What we do

On this page

Assessment
Pathways through the service
Voice and communication therapy
Psychological therapy
Facial hair reduction
Peer support service

The NRGDS service is for all people who experience gender dysphoria (persistent distress, confusion and/or discomfort as a result of a discrepancy between their gender identity and their sex assigned at birth). If an individual wishes to have medical or psychological treatment for their gender dysphoria, we aim to provide appropriate care and treatment to reflect this.

There are a number of interventions and treatment options available to people who wish to transition and change aspects of their body to better reflect, on the outside, how they feel on the inside, but this is not compulsory. Every person will be supported to make the right choices for them as an individual, with personally tailored treatment plans. There is no set pattern or expected pathway that everyone follows.

Some people who are distressed about their assigned sex have other health problems, such as physical or mental health difficulties. The service is open to all, but people with more complex needs may require additional support from other services.

We offer a treatment pathway focused on improving the physical and mental wellbeing of the people that we serve. We offer:

Comprehensive assessment
Medical interventions
Referrals for surgery and other treatments
Voice and communication therapy
Specialist psychological therapy
Advice and training to other professionals, including advice on medical treatments.

Further information about NRGDS is available at:
Northern Region Gender Dysphoria Service – Patient Information Leaflet

All of our work is guided by service specifications agreed with NHS England. Further information can be found at:
https://www.england.nhs.uk/publication/service-specification-gender-identity-services-for-adults-non-surgical-interventions
https://www.england.nhs.uk/publication/service-specification-gender-identity-services-for-adults-surgical-interventions

Assessment

The assessment process is completed in two parts – a first assessment meeting (which may be extended to include additional sessions if required) and a second assessment after an interim period for reflection and consideration of future plans. For more information about assessments please see Frequently asked questions

Pathways through the service

We’ve included two generalised pathways that many people choose – a Sample Feminising Pathway and a Sample Masculinising Pathway. These are offered to give an impression of what might be available and to help patients to make decisions about how to use their time in the service effectively. We are aware that not every individual would wish, or need, to have the treatments described here and we would seek to offer each individual a personalised treatment plan to meet their needs. Voice and communication and psychological therapies are available to anyone at any time should they require them, and so are not included in the sample pathways.

Sample Feminising Pathway

Referral
A person is referred to the service, for more information see the referrals page. The person and their GP will receive confirmation that their referrals has been accepted.

First assessment
If the referral is suitable the first assessment is offered. The assessor writes back to the GP and the service user and asks that the service user have blood tests at their GP surgery.

Second assessment
The assessment is reviewed and supplemented, this time with a lead clinician in the team.

Hormone therapy
Following the completion of the assessment process, treatment is usually discussed including hormone treatment, if this is relevant to the person. The service user will be asked to consider fertility preservation and will be supported with appropriate advice if this is felt to be relevant to them. The lead clinician writes to the GP to recommend treatment, blood tests and other investigations. The service user is usually required to book any tests directly with their GP practice. Thereafter, the service user meets with their lead clinician or another team member (their named professional) at regular intervals to review hormone treatment and adjust hormones carefully.

Facial hair reduction
The clinician offers a choice of hair reduction providers and, when the service user chooses one, sends a referral. The service user usually organises treatment directly with the provider.

Second opinion for genital surgery
Once the criteria for referral for genital surgery have been met, the service user can be referred for a second opinion for genital surgery with a clinician outside the team. This usually requires travel to Edinburgh for a single appointment.

First surgical consultation
When there are two opinions available, agreeing that the person has met the criteria for surgery, a referral is sent to the surgical provider of their choice. The service user travels to see the surgeon for an assessment appointment. Assessment will include a physical examination of the service user and a discussion about the surgery and after care. The surgeon sets criteria about physical health requirements including body weight for safe and successful surgical outcomes. Some people will be required to lose weight and/or stop using nicotine to be able to have safe surgery.

Genital hair removal (if required)
Some people require genital hair removal treatment to prepare for surgery. This can take more than a year to complete. The surgeon will make this referral if required.

Genital surgery
Surgery and some aftercare is offered by the surgical team and then the service user travels home to recover. The surgeon will offer at least one review appointment after surgery. Any problems with the outcomes of the surgery must be brought to the attention of the surgeon so that they can be addressed within 12 months.

Follow up
The team at NRGDS will also offer at least one follow up appointment after all surgery is complete.

Discharge
The service user can be discharged from the service at any time when they and the team agree that they have made use of all the desired treatments on offer or they are no longer able to make use of the service at that time.

Sample Masculinising Pathway

Referral
A person is referred to the service, for more information see the referrals page. The person and their GP will receive confirmation that their referrals has been accepted.

First assessment
If the referral is suitable the first assessment is offered. The team write back to the GP and the service user. The team ask the service user to go for a blood test at their GP surgery.

Second assessment
The assessment is reviewed and supplemented, this time with a lead clinician in the team.

Chest surgery
Once the criteria for referral for chest surgery have been met, the lead clinician can make a referral to a surgeon for this. If they are taking hormones it is preferable that they do so for 6 months before the surgery. The service user travels to see the surgeon for an assessment appointment. Assessment will include a physical examination of the service user and a discussion about the surgery and after care. The service user may also be asked for consent to take photographs before and after surgery; this is not obligatory and the person can refuse. The surgeon sets criteria about physical health requirements including body weight for safe and successful surgical outcomes. Some people will be required to lose weight and/or stop using nicotine to be able to have safe surgery. Surgery and some aftercare is offered by the surgical team and then the service user travels home to recover, the surgeon will agree follow up with the service user. Any problems with the outcomes of the surgery must be brought to the attention of the surgeon so that they can be addressed within 12 months.

