gender reassignment surgery nhs

Feminising surgery patient

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Feminising surgery

Feminising genital surgery aims to reduce gender dysphoria by aligning a trans person’s anatomy with their gender identity and identity expression goals..

Some transwomen decide that they want to have surgery to permanently alter their anatomy, however not all trans feminine people choose to have surgery.

All referrals are done via the gender identity clinic and the surgery and immediate follow-up care is handled by the Gender Dysphoria National Referral Support Service (GDNRSS).

Patients may be referred to the district nurse or GP if they require wound care in the days following the operation. Patients will remain under the care of the GDNRSS for a year, after which time any ongoing care will be discharged back to the GP.

Vaginoplasty surgery

A vaginoplasty is an operation which aims to remove the penis and testes and create a vagina, which is either sexually functioning or not. While there have been several different types of procedures in the past, most vaginoplasty operations are now carried out in a standard way.

The Nottingham Centre for Transgender Health can make recommendations for surgery for those who are suited to this type of operation.   

To find out more about the surgery services the NHS provide, you can read the service specification on the NHS England website. 

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Transition involves a profound change in your life; this may seem daunting but we are here to help. There are a range of challenges to be addressed during your transition, so we’ve prepared a checklist to help you prepare.

This list is not exhaustive. Transition involves much, much more than the obvious medical interventions of hormone therapy and surgery. You will also need to consider its social and legal implications, from formally changing your name through to dealing with the emotional aspects of informing family and friends.

Helpful hints for transition

• You will be provided with a great deal of new information about gender identity issues by the clinic. We recommend that you keep this and all correspondence relating to your treatment in a file, to support your Gender Recognition Certificate application in the future, should this be required. 
• Living life in your new social role may be very different to your current life and you are likely to have many new experiences; be ready for change and for some challenging situations. Ask your Named Professional for help if you feel overwhelmed by everything; difficult challenges can be overcome with help.
• Medication and hormone treatment may be offered. We strongly discourage self-medication with irregularly sourced drug treatments. Internet-sourced hormone therapies can be dangerous and are sometimes contaminated. Their use is likely to affect blood test results and, if our medical team are unaware of your self-medication, they may inadvertently offer inappropriate advice or recommend unnecessary investigation. Please, be honest with us. 
• Gender reassignment surgery (GRS) cannot be provided until you have lived in a social role appropriate to your gender identity for at least twelve months. 
• At some point, you will want to tell other people about your transition. We can advise you on how to carefully and sensitively inform all those who need to know about your transition, from family members to employers. Employers have legal responsibilities to protect you and Unite have written a guide on Trans Equality at Work, click here to view the Trans Equality at Work Guide . 
• You may be eligible for NHS-funded treatment to reduce your facial hair (epilation).  There is a limit to the amount of treatment funded by the NHS and there is no guarantee that this will reduce your facial hair to your complete satisfaction. If you want additional or future epilation treatment, you will have to pay for this yourself. We can advise you about this.
• Your pension and any benefits arrangements might be affected if you’re a transgender. Seek advice from your private provider and/or the Department of Works and Pensions .  
• Appropriate use of pronouns may become an issue. Politely advise people of your preferred pronoun.
• Transphobic hate incidents may happen and can take many forms including verbal and physical abuse through to threatening behaviour and online abuse.  Transphobic hate crime is a criminal offence.
• As you prepare for your new life you may require assistance with clothing, footwear, wigs, and cosmetics. You may also need guidance with this, your Named Professional will be able to provide advice on all these matters.

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Mental health, learning disabilities and speciality services

Northamptonshire Gender Identity Clinic (GIC) is one of 7 specialist clinics currently operating in England. From undertaking assessments and making recommendations to providing ongoing support throughout treatment, transition and gender reassignment, we strive to create a safe space where our patients are at the centre of what we do.

Our current estimated wait time

Our estimated wait time for initial assessments:

Our service is currently experiencing a high volume of patient demand. We appreciate your patience as we work to provide the best care possible. Please expect longer waiting times and we will do our best to attend to everyone’s needs as efficiently as possible.  

We are currently seeing patients who were initially referred to us in 2019.

The Northamptonshire Gender Service (NGS) is a multidisciplinary team, based at Danetre Hospital, Daventry, who aim to work closely with people to achieve good outcomes for the whole person.

How do I register for this service?

Meet the team, reviews and feedback, accessibility information, useful resources and links.

Northamptonshire Gender Identity Clinic (GIC) is one of 7 specialist clinics currently operating in England. Our multi-skilled team of professionals looks to provide support for people's gender diversity.

From undertaking assessments and making recommendations to providing ongoing support throughout treatment, transition and gender reassignment, we strive to create a safe space where our patients are at the centre of what we do. 

Who is this service for?   People wanting support with gender dysphoria

Your location could not be determined. To get directions please enter your postcode, below.

We accept referrals from your GP or NHS healthcare professional. We also accept self-referrals to the service. Referrals can be made using the referral forms. 

We only accept referrals for people aged 17 and above.

If you are self-referring we would ask that you discuss this referral with your GP as if they are not in agreement with long-term prescribing and monitoring this may affect future care.

• GP referral form for Gender Identity Clinic[pdf] 267KB
• Self referral form for Gender Identity Clinic[docx] 104KB

Disclaimer: Care has been taken to ensure information on this webpage is correct, however it is subject to change.  

More information on referrals

The referral should include the below:

The relevant referrer has completed either:

The service user must be 17 years old at the time of referral

A service user’s GP must be in agreement to the referral being made and has indicated on the referral form that they are willing to collaborate with the clinic by providing the treatment and monitoring required as part of the care plan. By doing this they are agreeing to prescribe and administer medicinal treatments that are advised by Northamptonshire’s GIC Consultants.

 Although the GP’s agreement to provide treatment is a non-binding agreement of shared clinical responsibility, without GP collaboration Northamptonshire GIC will be unable to progress further than providing a diagnosis, as the clinic is not commissioned or funded by NHS England to prescribe or administer medicines directly.

If there is a clinical history of mental health difficulties or physical conditions, the referral must clearly document this, any diagnosis, and indicate any interventions or treatments that are currently in place to manage any identified risks.

Our team is not commissioned or resourced to provide Crisis Management. Therefore, in times where someone is experiencing distress to the point that their own safety or the safety of others is at risk, we would want you to have the best support possible and so we would ask that the relevant services are in place to support you. This would not affect your later treatment with the clinic, it is important that those accessing our service have the best support for any other issues or concerns. If you find yourself in crisis please visit one of our Crisis Cafes , ring the Mental Health Number or if your are in danger call 999.

Gender Clinic Danetre Hospital H Block London Road Daventry Northants, NN11 4DY

Email:  [email protected] Telephone: 03000 272858

Mon-Fri: 09.00-17.00 (Appointment only)

How to find us

The Northamptonshire GIC is based at Danetre Hospital’s Mental Health Resource Centre in the small town of Daventry.  It is easily accessible from the M1 and M6 motorways.  There are nearby railway stations at Long Buckby and Northampton and a regular bus service from Rugby, Banbury and Northampton for those travelling by public transport.  You can find the local bus timetable online.

Parking is free and the clinic enjoys access from both front and rear hospital entrances for those arriving by taxi or car.

If you need help with travel, there may be help available. Let us know so we can help you complete the NHS help with health costs form  with you. Help with ravel costs may be available.

Our skilled and compassionate team includes:

• Speech and Language Therapy (Voice)
• Peer Support Worker
• Administrative Team

We have agreements with Oxford and Leicester Universities to take clinical psychology students on placement. We have agreements to take student nurses on placement.

It is important for us to hear from our clients about the service they have received so we can continually improve the service we provide.

You can access a feedback form  to give your comments or suggest any improvements for our service.

Thank you for taking the time to leave a response.

AccessAble provides information about accessibility at Danetre Hospital

The Equality Act 2010

The Gender Recognition Act 2004

Transgender Policy Guide for Employers 2015

The Workplace and Gender Reassignment: A guide for staff and managers

Providing Services for Transgender Customers

Interim NHS England Gender Dysphoria Protocol and Guideline 2013/14

Guidance on Prosecuting Cases of Homophobic and Transphobic Crime

A list of regional helplines

Beaumont Society

Gender Identity Research and Education Society

Gendered Intelligence

Press for Change

The Transgender Zone

LGBT Foundation

The Transitional Male

Switchboard LGBT+

Mind - Transgender helpline

More about our service

We provide a service for people seeking support around their gender diversity, we are commissioned to:

• Undertake diagnostic assessments for Gender Dysphoria
• Offer advice on hormone treatments to GPs with whom clinical responsibility is shared
• Provide specialist interpretation of blood test results that are undertaken by the GP
• Undertake physical examinations to ensure any risks are minimised and controlled
• Provide second opinion assessments for other Gender Identity Clinics
• Undertake assessments and make recommendations for gender reassignment surgeries
• Provide on-going support and monitoring throughout treatment, transition and gender reassignment.

The clinical team aim to provide a high quality gender identity service that:

• Follows NHS England Protocols on gender dysphoria to provide the framework for the clinical pathway through the service
• Is patient centred
• Promotes multidisciplinary working
• Advocates patient and health professional collaboration in formulating individualised care plans
• Supports and advises our primary care colleagues in the safe and effective delivery, monitoring and treatment of patients with gender identity needs
• Offers fair and equal access to the service;
• Signposts patients and other health professionals to appropriate information and support resources;
• Promotes positive awareness of gender issues and the legal rights of people who are transgender, in line with the Equality Act 2010.

Contact with the clinic

Appointments

It is very important that you attend your appointments at the scheduled time, we ask that you present to Reception within the Mental Health Resource Centre so that you can be booked in. If you are not able to attend an appointment please let us know at the earliest opportunity so that we can rearrange your appointment, also your cancelled appointment can be offered to someone else who is waiting to be seen. One further appointment will be offered by the clinic following a DNA (did not attend), but if that second appointment is not attended then you will be discharged from the service and referred back to your GP.  Where appointments are cancelled without notice, contact via the telephone will be made. If you are travelling a long distance to your appointment we recommend that you contact us prior to setting off to ensure your appointment has not been cancelled.

