We are meeting concerns on gender services

NHS England’s new Senior Responsible Officer for Gender Identity Services introduces a 12-week consultation on proposed new service specifications:

I want to begin my first blog by thanking predecessor Will Huxter who held this job for the last two years and has been a powerful advocate for the rights of trans people.

Since 2015 there has been much progress in how the NHS commissions and delivers the various treatments and interventions on the NHS pathway of care in England:

In response to long standing concerns of trans people, we now have clarity on the application and interpretation of the national 18 week Referral to Treatment standard along the entire trans-pathway, and all NHS-commissioned gender identity services will begin regular, consistent national reporting in 2018 so that there is absolute transparency about waiting times.

We have significantly increased financial investment in specialised gender identity services. This has helped meet increased demand, though the increasing numbers in recent years has been so significant that we have some way to go in bringing waiting times down. This is a priority for us and is one of the key drivers for our intention to re-tender the award of contracts for providing specialist gender identity services in the future.

We adopted a new service specification and clinical commissioning policy for the Gender Identity Development Service for Children and Young People in 2016, informed by a process of public consultation and stakeholder engagement.

We have established a multi-agency symposium of organisations and groups – including those representing trans-people – who have an interest in helping NHS England address system-wide issues of concern. Our initial work has focused on the development of a competencies framework for health care professionals working in gender identity services, under the leadership of Health Education England

We have convened a reconstituted Clinical Reference Group (CRG) for Gender Identity Services, under the chairmanship of Dr John Dean, to provide expert advice to NHS England. Its membership includes trans people. The CRG’s immediate priority has been to provide advice in the process of developing new service specifications for specialist adult services

In June 2017 the National Institute for Health Research, having taken advice from the CRG for Gender Identity Services, published a call for applications for research in the field of gender identity services. An improved evidence base will greatly assist the NHS in making decisions about the commissioning and delivery of gender identity services in the future.

Despite the progress, we know that some concerns persist. In speaking with Will, CRG members and groups representing trans people over the past few years, I have learned about the discrimination and inequalities experienced by trans people, and I am committed to working with them to address issues of concern.

I have two immediate priorities:

On 7 July 2017 we published two proposed service specifications for a 12-week public consultation covering both surgical and non-surgical interventions. These were informed by the outcome of a stakeholder engagement workshop that we held in January.

The specifications make proposals for how specialised gender identity services for adults will be commissioned and delivered in the future. The final versions will be informed by a consideration of the views put forward during consultation and they will be used in a national process of procurement later in this financial year. The procurement will determine which organisations are best placed to provide gender identity services for adults in the future in accordance with the new specifications.

I encourage people to take part in the consultation and associated events that we are hosting or attending.

I am mindful of the findings and recommendations of the Women and Equality Select Committee’s inquiry on Transgender Equality in 2016, particularly addressing the lack of cultural awareness in the NHS that can often act as a barrier to access for trans people, and in some cases discrimination.

The problems range from ignorance among front line staff about general issues such as the correct use of pronouns to more serious problems that can cause extreme distress to trans people and that raise concerns about safety and quality, such as the risk of hospitals placing trans people on wrong sex wards.

I have put into place a piece of work that will explore and test potential approaches for addressing these concerns in the wider NHS. Our immediate focus will be on NHS services that are part of the trans-pathway for adults but that are often delivered in non-specialist hospitals, and if we are successful we will share the learning from this initial work for application in the wider NHS. This work will very much benefit from the participation of trans-people and LGBT groups and we will share details through our list of registered stakeholders very soon.

I look forward to working with you all and my focus will be on establishing a model of care and configuration of providers that delivers the best possible quality of service.

I welcome your comments on this blog and will do my best to respond as quickly as I can.

James Palmer

James Palmer has been Medical Director for Specialised Services since NHS England’s inception in 2013. He is a member of NHS England’s Specialised Commissioning National Team. He is a Consultant Neurosurgeon at Plymouth Hospitals NHS Trust.


  1. Kali-Ann Gills says:

    I have no issues with my treatment so far however, I fear that I will be left “half finished”. NHS funding for electrolysis is insufficient for completing the treatment and there is no provision for any breast surgery. I have worked hard all my life and paid national insurance for forty years. An acceptable bust is extremely important to any woman and having to shave is degrading. I cannot wear anything that is pretty because I am so self conscious about my lack of a bust. Why is the mental impact of this conveniently ignored? Given accepted government figures that show over 80% of trans people are unemployed how on earth are we supposed to pay for breast augmentation ourselves? We enter transition to alleviate the damaging psychological anguish that we all feel yet,by refusing this surgery the NHS are simply compounding our problems. Please give us what we know we need not what you think we need. We are human beings not numbers on a spread sheet!!!.

