Hysterectomies – my additional response to draft NHS England protocol

Hysterectomies (with bilateral salpingo-oopherectomy)

 

Current situation and protocols

  1. Up until now, the Interim Protocol for Gender Dysphoria has listed hysterectomies + BSO as a core, commissioned procedure under the gender dysphoria pathway. It has also set standards for accessing hysterectomies on the grounds of gender dysphoria, derived from the WPATH standards (including requiring at least one signature from a gender clinic), and states a time frame in which hysterectomies should be undertaken (2-5 years from starting testosterone, on the grounds of possible risk of endometrial malignancy)
  2. In contrast, the good practice guide from the Royal College of Psychiatrists (2013) states that GPs can directly refer trans male patients for hysterectomies after a certain period of time living as male, without necessarily requiring specific endorsement from a gender clinic
  3. The new draft protocol does not propose to include hysterectomies + BSO as a core commissioned service, unless undertaken as part of a masculinising genitoplasty procedure. I assume that this is for reasons 4 and 5 below.

Considerations

  1. Hysterectomies with BSO in trans men and non-binary people are not a technically specialised procedure. As far as I am aware, any competent gynaecology unit should be able to conduct the procedure. There are some specific considerations (e.g. a laparoscopically-assisted procedure is usually preferred to preserve options for future phalloplasty), but again, most if not all gynaecology units should be technically capable of addressing these issues, provided that they know to do so.
  2. There are potential logistical/social difficulties in accommodating trans men and nonbinary people in gynaecological services, e.g. providing services sensitively, inpatient placement, use of correct name/title. However, making adaptations to address these issues would be covered under Equality Act 2010 requirements, and it does not seem reasonable to expect trans men to travel to a small number of specialist providers on the basis that local providers might unlawfully break the Equality Act.
  3. The clinical literature on trans masculine hysterectomies + BSO is very limited, and there seems to be little clear recognition of the fact that there are multiple reasons why hysterectomies and BSO are conducted in this population, including:
    • For some trans men, having ‘female’ internal anatomy is part of their experience of dysphoria. Accordingly, a hysterectomy and BSO is an important part of their gender dysphoria pathway, even if the procedure does not need to be conducted by a specialist provider.
    • Risk of malignancy due to unopposed testosterone. My understanding is that the clinical evidence on this is currently more theoretical than empirically established. Wesp (2017) and Feldman (2016) have recently reviewed the evidence and both do not recommend hysterectomy on prophylactic grounds for younger trans men unless there are specific concerns. In contrast, as noted at 1 above, NHS England currently does recommend hysterectomy on prophylactic grounds for all trans men within 5 years of starting testosterone, regardless of age or other risk factors. My perception from being in trans communities is that, many trans men are under the impression that having a hysterectomy is clinically urgent, and that they are at a direct and immediate risk, even at a relatively young age (e.g. early 20s) if they do not have one within the 5 year period. For some, this causes significant anxiety and distress.
    • Other gynaecological needs. It is already established that trans men and non-binary people should have access to a hysterectomy and/or BSO in situations where it would be clinically appropriate for a cis woman to have these procedures, and that this should never be delayed due to the gender dysphoria pathway.
    • Factors or combinations of factors which, in the cis female population, might not be deemed sufficient basis for a hysterectomy, but which, coupled with gender dysphoria, may be seen as sufficient basis for hysterectomy in trans men and non-binary people (e.g. unwillingness to undergo smear tests; painful or heavy menstrual cycles which do not stop on hormone therapy; a desire for permanent infertility). For some of these problems, it is possible that alternative procedures might be suitable – however, the evidence is again minimal.
    • There has been a historic assumption that trans men would never seek to become pregnant, and that testosterone leads quickly to permanent sterility. I suspect this has indirectly influenced attitudes to sterilising surgeries in this population, in that fertility preservation may not have always been taken into account in decisions about hysterectomies for people taking testosterone. It is becoming increasingly clear that this assumption is seriously flawed and that fertility preservation (including, in some cases, preservation of the ability to become pregnant) is important for many trans men and non-binary people, including those already taking testosterone.
  4. Anecdotally, it appears that GPs are often reluctant to refer a trans masculine patient for a hysterectomy without a signature from a gender clinic, and gynaecology units are often reluctant to accept such referrals without gender clinic approval. Occasionally this happens even where patients do have urgent gynaecological needs which would justify hysterectomy regardless of gender dysphoria, despite the fact that current protocols state that this should not happen.

Implications of the new protocol

  1. The new protocol will mean that the gender dysphoria pathway no longer specifies how trans men and nonbinary people can access hysterectomy and BSO on the NHS, unless they do so as part of another genitoplasty procedure. This will be the case even if (as above), they want to access hysterectomy purely as an intervention to address gender dysphoria. As a consequence, there may be a mismatch between their needs and local protocols, which may not currently recognise gender dysphoria as a grounds for hysterectomy.
  2. Gynaecology units, patients and GPs may not realise that a laparoscopic procedure would preserve future surgery options.
  3. The proposed ‘sign-off’ procedures for hysterectomy and BSO after the new protocol is adopted are unclear. Can the GP refer a trans masculine patient for hysterectomy without a signature from the gender clinic? Should a gynaecology unit accept such a referral? Are the gynaecology unit or the GP expected to establish for themselves whether the patient has persistent gender dysphoria, and are they capable of making this assessment? Do they have the correct information to discuss issues of risk (see below)? On the other hand, the new protocol does not state that gender service providers should issue signatures or advice regarding hysterectomies. Suppose a gender clinic adopts a policy of not signing off hysterectomies, but local GPs/gynaecology units refuse to provide them without a clinic signature?
  4. The new protocol will neither reiterate, nor revoke/amend the previous advice that trans men must have a hysterectomy within 2-5 years of starting testosterone. As noted above, my perception is that this belief is already thoroughly embedded in trans communities, and that unless NHS England specifically revokes or amends this guidance, trans men and non-binary people taking testosterone may continue to believe that they are at current direct risk unless they have a hysterectomy. GPs and local gynaecology services are unlikely to have up-to-date clinical knowledge on these issues. If NHS England does still consider that clinical risk is a valid basis for hysterectomy, this should be made clear in guidance, issued in a format to be taken into account by referrers/surgical providers locally. If NHS England considers that risk is no longer sufficient basis for recommending hysterectomy, this aspect of previous guidance should be explicitly revoked or amended in order to minimise confusion and distress (and to avoid potentially unnecessary surgeries).

Conclusions

  1. I broadly agree with the decision not to commission hysterectomies and oophorectomies as a specialised surgery. However, there needs to be much clearer information and guidance issued alongside the adoption of the new protocol. This needs to go beyond liaising with local gynaecology units about being more ‘trans-friendly’, and also include clear guidance on pathways and protocols, including an up-to-date clinical assessment of when hysterectomies should be considered or recommended for trans men and non-binary people, and any requirements that are in place. The service specification itself needs to clearly point to suitable guidance documents, and also to explicitly place a duty on gender identity non-surgical providers to issue advice, information and (if appropriate) ‘sign-off’ regarding hysterectomies conducted by local providers.

 

References:

Feldman, J. (2016). Preventative Care of the Transgender Patient: An Evidence-Based Approach. Principles of Transgender Medicine and Surgery. R. Ettner, S. Monstrey and E. Coleman. New York, Routledge.

Wesp, L. (2017). “Ovarian and endometrial cancer considerations in transgender men.”   Retrieved 3/2/2017, from http://transhealth.ucsf.edu/trans?page=guidelines-ovarian-cancer.

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