Clinic Letters

Northamptonshire GIC copy all correspondence sent to primary care (GP) colleagues to the service user at their home address, unless requested not to do so. Please let the GIC know how you would like your letter addressed; for instance gender, name, title, address. You can discuss this with your clinician at your appointment. We can also arrange for shortened versions containing just your treatment plan to be sent out if you should wish.

Prior to your first assessment with the GIC it may be that appointment letters or similar are addressed using the details we have on record, which may differ to someone’s preference. This will be due to what is recorded on our system but can be amended following your first contact.

We recognise that postal services can be unpredictable and clients who fail to attend appointments sometimes have informed us they had not received their appointment letter. We are aware that clinic letters following appointments are not always received as quickly as would be preferred. Unfortunately the length of time can vary due to staff capacity and number of appointments within a given period.

If you are expecting a clinic letter and have not received this within the expected time frame, please contact us via email/telephone.

GIC Emails/Telephone

The GIC can also be contact by email [email protected] . This way of communicating with the clinic can be used for queries such as appointments, letters, emailing blood results, GP queries, etc. Emails sent to the GIC will be responded to as quickly as feasible, but due to limited administrative support, the complexity of a matter, or advice required, this may take some time.

We would ask if the matter is urgent that you communicate by telephone on 03000 272858, and follow up with an email. If the matter is more urgent, typically this will concern prescriptions of hormones or blood results etc., it is likely that one of staff in the clinic will ring you directly and we would be grateful if you would keep the clinic informed of your current mobile number. This also speeds up communication about appointments, which unfortunately from time to time might need to be changed.

The role of the GP

Your GP is pivotal in the provision of your treatment pathway, hormone treatment and referral to other services, including secondary care services when there are co-morbid health concerns. Typically this might include unstable diabetes or hypertension, mental health and communication difficulties.

We recognise however that GPs from the wider referral base may have no knowledge of the field and from time to time GPs are reluctant to initiate treatment as they are unfamiliar with the use of this drug in particular outside of its licensed indications. GPs can seek guidance on our website with the information and links provided or contact us by phone/email found in the Contact Us section.

We will provide individual support to GPs by phone if required, particularly in the use of gonadorelin analogues such as Prostap.  We would ask that any GPs with concerns get in touch directly with the clinic, by phone or email and we are able to provide copies of the National Standards of Care and reference to relevant commissioning documents.

GPs should ensure they are involved in the referral process, particularly if another clinician or healthcare provider is referring (e.g. Tavistock GIDS, CMHT). In particular, it should be checked that the GIC’s referral form has been completed for agreement to collaborate on prescribing and monitoring.

In the case of self referral – we will advise in writing that a service user has self-referred to make the GP aware and request support and collaboration.

Why we require GP involvement

NHS England commissioned Specialist Gender Services are only commissioned and resourced to provide specialist assessment of gender related distress, some specific interventions and advice or onward referral for medical treatment of Gender Dysphoria.  These services and responsibilities are detailed in the NHS Interim Gender Dysphoria Protocol and Service Guideline 2013/2014.

Nationally, Gender Services successfully rely on cooperation with GP colleagues to provide prescribing and phlebotomy services as advised by the Gender Service – which is the case for all patients under our care.  This arrangement benefits the patient as it is convenient and maintains continuity of care with their local GP.  NHS England have made clear that GP or local CCG have the responsibility to ensure that patients have access to the treatments and monitoring that are advised by the Gender Service.  The prescription and phlebotomy advised can usually be undertaken by the GP, but otherwise they can be arranged by the local CCG to be provided between a local hospital and endocrinology service.  The Gender Service do not initiate nor co-ordinate these arrangements and they need to be arranged and managed locally.

The treatments advised are usually familiar to primary care practice, and specific prescribing and monitoring advice is available for the treatment of Transgender patients.  The prescription of medications ‘off licence’, particularly where there are no other suitable medications available for treatment, is common to other areas of medicine.  These roles and expectations are detailed in the Advice to Doctors Treating Transgender Patients .  Where colleagues are concerned about their knowledge and experience in prescribing and monitoring hormone interventions for Transgender patents, we are able to advise on each case individually and we are accessible Monday-Friday by phone and email.  CPD resources related to Transgender Care specifically for GP and primary care colleagues can be accessed here.

As we are unable to prescribe hormone treatments and provide phlebotomy services, we seek agreement with GP colleagues that they will do this prior to accepting the referral.  Given that a high proportion of patients who are assessed seek and are advised hormone therapy as an effective way to address Gender Dysphoria, a diagnosis without treatment is unhelpful and damaging.  Failure to provide the necessary treatment is the responsibility of the GP and local CCG, and if not provided may be discriminatory under the Equalities Act 2010 and will increase distress and harm to the patient.

Therefore we will not be able to progress treatment if there is no agreement in principal regarding the provision of advised treatment and phlebotomy services, or a detailed account of why it is in the best interest of the patient to be seen for assessment only.

Terminology

Diagnosis .

Northamptonshire Gender Clinic uses the ICD-10 classification system and you may see the term "Transsexual F64.0 - male to female" or "Transsexual F64.0 - “female to male” in the diagnosis section of clinic letters.

We recognise that terminology changes and classifications often lag considerably behind and that many service users object to the term "transsexualism" or "gender identity disorder". We are however obligated to use these terms until there is an official change in the classification system. Clinicians will be happy to discuss any particular wish you may have regarding how your condition is referred to in formal correspondence and wherever possible we will attempt to correspond with you in accordance with those wishes. From Jan 2022 the ICD 11 term will be “Gender Incongruence of adolescence or adulthood” (HA60).  When ICD 11 is incorporated into the NHS, this will be reflected in the team’s terminology

This service recognises that people undergoing treatment may not wish to be referred to as "patients" or "clients" and may have already had experience elsewhere in the UK or overseas and may have strong views, for example, of the role of professionals as gatekeepers of service and the relevance of counselling or psychological interventions and what they regard as a normal emotional state. We welcome your views and will seek to reflect that in your individual treatment plan.

Confirming and expressing gender identity should be a positive and empowering experience for everyone.

Gender Dysphoria

In recent years the needs of individuals identifying as transgender and experiencing gender dysphoria has become increasingly highlighted, raising their profile both within the NHS and in wider society through the media. For transgender people, the sex they were assigned at birth and their own internal gender identity do not match.

This incongruence can be a source of significant distress. Indeed, the DSM-5 identifies this distress as ‘gender dysphoria’, where up to 1% of the population reportedly experience ‘Gender Variance’ (WPATH 2011). This highlights an increasing demand for support for individuals experiencing gender dysphoria.

For some individuals who experience gender dysphoria, medical interventions alone, such as hormone therapy and gender reassignment surgery, can alleviate associated distress. Others may need more in depth support around their psychological wellbeing and mental health.

We recognise that there are identities other than the traditional binary identities. People who identify as non-binary may think of themselves as both man and woman (bigender, pangender, androgyne); neither man nor woman (genderless, gender neutral, neutrois, agender); moving between genders (genderfluid); or embodying a third gender.

The Northamptonshire GIC accepts referrals for people who identify as non-binary and this is in line with the guidance given to us by NHS East Midlands, who commission our service.

Non-binary individuals may have different goals to binary transgender individuals. This can lead to challenges regarding the treatments offered. Medical treatments and surgical procedures can create physiological changes that are not yet sophisticated enough to tailor to individual desires. The GIC always aims to explore, and cater to, someone’s goals and aspirations as fully as possible.

The Gender Identity Journey

A diagnosis of gender dysphoria can usually be made after two in-depth assessments carried out by two or more GIC specialist clinicians. However, each person is different and treatment plans vary according to the individual’s needs and circumstances.

Assessment can include:

• Personal history and background
• Exploration of gender identity and gender dysphoria
• History and development of gender dysphoric feelings
• Impact of stigma on mental health
• Availability of support from family, friends, and peers
• Physical health and a physical examination.

The assessment helps determine how someone experiences gender dysphoria and what their needs might be which could include:

• Whether someone has a strong desire to change physical characteristics as a result of gender dysphoria
• How someone manages any difficulties they experience
• How feelings and behaviours have developed over time
• What individualised support and treatment people require.

We recognise that individuals are unique and we would not seek to put service users under pressure to achieve particular arbitrary goals. 

However, we do ask that individuals explore with the clinician they are seeing any barriers to their living in role (typically these would be occupational or relationships with families) so that we may work out an appropriate treatment path and help identify resources for individuals who are experiencing difficulty. 

We generally find clients of this service are living fully in role within a year of presentation, comfortable and able to explore their emotional reaction to change in their appearance and the impact that has on who they meet and whether they feel safe and effective in their new identity. 

If needed we can advise you in applying for changes in your personal details and health service records and there is generally no charge for supporting letters to banks, licensing authorities, passport office etc. Links for further information can be found on on resource and guidance tab.

We also offer a ‘Welcome Workshop’ for people with upcoming initial assessment appointments. The workshop is run on a monthly basis, which people are automatically invited to attend. It is an opportunity to find out more about the gender clinic and to meet others involved. The workshop will include an overview of our service, physical health, and looking after ourselves.

Hormone therapy can be part of the process of changing the body, depending on someone’s gender identity and needs. Hormones usually need to be taken indefinitely, even if surgery is undertaken. The aim of hormone therapy is ultimately for someone to feel more comfortable with themselves. Possible changes from taking hormones are listed below.

Hormone treatments to assist with gender transition can only be commenced after two documented diagnoses of Gender Dysphoria/Transsexualism, alongside a satisfactory physical exam and blood results, as per our GIC guidelines.

Each person's treatment is individually tailored to achieve a safe and effective feminisation or masculinisation and is in keeping with national and WPATH guidelines.

Effects of Taking Oestrogen

• Penis and testicles getting smaller
• Less muscle
• More fat on hips
• Breasts becoming lumpy and increasing in size slightly
• Less facial and body hair

Effects of Taking Testosterone

• More body and facial hair
• More muscle
• Clitoris gets bigger
• Periods stop
• Increased sex drive (libido)
• Voice may get slightly deeper, but may not be as deep as other men’s voices.

Most physical changes, whether feminising or masculinising, occur over the course of two years. The amount of physical change and the exact timeline of effects can be highly variable.

