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The history of gender reassignment surgeries in the UK

For Pride Month, we are recognising the plastic surgeons who pioneered gender reassignment surgeries (GRS) in the UK. Gender reassignment surgery, also known as gender confirmation surgery or gender affirmation surgery, is a sub-speciality within plastic surgery, developed based on reconstructive procedures used in trauma and in congenital malformations. The specific procedures used for GRS have only been practised in the last 100 years.

Over the last decade, there has been an increase in society acknowledgement and acceptance of gender diverse persons. This catalysed an increase in referrals to gender identity clinics and an increase in the number of gender affirmation surgeries. GRS help by bringing fulfilment to many people who experience gender dysphoria. Gender dysphoria - a distress caused by the incongruence of a person's gender identity and their biological sex, drives the person to seek medical or surgical intervention to align some or all of their physical appearance with their gender identity. Patients with gender dysphoria experience higher rates of psychiatric disorders such as depression and anxiety. Gender-affirming medical intervention tends to resolve the psychiatric disorders that are a direct consequence of gender dysphoria.

Norman Haire (1892-1952) was a medical practitioner and a Sexologist. In his book, The Encyclopaedia of Sexual Knowledge (1933), he describes the first successful GRS. His patient, Dora Richter underwent 3 procedures reassigning from male to female between 1922-1931. The procedures included a vaginoplasty (surgical procedure where a vagina is created).

In the UK, gender reassignment surgeries were pioneered by Sir Harold Gillies. Harold Gillies is most famous for the development of a new method of facial reconstructive surgery, in 1917. During the Second World War, he organized plastic surgery units in various parts of Britain and inspired colleagues to do the same, training many doctors in this field. During the war, Gillies performed genital reconstruction surgeries for wounded soldiers.

British physician Laurence Michael Dillon (born Laura Maude Dillon) felt that they were not truly a woman. Gillies performed the first phalloplasty (surgery performed to construct the penis) on Dillon in 1946. In transitioning from female to male, Dillon underwent a total of 13 operations, over a period of 4 years.

Roberta Cowell (born Robert Marshall Cowell) is the first known Brit to undergo male to female GRS. After meeting Dillon and becoming close, Dillon operated illegally on Cowell. The operation helped her obtain documents confirming that she was intersex and have her birth gender formally re-registered as female. The operation that helped her transition was forbidden as it was considered “disfiguring” of a man who was otherwise qualified to serve in the military. Consequently, Gillies, assisted by American surgeon Ralph Millard performed a vaginoplasty on Roberta in 1951. The technique pioneered by Harold Gillies remained the standard for 40 years.

Gillies requested no publicity for his gender affirmation work.  In response to the objections received from his peers, he replied that he was satisfied by the patient's written sentiments: “To Sir Harold Gillies, I owe my life and my happiness”. “If it gives real happiness,” Gillies wrote of his procedures, “that is the most that any surgeon or medicine can give.” These words highlight the importance of plastic surgery in the mental wellbeing of transgender patients.

The BAPRAS Collection and Archive has an extraordinary assembly of fascinating archive and historical surgical instruments dating from 1900. Visit https://www.bapras.org.uk/professionals/About/bapras-archive or email [email protected] for more information.

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Nov 12, 2018

Written By Sophie Nevrkla

The history of transgender rights in the UK

The battle over gender rights and identity has taken on huge significance in the past few years. But our understanding of transgender issues has a long and complex history, which is helping shape the present legal landscape.

In 1951, Roberta Cowell made history as the first known British trans woman to undergo gender-reassignment surgery. ‘Betty’ Cowell, formerly ‘Bob’, had previously been a racing driver and a Spitfire pilot in the Second World War, happily married with two children. After telling her wife about her plans to transition, her wife severed all contact, and Roberta’s children—Anne, six and Diana, four—grew up without any knowledge of their missing father. Roberta Cowell died in 2011 in her flat in west London, alone, with just half a dozen people at her funeral.

