Adult trans care pathway: What CQC expects from maternity and gynaecology services

Page last updated: 12 May 2022
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When we assess maternity and gynaecology services, we will look at how they provide care for people who are on the trans care pathway.

Maternity and gynaecology services play a vital role in the trans care pathway. They can provide care to patients undergoing gender affirming surgery, as well as care for all trans men and non-binary people who are able to bear children. A person’s trans status is also relevant to NHS cancer screening programmes, pregnancy, and sexual health.

Gender reassignment (wording of the Act to mean trans status) is a protected characteristic under the Equality Act 2010, so we consider equality when we assess a service, and judge whether it is meeting the equality aspects of the Health and Social Care Act regulations.

Assessing care for trans and non-binary people in maternity and gynaecology services

To inform our assessments, we engaged with the LGBT Foundation to ask trans people what makes a good service. We will use this feedback when looking at the key questions and our local teams will talk with staff and ask questions about specific areas, or observe the environment if we visit a service.

Effective

Staff are aware of and understand issues relating to trans and non-binary people, and do not make assumptions about people’s bodies.

Healthcare professionals need to be aware of how people may experience physical examinations. For example, a trans person may prefer a clinician of their own gender to perform an examination or give personal care. Staff should ask the person if there is any way to minimise potential distress caused as a result. This includes how they may refer to intimate parts of the body in different ways. For example, several phrases such as ‘external pelvic area’, or ‘outer parts’ are considered more gender neutral, as well as using the term ’chest feeding’ instead of ‘breast feeding’.

Staff understand the funding and storage issues for gamete samples for trans and non-binary people who want to have children at a later date.

A trans or non-binary person undergoing either hormone treatment or surgery may become infertile and should be offered the opportunity to store gametes. In England, funding decisions about storage and fertility treatment are decided locally by clinical commissioning groups (CCGs). Some CCGs will fund treatment and others will not. The National Institute for Health and Care Excellence (NICE) provides guidelines to CCGs and medical professionals on who should be treated on the NHS. The normal maximum duration of gamete storage is 10 years, but for trans and non-binary people this can be extended to a maximum of 55 years.

To help gather evidence, inspectors will check monitoring data or speak with staff and ask questions relating to:

  • Training for staff on fertility, obstetrics and gynaecology issues, and good practice in delivering healthcare for trans and non-binary people. Staff should understand their role in the trans care pathway and when a trans or non-binary person’s identity is relevant to their healthcare, so they are confident in meeting people’s needs.
  • Fertility, pregnancy, antenatal, obstetric and postnatal care options for trans or non-binary patients, including awareness of local services and policies or how to access information.
  • The service’s policies on eliminating discrimination, bullying and harassment based on gender identity, gender expression and sexual orientation.

Caring

Staff respond positively to enable trans and non-binary people to feel confident when using services and address people by their preferred name, title and pronoun.

When interacting with a trans or non-binary person, it is best to ask each person how they want to be addressed and how they understand themselves. Ultimately, the ‘correct’ terminology is whatever the trans or non-binary person uses to describe themselves.

Staff are aware that a person’s voice on the phone may not match their preconceptions about their gender.

Staff should be aware that there is no reliable way to know whether a patient is trans or non-binary unless the patient tells them. It is important to be mindful of the language to use and avoid assuming gender. Misgendering someone can exacerbate their gender dysphoria and highlights the importance of using gender-neutral language.

Responsive

The service places trans or non-binary people on an appropriate ward, using side rooms and offering flexible options where appropriate.

We will assess whether services are following guidance from NHS England on delivering same-sex accommodation. Where trans and non-binary patients are cared for in an inpatient setting, services need to consider their privacy and dignity. When placing a person on a ward, services should ask the patient for their preference. People who live in their affirmed gender should always be offered accommodation according to their gender presentation. However, services need to consider whether care can be provided safely. They should also provide a side room or a single adjacent ward accommodation depending on:

  • the nature of the treatment or surgery
  • availability of beds
  • genital operative state of the patient
  • the patient’s history and wishes (including their own anxieties and concerns).

This approach may only be varied under special circumstances, for example where the treatment is sex-specific and a trans person needs to be placed in a ward for the opposite gender. It is only lawful if it is a proportionate way to achieve a legitimate aim. An example would be when a trans man is having a hysterectomy in a hospital where the only ward available is female gynaecology, and no side room is available. Services need to give particular consideration to obstetric care, so that it is both safe and in line with the person’s wishes. The service should discuss and agree arrangements that respect the person’s wishes, and have facilities ready before they are admitted. This means they won’t be disadvantaged by having to wait compared with other patients who need the same service.

The design of a hospital has considered trans and non-binary people, for example having gender-neutral toilets and interior decoration.

The hospital should either provide gender-neutral toilets, or support people to use the toilet that best matches their gender identity.

The service discusses and makes arrangements for trans men and non-binary people who want to give birth and supports them with antenatal and postnatal care.

There is limited information for healthcare providers on how to cater for trans men or non-binary people who become pregnant. Overall, pregnancy outcomes and complications do not appear to differ from the general population, but it is important to ensure care is positive and inclusive. Trans and non-binary people can experience feelings of loneliness and isolation during pregnancy, caused by gender dysphoria, lack of role models and prevailing societal views that a gestational parent should be a mother. These issues could result in them being at higher risk of postpartum depression. A trans or non-binary person giving birth may want to be referred to as ‘father/parent’ rather than ‘mother’. Trans men may choose to chest-feed their infants, even after having undergone chest surgery, and should be supported to do so. Services should also offer support to resume testosterone after the birth, if the person has asked for it.

To help gather evidence, we will check monitoring data or speak with staff and ask questions relating to:

  • positive feedback or complaints/suggestions for change from trans and non-binary people who have been inpatients, and the action taken
  • the number of trans and non-binary people using the service.

Services should also consider:

  • Effective key question: Ensure there are policies that communicate a zero-tolerance approach to discrimination, bullying and harassment based on gender identity, gender expression and sexual orientation. Staff should receive training and understand their role in the trans care pathway, and when a trans or non-binary person’s identity is relevant to their healthcare.
  • Responsive key question: Staff should be aware that it may be unlawful to disclose a patient’s trans identity without their consent under the Gender Recognition Act 2004. It is both good practice and compliant with law to respect a trans person’s identity and amend all medical records accordingly in line with their affirmed gender.
  • Well-led key question: Senior leaders should ensure that they are meeting both the rights and preferences of trans and non-binary people, with a specific focus on the culture of the service and how it engages with people. services need to gather the views of all patients, including trans and non-binary people, to improve patient experience and services for all. It is essential for both patients and staff groups to have an inclusive culture that takes into account the rights of diverse groups, including trans and non-binary people.

Further information

Find out more

The adult trans care pathway

Adult trans care pathway: what CQC expects from GP practices

Adult trans care pathway: what CQC expects from speech and language services