Meetings with a Clinical Psychologist may help to explore and clarify ideas and feelings, improve relationships, develop strategies to manage health pre- and post-operatively, as well as resolve or manage distress.

This could be for purposes such as:

• Exploring gender identity, role, and expression
• Addressing the negative impact of gender dysphoria and stigma on mental health
• Alleviating internalised transphobia
• Enhancing social and peer support
• Improving body image
• Promoting resilience.

These could be addressed through individual or group work as agreed during consultation.

We will discuss the surgical pathway relevant to your individual needs in a very early stage in your attending this service and will be sensitive to someone’s changing ambitions and do not expect or require service users to undergo surgery until they are ready for it, or if not part of their treatment goals.

The Northamptonshire GIC will make referrals endorsing and recommending surgical procedures to appropriately qualified physicians on the basis that it is their clinical opinion that the patient is both eligible and ready to undertake such procedures.

Whilst individual time spans can vary, the following guidelines apply:

• Upper body surgery (Bilateral mastectomy/Breast reconstruction) - Upper body surgery requires one documented clinical recommendation from a GIC Specialists who know the patient. This must be no sooner than 6 months after assessment with Northamptonshire GIC
• Lower Body surgery – Lower body surgery requires two recommendations from a GIC Specialist. This must be no sooner than 12 months after assessment with Northamptonshire GIC.

Not everyone experiencing gender dysphoria will feel they need surgery, or may only require very specific procedures. Individual needs are discussed throughout contact with the clinic.

The aim is to increase someone’s comfort with themselves and reduce gender dysphoria through surgery.

Masculinising surgery may involve

• Bilateral mastectomy (removal of both breasts)
• Hysterectomy (removal of the womb)
• Salpingo-oophorectomy (removal of the fallopian tubes & ovaries)
• Phalloplasty or Metoidioplasty (construction of a penis)
• Scrotoplasty (construction of a scrotum) and testicular implants
• Penile implant.

Feminising surgery may involve

• Orchidectomy (removal of the testes)
• Penectomy (removal of the penis)
• Vaginoplasty (construction of a vagina)
• Vulvoplasty (construction of the vulva)
• Clitoroplasty (construction of a clitoris with sensation).

Voice Modification

Voice modification.

We have a Speech & Language Therapist (SaLT) based within our hospital sites in Northampton and Daventry who can provide sessions for people if required.

The methods used are likely to vary depending on your needs but may involve moderating pitch, intonation, resonance, and articulation as well as non-verbal aspects such as posture and breathing.

Speech and Language Therapy (Voice Modification)

The Speech and Language Therapy – SLT (sometimes referred to as SaLT) department at Northamptonshire Gender Identity Clinic works with individuals who wish to achieve vocal change through voice and communication therapy. Current patients of the GIC can request referral to this service during a GIC appointment or by emailing the clinic.

Content: Voice and communication therapy with us typically involves work on resonance, pitch, articulation, intonation, pacing, volume and projection, as well as other voice and communication aspects. You do not need to have any prior voice knowledge or vocal training. The content of the therapy however is largely guided by the individual and their specific requirements. Voice therapy begins with a 1-on-1 initial session, which is where you will be able to meet your therapist, discuss what you’d like from therapy, your voice and communication objectives and learn more about what therapy entails. It is also a chance for you to ask any voice-related questions.

Format: A course of therapy here usually comprises 1-on-1 sessions. Group sessions may be offered after this, where available and if appropriate for the individual and their voice objectives. Remote voice sessions are often possible via prior agreement with the therapist.

We are committed to working with each patient to establish the most suitable therapy content and format for them to meet their voice goals and support them in developing the right voice for them.

What happens in an initial voice therapy appointment?

The initial appointment is mostly an information-gathering session for the therapist, but also for the patient. The therapist will ask you questions related to your voice. This will include questions like: Have you ever had speech and language therapy before? What is your current voice use like? What would you like from voice therapy? You do not need to prepare anything beforehand. The patient and therapist will set some short term voice goals and suggest aspects you could work on together in order to meet these goals. The therapist will also explain the format and timescale of the sessions. Usually the therapist (with consent) will take one or two very short (< 1 minute) audio recordings of your voice as a baseline.

Is it true that voice modification therapy is for trans women only?

No. We work with any GIC patient to help them develop the right voice for them. This includes non-binary individuals and trans men.

I would prefer to have voice modification therapy closer to where I live. Can I access voice therapy locally?

You can request referral to your local Adult Speech and Language Therapy service via your GP. If the referral is accepted, local voice therapy can be provided closer to your home.

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Gender reversal surgery is more in-demand than ever before

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Gender reassignment surgery has been available on the NHS for more than 17 years.

It’s a treatment for those experiencing gender dysphoria, whereby a person recognises a discrepancy between their biological sex and their gender identity.

Gender identity clinics are in place throughout the UK to provide support to those feeling distressed by the condition - but what happens when a trans person undergoes surgery and later decides to revert back to their original gender?

Is it possible? Is it safe? And is it available on the NHS?

These are not questions that are not easily-answered. Five phone calls and endless emails later, the details regarding what circumstances would allow for such a treatment to be carried out on the NHS remain muddled.

It's potentially why some of those seeking “reversal” surgeries are heading to a clinic in Serbia, where Professor Misoslav Djordjevic has been performing them for five years at the Belgrade Center for Genital Reconstructive Surgery.

A specialist in genital reconstruction with 20 years of experience, Prof Djordjevic began conducting the innovative procedures after a transgender patient who had undergone surgery to remove male genitalia requested a reversal.

It's by no means a common practice. He has performed just 14 surgeries to date and is currently in the process of treating two “reversal” patients, reports The Daily Telegraph , explaining that the procedure is extremely complex and can cost up to €18,000 (£15,965).

However, his services aren't easily-accessed. Djordjevic will only treat patients who have undergone a full one-year-long psychiatric evaluation and he stresses the importance of post-surgery aftercare, revealing that he remains in contact with the majority of his patients.

It's not simply a case of people regretting their decision, explains James Morton, manager at the Scottish Trans Alliance , who told The Independent that a range of factors could catalyse the desire for a gender reversal including unusual surgical complications, being worn down by transphobic harassment, family rejection, or developing religious or political beliefs that being transgender is unacceptable.

"If a person has regret about undergoing gender reassignment, it is especially important that they receive counselling and in-depth assessment before undergoing any surgery to attempt partial reversal as their chance of regretting further surgery could be even higher," he said.

"Any further NHS surgery is determined on an individualised case by case basis because the numbers are so tiny."

So far, Djordjevic has exclusively treated transgender females who have asked to recreate their male genitalia.

Known as phalloplasty, the procedure entails the construction of a penis from skin taken from the groin, abdomen or thigh. Though the surgery produces aesthetic results, many mistakenly assume that it will ultimately render one’s genitalia physically futile.

However, a 2013 study revealed that the introduction of penile stiffeners has allowed some plastic surgeons to create a fully functioning organ.

It is a much more risky procedure than its male to female counterpart, vaginoplasty, whereby the testicles are removed and the skin of the penis is used to artificially create a vagina.

Whilst awareness of non-binary issues has increased in recent years, gender reassignment remains a severely under researched topic, so much so that the NHS has produced an online e-learning guide to GPs who might be unfamiliar with gender dysphoria.

The severe lack of understanding surrounding the topic - and its reversal counterpart - became particularly prevalent last week, when a proposed study to explore why transsexual people may want to “detransition” was reportedly shut down by Bath Spa University so as “not to offend people.”

“The fundamental reason given was that it might cause criticism of the research on social media and criticism of the research would be criticism of the university and they also added it was better not to offend people,” James Caspian, the psychotherapist behind the proposed research, told BBC Radio 4 .

He confessed to being “astonished” at the university’s decision.

As of 30 August, there were 213 patients on the list for gender reassignment surgery at Imperial College Healthcare NHS Trust .

At present, there are no statistics regarding gender reversal surgeries in the UK.

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How to find an NHS gender dysphoria clinic

Trans and non-binary people's general health needs are the same as anyone else's. But trans people may have specific health needs in relation to gender dysphoria.

Your particular needs may be best addressed by transgender health services offered by NHS gender dysphoria clinics (GDCs).

All NHS GDCs are commissioned by NHS England, who set the service specifications for how they work.

A GP or another health professional can refer you directly to one of the GDCs. You do not need an assessment by a mental health service first. Neither does the GP need prior approval from their integrated care board (ICB). 

The websites of the clinics listed on this page also have useful information for you to think about before you see a GP. 

Children and young people's gender services

Children and young people should be referred to the National Referral Support Service for the NHS Children and Young People's Gender Service .

These NHS services specialise in helping young people with gender identity issues. They take referrals from anywhere in England.

Gender dysphoria clinics in London and the southeast

The Tavistock and Portman NHS Foundation Trust: Gender Dysphoria Clinic for Adults

Lief House 3 Sumpter House Finchley Road London NW3 5HR

Phone: 020 8938 7590

Email: [email protected]

The GDC website has an overview of information useful for anyone with gender identity needs, not just those in the area.

Gender dysphoria clinics in the north

Sheffield Health and Social Care NHS Foundation Trust Gender Dysphoria Service

Porterbrook Clinic Michael Carlisle Centre 75 Osborne Road Sheffield S11 9BF

Phone: 0114 271 6671

Email: [email protected]

The  Sheffield clinic's website includes information about referrals, clinic opening hours and links to eligibility criteria.

Leeds and York Partnership NHS Foundation Trust Gender Dysphoria Service

Management Suite 1st Floor The Newsam Centre Seacroft Hospital York Road Leeds LS14 6WB

Phone: 0113 855 6346

Email: [email protected]

The Leeds clinic's website covers referrals, commonly used medicines and information on the clinic's Gender Outreach workers.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Northern Region Gender Dysphoria Service

Benfield House Walkergate Park Benfield Road Newcastle NE6 4PF

Phone: 0191 287 6130

Email: [email protected]

The Northern Region Gender Dysphoria Service website has a range of leaflets, including information about referral, hormones and support groups.

Gender dysphoria clinics in the Midlands

Northamptonshire Healthcare NHS Foundation Trust Gender Dysphoria Clinic

Danetre Hospital H Block London Road Daventry Northamptonshire NN11 4DY

Phone: 03000 272858

Email:  [email protected]

Visit the  Northampton clinic's website for more information about how to get a referral and the role of the GP.