Since Cowell’s transition, knowledge and awareness of transgender people has grown by a significant margin. Gradually, the word ‘transsexual’ has been phased out in favour of ‘transgender’, a more inclusive term to describe someone who doesn’t identify with the gender they have been assigned at birth, but may not have had gender reassignment surgery.

Since 2000, the legal rights of trans people have begun to be entrenched more seriously in UK law. Since Caitlin Jenner came out as a woman in April 2015, an even brighter media spotlight has been placed on the trans community, particularly on trans women, and celebrity activists such as Laverne Cox and Munroe Bergdorf have worked to promote the cause and link it to wider struggles for equality happening in the UK, the US and across the world.

In 1963, fashion model April Ashley (who transitioned to become physically female in 1960) and Arthur Corbett married; by 1963, the marriage had broken down. When the marriage was eventually annulled in 1970, it was on the basis that the court considered Ashley to be male, though Corbett had been aware of Ashley’s transition at the time they wed. What came to be known as the Corbett v Corbett divorce case established the legal precedent that a person’s sex couldn’t legally be changed from that which is assigned at birth. From Corbett v Corbett onwards, members of the trans community were confined to an awkward space, unable to inhabit fully their genders and bodies in the eyes of UK law or society.

As the 20th century progressed, more and more trans people begin to take cases to court on the grounds of discrimination in the workplace and wider society. In 1986, trans man Mark Rees brought a case to the European Court of Human Rights, complaining that UK law prevented him from gaining legal status that recognised him as male. Though he didn’t win his case, the court discussed at length the legal marginalisation of the trans community—a theme that would be revisited in Goodwin v United Kingdom (2002).

The workplace, too, provided a space for discrimination. In 1996, the milestone case P v S and Cornwall County Council saw that a woman, named as P in court proceedings, had been dismissed from her workplace after informing employers that she was undergoing gender-reassignment surgery. After taking her employers to an employment tribunal, the court ruled that she was wrongfully dismissed; it became the first piece of case law to prevent discrimination in employment or vocational education on the basis of someone being trans. These subtle shifts in the 1980s and 1990s set the stage for more changes during the course of the 21st century. The early 2000s saw the slow beginnings of the legislative codification of trans rights under successive Labour governments.

In this more liberal climate, Goodwin v United Kingdom (2002) provided landmark change for the trans community. Christine Goodwin had faced sexual harassment at work during and subsequent to her gender reassignment. She complained to the court that due to her male legal status, she was forced to pay National Insurance contributions until the age of 65 rather than 60. Goodwin also stated that because her NI number must remain the same under UK law, her employer was able to find out that she had worked for the company previously under a different name and gender, which resulted in more humiliation and harassment. Further to this, the court heard that another woman, referred to as ‘I’ in court proceedings, had been refused a place on a nursing course after she refused to present her birth certificate. 

The individuals protested the lack of legal recognition of trans people, their gender and their post-operative sex, and their poor treatment with respect to employment, social security and pensions, as well as their inability to get married as either male or female. The European Court of Human Rights ruled in 2002 that UK law violated the right of transgender people to a private life, and the right to marry and start a family. Judges ruled that the UK Government should help trans people by issuing new birth certificates to reflect their gender identity, and permit their marriage to an individual of the opposite gender. Here, the Government was held directly accountable for the lack of protections for the trans community. For the first time, the lawmakers were forced to provide for the oppressed minority, recognising their gender identity and right to the same freedoms as other individuals.

This UK Government’s loss of the Goodwin case resulted in the introduction of the Gender Recognition Act in 2004, perhaps the most significant and wide-reaching piece of trans-focused legislation. Under the Act, the government awarded trans people full legal gender recognition and allowed them to acquire new birth certificates. Rather than being denied or dismissed, trans people had their personal identity recognised here for the first time in UK law. These moves towards acceptance culminated in the Equality Act of 2010, which, among other things, banned discrimination in the workplace and wider society on the basis of gender reassignment.

