CMAGIC - Questions and answers

Q: What is the CMAGIC Collaborative?

A: CMAGIC Is the Cheshire and Merseyside Adult Gender Identity Collaborative.  The collaborative was set up to improve service provision for transgender and non-binary patients (TGNB). 

CMAGIC is made up of representatives from neighbouring clinical commissioning groups (organisations who decide and buy most of the NHS services in the local areas for the populations they are responsible for) including Sefton, Wirral, Halton, St Helens, Liverpool and Knowsley. It also includes GPs, an endocrinologist and patient representatives who have been working together for many years to develop a unique holistic service that will provide additional patient support. The collaborative has been delivering award winning services for trans and gender non-binary (TGNB) people in Sefton and has an established network in the area.


Q: What is the CMAGIC Pilot?

A: CMAGIC is one of the new NHS gender incongruence pilots for adults (age 17 and over) and brings together clinicians, community groups, and NHS services to provide a community-based approach to improving access to gender identity healthcare.

The CMAGIC Collaborative developed the Cheshire and Merseyside CMAGIC Pathway with Mersey Care NHS Foundation Trust  be awarded the contract to deliver the pilot for two years. The CMAGIC service offers a partnership approach to TGNB care and integrates specialist gender care within primary care and across community groups.

The service offers flexible, tailored support options, assessment for and diagnosis of gender incongruence, hormone therapy (including prescriptions and monitoring), referrals to voice therapy hair removal, psychological therapy and referral for assessment to surgical providers. The service will work to NHS England’s and Improvements National Service Specification for Gender Incongruence services.


Q: How can I get seen by CMAGIC? 

We are targeting patients already on the waiting list of NHS gender identity clinics.

CMAGIC eligibility criteria is as follows:

  • You are 17+, eligible for NHS treatment and registered with a GP in Cheshire and Merseyside

And

  • You are on a waiting list for an existing NHS Gender Incongruence Clinic and are yet to attend your first appointment.

CMAGIC is in the process of directly contacting all eligible people to inform them of the service to provide an opportunity to transfer to CMAGIC as a service user.


Q: I am eligible. Why haven’t I been contacted? 

A: You may not have heard from this service for a number of reasons. For instance, CMAGIC may not be aware that you are currently on a waiting list for an NHS Gender Incongruence Clinic (i.e. we don’t know that you’ve been referred), or your details may not be up-to-date with your NHS GP. Other reasons may include, if you are likely to be seen within three months, or if you have particular circumstances which mean that the clinic you have already been referred to is the best place for you to be seen.


Q: How is CMAGIC different from existing NHS gender Incongruence clinics?

A: CMAGIC is one of the new pilot services commissioned to delivering gender identity healthcare in an innovative and more accessible way. Our service model includes integration with existing NHS GPs and local community groups as a means of providing a more flexible service that supports people who are exploring their gender. Many of our service delivery partners have worked in gender identity healthcare for years, and we have several team members with lived experience.

We can provide assessment for (and diagnosis of) gender incongruence, and access to various elements of medical transition (should people choose it). Some of the services we offer may be familiar to you within a gender incongruence clinic:

  • Support and advice around gender identity (including advice on peer support)
  • Assessment and diagnosis of gender incongruence
  • Referral to speech and language therapy
  • Prescriptions and monitoring of hormone therapy and working with your GP when possible
  • Assessment and recommendation of readiness and referral for surgery
  • One-to-one and group interventions with an experienced psychologist

The collaborative can also offer:

  • One-to-one and group psychosexual therapy (a space to explore and reduce gender incongruence as it relates to your sex life, as well as a range of sexual problems)
  • Workshops to improve self esteem, reduce incongruence and improve wider wellbeing
  • Workshops and activities to improve health, fitness and nutrition The Butterfly Clinic @ Axess Liverpool - Axess Sexual Health

Q: I don’t want to transfer my gender care to CMAGIC, what happens? 

A: When you are contacted and offered an appointment simply let us know if you do not want to transfer your care to CMAGIC. You don’t need to give us a reason and you will keep your place on the specialist clinic waiting list.


