NHS Specialised Gender Identity Service

A care agreement between the service and service user

What you should expect of us as a service provider …

General principles

Respect you as an individual, with individual beliefs, concerns and needs.
Respect for diversity in gender identity and expression, and a willingness to work with people with non-binary and other trans* people with different experiences of gender, or who do not consider gender to be part of their experience.
Respect for differences in sexual identity, including asexuality (an absence of sexual attraction), amongst trans* people.
Acknowledgement that differences in gender identity development are not usually the consequence of mental health problems, and that, whilst trans* people may at times be distressed by their gender dysphoria; they are not usually mentally ill or “disordered”.
Acknowledgement of the stigma that is often experienced by the trans* community, its impact on the individual, and help with reducing it and/or addressing its consequences.
A partnership between you, the service user, and us, the service provider, focussed on your recovery and/or the achievement of your gender identity-related agreed goals.
Equitable provision of care for all, regardless of whether they have previously had private care or have self0medicated outside medical supervision.
Your empowerment as a service user, providing you with information, support and advocacy, so that you can make well informed choices about your future.
The opportunity to give feedback to The Laurels and NHS England through comments, compliments or complaints; your feedback is essential if we are to improve and better serve our service users.
The opportunity to participate in helping The Laurels to develop its services in the future, by submitting suggestions or volunteering.

Care and services provided

Provision of care that is consistent with Good practice guidelines for the assessment and treatment of adults and gender dysphoria (RCPsych, October 2013;
Provision of a package of NHS funded services, as described in the NHS England Interim Gender Dysphoria Protocol and Service Guideline 2013/14 (this document may be downloaded via a link at the bottom of the following Web page: which have been specifically planned for and agreed with you, as an individual.
An opportunity to present and discuss your gender concerns with a therapist and a doctor, usually over 4 one hour consultations in Exeter, and to receive recommendations about future care options that may help you achieve your goals. A written report of this assessment and recommendations will be provided to you, the doctor who referred you to The Laurels and to your GP.
Should the assessment recommendations include continuing your care at The Laurels, we will agree with you a plan for you during your care with our service, your “care agreement”; this will be provided in writing and will be updated regularly as you progress through our care pathway. It will include approximate timelines for when you will be offered specific interventions (psychological therapies, gamete storage, hormone therapies, speech therapy, hair removal, surgeries, etc., etc.), and what, if any, requirements will need to be completed in order for you to access them.
Provision of regular appointments with our clinical team, as described in your care agreement; this may include appointments with doctors, psychological therapists, speech therapists, epilation (hair removal) therapists, surgeons, and for work in groups; you should expect to attend at least 12 appointments per year, and perhaps up to 25 appointments per year, according to your clinical need.
We will not change your appointments without good reason and, except in case of emergency or some unforeseen crisis, without giving you reasonable notice, usually at least 4 weeks.
Your medical records, Gender Identity Clinic paperwork and computer details will be changed when we receive an original version of your change of name deed/statutory declaration, which we will copy and keep in your records with us. Once we have your change of name document, we will help you with applications to change your passport, driving licence, etc.
Advice on and help with the acquisition of a Gender Recognition Certificate.
Should we be unable to agree about your care, you can request to be referred to another NHS England commissioned Specialised Gender Identity Service provider for a second opinion.
You can request a complete transfer of your gender identity related care to another NHS England commissioned Specialised Gender Identity Service provider (see note X, below).

Working with your GP and other NHS services

We will work with your GP and other NHS service providers, and encourage them to develop their knowledge of gender identity development and trans* health issues.
We will endeavour to establish a shared care partnership with your GP, in order that they can work both with you and with our service, to deliver the interventions necessary to achieve your agreed goals.
We will work with other parts of the NHS, clinical and administrative, to help them provide services that are responsive to, respectful of and meet the needs of trans* people.