Despite these steps, UK law still reflects a limited understanding of the nuances that exist within transgender identity. Birth certificates and passports in the UK still only allow for the options ‘male’ or ‘female’, meaning that non-binary individuals aren’t recognised by law. Other western states are leading the way: Ontario became the first Canadian province to offer non-binary options on birth certificates in March 2018, denoted by an ‘X’. Though Gendered Intelligence was founded in the UK in 2008 to spread understanding of gender diversity, it’s only over the course of the last few years that the concerns of nonbinary individuals have been included in the wider conversation about trans rights. Perhaps enacting legislation to promote the ‘they’, rather than simply the ‘he’ or ‘she’, will be the next big shift over the following decades, as our perception of ‘gender’ changes and develops.

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Treatment - Gender dysphoria

Treatment for gender dysphoria aims to help people live the way they want to, in their preferred gender identity or as non-binary.

What this means will vary from person to person, and is different for children, young people and adults. Waiting times for referral and treatment are currently long.

Treatment for children and young people

If your child may have gender dysphoria, they'll usually be referred to one of the NHS Children and Young People's Gender Services .

Your child or teenager will be seen by a multidisciplinary team including a:

• clinical psychologist
• child psychotherapist
• child and adolescent psychiatrist
• family therapist
• social worker

The team will carry out a detailed assessment, usually over 3 to 6 appointments over a period of several months.

Depending on the results of the assessment, options for children and teenagers include:

• family therapy
• individual child psychotherapy
• parental support or counselling
• group work for young people and their parents
• regular reviews to monitor gender identity development
• referral to a local Children and Young People's Mental Health Service (CYPMHS) for more serious emotional issues

Most treatments offered at this stage are psychological rather than medical. This is because in many cases gender variant behaviour or feelings disappear as children reach puberty.

Hormone therapy in children and young people

Some young people with lasting signs of gender dysphoria who meet strict criteria may be referred to a hormone specialist (consultant endocrinologist). This is in addition to psychological support.

Puberty blockers and gender-affirming hormones

Puberty blockers (gonadotrophin-releasing hormone analogues) are not available to children and young people for gender incongruence or gender dysphoria because there is not enough evidence of safety and clinical effectiveness.

From around the age of 16, young people with a diagnosis of gender incongruence or gender dysphoria who meet various clinical criteria may be given gender-affirming hormones alongside psychosocial and psychological support.

These hormones cause some irreversible changes, such as:

• breast development (caused by taking oestrogen)
• breaking or deepening of the voice (caused by taking testosterone)

Long-term gender-affirming hormone treatment may cause temporary or even permanent infertility.

However, as gender-affirming hormones affect people differently, they should not be considered a reliable form of contraception.

There is some uncertainty about the risks of long-term gender-affirming hormone treatment.

Children, young people and their families are strongly discouraged from getting puberty blockers or gender-affirming hormones from unregulated sources or online providers that are not regulated by UK regulatory bodies.

Transition to adult gender identity services

Young people aged 17 or older may be seen in an adult gender identity clinic or be referred to one from a children and young people's gender service.

By this age, a teenager and the clinic team may be more confident about confirming a diagnosis of gender dysphoria. If desired, steps can be taken to more permanent treatments that fit with the chosen gender identity or as non-binary.

Treatment for adults

Adults who think they may have gender dysphoria should be referred to a gender dysphoria clinic (GDC).

Find an NHS gender dysphoria clinic in England .

GDCs have a multidisciplinary team of healthcare professionals, who offer ongoing assessments, treatments, support and advice, including:

• psychological support, such as counselling
• cross-sex hormone therapy
• speech and language therapy (voice therapy) to help you sound more typical of your gender identity

For some people, support and advice from the clinic are all they need to feel comfortable with their gender identity. Others will need more extensive treatment.

Hormone therapy for adults

The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. The hormones usually need to be taken for the rest of your life, even if you have gender surgery.

