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Gender identity

The role of specialist nurses in gender identity services

Nurse specialists can support patients through the gender dysphoria care pathway

5 key points

  1. Gender dysphoria is not about sexuality; it is about the person and their gender
  2. Treatment and surgery is available to those clients who are ready and eligible
  3. Transition to the opposite gender can be a lengthy process. The length of time taken from assessment to post surgery is on average three years
  4. Funding for treatment and surgery needs to be requested from local primary care trusts unless commissioning arrangements are in place
  5. There are a number of gender services across the UK; to find the nearest one ask local GPs

The Leeds Gender Identity Service provides assessment and treatment for people diagnosed with gender dysphoria, which occurs when people believe their biological gender is not consistent with how they feel inside. Many people with this condition express a wish to transition and live full time in their true gender. In some cases, if left untreated, gender dysphoria can lead to deterioration in mental, physical and social health.

The care pathway

After a period of assessment, if appropriate, clients follow a care pathway, which was implemented to standardise care and maintain safe practice for those wishing to transition into the new gender.

The care pathway is as follows:

  • Social gender transition;
  • Hormones;
  • First opinion before referral for surgery;
  • Referral for a second opinion;
  • Referral for gender reassignment surgery;
  • Post-surgery follow-up.

Other interventions may include: referral for voice coaching; laser hair removal; breast augmentation; access to the service-user peer-support group; and one-to-one support with people who have already moved through the care pathway.

The team is made up of seven clinical nurse specialists (CNSs), an occupational therapist, two consultant psychiatrists, a sessional voice coach, a clinical team manager, a pharmacist, a practitioner with special interest and a team administrator.

Assessment

The CNSs use a range of skills, by continually assessing and evaluating clients who wish to transition. For clients to be accepted onto the care pathway, the following factors must be considered: physical health; social health; mental health; persistent discomfort of the biological gender; identifying with the opposite gender; and whether clients have made a self-diagnosis of gender dypshoria. Finally, the specialist team needs to provide a confirmed diagnosis of gender dysphoria with transsexualism during the assessment process so that clients can move forward to the care pathway.

Social gender transition

During the social gender transition, CNSs work collaboratively with clients to support them through this crucial stage, in which they change their name, engage in meaningful activity in the true gender and change personal details including passport and driving licence. Clients need ongoing support from nurses at this stage as they will have lived in their true gender for 3-6 months on a full-time basis. If clients are unable to do this at this point of the care pathway, they could be discharged from the service until they are ready to move forward.

During this stage a care plan is devised which looks at clients’ individual needs in relation to successful transition.

Ways of working

The service adopts the bio-psychosocial model and provides the following: fact finding; family work; counselling skills; a cognitive behaviour therapy approach; health promotion; practical support; and brief solution-focused therapy.

During the first two parts of the care pathway, it is vital to adopt socratic questioning styles, which seek to get people to answer their own questions by making them think and drawing out the answer from them.

For example: What does it mean to you to change gender? How will you tell others about your gender change? How do you think people will respond? At this point it is crucial that the client-nurse relationship is well established to ensure the client feels supported psychologically. CNSs explore the consequences of the life choices clients choose to take, which may be challenging at times.

A key skill is being able to identify whether clients are eligible and ready to move through to each stage of the care pathway. It is important to understand timescales and to work at a safe pace for each individual. CNSs also discuss clients’ expectations, allowing them to understand possible outcomes of surgery and feelings after surgery.

Advice for nurses

Nurses working with a patient who they think may have gender dysphoria should consider the following points:

  • Is the person willing to discuss their gender issues?
  • Suggest they carry out as much research as possible on gender dysphoria;
  • Can they speak to other transgender people?
  • Suggest that the person speaks to their GP for further advice.

Vanessa Noble is clinical nurse specialist at Leeds Gender Identity Service, Leeds and York Partnership Foundation Trust

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