Nottinghamshire Healthcare NHS Foundation Trust The Nottingham Centre for Transgender Health

12 Broad Street Nottingham NG1 3AL

Phone: 0115 876 0160

Email: [email protected]

Visit The Nottingham Centre for Transgender Health website  for more information about how to get a referral.

Gender dysphoria clinics in the southwest

Devon Partnership NHS Trust West of England Specialist Gender Dysphoria Clinic

The Laurels 11-15 Dix's Field Exeter EX1 1QA

Phone: 01392 677 077

Email: [email protected]

The Laurels' website has information about the types of services on offer and the help available during transition.

New gender dysphoria services in 2020

In 2020 new NHS gender dysphoria services for adults will open in Greater Manchester, London and Merseyside.

These services will be delivered by healthcare professionals with specialist skills and based in local NHS areas, such as sexual health services. Full details will be available once each service is opened.

Initially, access to these services will be available to people who are already on a waiting list to be seen at one of the established gender dysphoria clinics.

NHS England will assess how useful these new pilot services are.

Page last reviewed: 13 May 2020 Next review due: 13 May 2023

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Changing a trans person's name and gender marker on NHS systems

Advice and Information - 28 July 2021

A trans person can change their name and gender marker at their GP practice just by requesting it. They do not need to have been to a Gender Identity Clinic, taken any hormones, undergone any surgery, or have a Gender Recognition Certificate.

The law in the UK regarding names is actually very unusual, stating that anyone can call themselves by any first name without any documentation at all – as long as they are known by it, it is a legal name! Despite this, Primary Care Support England (PCSE) recommend that healthcare services see a deed poll before changing a patient’s name on their medical record. For this reason, almost all GP practices will ask for a deed poll when amending patient’s names/details.

Patients can obtain a free Deed Poll online at freedeedpoll.org.uk

Changing a patient’s name will not change the gender marker on their medical records. If patients wish to change their gender marker, they must request this. The practice will have to notify PCSE and should make the patient aware of the possible time scales and implications of changing their gender marker (e.g. changes to recalls for cancer screening services).

According to PCSE, when a patient changes gender, they are given a new NHS number and must be registered as a new patient at your practice. All previous medical information relating to the patient needs to be transferred into a newly created medical record.

When the patient informs the practice that they wish to change gender, the practice must inform the patient that this will involve a new NHS number being issued for the them, which is not reversible. If the patient wanted to change their gender marker back to the gender they were assigned at birth, patients would receive a third NHS number. The practice should confirm this has been discussed with the patient when notifying PCSE.

The process (outlined by PCSE) for changing a patient’s gender marker is as follows:

• The practice notifies PCSE via the enquiries form that a patient wishes to change their gender. The practice should include the patient’s name and NHS number in the notification to PCSE, plus confirmation that they have discussed with the patient that this will involve the creation of a new NHS number
• PCSE sends the practice a deduction notification for the patient and emails the main contact for the practice (if available) the new details for the patient
• The practice accepts the deduction and registers the patient using the new details provided by PCSE. Important: Do not update the patient’s original record with their new NHS number. If this happens they will not be registered and will miss out on continuity of care
• PCSE sends a new patient medical record envelope with the patient’s updated details to the practice

The practice creates a new patient record using the new details, and transfers all previous medical information from the original medical record

Any information relating to the patient’s previous gender identity should not be included in the new record. Practices can use gender neutral language and anonymise patient details to retain important information. For example, using phrases such as ‘the patient had a smear on….’ rather than ‘she had a smear on…’. This is to protect confidential information and ensure the practice is in line with the Gender Recognition Act 2004 which makes disclosing an individual’s trans history unlawful in many instances

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• Open access
• Published: 19 August 2024

Discontinuing hormonal gender reassignment: a nationwide register study

• Riittakerttu Kaltiala   ORCID: orcid.org/0000-0002-2783-3892 1 ,
• Mika Helminen 2 ,
• Timo Holttinen 3 &
• Katinka Tuisku 4  

BMC Psychiatry volume  24 , Article number:  566 ( 2024 ) Cite this article

Metrics details

With increasing numbers of people seeking medical gender reassignment, the scientific community has become increasingly aware of the issue of detransitioning from social, hormonal or even surgical gender reassignment (GR). This study aimed to assess the proportion of patients who discontinued their established hormonal gender transition and the risk factors for discontinuation.

A nationwide register-based follow-up was conducted. Data were analysed via cross-tabulations with chi-square statistics and t tests/ANOVAs. Multivariate analyses were performed via Cox regression, which accounts for differences in follow-up times.

Of the 1,359 subjects who had undergone hormonal GR in Finland from 1996 to 2019, 7.9% discontinued their established hormonal treatment during an average follow-up of 8.5 years. The risk for discontinuing hormonal GR was greater among later cohorts. The hazard ratio was 2.7 (95% confidence interval 1.1–6.1) among those who had accessed gender identity services from 2013 to 2019 compared with those who had come to contact from 1996 to 2005. Discontinuing also appeared to be emerging earlier among those who had entered the process in later years.

Conclusions

The risk of discontinuing established medical GR has increased alongside the increase in the number of patients seeking and proceeding to medical GR. The threshold to initiate medical GR may have lowered, resulting in a greater risk of unbalanced treatment decisions.

Trial registration number (TRN)

Not applicable (the paper does not present a clinical trial).

Peer Review reports

In gender medicine, transition refers to people with sex-discordant gender identities making changes in their lives to live in their experienced gender, socially (appearance, name, personal pronouns), juridically (identity documents) or medically (hormonal and surgical medical interventions that modify secondary sex characteristics ) . Detransition refers to people aborting their initiated transition and reversing it, totally or partially, to live in a sex-accordant role by reversing the abovementioned steps of transition.

Recent decades have witnessed an exponential increase in those seeking medical interventions to support their transition (medical gender reassignment, GR), with an increasing share of younger individuals of the female sex [ 1 , 2 ]. Psychiatric morbidity among people who contact specialized gender identity services (GISs) has increased simultaneously [ 2 , 3 ] and is particularly pronounced among the youngest age groups [ 4 ].

It has long been assumed that very few patients embarking on medical GR regret their choice and seek to reverse it. From the 1970s to the 2010s, estimates of those regretting their initiated GR were only in the region of 2% [ 5 , 6 ]. However, more recent research suggests that alongside the increase in the number of people accessing medical gender reassignment, reversing the initiated transition seems to be increasing [ 7 ]. In recent samples, 20–30% of those who initiated hormonal GR discontinued hormonal treatment in four to five years [ 8 , 9 ]. It is possible that some patients discontinue hormonal treatment because they have reached their transition goals. Some changes, such as lowering of the voice, can be reached with relatively short hormonal treatments and are permanent, while maintaining some other changes require permanent treatment.

People abandoning their gender transition have reported various reasons for doing so, such as coming to terms with their natal sex, concerns about medical complications, attributing gender dysphoria to reasons other than gender identity, such as trauma or mental disorders, finding that the transition did not alleviate distress, struggles with sexual orientation and discrimination [ 10 , 11 ]. More importantly, those who have detransitioned have repeatedly reported that before their embarking on medical GR, insufficient attention was given to their mental health and psychosocial problems, which, in retrospect, they believed played a major role in their desire to transition. They have expressed concerns that assessments for medical gender reassignment were too superficial, with no search for explanations for their distress beyond an assumed stable sex-discordant identity requiring transition. [ 10 , 11 ]. This contradicts calls to lower the threshold for medical gender reassignment [ 12 , 13 ]. Several recent national guidelines and recommendations [ 4 , 14 , 15 ], however, emphasize the appropriate treatment of psychiatric comorbidities and associated difficulties as well as a psychosocial intervention facilitating identity exploration as first-line interventions for gender dysphoria before considering medical interventions, particularly for young people.

In Finland, gender identity assessments potentially leading to medical GR interventions are conducted at two of the country’s five university hospitals. Services for legal adults (> 18 years) have been available since the early 1990s [ 16 ] and became available to minors in 2011 [ 17 ]. The national guidelines require minors presenting with feelings of gender dysphoria to first undergo psychosocial intervention to support identity exploration and to receive appropriate treatment for any severe mental disorders [ 14 ], after which they can proceed to the centralized GIS, where diagnostic assessments are carried out by specialized mental health teams. Both GISs have separate diagnostic teams for minors and for adults. Hormonal GR interventions are initiated at the same hospitals in gynecological outpatient clinics, and after stabilization, hormonal treatment is transferred to services in the patients’ places of residence. Genital surgeries with gender identity indication are nationally centralized to one university hospital and require recommendations from both nationally centralized diagnostic GIS units. Psychiatric treatment for any concomitant mental health condition is provided at the specialized secondary care or primary health care facility in the patient’s place of residence. Until 2022, diagnostic assessments at the nationally centralized GIS were also a prerequisite for registered sex change, but since 3 April 2023, legal adults have been granted legal GR on the basis solely of their own request. Medical GR remains nationally centralized and is available case-by-case after a comprehensive diagnostic assessment by a multidisciplinary mental health team, as outlined in the national guidelines [ 14 , 18 , 19 ].

An important ethical principle in all medicine is to not harm. A more severe or life-threatening condition may justify greater risks in its treatment. In medical gender reassignment, hormonal and surgical interventions are performed on physically healthy bodies. If the patient subsequently regrets the changes brought by the treatments, not to mention undesired side effects, this can be considered harmful. As in other Western countries, alongside the vastly increasing number of referrals to the GIS, increasing numbers of younger people with increasingly common psychiatric needs have initiated medical GR in Finland [ 2 ]. This may be followed by increasing numbers of people who later feel otherwise about their medical GR. On the other hand, the purpose of the nationally centralized and comprehensive assessment before medical GR is to ensure reasoned treatment decisions and satisfactory patient outcomes, avoiding possible regrets. This may counteract the risks related to the more complex presentations among those seeking medical GR. Those abandoning their gender transitions have repeatedly claimed that the distress accompanying their situation is not appropriately addressed [ 20 ]. It is crucial to take seriously the desire to reverse medical GR and to ascertain its likelihood and predictors to target medical GR safely and provide appropriate services for those opting out of treatment that has resulted in irreversible changes in a healthy pretreatment body. In the present study, we referred to national registry data to determine which patients are likely to discontinue hormonal GR. More specifically, we asked:

How commonly did people who proceeded to hormonal GR after assessment in the nationally centralized GIS from 1996 to 2019 discontinue their established hormonal GR?