Q: What happens at my first appointment?

A: Your first appointment with CMAGIC will last around one hour. We are happy to use video consultation to help reduce travel or any access issues, as well as keeping you safe during the ongoing Covid-19 pandemic.

We’ll ask you if you are comfortable with video consultation when we book your appointment. Don’t worry about the technology, simply having a mobile phone with Wi-Fi or data, a camera, and a quiet place to talk is all we need. If you do not have a phone, or would prefer a face-to-face appointment this will be arranged when we book your initial consultation.

You will be contacted by one of our specialist GPs on the day of your appointment. We normally send a text message to remind you and we do the best we can to run exactly to time.

This consultation is an opportunity for you to explore the services we offer in more detail and to ask questions about various aspects of social or medical transition. During this initial discussion, we would also like to learn a bit more about you. This helps us to offer the most appropriate information and support.

We will most likely discuss:

  • Your gender identity, your feelings about it and how they may have changed and developed over time
  • Your hopes and goals for the future
  • Various aspects of your life, such as hobbies, work, or education
  • Your wellbeing, including your mental health (both currently and in the past)
  • Your relationships and support networks
  • Your next steps

Get the most out of your consultation:

  • Bring a list of questions you would like to ask
  • Take notes during your appointment
  • Ask us to repeat any information that wasn’t clear
  • Consult us with a friend, family member, case worker or partner present in the room.

When we booked your initial appointment we asked for your consent to access your existing NHS records, this includes your GPs clinical system. If you are hoping to access physical interventions such as hormone therapy or referral for surgery we will be using this system to check your medical history (including any health conditions and/or medication you might be taking). We’ll also review your height, weight and blood pressure, and request some blood tests. This health check does not involve a genital or chest examination. By undertaking the health check during your first appointment, we can be ready to start hormone therapy at your second appointment if:

  • The second clinician agrees it is in your best interests
  • You’ve read and understood the information we gave you
  • You’re feeling ready to start hormones therapy
  • It’s medically safe for you to do so.

At the end of your first consultation we will give you some written information about the services in the area, as well as information about hormone therapy and/or gender affirming surgeries if required. Please read this information before your second appointment (usually in 4-6 weeks) and highlight or make notes of any areas you would like more information about.


Q: Do I have to dress a certain way at my appointments?

A: There’s no set way to dress ‘like a man’, ‘like a woman’ or ‘like a non-binary person’ and we strive to provide a service where all trans/non-binary people can be themselves. We recognise that gender identity is very different from gender expression; all we ask is that people dress however they feel most comfortable on the day; because we are usually using video consulting you will be safe, in your own home, or where ever you have access to the technology.


Q: Who will I see at my appointments?

A: We are a team of professionals from a range of backgrounds and roles (nursing, psychology and medical). As a pilot Gender Incongruence Clinic, our team will be receiving on-going training and clinical supervision from an experienced specialist consultant in gender incongruence. They may join your video consultation or possibly review your case with our team at a later date.

We will always ask your permission for either a colleague or a supervisor to sit in on your appointments if it is required as part of our training. We will ask your consent when booking your appointment and you are welcome to decline.


Q: Will I be ‘diagnosed’ by the CMAGIC service?

A: Many of the services which support and treat trans people require a diagnosis to access care. Although the medical profession is changing its view away from gender identity disorder, to recognising the distress it can cause people who are trans or non-binary as gender Incongruence. The service cant make the relevant diagnosis for medical and legal purposes.


Q: How confidential is the CMAGIC service? 

A: Confidentiality is a fundamental component to the running of any health service, and we follow the same policies as the wider NHS. There are strict laws that we must adhere to regarding the use, sharing, disclosure, storage and transfer of patient identifiable information.

Did you know that “outing” a patient without consent is a crime and punishable by up to two years in prison? Any personal information you share with us will be held in the strictest confidence. Your clinical records are stored within your GP record, and shared only with your consent.


Q: Will I need to have blood tests?

A: You will need blood tests as part of the safe prescribing and monitoring of hormone medication. These tests are requested by our clinicians and can be carried out at your local phlebotomy service or your local GP practice.