What we ask of you, as a service user …

General principles

We ask that you notify us if you change your GP, your address, your email address or telephone number.
When you are offered an appointment at The Laurels, we ask you to confirm with our secretary, by email, letter or telephone, your intention to attend the appointment, or to request an alternative date or time.
We ask that you attend your appointments at The Laurels, or with other providers within our clinical network, when requested

If you do not confirm, cancel or do not attend, you will be offered a maximum of two further appointments. If you cancel or fail to attend three consecutive appointments without good reason then you may be discharged.
If you are discharged, your doctor at The Laurels will write to your GP with recommendations for your future gender identity related health care; your GP will be under no obligation to follow these recommendations and may not agree to continue prescribing hormone therapies.
We will not make specific recommendations or advice about hormone therapy or other interventions for individuals who do not attend appointments and have not had a recent consultation and medical staff at The Laurels; typically, this will apply to service users who have not been seen for more than six months. Without first-hand, up to date knowledge of your health and progress in response to the treatments we have previously recommended, it is not ethically acceptable, and may be unsafe, to recommend or offer specific advice about medical intervention.

Should you have to cancel and rearrange your appointment, we ask you to give as much notice as possible so that the appointment may be offered to another service user.
We ask that you do not request clinical advice by telephone or email, except in an emergency, and that you ask for advice or pose questions about your care during your regular consultations with team members at The Laurels (exception: by agreement, some regular consultations may be conducted by telephone or Skype).
Whilst we acknowledge that dealing with gender identity related issues is, at times, stressful, we ask that you communicate with us in a respectful manner, even if you disagree with us.

Working with GPs and other NHS services

We ask that you bring any personally held notes with you at each appointment and that these are kept up to date in line with our recommendations.
If you have blood tests with your GP for the purpose of monitoring the treatments recommended at The Laurels, we ask that you request a copy of the results at the time your blood sample is taken and bring them with you to your next appointment at The Laurels.

Other important information …

The Specialised Gender Identity Service at The Laurels, which is part of Devon Partnership NHS Trust, is a national service provider commissioned by NHS England. It is one of seven Specialised Gender Identity Services (sometimes called “Gender Clinics”) in England; they are located in Newcastle, Sheffield, Leeds, Nottingham, Northampton, London and Exeter.
People who need specialist advice about gender identity, and who are registered with a GP anywhere in England, are able to request a referral to any of the seven English service providers. However, when choosing a provider service, they must take into consideration how their choice will affect their ability to engage with that service. Service users of The Laurels will be asked to attend at least 12 appointments per year in Exeter, and may be offered up to 25 appointments per year, according to their needs. You should assume that all appointments will be face-to-face, in Exeter, although some consultations, by mutual agreement, may be provided through electronic media. If, for whatever reasons, you would find it difficult to attend appointments in Exeter, you should choose a service closer to your home.
Each service is part of a “clinical network”, which, in the case of The Laurels, consists not only of the team based in Exeter (doctors, psychological therapists, speech therapists) but also providers based in other, sometimes distant, locations. These providers have special experience and expertise in working with people with differences in gender identity development. A local provider unit of, say, breast surgery, may be highly skilled and provide an excellent service to the general population, but not have the specific experience and expertise necessary to provide optimal experience and outcomes for trans* people.

Feminising (male-to-female) genital reconstructive surgery: the sole providers are currently located in Brighton and London.
Virilising (female-to-male) genital reconstructive surgery: the sole provider is currently located in London.
Feminising and virilising breast surgery: a register of providers is in development; please discuss this with the clinical team.
Speech therapy:
Epilation (hair removal) therapy: a register of providers is in development; please discuss this with the clinical team.

The clinicians at The Laurels work together in the planning and delivery of your care; they come from different professional disciplines (medicine, psychotherapy, nursing, etc.) and, together, form a Multidisciplinary Team (MDT). Potentially life-changing decisions about your care will, of course, first be discussed with you and then discussed within the MDT; such discussions are usually uncontroversial. One of the tasks of the MDT is to monitor clinical decision-making, to promote safe and effective clinical practice, and to ensure that standards of care are maintained. Your confidentiality will be strictly respected protected with the MDT, but you should be aware that clinicians may share any information relevant to your care with the MDT.
Travel and accommodation expenses for appointments at The Laurels, or for appointments with other providers within our clinical network, such as for surgeons, are not reimbursed by our service. It may be possible to reclaim such expenses from other agencies; whilst we can provide evidence of attendance to accompany such applications, we do not make applications on behalf of service users or assist in the resolution of disagreements with other agencies.
We will not provide individual, specific advice on hormone therapy or other interventions directly to former service users who have been discharged, although we are willing to provide general guidance and advice to their GPs, upon request from that GP.

Therapist Signature:Date:

Service User Signature:Date:

Trust Headquarters – Wonford House, Dryden Road, Exeter, Devon, EX2 5AF - Telephone: 01392 208866