The South and West Development and Evaluation Serv

SurgicalgenderreassignmentformaletofemaletranssexualpeopleSeptember1998ThisreporthasbeenpreparedaspartoftheDevelopmentandEvaluationServicefundedbytheResearchandDevelopmentDirectorateSouthandWest.Itisintendedtoproviderapid,accurateandusableinformationonhealthtechnologyeffectivenesstopurchasers,clinicians,managersandresearchersintheSouthandWest.Thisreportmaybephotocopied.ThefulltextisavailableontheInternet:://ww.soton.ac.uk/~dec/DECevelopment&valuationommitteeReportNo.88TheSouthandWestDevelopmentandEvaluationServicePurposeTheDevelopmentandEvaluationServiceisfundedbytheResearchandDevelopmentDirectorateoftheNHSExecutive(SouthandWestRegionalOffice)toproviderapid,accurateandusableinformationonthecosteffectivenessofhealthtechnologiesinresponsetotheneedsofNHScommissionersandproviders.TheserviceTheservicehastwoelements:astructuredreview,typicallypreparedinthreetosixmonths,andtheDevelopmentandEvaluationCommittee(DEC)madeupofseniorcliniciansandotherindependentindividualswhichmeetsquarterly.TheDECconsidersthequalityofavailableevidenceandthelikelyvalueformoneyofferedbytheinterventionpresentedinthereport,andreachesajustifiedconclusiononthesupportitgivestheintervention.MethodsDECreportsareinformedbyonlineliteraturesearch,areviewofbibliographiesandreferencelistsandconsultationwithclinicalexperts.Evidenceissoughtontheeffectivenessofinterventions,theircostandtheepidemiologyofthehealthproblemconcerned.Appraisalofevidenceforeffectivenessisguidedbystandardchecklists(particularlythosedevelopedfortheCriticalAppraisalSkillsProgramme).Detailedandfullyaccuratecostinformationisoftennotavailable.Extracontractualreferraltariffsandotherlessprecisecostestimatesareusedwhentheyaretheonlysourceofcostingstotherequiredlevelofdetail.Theresultsofrelevantstudiesarepresentedindividuallyandthemostplausibleresultsusedinfurtheranalysis.TheIndexofHealthRelatedQualityofLifeisusedtoestimatebenefitsasQualityAdjustedLifeYears(QALYs)wherepossible.QALYestimatesarecombinedwithcostdatatoprovideanestimateofcostutility,allowingcomparisonofthevalueformoneyoftheinterventioninprovidinghealthgain.Uncertaintiesinestimatesofcostsandbenefits(andthereforethevalueformoneyassociatedwithimplementationoftheinterventionconcerned)areexploredinsensitivityanalyses.TheconclusionsoftheDECfallintooneoffivepredefinedcategories:StronglysupportedSupportedLimitedsupportNotsupportedNotprovenReportsarecirculatedwidelythroughouttheSouthandWestRegionbytheNHSExecutiveandarepublishedinfullontheDECinternetsite:~dec/InterDECTheWessexInstituteforHealthResearchandDevelopmenthasnowjoinedawidercollaborationwiththreeunitsinotherRegions(theTrentWorkingGrouponAcutePurchasing,theScottishHealthPurchasingInformationCentreandtheUniversityofBirminghamInstituteforPublicEnvironmentalHealth)tosharetheworkonreviewingtheeffectivenessandcost-effectivenessofclinicalinterventions.Thisgroup,InterDEC,willsharework,avoidduplicationandimprovethepeerreviewingandqualitycontrolofthesereports.ThisreportwaspreparedbasedonliteratureavailableuptoApril1988byLesleyBest,KenSteinSeriesEditors:DrRuairidhMilneandDrKenSteinWessexInstituteforHealthResearchandDevelopmentReporttotheDevelopmentandEvaluationCommitteesNo.88sSeptember1998Surgicalgenderreassignmentformaletofemaletranssexualpeople1SURGICALGENDERREASSIGNMENTFORMALETOFEMALETRANSSEXUALPEOPLEConclusionoftheDevelopmentandEvaluationCommitteeConclusion:NotprovenCommentary:Itisclearthatasmallnumberofpeoplemayexperienceimportantbenefitsfromthistechnology.However,thepotentialhazardsoftreatmentareconsiderableandmorerigorousresearchisrequiredintothelongtermrisksandbenefitstosupportcaseselectionandjustifyservicedevelopment.Wheresurgeryisperformeditshouldberestrictedtospecialistcentreswithproventechnicalexpertiseandwhichhaveclearprotocolsforpatientselectionandgoodclinicalauditinplace.Pendingimprovementstotheevidencebaseinthisarea,theCommitteenotedthevalueofguidelinessuchasthosepromulgatedbytheHarryBenjaminGenderDsyphoriaAssociationinidentifyingminimumstandardsofcareforpeopleapplyingforsurgery.SummaryofthereportŸTheproposalisforsurgicalgenderreassignmenttobeavailableforcarefullyselectedtranssexualpeople.Surgeryisnotacosmeticintervention,butonethatattemptstoreconcileanindividual’scoreidentityandtheirphysicalcharacteristics.ŸThereisnocomparablealternativetogenderreassignmentsurgeryinthosewhoareeligibleforsurgery.IndividualswhoarerefusedNHStreatmentmayapproachprivateclinics,bothintheUKandabroad.ŸTheprevalenceoftranssexualismhasnotbeenstudiedinthiscountryinrecentyears.Europeanstudiessuggestthattheremaybe150maletranssexualpeopleintheSouthandWestregion,andwemayexpectfiverequestsforsurgicalgenderreassignmenteachyear.ŸCurrentevidenceconsistsofoneprospectivecontrolledstudy,numerouscaseseries,andonecross-sectionalstudy.Moststudiesabouttheeffectivenessofsurgicalgenderreassignmenthavenotcollecteddataprospectivelyandarehamperedbylossestofollowupandlackofvalidatedoutcomemeasures.ŸItisevidentthatanumberofmaletofemaletranssexualpeopleexperience