It is important to have regular blood tests to check your hormone levels, liver and kidney function, and your full blood count. If and when you start taking new medication as part of your care, we will most likely check your bloods at one, three and six month intervals. Once people are stable on their hormones, blood tests are required every six months to one year.

We will start you on your medication and take responsibility for monitoring in the early stages. However, we will work to ensure your GP surgery feels competent and confident in carrying out your blood monitoring (and injections – if needed) in the long term. Depending on circumstances we may need to arrange for injections at one of our clinical locations.


Q: Will I be able to go on hormones straight away?

A: At your first consultation we’d like you to undertake a virtual physical health check with our clinicians. This will include taking your medical history and a sexual health screen (if necessary or appropriate). We’d also like to review your blood pressure, height and weight from your GP clinical record, and also arrange for blood tests. These tests will look at your full blood count, hormone levels, and your kidney and liver function. We’ll also give you some information about hormone therapy to take away with you and read before your next visit.

Our clinical team will have reviewed your blood results by the time you have your second consultation (4-6 weeks later) and will have made a recommendation for a prescription. If the clinician agrees it is in your best interests at your second appointment, you’ll have the option of starting hormone treatment on that day. This is also the case for people who have already received a diagnosis of gender incongruence from an NHS approved practitioner in another setting.

We understand that some people may wish to wait and/or access additional support before starting hormone therapy (if they choose to take hormones at all). We can signpost to a range of services designed to support our service users to make the best possible choices about their gender care (including peer support, clinical psychology and psychosexual therapy), and those decisions will always be led by you.

We also ask that all service users who are interested in hormone therapy read the information from the Human Fertilisation and Embryology Authority about trans/non-binary people and fertility preservation


Q: Can I be referred for surgery straight away? 

A: Immediate referral is dependent on a number of factors. For instance, some people may be seen by our service although they have already received a diagnosis of gender incongruence from another approved provider. If this is the case, it may take less time for that person to be assessed for surgery compared to a person who has never had any formal support around their gender incongruence.


Q: How long does it take to be seen by CMAGIC?

A: The CMAGIC pilot has been commissioned for two years. The collaborative has already started to roll out a Trans Health service to local areas, the first being Sefton in 2017, this Trans Health service supports GPs and patients in ongoing care and prescribing. In this pilot, we hope that eligible people will be assessed for suitability for treatment and, if beneficial, will subsequently have access to any gender affirming care that is available via the NHS (including hormones, speech therapy, talking therapies and group work to reduce Incongruence, and surgery). Currently waiting times for Gender Identity Clinics is approximately 30 months, CMAGIC intends to reduce this waiting time considerably over the course of the pilot.


Q: How long will I wait between appointments?

A: CMAGIC offers a safe, efficient service. Time between your first and second appointments is usually four to six weeks (unless you choose otherwise). Some people may choose longer periods between appointments for a number of reasons e.g. to access additional support or services, or to spend more time thinking considering the various options available to them. We’re a flexible service and we’ll be led by you.


Q: I’m not eligible for the CMAGIC pilot, can I get help with self-medicating? 

A: If you are taking hormones that have not been prescribed to you by a registered medical professional, we would encourage you to speak with your GP, or, if available in your area, the Trans Health service.

As you are taking medication that we did not prescribe to you, we’re not able to provide guidance about how to take it. However, we can help your GP in explaining what your bloods results mean and highlight any abnormalities. You can use this information to make an informed choice about how to continue with your medication.


Q: I’ve been diagnosed with gender Incongruence in a non-NHS service; do I need to receive a diagnosis by CMAGIC?

A: Not necessarily. We want to make sure that CMAGIC is as easily accessible as possible, and we understand that many people will have been diagnosed in private services or abroad, and that some may have started hormone therapy or even had some surgeries prior to being seen by us.

If you received your gender incongruence diagnosis from a health professional who can evidence appropriate training and experience in assessing, diagnosing and prescribing for gender Incongruence then you will not need to receive a diagnosis from CMAGIC.

