1. Time for a Change The North Wales GID Referral and Management Pathway Martin J. Riley Principal Psychological Therapist Department of Psychological Therapies, Wrexham

2. 19/12/20152 Background and History North Wales: –Pop n. 670,000 –Mixed rural, urban and coastal communities Service development stimulated by: –Local demand: Prevalence rate 8 to 20/100,000 = approx.120 people with severe gender dysphoria. –Previous GRS provision at Glan Clwyd Hospital –Interested clinicians Initially separate service initiatives: –NW Wales (based in Adult Mental Health Services) –Central & NE Wales (Psychosexual Clinic)

3. 19/12/20153 The North Wales Pathway Pathway emerged out of the work of the two clinicians since 1999. Services amalgamated in 2010 as part of Betsi Cadwaladr University Health Board “A work in progress” Role of clinic: –Coordinating services & clinicians –Coordinate applications for funding for ‘out of area’ services. –Supportive role

4. Service Aims To provide a Gender Identity Service in North Wales offering assessment, diagnosis, treatment and support to transgendered adults. To provide coordination, consultation, clinical supervision and education to all health care professionals involved in the care of this client group.

5. Service Objectives 1 The assessment of patients referred with gender identity problems leading to a formal diagnosis of GID. The formulation and implementation of patient specific treatment and management plan including the Real Life Experience (RLE). Monitoring transgendered patients’ progress through the care pathway and in particular their progress through the RLE. Coordinating with other colleagues and sharing care in the guidance and support of the patient through hormone therapy. To advise and enable appropriate decision making regarding accessing gender confirmatory procedures e.g. electrolysis and cosmetic surgery.

6. Service Objectives 2 To offer guidance and support to enable patients to determine the point at which they are ready and eligible for gender reassignment surgery. Coordinating with colleagues and funding bodies to ensure the timely securing of funding for out of area referral. To coordinate and collaborate in the making of a referral to a surgical provider. Coordinating with and planning of shared follow up and support of patient with surgical providers. Conducting post transition follow up and psychological aftercare following completion of transition.

7. Service Objectives 3 Encouraging and supporting the requirements of clinical governance, audit and evaluation of the outcome of interventions. Participating in formal and informal training and education to disseminate knowledge. Offering opportunities for formal and informal clinical consultations and establishing regular meetings for individual and group clinical supervision. Providing a repository of expertise and clinical resources related to the psychological care of clients with GID.

8. The North Wales GID Pathway Initial referral Consultant Psychiatrist GID Clinic ? Exploratory Therapy Diagnosis confirmed Plan for transition GP informed Diagnosis or management plan uncertain Refer for independent 3 rd assessment Assessment and Diagnostic Phase = liaison & cross referral

9. The North Wales GID Pathway Transition & Confirmation Phase Transition commences Regular follow up / support from GID clinic Transition continues Real Life Test / Experience Speech Therapy Endocrinology Confirmatory procedures E.g. Electrolysis; breast augmentation; lipoplasty etc. (Not currently NHS funded) Employment / F.E or H.E Engagement in local community Family support Completes transition after 18 / 12 Discussion / plans for further treatment

10. The North Wales GID Pathway Completion Phase Completes transition after 18 / 12 Discuss / plan for further treatment Surgery not indicated or requested GID clinic Follow up for 6/12 – 1 yr. Discharge from clinic GP informed Surgery indicated and requested Second opinion sought if required LHB clinical gatekeeper confirmation Application to WHSSC for funding Funding approved by WHSSC Referral from GID Clinic to GRS provider on WHSSC ‘approved list’

11. The North Wales GID Pathway Consolidation Phase Surgical assessment Continued local support from GID clinic (± further preparatory physical or psychological therapies) Surgical workup Surgery Surgical OPD follow up GID clinic follow up GP careLiaison GID Clinic follow up & consolidation =>1 year post transition Discharge from GID clinic GP informed

12. The Future? Equalities Impact Assessment Mental Wellbeing Impact Assessment Refine and develop local services A template for service development across Wales?

13. Time for a Change?