It's important to remember that hormone therapy is only one of the treatments for gender dysphoria. Others include voice therapy and psychological support. The decision to have hormone therapy will be taken after a discussion between you and your clinic team.

In general, people wanting masculinisation usually take testosterone and people after feminisation usually take oestrogen.

Both usually have the additional effect of suppressing the release of "unwanted" hormones from the testes or ovaries.

Whatever hormone therapy is used, it can take several months for hormone therapy to be effective, which can be frustrating.

It's also important to remember what it cannot change, such as your height or how wide or narrow your shoulders are.

The effectiveness of hormone therapy is also limited by factors unique to the individual (such as genetic factors) that cannot be overcome simply by adjusting the dose.

Find out how to save money on prescriptions for hormone therapy medicines with a prescription prepayment certificate .

Risks of hormone therapy

There is some uncertainty about the risks of long-term cross-sex hormone treatment. The clinic will discuss these with you and the importance of regular monitoring blood tests with your GP.

The most common risks or side effects include:

• blood clots
• weight gain
• dyslipidaemia (abnormal levels of fat in the blood)
• elevated liver enzymes
• polycythaemia (high concentration of red blood cells)
• hair loss or balding (androgenic alopecia)

There are other risks if you're taking hormones bought over the internet or from unregulated sources. It's strongly recommended you avoid these.

Long-term cross-sex hormone treatment may also lead, eventually, to infertility, even if treatment is stopped.

The GP can help you with advice about gamete storage. This is the harvesting and storing of eggs or sperm for your future use.

Gamete storage is sometimes available on the NHS. It cannot be provided by the gender dysphoria clinic.

Read more about fertility preservation on the HFEA website.

Surgery for adults

Some people may decide to have surgery to permanently alter body parts associated with their biological sex.

Based on the recommendations of doctors at the gender dysphoria clinic, you will be referred to a surgeon outside the clinic who is an expert in this type of surgery.

In addition to you having socially transitioned to your preferred gender identity for at least a year before a referral is made for gender surgery, it is also advisable to:

• lose weight if you are overweight (BMI of 25 or over)
• have taken cross-sex hormones for some surgical procedures

It's also important that any long-term conditions, such as diabetes or high blood pressure, are well controlled.

Surgery for trans men

Common chest procedures for trans men (trans-masculine people) include:

• removal of both breasts (bilateral mastectomy) and associated chest reconstruction
• nipple repositioning
• dermal implant and tattoo

Gender surgery for trans men includes:

• construction of a penis (phalloplasty or metoidioplasty)
• construction of a scrotum (scrotoplasty) and testicular implants
• a penile implant

Removal of the womb (hysterectomy) and the ovaries and fallopian tubes (salpingo-oophorectomy) may also be considered.

Surgery for trans women

Gender surgery for trans women includes:

• removal of the testes (orchidectomy)
• removal of the penis (penectomy)
• construction of a vagina (vaginoplasty)
• construction of a vulva (vulvoplasty)
• construction of a clitoris (clitoroplasty)

Breast implants for trans women (trans-feminine people) are not routinely available on the NHS.

Facial feminisation surgery and hair transplants are not routinely available on the NHS.

As with all surgical procedures there can be complications. Your surgeon should discuss the risks and limitations of surgery with you before you consent to the procedure.

Life after transition

Whether you've had hormone therapy alone or combined with surgery, the aim is that you no longer have gender dysphoria and feel at ease with your identity.

Your health needs are the same as anyone else's with a few exceptions:

• you'll need lifelong monitoring of your hormone levels by your GP
• you'll still need contraception if you are sexually active and have not yet had any gender surgery
• you'll need to let your optician and dentist know if you're on hormone therapy as this may affect your treatment
• you may not be called for screening tests as you've changed your name on medical records – ask your GP to notify you for cervical and breast screening if you're a trans man with a cervix or breast tissue
• trans-feminine people with breast tissue (and registered with a GP as female) are routinely invited for breast screening from the ages of 50 up to 71

Find out more about screening for trans and non-binary people on GOV.UK.