  2. Ginny Jones says:

    Dear Mr Palmer,
    I have recently received an email from the laurels in Exeter after enquiring as to my progress on the waiting list. They replied –

    “The people currently at the top of the list were referred at the end of May 2016. However, please note they have been at the top of the waiting list for over a year.”

    The website tells me that current waiting times for first appointment is 30 months and for treatment a further 26 months!

    The way in which this waiting list is being managed is not open to public scrutiny. For example, I suspect that adolescents having been treated prior to 18 by the tavistock clinic, have their treatment continued by adult services. The net effect would be that they are effectively being prioritised for treatment over adults waiting on the list. Is this the case?

    If it is, it leaves older patients more likely to become an anaesthetic risk due to chronic illness and hence unelligible for surgery (having spent their life already subject to discrimination).

  3. Kate says:

    How does NHS England intend to stop the unauthorised sharing of Trans patients personal information on the various computer platforms used by Hospitals and GP’s. Is it not about time for everyone to followed the GDPR, The GRA Section 22 and the Equality Act with respect of the protected Characteristic of Gender Reassignment. All to often highly personal and confidential information is available for all staff to read regardless of what department they work in. Even the GMC’s own guidelines makes it clear, that a clinician should receive the patients written permission before sharing any Gender related information with any other doctor. And this information should not be shared with any other party. Yet receptionists in GP’s surgeries can see inappropriate summary records for Trans patients without such permissions. The same also happens in hospitals. This should not be happening 14 years on from the 2004 Gender Recognition Act. What needs to happen for the NHS to follow the law ?

  4. Mirade pretty says:

    People think it is a joke that I am pretty girl. Because I am a 49year old man but I am going to explode if I can’t be mirade wish people who I know. Know that I am a crossdresser and have been since I 9year old .not a lot of time left to be me.please can you help me I’m going to transition soon. But I could do with a little bit of advice because I will be a girl. But don’t want to hurt anyone .This is not trivial it’s going to be very rough to me because my breasts are getting bigger and I will not stop the wheels suffering from anxiety and depression aswell please help me

    • NHS England says:

      Hi Mirade,

      For any medical advice please speak to your GP, or call 111.

      Kind Regards
      NHS England

  5. anna jeannette dixon says:

    in 1991 i went though hell just after surgery and left in a cubic for ten days with no help from the nursing staff and just up on a dip with no food for this ten days when the ward sister come back from she holidays she walking into my cubicle and saw the state I was in and was shocked to her core, she never seen any one in such a state as I was, left in a dirty cubicle and laying in my own fessies for ten days and left naked with no help or interaction from nurses and the surgery was more like buchary the nhs made 3 attempts to put thing right but fail dismally pain was not in this is was more like hell and the NHS as tried to cover all there mess up by denying everything I am now 64 and living alone and will not socialize I got a job and have kept my head down said nothing just tried to keep going to survive but i was a real mess and still having urinal problems witch the NHS will not sort out they used me as there guinea pig and pin cushion

    • NHS England says:

      Hi Anna,

      I’m sorry to hear about your poor experience of care. You can find more information on how to make a complaint about NHS Services on the NHS Choices website.

      Kind Regards
      NHS England

  6. Pauline Jeenes says:

    Due to my inability to attend the gender clinic in Nottingham due to my various increasing physical and psychological ailments in 2013/24 after changing my identity and title from male to female and have been living in my gender roll since and to being unpassable as a woman visually with my masc. features I was denied access to the hormones I desired to go towards correcting the mistake of this prison they call a body trapped between worlds

    I thought and hope that maybe this should be addressed in perhaps something with special circumstances with a local GP’s allowing a patient who as above lives full time in the gender roll and is unable to attend the gender meetings in which the patient would with full knowledge with signing a waver where the Dr’s are happy to prescribe that the doctor’s and the surgery was not to be held responsible for the outcome of the hormones prescribed to that a patient could then under specific circumstances be able to have the desired controlled hormones. I can give details of the above ailments if required.

    • NHS England says:

      Hi Pauline,

      I’m sorry to hear about your poor experience of care. You can find more information on how to make a complaint about NHS Services on the NHS Choices website.

      Kind Regards
      NHS England

  7. Keith Lang says:

    Are the results of the consultation out yet?
    I asked for some kind of counselling earlier in the year and I am still waiting for any kind of reply after local no progress and a wish to be referred to a GIC

  8. Laura Fraser says:

    All well and good re the service specifications – but where are we with the clinical commissioning policy – has there been any progress since the Interim Protocol?