What are the predictors of discontinuation in terms of age, age at admission to the GIS, direction of transition, surgical treatment, psychiatric treatment needs and cohort effects?

Has the risk of discontinuing hormonal GR changed over time?

Design and setting

A register-based follow-up study was conducted using information held in health care registers in Finland. These comprehensive and reliable national registers can be used to study large patient groups and collate information from different registers (on an individual level) via the unique personal identity code assigned to each permanent resident of Finland. Register data can be applied for research purposes from the Finnish Social and Health Data Permit Authority Findata and Statistics Finland. Data extraction, linkages and pseudonymization are carried out by these authorities, and researchers are allotted a special secure connection for pseudonymized data only. Analyses producing unduly precise information potentially enabling a person to be identified must be amended to ensure the anonymity of the persons included. The present study obtained ethical approval from the ethics committee of Tampere University Hospital (R20040R) and relevant permissions from Findata (THL/5188/14.02.00/2020) and Statistics Finland (TK/1016/07.03.00/2020). In accordance with Articles 6e and 9i and j of Regulation (EU) 2016/679 of the European Parliament and of the Council [ 21 ], no individual informed consent was needed.

A personal identity code is assigned at birth (or upon obtaining Finnish citizenship). This indicates sex (male or female). Legal sex change entails a new identity code. People are listed in the national registers according to their currently valid personal identity code. This code serves to retrieve data from various registers (including earlier data under the original identity code). Researchers cannot obtain information about identity code changes (changes in juridical sex). Researchers using the data never see the actual identity codes.

Data extraction

Subjects referred to either of the two nationally centralized GISs were identified from the hospital databases of Tampere and Helsinki University Hospitals. The first contact with a diagnostic team in either of the two GISs was recorded as the index date. The Finnish Social and Health Data Permit Authority Findata combined the lists from the two hospitals. A total of 3,665 individuals were identified as having contacted the nationally centralized gender identity units between 1996 and 2019. Of these, 1,359 had initialized and embarked on feminizing or masculinizing hormonal treatment (see below, next paragraph) and formed the subjects of the present study.

The register of the Social Insurance Institution of Finland (KELA), with information on prescription medications purchased and information on reimbursement, was used to obtain information on hormonal GR in the clinical GD group. Persons diagnosed with F64.0 (since 2020, also F64.8) in the nationally centralized gender identity units are entitled to special reimbursement (code 121) for their hormonal treatment, as are patients suffering from specified endocrine disorders. In the treatment of gender dysphoria, special reimbursement is available when hormonal treatment has continued for more than a year. The data on prescription medications were collected up to the end of 2021.

The Care Register for Health Care [ 22 ] was used for information on all treatment contacts to specialist-level psychiatric services from 1994 to 2022. The register, which has been in operation since 1994, includes all outpatient and inpatient contacts with specialist-level health services in Finland. For all contacts, admission and discharge dates were extracted. The Care Register for Health Care was further used to provide information on gender reassignment surgeries.

The Population Register provided information on those deceased and their dates of death.

Discontinuing hormonal GR

Subjects entitled to special reimbursement for hormonal treatments were considered to have discontinued their hormonal GR if they had purchased no hormones for more than 12 months before the end of the data collection or, if deceased, for 12 months or more before their death, or if they had been purchasing specially reimbursed feminizing hormones but had later switched to masculinizing hormones, or vice versa. To obtain reimbursements for prescription medications from the Social Insurance Institution of Finland (KELA), these medications can be purchased for only three months at a time. Thus, not purchasing them for over a year means that they are most likely not being taken. The last date of purchase of the originally prescribed hormonal GR medication was recorded. Patients who discontinue hormonal GR may require birth-sex accordant hormonal replacement to detransition after gonad removal or if their natural hormone production does not resume. For subjects whose specially reimbursed hormone treatment had changed from masculinizing to feminizing or vice versa, the last date of purchase of the originally initiated type of hormonal GR was recorded.

Types and durations of hormonal GR

In the analyses, hormonal GR was divided into feminizing and masculinizing. The duration of hormonal GR with special reimbursement was calculated in months from the dates of first and last/latest purchase of the originally initiated masculinizing/feminizing hormones.

Time variables

The subject’s year of birth was used in the analyses as a continuous variable. The year of initial contact with the GIS (index year) was categorized into intake cohorts with the first contact with the GIS in 1996–2005 vs. 2006–2012 vs. 2013‒2019. As the inclusion period did not fall into three even periods, the first period, with a clearly lower case load, was extended.

Age at first contact with the GIS (index date) was calculated from the dates of index contact and birth. Age in years was used in bivariate analyses as a continuous variable. In multivariable analyses, age was divided into adolescent (up to 22 years old) and adult (23+) at index contact.

Gender reassignment surgeries

The gender reassignment surgeries recorded were genital surgery (vaginoplasty, phalloplasty/metoidioplasty) and chest masculinization.

Specialist-level psychiatric treatment contact

Specialist-level psychiatric treatment contacts other than those related to gender identity assessment were recorded. Having received specialist-level psychiatric treatment was used in the analyses as a comprehensive dichotomous variable (yes/no). Furthermore, having specialist-level psychiatric treatment contact before entering the GIS (yes/no) was used, as was having specialist-level psychiatric treatment two or more years after entering the GIS (yes/no).

Statistical analyses.

Bivariate associations between discontinuing hormonal GR and the explanatory variables were studied via cross-tabulations with chi-square statistics (Fisher’s exact test where appropriate) and the Mantel‒Haenszel test for categorical variables and t tests and ANOVA for continuous variables. Multivariate associations were studied via Cox regression, accounting for differences in follow-up times. Discontinuing hormonal GR was entered as the dependent variable. The independent variables entered were (1) direction of hormonal treatment (masculinizing/feminizing), year of birth and index year cohort; (2) GR surgeries; (3) age at first entering the GIS (adolescent vs. adult); and (4) and, finally, having received specialist-level psychiatric treatment (yes/no). Hazard ratios (HRs) with 95% confidence intervals are given. The cut-off for statistical significance was considered p  < 0.05.

There were 1,359 people who, after having been assessed in the nationally centralized GIS, had purchased masculinizing or feminizing hormones with a special reimbursement code. The mean (sd) age of the participants on admission to the GIS was 25.6 (9.3) years, and 49.1% of them were under 23 years of age. In total, 467 (34.4%) had received feminizing treatment, and 892 (65.6%) had received masculinizing treatment. At index contact with the GIS, those who subsequently initiated feminizing GR were older than those who proceeded to masculinizing GR (29.7 (11.1) vs. 23.4 (7.3) years, p  < 0.001). The mean (sd) duration of hormonal GR was 62.0 (57.0) months, with a median of 44.5 months, with no difference between masculinizing and feminizing treatments. Genital surgeries were more commonly performed on those who had proceeded to feminizing treatment (46.7% vs. 14.9%, p  < 0.001). Among those on masculinizing treatment, 41.5% had undergone chest masculinization. Among all patients proceeding to hormonal GR, 57.4% had ever had treatment contact with specialist-level psychiatric care.

A total of 107 subjects (7.9% of those who had started hormonal GR and obtained special reimbursement for it) had not been purchasing GR hormones for at least a year before the end of data collection (or before the subject died) or had changed from feminizing GR to masculinizing treatment, or vice versa. These were considered to have discontinued hormonal GR. Among those who had obtained feminizing GR, 10.5% had discontinued hormonal treatment, and among those who had obtained masculinizing GR, 6.5% ( p  = 0.004). Those who discontinued hormonal GR were slightly older at the index contact and at their latest purchase of specially reimbursed hormones than those who continued hormonal GR. The two groups had used hormonal GR for comparable periods. Those who discontinued and those who stayed on hormonal GR had comparable specialist-level psychiatric treatment contacts. (Table  1 )

Those who discontinued and those who continued hormonal GR had equally common specialist-level psychiatric treatment contact before contacting the GIS (15.3% vs. 17.8%, p  = 0.5) as well as two or more years after entering the GIS (59.9% vs. 57.0%, p  = 0.2).

Changes across intake cohorts

The basic characteristics of the subjects changed across intake cohorts. The mean (sd) age among those who had contacted the GIS from 1996 to 2005 and subsequently proceeded to hormonal GR was 31.1 (7.9); from 2006 to 2012, it was 25.7 (9.3); from 2013 to 2019, it was 24.8 (9.2) years ( p  < 0.001); and the proportion of adolescents (< 23-year-olds) was 13.7% vs. 48.9% vs. 53.6% ( p  < 0.001). The proportion of those seeking change towards masculinity increased, and the same change was observed among those discontinuing hormonal GR. The proportion of those with specialist-level psychiatric treatment contacts fluctuated between cohorts among those continuing hormonal GR but remained unchanged among those who discontinued it (Table  1 ).

Multivariable analyses

The hazard ratio (HR) for discontinuing hormonal GR was greater among those in the latest intake cohort (2013–2019) as compared to those in the earliest cohort (1996–2005) when the type of hormonal GR (masculinizing vs. feminizing) and year of birth were accounted for (Table  2 Model 1) and when surgical GR (Table  2 Model 2), age at index admission (adolescent vs. adult) (Table  2 Model 3) and, finally, specialist-level psychiatric treatment contact (Table  2 Model 4) were added. Genital surgeries were associated with a decreased HR for the discontinuation of hormonal GR. Earlier year of birth was very slightly but statistically significantly associated with increased HR for discontinuing hormonal GR in the first models but levelled out in subsequent models.

Confirmatory analyses

Because the oldest individuals in the sample may have discontinued hormonal GR due to reaching the age of natural decline in hormonal levels, the final model was repeated among individuals younger than 60 at the end of data collection, but this did not change the findings.

A further confirmatory analysis was carried out using data from those subjects whose index contact was before 2018 because of the rather short follow-up times among those who had started their gender identity assessments in 2018 or 2019. This caused no changes to the findings presented in Table  2 .