NHS guidelines for gender dysphoria

NHS England has published what are known as service specifications that describe how clinical and medical care is offered to people with gender dysphoria:

• Non-surgical interventions for adults
• Surgical interventions for adults
• Interim service specification for specialist gender incongruence services for children and young people

Review of gender identity services

NHS England has commissioned an independent review of gender identity services for children and young people. The review will advise on any changes needed to the service specifications for children and young people.

Page last reviewed: 28 May 2020 Next review due: 28 May 2023

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History of Facial Feminization & Gender Confirmation Surgery

The Beginnings of Facial Feminization & Gender Confirmation Surgery

The Very First Known Case of Gender “Reassignment” Surgery

In 1906,  Karl “Martha” Baer  attempted suicide by stepping in front of a streetcar in Berlin after an affair with a married woman had been discovered. Baer was found to be presenting as male despite papers identifying him as female.

The Early, Experimental Years (1922-1969)

The origins of gender confirmation surgery can be traced back to the early 20th century when gender-related surgery was experimental and rare. One of the first identifiable recipients of gender confirmation surgery was  Rudolph “Dorchen” (Little Dora) Richter , who had an orchiectomy in 1922 by her own request at the  Institut für Sexualwissenschaft , founded by Magnus Hirschfeld in Berlin. Then later in 1930, she underwent penectomy by Dr. Levy-Lenz and then vaginal reconstruction by Dr. Gohrbrandt.

Lili Elbe, a Danish Transgender woman, was the next known case in 1930 . The first surgery (removal of the testicles) was made under the supervision of sexologist Magnus Hirschfeld in Berlin. The rest of her surgeries were carried out by Dr. Kurt Warnekros, a doctor at the Dresden Municipal Women’s Clinic.

During the 1950’s, transgender women benefited from newly available female sex hormone therapy. One of the pioneers in this field was German-born Psychiatrist and Sexologist,  Dr. Harry Benjamin , a peer of Dr. Hirschfield in the early 20th century in Germany. After immigrating to the United States, Dr. Benjamin became known internationally for his efforts to advance the field of non-surgical care for transgender individuals. He published papers and lectured to professional audiences extensively, and his book,  The Transsexual Phenomenon , was the first large work describing and explaining the affirmative treatment path he pioneered.

He also established the world’s first clinical psychiatric practice focused on the medical and psychological needs of the transgender individual. For over five decades, Benjamin conducted treatment in collaboration with carefully selected colleagues of various complementary disciplines for hundreds of patients with gender identity issues – and Christine Jorgensen was one of his early patients in the 1950s.

In 1952,  Christine Jørgensen , an American trans woman, had gender confirmation surgery in Denmark. When her transformation made the front page of the New York Daily News, she became an overnight sensation, and she used the opportunity to become a strong advocate for the rights of all transgender people.

MTF Gender Confirmation and Facial Feminization in the United States (1966-present)

The first male-to-female surgeries in the United States took place in 1966 at the Johns Hopkins University Medical Center. The first physician in the United States to perform gender confirmation surgery was the late Dr. Elmer Belt, who did so until the late 1960s.

Another notable person to transition was  Renée Richards . She underwent male-to-female gender confirmation surgery in the mid-1970s, and successfully fought to have transgender people recognized officially with their new gender.

Beginning in 1983,  facial feminization surgery (FFS)  (in addition to body-focused male-to-female gender confirmation surgery) was pioneered by  Dr. Douglas K. Ousterhout  in San Francisco. The popularity of facial gender confirmation has grown over the past 15 years for those pursuing male-to-female surgery.

Dr. Douglas Ousterhout – the Pioneer of Facial Feminization Surgery

Douglas K. Ousterhout, MD, DDS , is widely regarded as the world’s pioneer of facial gender confirmation.

