Information about transition

Introduction

Liberate’s Trans team are working closely with Guernsey’s Health Department professionals to advance the system of care for Trans and Non-Binary patients.

In 2022 a new health agreement was introduced meaning that Trans and Non-Binary adults in Guernsey can now access timely, government-funded, gender-affirming health care.

To find out exactly what is covered by the States of Guernsey, you can read their Gender Reassignment Services policy. This Policy sets out the scope of Gender Reassignment Services which will be routinely funded by the Committee for Health and Social Care (CHSC), and what is currently excluded.

You can of course choose to self-fund your medical transition through a private clinic if you are over 18.

If people want to medically transition they will need to be referred to an adult Gender Identity Clinic (GIC). Most people who want to transition will be struggling with gender dysphoria

Gender dysphoria is a condition where a person experiences discomfort or distress because there is a mismatch between their biological sex and gender identity. This mismatch between biological sex and gender identity can lead to distressing and uncomfortable feelings, and this is a recognised medical condition – and not a mental illness – for which treatment is sometimes appropriate.

The guidance and information published by the NHS may be more up to date than we can keep this website, so we would advise people to read this for the current advice, especially around recommendations and impact of hormone treatment.

Treatment for Adults

Adults with gender dysphoria should be referred to a specialist adult Gender Identity Clinic (GIC). These clinics can offer ongoing assessments, treatments, support and advice, including:

• Mental health support, such as counselling
• Cross-sex hormone treatment
• Speech and language therapy – to help alter your voice, to sound more typical of your gender identity
• Hair removal treatments, particularly facial hair
• Peer support groups, to meet other people with gender dysphoria
• Relatives’ support groups, for your family

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

Hormone Therapy for Adults

Hormone therapy for adults means taking the hormones of your preferred gender:

• A Trans man (female to male) will take testosterone (masculinising hormones)
• A Trans woman (male to female) will take oestrogen, usually in combination with anti-androgens (feminising hormones)
• A Non-Binary person may pursue micro-dosing of masculinising or feminising hormones. Micro-dosing is the technical term for using any dose below the average prescribed for maximum effect.

The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. These hormones start the process of changing your body into one that is more female or more male, depending on your gender identity. They usually need to be taken indefinitely, even if you have gender reassignment surgery.

Hormone therapy may be all the treatment you need to enable you to live with your gender dysphoria. For some, especially Non-Binary people, the hormones may improve how you feel and mean that you do not need to start living in a preferred gender or have surgery.

Changes in Trans Women or from Feminising Hormones

If you are a Trans woman, changes that you may notice from hormone therapy include:

• Your penis and testicles getting smaller
• Less muscle
• More fat on your hips
• Your breasts becoming lumpy and increasing in size slightly
• Less facial and body hair

Hormone therapy will not affect the voice of a Trans woman.

Changes in Trans Men or from Masculinising Hormones

If you are a Trans man, changes you may notice from hormone therapy include:

• More body and facial hair
• More muscle
• Your clitoris (a small, sensitive part of the female genitals) getting bigger
• Your periods stopping
• An increased sex drive (libido)

Your voice may also get slightly deeper, but it may not be as deep as other men’s v

Risks

There is some uncertainty about the possible risks of long-term masculinising and feminising hormone treatment, and you should be made aware of the potential risks and the importance of regular monitoring before treatment begins.

Some of the potential problems most closely associated with hormone therapy include:

• Blood clots
• Gallstones
• Weight gain
• Acne
• Hair loss from the scalp
• Sleep apnoea– a condition that causes interrupted breathing during sleep

Hormone therapy will also make both Trans men and Trans women less fertile. There is no guarantee that fertility will return to normal if hormones are stopped. Your specialist should discuss the implications for fertility before starting treatment, and they may talk to you about the option of storing eggs or sperm (known as gamete storage

Monitoring

While you are taking these hormones, you will need to have regular check-ups, either at your gender identity clinic or your local GP surgery. You will be assessed, to check for any signs of possible health problems and to find out if the hormone treatment is working.

If you do not think that hormone treatment is working, talk to the healthcare professionals who are treating you. If necessary, you can stop taking the hormones (although some changes are irreversible, such as a deeper voice in trans men and breast growth in trans women).

Alternatively, you may be frustrated with how long hormone therapy takes to produce results, as it will  take a few months (or even years) for changes to develop. Hormones have the potential to change your bone structure and height if you have not experienced ‘epiphyseal closure’, which generally occurs around the age of 25.