Changes in the discontinuation of hormonal GR over time

Survival curves for the three index date cohorts suggested that the discontinuation of hormonal GR emerged in a shorter time from the earliest to the latest intake cohort (Fig.  1 ). To explore this further, discontinuation within two years of obtaining special reimbursement for hormonal GR was scrutinized among those with index dates before 2018. Among the two earlier intake cohorts (combined due to small cell frequencies in the original categories), 1.3% of those who had started hormonal GR discontinued it within two years; among the latest intake cohort, 2.9% ( p  = 0.06).

Time (in years)* to discontinuing hormonal gender reassignment in the different intake cohorts (1 = 1996–2005, 2 = 2006–2012, 3 = 2013–2019). *modeled by Cox regression

In this nationally representative register study covering subjects proceeding to hormonal GR over three decades, 7.9% discontinued their established hormonal GR. The risk for discontinuing hormonal GR was greater in the latest intake cohort (2013–2019) than in the earliest cohort (1996–2005). Genital surgeries were associated with a decreased risk of discontinuing hormonal GR. Over the decades, the time to discontinuation grew shorter.

The proportion of those who discontinued treatment was smaller than that reported in the most comparable study [ 9 ] from the USA, where almost one-third of adolescents and young adults discontinued their hormonal GR within four years. The relatively low discontinuation rate in our study may be due to the comprehensive assessment in the nationally centralized GIS before initiating hormonal treatments. When severe psychiatric comorbidities are present, great care is taken in considering physical interventions [ 2 , 14 , 17 ]. The proportion of those who discontinued their established hormonal GR was nevertheless manifold compared with earlier reports of proportions regretting medical transition among samples who had initiated their treatments between the 1960s and 2010s [ 5 , 6 ]. However, both of those reports focused on actively expressed regrets, and in the latter study [ 6 ], the proportion lost to follow-up—with later development thus unknown—was high. The proportion discontinuing their established hormonal GR in the present study was comparable to the proportion defined as detransitioners (those who discontinued treatment and reverted to living in their original gender role) in a register-based study of 175 subjects initially assessed in 2017–18 in the UK [ 7 ]. However, in that UK study, a clearly greater additional share of the studied group also subsequently disengaged from the treatments or did not adhere to their treatment plan. In a study evaluating the situation of people diagnosed with GD in a specified GP practice population [ 8 ] and, as noted, in a register study in the USA [ 9 ], much greater shares discontinued their medical GR. Direct comparisons among these studies are not feasible because of their different focuses and methodologies. However, together with the most recent studies, our study suggests that discontinuing hormonal GR is a significant phenomenon in gender medicine, and studies reporting the experiences of detransitioners [ 10 , 11 ] suggest that it is often related to profound psychological distress.

In multivariate models accounting for differences in follow-up times and for changes in patient characteristics across intake cohorts, the risk of discontinuing hormonal GR was almost threefold among those patients who had contacted the GIS from 2013 to 2019 compared with those who had contacted the GIS from 1996 to 2005. Our findings also suggest that the time to discontinuation of hormonal GR may have shortened among the later patients; however, in the latest intake cohort, more discontinuations may still emerge, and this will eventually affect the final conclusions about the average time to discontinuation. The proportion of subjects who discontinued after short use, a maximum of two years of specially reimbursed medication use, nevertheless appeared to have increased. (This will mean a maximum of three years of total use, given the rules on special reimbursement). Over the whole study period, the number of people seeking GR increased manifoldly [ 2 ], as did the number of subjects proceeding to hormonal GR. Alongside with this, the risk of discontinuing established medical GR has also increased. The populations seeking medical GR may have changed in a way that limits positive treatment outcomes. It is already known that subjects currently seeking medical GR are, unlike earlier, predominantly birth-registered females, who are younger than before and present with more psychiatric comorbidities than before [ 1 , 2 , 3 , 20 ]. These observations may suggest that an increasing share of GD patients actually do not present with achieved, consolidated identity [ 20 , 23 ]. In particular, medical transition early in terms of identity development may increase the risk of unbalanced treatment decisions, and this risk appears to have increased towards the present day, with detransitioning as the next step. Greater attention to gender identity issues and GR in the media and social media as well as assertive advocacy for medical GR may play a role in these developments [ 20 , 24 , 25 ].

Somewhat unexpectedly, the need for specialist-level psychiatric care did not differentiate those who continued and those who discontinued hormonal GR. Approximately one in six of the patients who had started hormonal GR, both those who later discontinued and those who continued the treatment, had needed specialist-level psychiatric treatment before embarking on gender identity assessments. This number was clearly less than that of all patients who were in contact with the GIS [ 2 ]. It is expected that the two groups would be comparable at the time of the decision to initiate medical GR and suffer fewer psychiatric comorbidities than those who could not start medical GR. However, psychiatric treatment needs increased vastly after the index contact with the GIS in both groups who proceeded to medical GR, those who subsequently discontinued it and those who continued on hormonal GR. A more detailed analysis of the nature of psychiatric needs and subsequent identity struggles is needed to better understand the discontinuation of medical GR in the future. According to the multivariable analyses, the risk for discontinuing hormonal GR did not differ between those who had initially contacted the GIS during adolescence (< 23 years) and those who had contacted in adulthood. This may be due to assessments being particularly cautious with younger patients, whereas with middle-aged subjects, self-determination may be accorded greater significance.

Having undergone genital surgeries was predictive of a decreased risk of discontinuing hormonal treatments. This may be due to strict treatment protocols requiring psychological stability as part of eligibility for genital surgeries. A recommendation letter is required from both the nationally centralized GIS for gender surgeries to ensure both the patient’s capacity to consent and that their psychological and psychosocial resources will suffice to recover from major surgery.

Methodological considerations.

A strength of the present study is the use of nationwide registry data over three decades. The registers are comprehensive since treatment providers are required by law to report to them all the information on which this study relies. The subjects were identified in the databases of the hospitals where the nationally centralized GISs operate, thereby ensuring the reliability of sampling. The long inclusion period made it possible to analyse changes over time. A limitation is that only subjects who had obtained the special reimbursement code for their hormonal GR were included. There may be subjects who discontinued hormonal GR before their entitlement to special reimbursement (which can take place after a year), and their number is not known. Another limitation is that registers include no information on the reasons for discontinuing hormonal GR. Given the ample publicly funded health services and the special reimbursement for hormonal GR, financial problems are an unlikely reason. Further changes in identity, medical complications or concerns over them, not being helped by GR or social reasons, may contribute [ 10 , 11 , 20 ]. It is also possible that some achieved their goals and therefore discontinued, although this seems implausible in the case of discontinuation after many years. A more profound understanding of the reasons for discontinuing medical GR will require studies using information elicited directly from patients. A further limitation is that regarding the need for psychiatric treatment, this research focused on specialist-level service contacts reflecting severe psychiatric needs. Mild to moderate mental disorders are treated in primary health care. Thus, the need for psychiatric treatment was likely somewhat underestimated in the present study. A limitation is that the possible use of hormonal GR through unofficial routes was not addressed. Publicly funded medical GR interventions are possible only through nationally centralized gender identity services. Obtaining hormonal GR via unofficial routes would likely be related to medical GR not being considered timely in the official treatment route. This finding may suggest that the discontinuation of hormonal GR can be more common among those who obtain hormones unofficially. We combined minors (< 18 at intake to the GIS) and late adolescents (18–22-year-olds at intake) because before 2011, minors entered the assessments only occasionally. Brain development, personality development and identity consolidation continue well beyond the age of reaching legal adulthood [ 23 , 26 , 27 , 28 , 29 , 30 ]. Finally, discontinuing hormonal GR, desisting from identifying in a sex-discordant way, detransitioning and regretting medical GR are concepts referring partly to the same phenomenon but not totally overlapping [ 20 ]. A register-based study cannot reach these nuances.

Discontinuing established medical GR appears to be less common in Finland than reported elsewhere. This is likely due to careful, comprehensive assessment before initiating physical treatments. The risk of discontinuing established medical GR has nevertheless increased alongside increases in the number of patients seeking and proceeding to medical GR. In later intake cohorts, discontinuation also appears to emerge earlier. The threshold to initiate medical GR may have decreased, resulting in greater risks of suboptimal decisions. More research is needed on practically all aspects of detransitioning from medical GR.

Data availability

The authors are not allowed to give the data to any party. Information about how to apply Finnish register data for research purposes can be found in www.findata.fi.

Abbreviations

• Gender dysphoria

Gender identity service

Hazard ratio

Confidence interval

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RK, MH, TH and KT all contributed substantially to the design of the work; TH and RK curated the data; RK performed the analyses; MH consulted in statistical analyses; RK, MH, TH and KT interpreted the results; RK had the main responsibility of drafting the manuscript; MH, TH and KT participated in drafting the manuscript and approved the version submitted. All the authors have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. All the authors reviewed and approved the manuscript.

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Kaltiala, R., Helminen, M., Holttinen, T. et al. Discontinuing hormonal gender reassignment: a nationwide register study. BMC Psychiatry 24 , 566 (2024). https://doi.org/10.1186/s12888-024-06005-6

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Fact Check: Walz Didn't Sign Bill Permitting 'Gender Reassignment Surgery for Children'

U.S. Democratic vice presidential nominee and Minnesota Gov. Tim Walz signed a bill allowing "gender reassignment surgery for children."

After presidential hopeful (and current U.S. vice president) Kamala Harris picked Minnesota Gov. Tim Walz to be her running mate on Aug. 6, 2024, rumors began to circulate that he had signed a bill allowing gender-reassignment surgery for children:

Tim Walz signed a bill that lets the State take away ur kids if you d/n/agree to sterilize them & chop off their body parts in the name of “gender affirming care.” So if your 14-yr-old is sad but thinks it’s gender confusion & u object to castrating him, the St takes custody — Megyn Kelly (@megynkelly) August 6, 2024

The above post ( archived ) by conservative television and podcast host Megyn Kelly had been viewed 2.4 million times as of this writing, and had received 70,000 likes. People responded to the claim with outrage, warning that Walz would "destroy" the country:

Tim Walz has destroyed MN and will do the same for this country if people don’t wake up! — Sarah Smith (@Defundmedianow) August 6, 2024

After examining the text of the law, and in light of current standards of gender-affirming care, however, we have rated the claim "False." Here is what's true:

First, on March 8, 2023, Walz signed an executive order protecting the right of gender-diverse adults and parents of gender-diverse children to seek and obtain gender-affirming medical care. The same order turned Minnesota into a sanctuary state for gender-diverse people from other states to seek and obtain gender-affirming medical care, shielding them from extradition or sanctions.