After training with Dr. Paul Tessier, the father of craniofacial surgery, Dr. Ousterhout returned to San Francisco where he helped launch the Center for Craniofacial Anomalies at the University of California, San Francisco, Medical and Dental Centers.

His work at the Center for Craniofacial Anomalies at UCSF paved the way for his future focus–pioneering work and expertise in FFS.

Dr. Ousterhout began his private practice in San Francisco in 1973, making the practice one of the oldest continuing plastic surgery practices on the west coast. His specialty became facial feminization surgery for trans women, and he was widely considered the foremost facial feminization surgeon in the United States.

Dr. Douglas Ousterhout’s First Facial Feminization Surgery in 1983

In 1982, Dr. Ed Falces, a plastic surgeon who performed body-focused gender confirmation surgeries, approached Dr. Ousterhout with a request from “Lucy”, one of his male-to-female transgender patients. Lucy wanted plastic surgery to make her face appear more feminine. Dr. Ousterhout agreed to the collaboration with Dr. Falces and performed a  forehead feminization  procedure on Lucy – which involved the “ Ousterhout Type II ” forehead procedure.

Up until this point, Dr. Ousterhout’s practice had predominantly involved with reconstructing faces and skulls of people who had suffered birth defects, accidents, or other trauma. After assisting Dr. Pratt with Lucy, he was keen to understand better what was deemed a “female face” for future craniofacial procedures he might undertake.

Dr. Ousterhout conducted extensive research to identify which facial features were consituted feminine in shape and size. He derived measurements defining those features from a series of cephalograms taken in the 1970s, and then worked with a set of several hundred skulls to determine if he could consistently differentiate females and males using those measurements only.

Dr. Ousterhout then began adapting surgical techniques and materials he already used to transform and feminize the male face. For over two decades, he added more procedures and developed more aggressive techniques, with the goal of producing better outcomes and more attractive faces for transgender patients.

Just some of the new techniques and procedures he performed in FFS included advancing the hairline; making the forehead smaller and rounder; reducing the brow ridge; shortening and narrowing the nose; shortening the upper lip; shortening the chin; narrowing the jaw; and reducing the laryngeal prominence.

In 1998, Dr. Ousterhout left the University to devote approximately 80% of his practice time to the care of the transgender.

In 2006 he was one of only about twelve surgeons in the world performing FFS.

In the course of more than 30 years, he has performed thousands of successful facial feminization surgeries–seeing each patient as an individual who deserved to have their desired physical appearance and enhanced self-esteem. His contributions to patients and the medical community are unparalleled and he is known by the medical community as the pioneer of facial feminization surgery.

In addition to publishing well over a hundred scientific publications, Dr. Ousterhout published his medical textbook  Aesthetic Contouring of the Craniofacial Skeleton  in 1991. In 2009, he published  Facial Feminization Surgery , a guide for the prospective patient, which was based on having completed nearly seven thousand various procedures on eleven hundred patients.

Dr. Deschamps-braly Continues Dr. Ousterhout’s Legacy with Continued Innovation in the Field of Gender Reassignment Plastic Surgery.

Dr. Deschamps-Braly  is the only surgeon that Dr. Ousterhout has trained and mentored in the art and practice of gender facial confirmation surgery. He carries on the practice of a longstanding and innovative surgical practice in  Facial Feminization Surgery (FFS)  and now also groundbreaking work in  Facial Masculinization Surgery (FMS)  – incorporating the best of tradition and innovation in transgender plastic surgery.

In fact, Dr. Deschamps-Braly has just completed the world’s first  Adam’s apple augmentation via natural implant involving the insertion of an implant made from the patient’s own rib cartilage to increase the size of the Adam’s apple to make it appear more masculine.  Read more about facial masculinization here.

Like his mentor Dr. Ousterhout, Dr. Deschamps-Braly maintains a full surgical schedule, as well as a prolific academic career authoring numerous papers on craniofacial surgery. He also travels extensively presenting at various national and international conferences on a range of plastic and craniofacial surgery topics.