  9. Laura says:

    In view of the draft service specifications – is there any development on a new Clinical Commissioning policy for Gender Identity Services? Or is the interim protocol still in play? A reply would be appreciated.

  10. Mandy Cameron says:

    I was diagnosed with GID in 1996. I did not have a successful hormonal reassignment and did not develop secondary sex characteristics, breast development was less than 34AA. The GI Clinic put me forward for breast augmentation in 2005 stating that if the surgery was funded I could move on in the clinic and could then be released from treatment, the West Berks PCT have continually refused referrals using every excuse in the book, in fact I could probably write a book about the excuses, some are beyond the ridiculous. After 21 years, I am legally female, physically male, but I cannot function as either, I am stuck in a gender limbo and my GP is still trying to get funding for me, perhaps James Palmer could explain such an injustice in modern Britain ?

  11. Alex O'Rourke says:

    It seems to me that NHS England`s so-called Gender services are more a job creation for clinicians than providing decent care for trans people.

    I was recently assessed at CharingX. The shrink couldn’t even manage to treat me with respect, which ought to be done as a matter of course. She also discriminated against me because of my age and appearance.Have you people never heard of the Equality act 2010,the Human Rights act 2008 and the NHS Constitution and so on? Useless

  12. Honest Jane says:

    Is it any surprise yet another attempt by Specialised Services is being made to convince the naïve, that indulging in poor practice achieves fair and meaningful documents of a high standard?
    They may have, foolishly, convinced themselves, or allowed themselves to be deceived into believing, toxic and self-important behaviour achieves this.
    It never does, it only excuses rising levels of discriminative practice, so abundant, yet so preventable by meaningfully listening to advice from those who actually know their communities, not those who think they do.

    • NHS England Specialised Commissioning team says:

      I’m sorry that you have concerns at the way in which NHS England has engaged with trans people and organisations that represent them in the process for developing the proposed service specifications. The proposals have been informed by a number of workshops and other events that we have held with trans people over the past few years, and we are now holding a public consultation so that everyone with an interest in these documents has an opportunity to have their say. No decisions will be made on the final version of the specifications until the outcome of consultation has been carefully considered.

  13. Chris Hart says:

    Dear James,
    My name is Chris Hart I am the MD of Cristianos Laser Clinic. We have been providing hair removal(laser Intense Pulsed Light and electrolysis for both F2m and M2f patients for 20 years over five national sites. I was privileged to have been asked by Dr Dean to give expert information to the Depilation Sub Committee and despite providing information in respect of a Clinical Paper looking specifically at light assisted facial hair removal in M2F patients this does not appear in the evidence review. in fact to states no trials have taken place looking at this patient group. I am concerned at both the number of treatments and the limited modalities on offer to patients in the new proposal. I believe this will greatly reduce patient choice and indeed may lead to Health and safety issues.
    I also would like to request the North event is rescheduled as the consultation document was issued on the 7th and the event on the 8th.

  14. Adam Butcher says:

    Dear Sir

    what about the mental health of the person who is going though the Gender Identity Services.

    • NHS England Specialised Commissioning Team says:

      Dear Adam. The two service specifications that we are consulting on take into consideration the mental health of people accessing services. In particular the non-surgical specification describes how patients will have access to a named professional and lead clinician who will assess and manage health risks as a routine part of each individual’s initial assessment. This will include looking at their ongoing health risk management through regular clinical review process and this will include identifying any mental health issues.

  15. Bernard Reed says:

    Dear James, The Gender Identity Research and Education Society (GIRES) applauds the sustained effort by NHS England (NHSE) to improve gender identity services for children, adolescents and adults. It is heartening that Will Huxter’s work will be continued by a person of such high status within NHSE. We will be very pleased to be involved in the current consultations regarding adult services and were encouraged by the care that Dr John Dean, Steve Hamer and Sara Greater took to listen and respond to stakeholders’ views at the first consultation event in Manchester on 8 September. Regarding the service for adolescents, we are disappointed that the current service specification and policy have been based on a deeply flawed evidence review. We have informed NHSE of the errors in that document and suggest that the resulting specification and policy be urgently reconsidered. Kind regard, Bernard Reed, Trustee, GIRES

    • NHS England Specialised Commissioning Team says:

      Dear Bernard. Thank you for your feedback, and for taking part in the event in workshop in Manchester. As you know, the service specifications that NHS England is currently consulting on are for adults aged 17 and above. There are no plans at the moment to re-open the consultation on the service specification and policy for services for children and adolescents.

  16. Claire Eastwood says:

    There was a rail strike on July 8th so that anyone who doesn’t drive or live in the Manchester area could not get to the Sparkles consultation.

    Can you rerun a northern consultation please