Hormones for gender dysphoria are also available from other sources, such as the internet, and it may be tempting to get them from here instead of through your clinic. Hormones from other sources are not licensed and therefore not safe. If you do to use these hormones, let your doctors know so that they can monitor you.

Social Gender Role Transition (SGRT)

If you want to have gender reassignment surgery, you will usually, but not always, need to have lived in your preferred gender identity full time for at least a year. This is known as ‘Social Gender Role Transition’ (previously known as ‘real life experience’ or ‘RLE’) and it will help in confirming whether permanent surgery is the right option.

You can start your Social Gender Role Transition as soon as you are ready, or after discussing it with your care team, who can offer support throughout the process.

The length of the transition period recommended can vary, but it is usually between one and two years. This will allow enough time for you to have a range of experiences in your gender role, such as holidays and family events.

For some types of surgery, such as a bilateral mastectomy (removal of both breasts) in Trans men, you may not need to complete the entire transition period beforehand.

Surgery

Once you have completed your Social Gender Role Transition and you and your care team feels you are ready, you may decide to have surgery. It is worth noting that only around a third of trans people surgically transition – this number may be surprising for some and could be down to a number of factors including lack of access to medical care.

The most common options are discussed below, but you can talk to members of your team and the surgeon at your consultation about the full range available.

Surgery for Trans Men 

For Trans men, surgery may involve:

• A bilateral mastectomy (removal of both breasts) – this is also available for AFAB non binary people
• A hysterectomy (removal of the womb) – please note that this is done off-island (as part of the health care agreement) at a specialist gender clinic. This due to the potential issues if someone may potentially want to have lower surgery in the future.
• A salpingo-oophorectomy (removal of the fallopian tubes and ovaries)
• Phalloplasty or metoidioplasty (construction of a penis)
• Scrotoplasty (construction of a scrotum) and testicular implants
• A penile implant

A phalloplasty uses the existing vaginal tissue and skin taken from the inner forearm or lower abdominal wall to create a penis. A metoidioplasty involves creating a penis from the clitoris, which has been enlarged through hormone therapy.

Surgery for Trans Women

or Trans women, surgery may involve:

• An orchidectomy (removal of the testes)
• A penectomy (removal of the penis)
• Vaginoplasty (construction of a vagina)
• Vulvoplasty (construction of the vulva)
• Clitoroplasty (construction of a clitoris with sensation)
• Breast implants
• Facial feminisation surgery (surgery to make your face a more feminine shape)

If you are feeling anxious or depressed since having treatment, speak to your GP or a healthcare professional at your clinic.

Please note that while accessing medical care there are legal safeguards to protect against discrimination ***see guidelines for gender dysphoria*** but other types of

Things to note when accessing medical transition pathways

• Some people only need one appointment for a diagnosis or for certain treatments others will need more, especially if there are other medical, mental health or social issues to take into consideration.
• Diagnosis, hormone treatment and surgery are not, and nor is it meant to be, automatic. As frustrating as this may be for people these strict measures are in place to keep you safe and make sure any medical transition pathway is correct for you.
• You will be asked to go in to minute detail of your mental health history and life experiences – be prepared for some very invasive questions. We know this can be very triggering and distressing make sure you are mentally prepared.
• If you are having surgery appointments you may need to show the surgeon your body at a first appointment – we know this can be very distressing for people with body dysmorphia but it is a necessary part of being able to make surgical decisons.
• Make sure you are clear about what the next steps are. You may have to sign off what has been recommended in the appointment for them to proceed to the next stage of your transition plan. Make sure you read any correspondence throughly.

Transition and Sexual Orientation

During or after medical transition, it is possible for a person to experience a change of sexual orientation. For example, a Trans woman who was attracted to women before medically transitioning may be attracted to men after. However, this varies greatly from person to person, and the sexual orientation of many Trans people does not change.

If you are going through the process of transition, you may not know what your sexual preference will be until it is complete. However, try not to let this worry you. For many people, the issue of sexual orientation is secondary to the process of transition itself.

Treatment for Under 18's

If a person is under 18 and thought to have gender dysphoria, they will usually be referred via Children and Adolescent Mental Health Services (CAMHS) to a specialist child and adolescent Gender Identity Clinic (GIC).

Staff at these clinics can carry out a detailed assessment of your child, to help them determine what support they need. Depending on the results of this assessment, the options for young people with suspected gender dysphoria can 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
• Gonadotrophin-releasing hormone (GnRH) analogues (i.e. hormone blocking therapy)

A young persons treatment should be arranged with a multi-disciplinary team (MDT). This is a group of different healthcare professionals working together, which may include specialists such as mental health professionals and paediatric endocrinologists (specialists in hormone conditions in young people).