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High court to decide if children can consent to gender reassignment

A landmark test case to establish whether children can give informed consent to medical treatment for gender reassignment begins in the high court this week.

Lawyers acting for Susan Evans, a former psychiatric nurse at the Tavistock and Portman NHS foundation trust, which runs the UK’s only NHS gender identity development service (Gids), and “Mrs A”, the mother of an autistic 15-year-old girl who is on the Gids waiting list, will file papers to commence proceedings in a judicial review brought against the trust and NHS England.

At the heart of the case is the provision of puberty blockers and cross-sex hormones to young people who wish to transition or are considering doing so.

“We are essentially seeking to say that the provision at the Tavistock for young people up to the age of 18 is illegal because there isn’t valid consent,” said Paul Conrathe, a solicitor with Sinclairslaw, which is representing Evans and the mother.

Providing this treatment – puberty blocking and cross-sex hormones – to any young person who wants them requires, he argues, “a specific order of the court on a case-by-case basis. [The treatment] cannot be delivered as a matter of general approach”. Conrathe suggested the legal action would be “pressing the case of Gillick to its breaking point”.

In 1983, Victoria Gillick, a Roman Catholic mother of 10, challenged the right of doctors to prescribe contraception to girls under the age of 16 without their parents’ permission or even knowledge. Two years later the House of Lords affirmed the doctors’ right, ruling that “the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to fully understand what is proposed”.

But Conrathe said the “Gillick competence” test should not apply when it comes to gender reassignment: “The issue is whether the young person is of sufficient maturity and capacity to understand the consequences of their actions. We say it is a leap too far to think that Gillick as a judgment could apply to this type of scenario, where a young person is being offered a treatment with lifelong consequences when they are at a stage of emotional and mental vulnerability. It simply doesn’t compute, and therefore whatever medical professionals say is consent is not valid in law.”

He acknowledged that the case would break new ground. “I don’t think there has been any case that has tested a policy or practice in this way. There may have been the odd case that has come up but not one that has challenged a health service for making this service available.”

According to her crowdfunding page on the CrowdJustice website, Evans raised concerns about the treatment approach of the Tavistock with its clinical management team.

“The alarm bells began ringing for me when a colleague at the weekly team clinical meeting said that they had seen a young person four times and they were now recommending them for a referral to the endocrinology department to commence hormone therapy,” she writes.

Her actions triggered an internal inquiry in 2004 but Evans left the trust as she felt “nothing really changed”. Her husband, Marcus, resigned as a governor of the trust last February, accusing its management of having an “overvalued belief” in the expertise of the Gids that was “used to dismiss challenge and examination”.

On the CrowdJustice website, Mrs A, the mother of the autistic teenager, said she worried that “no one (let alone my daughter) understands the risks and therefore cannot ensure informed consent is obtained”.

NHS England said it would not comment ahead of the hearing. A spokeswoman for the Tavistock and Portman NHS trust said: “It is not appropriate for us to comment in detail in advance of any proposed legal proceedings. The Gids is one of the longest-established services of its type in the world, with an international reputation for being cautious and considered. Our clinical interventions are laid out in nationally set service specifications. NHS England monitor our service very closely. The service has a high level of reported satisfaction and was rated good by the Care Quality Commission.”

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How much does mtf gender reassignment surgery cost, what happens at the consultation for mtf gender reassignment surgery, how do i prepare for my surgery, what happens on the day of surgery, what aftercare will be provided for me, what happens if there is a complication.

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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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What is gender reassignment surgery?

Gender reassignment surgery is any surgical procedure involved in facilitating a male-to-female (MtF) or female-to-male (FtM) transition . Gender reassignment surgery is complex and can involve a number of separate procedures, carried out over several operations.

When is gender reassignment surgery required?