Second, in April 2023, Walz signed a bill into law that protected gender-diverse people, including children, who have obtained gender-affirming care in Minnesota from "out-of-state" interference, thereby enshrining Minnesota's status as a sanctuary state for gender-diverse people seeking care .

The same bill gave Minnesota courts " temporary emergency jurisdiction " if a child from another state seeking gender-affirming care had been unable to obtain it. Contrary to Kelly's claim, however, which the Republican Donald Trump/J.D. Vance presidential ticket also helped spread , in such a situation the state, under this legislation, did not give itself the right to claim custody of the child. Instead, it claimed jurisdiction to rule in custody disputes. The legislation allowed a path to conflict resolution for parents and a child who disagree on whether the child should obtain care, Kat Rohn, executive director of LGBTQ+ advocacy organization OutFront, told The Washington Post . 

Based on Snopes' reading, the legislation granted Minnesota courts jurisdiction over custody matters if the child was present in the state, including if the child had arrived in Minnesota for the purpose of seeking gender-affirming health care. The mechanism of "temporary emergency jurisdiction" already existed, but the new legislation amended it to include cases where the child had been unable to obtain gender-affirming care.

Neither the executive order nor the new law consecrated a right to "gender reassignment surgery for children," however. Both texts emphasized access to gender-affirming health care. Further, a word search revealed no mention of "surgery" in either document. This made sense, as gender-affirming health care includes a large array of interventions. 

It was also consistent with the current standard of such care , which in childhood allowed for psychological and medical support for a social transition, such as adopting other names, choosing other pronouns, and being able to present oneself as part of one's chosen gender. It may also allow for treatment that slows puberty, which is reversible. However, the same guidance recommends that irreversible procedures — notably, gen*t*l surgery — should be delayed until adulthood.

HF 146 1st Engrossment - 93rd Legislature (2023 - 2024). https://www.revisor.mn.gov/bills/text.php?number=HF146&version=1&session=ls93&session_year=2023&session_number=0 . Accessed 8 Aug. 2024.

Nirappil, Fenit. 'Walz Made Minnesota a "Trans Refuge", Championing Gender Affirming Care'. The Washington Post, 7 Aug. 2024, https://www.washingtonpost.com/politics/2024/08/07/tim-walz-minnesota-trans-refuge-bill/ . https://archive.is/PC3Xd.

Rascouët-Paz, Anna. 'No, Biden Didn't Say Kids Should Be Allowed to Get "Transgender Surgery"'. Snopes, 23 May 2024, https://www.snopes.com//fact-check/biden-gender-affrming-surgery/ .

Walz, Tim. EO 23-03, 8 Mar. 2023, https://mn.gov/governor/assets/EO%2023-03%20Signed%20and%20filed_tcm1055-568332.pdf .

Improving access to gender reassignment surgery: The story so far

News - 22 August 2016

Recent figures show that as more referrals are being made to gender identity clinics and resources are stretched, some people are experiencing extensive waiting times for appointments .

We first heard about this issue in 2014 when local Healthwatch told us that people were experiencing long delays for gender reassignment surgery. We wrote to NHS England to highlight this problem, and to recommend a number of changes to help improve access to these services. Meanwhile, local Healthwatch have been working within their communities to understand people’s experiences and help improve access to services for transgender and non-binary people.

Whilst there is still a long way to go, some positive progress has been made to help ensure that people get the support they need, when they need it. Here we explore what has happened so far, and what needs to happen next.

Progress so far

The NHS has announced £6.5m of increased funding for gender identity services next year. This year services have already benefited from a £4.4m allocation, as well as additional funding to help bring waiting times down. In addition, Health Education England and NHS England are exploring ways to address recruitment gaps, staff retention issues, and training needs amongst teams delivering gender identity treatment.

NHS England has recognized the importance of listening to patients’ views in order to improve services and its intention to keep working with local Healthwatch to do so .

What are local Healthwatch doing?

Local Healthwatch have been working to help improve access to gender reassignment surgery for people across the country. Here are four examples of how they are working on the ground:

1. In Hampshire, Healthwatch have worked in partnership with Chrysalis, a charity supporting transitioning adults, to understand local people’s experiences. They have also worked together to raise awareness amongst Clinical Commissioning Groups and GPs of people’s needs whilst on the transgender journey.

2. Healthwatch Hertfordshire's work has led to the appointment of six local Transgender Champions, who raise awareness of the needs and experiences of the transgender community. GPs and local health care professionals in the area are also being given updated guidance on how to support transgender and non-binary people.

3. Healthwatch Devon published a report based on the experiences of 149 local people who spoke to them about their experiences of accessing support and treatment. It identified a number of areas for improvement, including waiting times, quality of information, and understanding about transgender issues.

4. Healthwatch Telford and Wrekin raised concerns with NHS England about delays to the development of the new Gender Identity protocol. This aims to create greater consistency in the way that gender identity services are created and is now likely to be introduced in September 2016.

What happens next?

Whilst strong progress has been made, there is still a long way to go to ensure that people get the treatment they need in a timely fashion. It is vital that the conversation continues between those with the power to improve access to gender identity services, and the transgender and non-binary community. Local Healthwatch will continue to listen to people’s concerns and to work with NHS England to scrutinise local systems and call for change.

Feeling lost and unsure where to turn?

There's a local Healthwatch in every area of England. So no matter where you live, there's help nearby. Come and have a chat! We can offer information and advice to help you get the support you need.

Find your nearest Healthwatch

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The NHS Ends the "Gender-Affirmative Care Model" for Youth in England

Following extensive stakeholder engagement and a systematic review of evidence , England’s National Health Service (NHS) has issued new draft guidance for the treatment of gender dysphoria in minors, which sharply deviates from the “gender-affirming” approach. The previous presumption that gender dysphoric youth <18 need specialty “transgender healthcare” has been supplanted by the developmentally-informed position that most need psychoeducation and psychotherapy. Eligibility determination for medical interventions will be made by a centralized Service and puberty blockers will be delivered only in research protocol settings. The abandonment of the "gender-affirming" model by England had been foreshadowed by The Cass Review's interim report , which defined "affirmative model" as a "model of gender healthcare that originated in the USA."

The reasons for the restructuring of gender services for minors in England are 4-fold. They include (1) a significant and sharp rise in referrals; (2) poorly-understood marked changes in the types of patients referred; (3) scarce and inconclusive evidence to support clinical decision-making, and (4) operational failures of the single gender clinic model, as evidenced by long wait times for initial assessment, and overall concern with the clinical approach.

The new NHS guidance recognizes social transition as a form of psychosocial intervention and not a neutral act, as it may have significant effects on psychological functioning. The NHS strongly discourages social transition in children, and clarifies that social transition in adolescents should only be pursued in order to alleviate or prevent clinically-significant distress or significant impairment in social functioning , and following an explicit informed consent process . The NHS states that puberty blockers can only be administered in formal research settings, due to the unknown effects of these interventions and the potential for harm. The NHS has not made an explicit statement about cross-sex hormones , but signaled that they too will likely only be available in research settings. The guidelines do not mention surgery , as surgery has never been a covered benefit under England’s NHS for minors.  

The new NHS guidelines represent a repudiation of the past decade’s approach to management of gender dysphoric minors.  The “gender-affirming” approach, endorsed by WPATH and characterized by the conceptualization of gender-dysphoric minors as “transgender children” has been replaced with a holistic view of identity development in children and adolescents. In addition, there is a new recognition that many gender-dysphoric adolescents suffer from mental illness and neurocognitive difficulties, which make it hard to predict the course of their gender identity development.

The key highlights of the NHS new guidance are provided below.* 

1. Eliminates the “gender clinic” model of care and does away with “affirmation”

• The NHS has eliminated the “gender clinic” model of care where children are seen solely by a specialist gender dysphoria practitioner, replacing it with standard care in children’s hospital settings.
• Rather than “affirming” a transgender identity of young person, staff are encouraged to maintain a broad clinical perspective and to “embed the care of children and young people with gender uncertainty within a broader child and adolescent health context.”
• “Affirmation” has been largely eliminated from the language and the approach. What remains is the guidance to ensure that “assessments should be respectful of the experience of the child or young person and be developmentally informed.”
• Medical transition services will only be available through a centralized specialty Service, established for higher-risk cases. However, not all referred cases to the Service will be accepted, and not all accepted cases will be cleared for medical transition.
• Treatment pathway will be shaped, among other things, by the “clarity, persistence and consistency of gender incongruence, the presence and impact of other clinical needs, and family and social context.”
• The care plan articulated by the Service will be tailored to the specific needs of the individual following careful therapeutic exploration and “may require a focus on supporting other clinical needs and risks with networked local services.”

2. Classifies social gender transition as an active intervention eligible for informed consent

• The NHS is strongly discouraging social gender transition in prepubertal children.
• diagnosis of persistent and consistent gender dysphoria
• consideration and mitigation of risks associated with social transition
• clear and full understanding of the implications of social transition
• a determination of medical necessity of social transition to alleviate or prevent clinically significant distress or impairment in social functioning
• All adolescents will need to provide informed consent to social gender transition.

3. Establishes psychotherapy and psychoeducation as the first and primary line of treatment

• All gender dysphoric youth will first be treated with developmentally-informed psychotherapy and psychoeducation by their local treatment teams.
• Extensive focus has been placed on careful therapeutic exploration, and addressing the broader range of medical conditions in addition to gender dysphoria.
• For those wishing to pursue medical transition, eligibility for hormones will be determined by a centralized Service, upon referral from a GP (general practitioner) or another NHS provider.

