered a hospital bed many times since my last visit about 15yrs ago, I refuse to go into hospital nowdays because whilst they clear my skin up 100% in hospital it has always come back as bad or worse when i'm released. My most recent dermatologist agrees that it makes more sense to manage it in the real world but should it get too bad they may overrule this & insist on taking me in.

I've been on imno suppressants twice now but the risks of such a medication make it a short term solution only as the benefits are outweighed by the side effects & long term complications such as a high risk of cancer, bone marrow failure, liver & kidney failure, this medication is pretty much a last resort for dermatologists.

Now that i've typed that I realised that I could have just said that there are no more options left to try to clear my skin.

[Jayne]

How much do you sense this is because of arbitrary factors like resistant or obstructive care givers, as opposed to some sort of patterns of active defiance from clients? I hate to frame it in these terms when I realize it's so much more complicated than that, but some of the stories I've read often have me thinking that the clients might have been resisting giving the caregivers the sort of assurances they might have wanted to have to feel that RLT was going well enough to be predictive of a good outcome once they started someone along on some of the unalterable parts of the process?

From my point of view it feels like an obstructive care giver, on my first consultation I was told I would have to have my name changed before this appointment & did not hesitate to act upon this, I was not instructed on my first appointment that I would have to start presenting as female but did so anyway.
When I told the Dr on my second visit that I was presenting as female approximately 60 - 70% of the time he told me that I needed to be female 100% of the time before my next visit despite the fact that I explained carefully about my skin problem, I stated clearly that as soon as I no longer need to use make-up to hide facial hair I would be female forever & I clearly explained that I find it depressing not being able to be female every second of every day.
I don't see how I could move my transition further or faster until I start HRT so this Dr is placing an unreasonable barrier infront of me, one bright note is that he is not my regular shrink, my next appointment is with Dr Lorimer who I felt was much more understanding & reasonable.

Padma is spot on about the differences depending on where you live, for example, i've been told that my PCT is one of the better ones as they rarely refuse funding even though they are one of the slower ones to grant funding.

[Jayne]

Though, if you self-medicate or go trough a private clinic. Can you get the NHS benefits such as laser and SRS then, if you then start going trough NHS?

Edit: While there's a topic about NHS and it's guidelines, I hope I could go slightly off-topic and ask another question... Would they cancel somebodys prescription for HRT if they bring up being depressed and suicidal?
Asking because I came across somebody who was, but was scared of having their HRT canceled if she sought help. And since I've heard NHS can be a bit tricky, I would want to have some idea of if her fears are legitimate or not, if I would 'talk' to her again.

According to the guidelines if you are self medicating they should bring you into a controlled regime of medication.
I believe you can opt to go private for some parts & re-join the NHS for any parts you cannot fund yourself but don't take that as gospel as it's what i've heard from others, i'm going to digest the entire guideline in the next few days so if I find a definate answer i'll let you know.

I've been told that they will not stop HRT due to depression. I'm being treated for depression & there has been no mention about this being a barrier to me starting HRT.
Advise her to ask her GP about the wellbeing therapies service, my GP has given me details to contact them for free therapy but all the contact details are local