Surgery is generally the last step of a person’s transition. In the UK, to receive gender reassignment surgery through the NHS you need to first spend twelve months living in a social role appropriate to your gender identity. Gender reassignment surgery also comes after any hormonal treatment you have received, whether oestrogen (for MtF transitions) or testosterone (for FtM transitions).

What does it involve?

The exact procedures involved depend on whether you are undergoing a MtF or FtM transiton:

Male-to-female transition

The procedures involved in a male-to-female transition include:

• removal of the penis and testes
• breast implants
• construction of a vagina, vulva and clitoris – usually from the skin from the penis
• surgery on the face to make it more feminine
• in some cases, the removal of the prostate gland

Female-to-male transition

The procedures involved in a female-to-male transition include:

• removal of the breasts
• removal of the womb, ovaries and fallopian tubes
• construction of a penis and testes – using vaginal tissue and skin from the forearm
• a penile implant

In both forms of surgery, the aim is to retain sexual sensation and function.

The extent of follow-up care depends on how much surgery you elect to have and where you have the procedure. It is very likely you will receive psychotherapy to help you adjust to your new body and lifestyle.

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Created on: 02-10-2017

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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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This is also known as sex-reassignment surgery or gender-reassignment surgery. These surgeries help patients’ physical appearance and function, as well as resemble their identified gender.

The surgery can be divided into “top surgery” and “bottom surgery.”

• “Top surgery” creates breasts for male-to-female transgender patients or removes breasts for female-to-male transgender patients.
• “Bottom surgery” for male-to-female transgender patients includes removing male genitalia and creating female genitalia.
• “Bottom surgery” for female-to-male transgender patients includes creating male genitalia from one’s own tissues or using of implants in combination with one’s own tissue.

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What is it and will it make fares cheaper?

Yorkshire mum raising money for 'amazing' daughter's gender reassignment surgery.

A mum is raising money to help pay for her "amazing" daughter's gender reassignment surgery following massive waiting lists for treatment on the NHS.

Dawn Womack, from Wakefield , is raising the money to help her daughter Zoey, who has been transitioning since she was 16. Now 19, she faces long waiting lists on the NHS before she can get the treatment she so desperately needs.

Due to these long delays, Zoey has been suffering with her mental health and so Dawn has decided to instead raise money to pay for the surgery. Due to it being cheaper abroad, she has now booked the surgery in Madrid, Spain.

Read More: Life in Yorkshire 'takeaway town' where two key gripes always annoy locals

Dawn said: "She's been transitioning since she was 16 and there's been no medical support whatsoever for that. So it's meant that we've had to fund hormones ourselves.

"She has not even been able to get anything for her mental health through the GP, there's just no support whatsoever for it. So we've been funding the hormone treatment ourselves and so this has led to doing it online because it's so expensive to do it the right way."

Dawn added: "The reason for the GoFundMe is for gender reassignment surgery. So the waiting list currently in the UK, it'll take you five years but that increases every time I look at the waiting list, it's increased even more. Once they're at the top of the waiting list then waiting for an appointment and having to have hormone treatments through the NHS for two years before they will even consider surgery.

"That means she could be looking at eight to ten years before she could get gender reassignment surgery here in the UK."

Sadly, due to Zoey's mental health, Dawn doesn't believe she can wait that long. Dawn said: "Her mental health is so bad, living in the wrong body, she just wouldn't be here by then."

Get all the latest and breaking news in Yorkshire by signing up to our newsletter here.

Dawn has also paid tribute to Zoey's bravery, saying: "She has a very dry sense of humour, she's very funny and she's currently at university studying animal behaviour.

"She's into music, very much into films and photography, she's a really good photographer. She loves getting out and taking photographs and she models herself and takes photographs of herself which I think is really brave and helps her to feel confident in herself.

"She's a great big sister to her little brother, who absolutely adores her. She's my world, she's just amazing and she's the bravest person I ever met."

So far the campaign has raise £1,000, with a target of £5,000 at the current time, and the money needs to be raised by July 15, 2024. You can donate to the campaign here.

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