Most treatments offered at this stage are psychological, rather than medical or surgical. This is because the many young people with suspecte

Hormone Therapy for Young People

If a young person has gender dysphoria and they have reached puberty, they could be treated with gonadotrophin-releasing hormone (GnRH) analogues. These are synthetic (man-made) hormones that suppress the hormones naturally produced by the body.

Some of the changes that take place during puberty are driven by hormones. For example, the hormone testosterone, which is produced by the testes in boys, helps stimulate penis growth.

As GnRH analogues suppress the hormones that are produced by a young person’s body. They also suppress puberty and can help delay potentially distressing physical changes caused by their body becoming even more like that of their biological sex, until they are old enough for the treatment options discussed below.

GnRH analogues will only be considered for if assessments have found that they are experiencing clear distress and have a strong desire to live as their gender identity.

Myths around medical care for Trans youth

There are a lot of myths and rumours around the treatment that young Trans people can and can not access. Handily there was a ‘Freedom of Information’ request submitted to the Health department around the medical care of Trans people in Guernsey – Gender identity issues relating to Bailiwick children under the age of 18 and some ‘Rule 14’ questions submitted by a Deputy in 2023 which help clear up quite a few of these. You can find a list of questions and the answers provided by the Committee for Health and Social Care.

Things to highlight include:

• ZERO Under 18’s in Guernsey who are accessing treatment for gender dysphoria have ever been prescribed hormone blockers or hormones.
• Only 30 young people have been referred to the child and adolescent GIC in the previous 10 years. Which is an average of 3 per year.
• 50% of young people who attend GIDS went on to adult services and 50% didn’t.

NOTE: Young people with suspected gender dysphoria will usually be referred (via an appointment at CAMHS) to the Gender Identity Development Service (GIDS) which is part of the NHS. Here they may have previously been able to access hormone blockers but due to long wait times at youth gender identity clinics these have bee very hard for anyone to access. It is worth noting that currently (as of the start of 2024) hormone blockers are only available as part of clinical research. Current ‘lead-times’ to see a youth gender identity clinic are around 4+ years for a first appointment. At the beginning of 2024 a new private youth GIC Gender Plus received their Care Quality Commission (CQC) registration (the CQC is England’s independent regulator of Health and Social Care). This enables them to offer a private service for gender assessments, therapy and support, hormone treatment for over 16’s (if they have been on hormone blockers for over a year as per NHS guidelines), and autism assessments (there is a large crossover between the LGBTQ+ community and people who are neurodivergent).

There are a lot of misunderstanding around hormone blockers which have been prescribed since the 1970s for children with precocious puberty. Puberty blockers are currently a recommended intervention for Trans youth at the start of puberty (when such interventions are usually requested) and are endorsed by the global Endocrine Society and WPATH (the World Professional Association for Transgender Health).

The recommended use of these is being looked at as part of the Cass Independent Review of GIDS. If you want to know more about this please have a read through the review.

Other things worth noting for younger Trans people trying to access the NHS youth GIDS or an adult Gender Identity Clinic (GIC):

• From the age of 16, teenagers who’ve been on hormone blockers for at least 12 months may be given cross-sex hormones, also known as gender-affirming hormones (but this is rare)
• Young people aged 17 or older may be seen in an adult gender identity clinic or be referred to one from GIDS.
• As of the time of writing (at the start of 2024) GIDS is currently closed for referral’s while the NHS developed two new GIDS centre to ensure, as stated in the Cass report, that ‘Children and young people with gender incongruence or dysphoria must receive the same standards of clinical care, assessment and treatment as every other child or young person accessing health services’ and they currently do not.

You can read more about the Cass Interim Report

This section of the website will be updated when we have more information on the outcomes of the Cass Report.

You can find out more about the latest recommended treatments, risks and advice for gender dysphoria for young people via the NHS.

Transition to Adult Services

When a young person reaches 18, their care will usually be transferred to a gender clinic specialising in support and treatment for adults with gender dysphoria. If you would like to access the Guernsey Health agreement with their preferred private GIC you will need to specify this to the States of Guernsey Health department.

By this age, doctors can be much more confident in making a diagnosis of gender dysphoria and, if desired, steps can be taken towards more permanent hormone or surgical treatments, to fit with their gender identity.