Hysterectomy and Bilateral salpingo-oophorectomy (HBSO)
Some service users wish to have surgery to remove internal reproductive organs, this can include the cervix, womb, fallopian tubes and ovaries. Some people have this procedure as part of genital surgery. Others choose to have it separately and / or may not wish to have genital surgery. The referral process will require a second opinion from another member of the team at NRGDS which will be arranged as required.

Second opinion for genital surgery
Once the criteria for referral for genital surgery have been met, the service user can be referred for a second opinion for genital surgery with a clinician outside the team. This usually requires travel to Edinburgh for a single appointment.

First genital surgery consultation
When there are two opinions available, agreeing that the person has met the criteria for surgery, a referral is sent to the masculinising genital surgery surgical provider. The service user will have to travel to London to be seen for an assessment appointment. Assessment will include a physical examination of the service user and a discussion about the surgery and after care. The surgeon sets criteria about physical health requirements including body weight for safe and successful surgical outcomes. Some people will be required to lose weight and/or stop using nicotine to be able to have safe surgery.

Donor site hair removal
If a service user chooses phalloplasty, their surgeon might identify that they need hair removed from the part of their body to be used in the surgery. This decision would be made at the surgical consultation. The surgeon will make this referral if required.

Genital surgery
Surgery and some aftercare is offered by the surgical team and then the service user travels home to recover. The surgeon will review the person and the stage of the surgical process, in London. The process usually involves at least 3 admissions to hospital for surgery, which are arranged by the surgical team. Once all surgery is complete, the surgeon will offer at least one review appointment.

Follow up
The team at NRGDS will also offer at least one follow up appointment after all surgery is complete.

Voice and communication therapy

Voice and communication therapy (also known as Speech and Language Therapy) offers service users the opportunity to reflect on and make changes to their voice, communication and personal presence if they wish to. This is available to anyone using the service regardless of whether they are receiving hormone treatment.

Effects of hormones on the voice
Oestrogen hormone therapy does not affect the size or function of the larynx and vocal folds so pitch is unaltered. Instead, voice change is achieved through exercises and training within the therapy, together with regular outside practice from the individual. Voice change takes consistent practice to acquire. Testosterone hormone therapy promotes growth of the vocal folds over several months which produces a lower pitch of voice.

Initial appointment
This is an information gathering appointment for both the service user and the therapist, and an opportunity for patients to discuss their concerns and hopes about their voice and communication and what they would like to achieve. During this appointment, we will:

Take a case history related to your communication goals
Listen carefully to your voice to ensure it is working healthily
Take a baseline recording of pitch
Explain how the voice works, the process of voice change and what is possible
Provide initial exercises and advice about home practice
Make a plan for how many follow-up sessions are required

Therapy Model
Individuals will be offered up to five therapy appointments at monthly intervals to assist the process of voice practice and change. For those seeking to feminise their voice, help will be offered to:

raise pitch to a comfortable degree without strain
achieve a brighter resonance
explore intonation patterns
use a feminine voice on the phone
project voice over background noise
cough at pitch

For those seeking to masculinise their voice, help will be offered to:

understand the effect of testosterone on the voice by measuring pitch and tracking the changes over time
develop a stronger breath support needed for larger vocal folds created by testosterone therapy
access increased chest resonance
explore intonation patterns

For those identifying as non-binary, therapy goals will be individualised according to what the service user is hoping to achieve in your gender expression through:

work on pitch, resonance and intonation
communicative power and personal presence

Voice groups
After individual one-to-one sessions where vocal skills are taught, a voice group programme can be undertaken. Groups will be made up of no more than 10 members. This will be an opportunity to consolidate vocal skills and generalize them in a wider communicative setting.

Voice and communication change is a process. It takes time to achieve and consists of small changes which add up to a significant difference. We aim to help service users achieve a voice which feels congruent for them. Commitment to practice the exercises given is an essential part of the process. It is designed to be a supportive, collaborative, enjoyable and confidence-building process.

Psychological therapy

Psychological therapy is consider for any person in the service who needs therapy, support, counselling or guidance to reduce their gender dysphoria. We recognise as a team that many of the people using the service will usually have good mental health and most will never need psychological therapy to meet their goals of wellbeing and resilience.

A small number of people will need space to reflect, help to change or support to manage difficult relationships with their body, other people or the world around them. We offer a range of individual therapies.

Referrals usually come from service users, via a clinician in the gender team, after a discussion which identifies a need for therapy. Some people are referred to the service purely to receive specialist psychological therapy for gender dysphoria. However, we do not provide generic mental health care and such needs should be met in the community in the usual way.

Some people have complex difficulties that need to be assessed or managed before they can proceed with treatment. Those people may be asked, by the multidisciplinary team, to undertake a period of reflective psychological therapy, either in this service or in a mental health service, to ensure that it is safe and appropriate for them to proceed with permanent or life changing treatments. Many people who undertake therapy for this reason find it positive and useful for their wellbeing and resilience.

Facial hair reduction

Facial hair reduction is performed by private companies via NHS arrangements. Funding is available for each individual to receive 8 sessions of laser or an equivalent of electrolysis hair reduction on their face. Laser hair removal is best suited for contrasting hair and skin colour (e.g. dark hair on pale skin, or light hair on darker skin), and electrolysis for where there is less contrast between the skin and hair colour. Some people require a combination of both to achieve the best results.

If you want to have hair reduction, then you will need to choose the most convenient provider for you to visit. The providers available depends on where the service user lives. A clinician in the team will ensure the referral is made where required.

Peer support service

The NRGDS Peer Support Service is available to offer support during this waiting period. They can help with coping with the waiting times and making any desired changes through one-to-one and/or group support, as well as answering questions and providing a safe forum to discuss issues and share experiences with other transgender people.