4. Sharply curbs medical interventions and confines puberty blockers to research-only settings

• The NHS guidance states that the risks of puberty blockers are unknown and that they can only be administered in formal research settings. The eligibility for research settings is yet to be articulated.
• The NHS guidance leaves open that similar limitations will be imposed on cross-sex hormones due to uncertainty surrounding their use, but makes no immediate statements about restriction in cross-sex hormones use outside of formal research protocols.
• Surgery is not addressed in the guidance as the NHS has never considered surgery appropriate for minors.

5. Establishes new research protocols

• All children and young people being considered for hormone treatment will be prospectively enrolled into a research study.
• The goal of the research study to learn more about the effects of hormonal interventions, and to make a major international contribution of the evidence based in this area of medicine.
• The research will track the children into adulthood.

6. Reinstates the importance of “biological sex”

• The NHS guidance defines “gender incongruence” as a misalignment between the individual’s experience of their gender identity and their biological sex.
• The NHS guidance refers to the need to track biological sex for research purposes and outcome measures.
• Of note, biological sex has not been tracked by GIDS for a significant proportion of referrals in 2020-2021.

7. Reaffirms the preeminence of the DSM-5 diagnosis of “gender dysphoria” for treatment decisions

• The NHS guidance differentiates between the ICD-11 diagnosis of “gender incongruence,” which is not necessarily associated with distress, and the DSM-5 diagnosis of “gender dysphoria,” which is characterized by significant distress and/or functional impairments related to “gender incongruence."
•  The NHS guidance states that treatments should be based on the DSM-5 diagnosis of “gender dysphoria.” 
• Of note, WPATH SOC8 has made the opposite recommendation, instructing to treat based on the provision of the ICD-11 diagnosis of “gender incongruence.” “Gender incongruence” lacks clinical targets for treatment, beyond an individual’s own desire to bring their body into alignment with their internally-held view of their gender identity.

8. Clarifies the meaning of “multidisciplinary teams” as consisting of a wide range of clinicians with relevant expertise, rather than only “gender dysphoria” specialists

• The NHS guidance clarifies that a true multidisciplinary team is comprised not only of “gender dysphoria specialists,” but also of experts in pediatrics, autism, neurodisability and mental health, to enable holistic support and appropriate care for gender dysphoric youth.
• neurodevelopmental disorders such as autistic spectrum conditions
• mental health disorders including depressive conditions, anxiety and trauma
• endocrine conditions including disorders of sexual development pharmacology in the context of gender dysphoria
• risky behaviors such as deliberate self-harm and substance use
• complex family contexts including adoptions and guardianships
• a number of additional requirements for the multidisciplinary team composition and scope of activity have been articulated by the NHS.

9. Establishes primary outcome measures of “distress” and “social functioning”

• The rationale for medical interventions for gender-dysphoric minors has been a moving target, ranging from resolution of gender dysphoria to treatment satisfaction.  The NHS has articulated two main outcome measures of treatment: clinically significant distress and social functioning .
• This is an important development, as it establishes primary outcome measures that can be used by researchers to assess comparative effectiveness of various clinical interventions. 

10. Asserts that those who choose to bypass the newly-established protocol will not be supported by the NHS

• Families and youth planning to obtain hormones directly from online or another external non-NHS source will be strongly advised about the risks.
• Those choosing to take hormones outside the newly established NHS protocol will not be supported in their treatment pathway by NHS providers.
• Child safeguarding investigations may also be initiated if children and young people have obtained hormones outside the established protocols.

With the new NHS guidance, England joins Finland and Sweden as the three European countries who have explicitly deviated from WPATH guidelines and devised treatment approaches that sharply curb gender transition of minors. Psychotherapy will be provided as the first and usually only line of treatment for gender dysphoric youth.

The full text of the NHS guidance can be accessed here .

 * This is a transitional protocol as the NHS works to establish a more mature network of children’s hospitals capable of caring for special needs of gender dysphoric youth. A fuller service specification will be published in 2023-4 following the publication of the Cass Review’s final report .

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I changed sex after becoming suicidal & medics diagnosed me as trans – I regretted it and now live as neutered man

• Julie Bindel
• Published : 18:16 ET, Aug 16 2024
• Published : Invalid Date,

RITCHIE HERRON lives in pain.

He struggles with incontinence, weakened bones, a numb crotch and suicidal feelings.

But the 35-year-old’s symptoms are not the result of a genetic disorder or disease.

In fact, they were entirely avoidable.

Ten years ago, Ritchie, who was born a male, had two 30-minute medical appointments that resulted in him being diagnosed as transgender [trapped in the wrong body].

An NHS gender clinic referred him for an operation to remove his genitals.

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But Ritchie says he had serious misgivings ahead of the surgery and now bitterly regrets it.

Ritchie, who is gay, is one of a growing community of detransitioners — people who regret their gender operations.

Such is the demand for detransitioning, the NHS this month announced it is launching a new service for patients who want to return to their birth gender.

Ritchie finally feels like his concerns are being taken seriously.

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He says: “I regret undertaking this procedure. I regret having that surgery and I regret trusting the people who recommended it to me.

“It’s less about doing the impossible and reversing what cannot be reversed. It’s more about improving the quality of life of those who have been harmed by the previous surgeries.”

For him, this would mean urinating is no longer painful, he does not suffer constant infections, and he can access proper guidance on hormones and aftercare.

Love-bombing

He adds: “I understand that you can’t recreate what was lost; there is no going back with this. But we are not having these issues resolved in the way that you would expect, with the pain, and especially the psychological side.”

Growing up, Ritchie suffered from severe obsessive compulsive disorder, autism and regular panic attacks.

He was bullied at school and increasingly found himself escaping online.

“The problem is,” he tells me, from his home in Newcastle , “I found some really dodgy websites and a lot of predators hanging around.”

I had hidden the fact that I was gay, from myself even, and all of a sudden it made sense that I was really a woman Ritchie

After years of suppressing his homosexuality, Ritchie came across a website that discussed “gender dysphoria”, and became convinced he wanted to become a woman.

He began posting photographs of himself online and soon much older men, some in their 50s, were love-bombing him.

Ritchie explains: “I had hidden the fact that I was gay, from myself even, and all of a sudden it made sense that I was really a woman.”

But when he began feeling suicidal, aged 24, he went to his doctor.

Ritchie now knows he had post-traumatic stress disorder, but at the time all he knew was that he felt very unwell.

He claims he was diagnosed as transgender without his mental health issues being explored or treated.

The NHS waiting list was long, so in March 2014 he took out a loan to attend a private clinic, which can offer formal diagnosis and access to hormone medications and surgeries.

He was given two 30-minute assessment appointments.

The psychiatrist’s first recommendation was that Ritchie take testosterone blockers, which reduce masculine traits such as facial hair.

He was then recommended surgery.

Ritchie says: “I was very vulnerable.”

By March 2015 he was a patient at Newcastle’s NHS gender clinic.

He says: “The first question you get asked there is, ‘Do you want genital surgery?’ I wasn’t sure. But I’d heard you could get therapy if you were on the waiting list for surgery, so I said yes.”

Four months later he was referred for vaginoplasty [surgery to remove the male genitalia to create a vagina].

He turned down the surgery, saying he was unsure — but continued going to therapy, because it was “a lifeline” for him.

There was another referral for the operation in 2017.

This time, Ritchie was told that turning it down would result in him being discharged from the service.

It sent him into a “tailspin”.

He says he was persuaded into surgery without having really thought about what it would entail.

As he was wheeled into the operating theatre in May 2018 Ritchie realised he was making a mistake.

He says the results of the “gender-affirming treatment” immediately worsened his mental and physical health.

Six years later Ritchie’s surgical scars still weep, it takes him ten minutes to urinate and he has little sexual function.

Hormone blockers have wreaked havoc on his bones.

Ritchie considers himself to be a victim of “experimental surgery”.

He explains: “Just because it’s been an amputation that’s been done for many decades doesn’t mean it’s refined.

“It’s still experimental.”

Ritchie’s expectations from the NHS’s recently announced detransitioning service are measured.

All of a sudden, we’ve got this community of people who are going to lovebomb us and affirm us. They’re not going to challenge us. And you obviously don’t want to lose that Ritchie

He insists he does “not want to be referred for another “set of surgeries”.

He says: “I’m just looking to minimise the pain and suffering that I’m enduring.

“Hopefully there are other procedures that might work that can help with what I have, rather than going down another experimental route.”

Best interests

Ritchie adds: “Obviously it is very emasculating to not have male genitals.

“It’s one of my hesitations with going on a complete dose of testosterone, because . . . what am I turning into?

“I’ve already castrated myself and it’s like, I don’t want to get bald and get a beard and all that when I haven’t got anything down below. It already doesn’t look quite right.”

Ritchie feels strongly that there needs to be an immediate “pause on all of these surgeries and a systematic review of the data”.

He adds: “Not just the people who answer surveys six months after surgery, but what does the longitudinal data say?”

He points out that, prior to transitioning, many patients were extremely depressed and isolated.

Ritchie says: “All of a sudden, we’ve got this community of people who are going to lovebomb us and affirm us. They’re not going to challenge us. And you obviously don’t want to lose that [community]”.

Ritchie wants there to be more protections in place.

He says: “My case is a good chance to illuminate that. The detransitioners have a role to play in the trans debate, because a lot of people haven’t been listened to and are very angry.”

He fears young transitioners may not have the confidence to fight for their care like he has.

Ritchie says: “They are very much alone.”

In the meantime, he worries about what the future will look like for those who have decided to transition.

He says: “On paper, transitioning sounds brilliant, but in reality, it is nothing like it. And how you feel in the first year, may change over time”.

Ritchie warns: “I don’t want you to do what I did and just assume that [the clinicians] have your best interests in heart.”

Today, this brave campaigner is looking to the future and is in a happy relationship.

He says: “I do have a partner who is very understanding.

“There’s more to relationships than sex, but I’m not going to deny it’s not a big part.

“And I’ve just kind of accepted that a lot of my pleasure is kind of forfeit in this.

“I just don’t have it. But I get a lot of benefit from being with him and seeing his pleasure.”

While Ritchie still grieves for his former body, he says: “I will always see myself as a man.

“I’m quite happy being a little bit androgynous.

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“I’m a neutered man, but I’m still a man.”

Newcastle’s NHS gender clinic was contacted for comment.

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