Appropriate training and experience can include:

  • Formal links with an NHS commissioned specialised Gender Incongruence Clinic
  • Formal links with relevant professional associations
  • Previous time spent working in NHS-commissioned Gender Incongruence Clinics
  • Attendance of relevant meetings, workshops or seminars
  • Obtaining supervision from a health professional with relevant experience
  • Participating in credible research related to gender non-conformity or gender Incongruence.

Q: I am already on hormones but I still want surgery or speech therapy. Can I be seen by CMAGIC if I’m eligible? 

A: A number of people will be on the specialist waiting list at various different life and transition stages. As long as you meet the service criteria and have not already been seen at an existing NHS Gender Incongruence Clinic, you are eligible to be seen by CMAGIC.


Q: I’m hoping to have some type of gender-affirming surgery. What could delay this? 

A: Choosing the right surgeon is a big step. Make sure you explore the types of procedure(s) you want thoroughly, find out as much as possible about the surgeon, and review pictures of their previous results. These are often available on request from the surgical providers themselves as well as from various community websites.

Whilst we can assess people for their readiness to undergo gender affirming surgical procedures, we are not responsible for the waiting lists for individual surgical providers. However, many providers will have cancellation lists for people who are able to undergo surgery at short notice.

Some of the factors that might cause delays to surgery include:

  • Getting to a healthy weight – There are a number of risks associated with procedures that require a general anaesthetic. Each surgical team will have its own guidelines about weight (under or over weight), as this will affect a person’s risk of surgical complications. Providers will usually set a weight range for those they consider suitable for surgery, which is often a body mass index (BMI) of 18-30. If you know your weight and height, you can calculate your BMI here, or you may wish to check your weight at your local pharmacy.
  • Giving up smoking – Smokers are significantly more likely to experience complications during or after surgery and some surgical providers will not operate on people who are active smokers. Not only are smokers at risk of serious complications from undergoing surgery, smoking can also affect the healing process and cause tissue death where skin has been grafted. Talk to your GP about giving up smoking or contact your local Stop Smoking service.
  • Hair removal – Certain surgeries might require a person to undergo hair removal procedures before the procedure. E.g. a person having phalloplasty (surgery to create a penis) might want to permanently remove the hair on their forearm if it is being used to create the penis shaft and urethra. Those having vaginoplasty or vulvoplasty (surgery to create a vagina or vulva) will require hair removal on any skin sites that will be resituated to the inside of the body in order to avoid future complications.
  • Other health conditions – There are a number of physical health conditions which may need to be controlled or treated before undergoing surgery e.g. genital warts if you are having genital surgery.

Optimising your psychological wellbeing is also important. Sometimes just thinking about a hospital stay or having a surgical procedure can cause some people to experience anxiety. Additionally, undergoing surgery with a general anaesthetic can have a big impact on your mood and energy levels. The recovery process can also  be tiring, and can cause some people to feel lonely, vulnerable or scared. Particularly if you’ve never had an operation before and are unsure if you are healing as you would expect or wondering if you are taking good care of your wounds.

Getting yourself feeling as though you are well prepared for surgery and the healing process is important, as is asking questions to your surgical team if you’re unsure about something once you’re discharged home. Lots of surgical providers are happy to provide remote follow up over the phone or e-mail, including reviewing pictures of any tissue or stitches that you may be worried are not healing as they should.


Q: Can I be honest about my mental health, sex life, drug use, sex work or an abusive relationship?

A: Yes. The team has experience of working with people from all walks of life, including the trans and wider LGBTQI+ communities, and those who live with wellbeing challenges.

We understand that trans/non-binary people face day-to-day challenges that can result in poor mental health, including thoughts of suicide and self-harm. These thoughts and feelings do not (in and of themselves) constitute a barrier to accessing care. We strive to provide our service users with the tools and coping strategies they need to improve their mental wellbeing and develop their resilience.

With your consent, we aim to work in partnership with any existing support services you may access (e.g. mental health teams, learning difficulty or eating disorder services) to ensure you feel safe and supported in making decisions about your care with CMAGIC.


Q:Can you provide supporting letters for my gender recognition certificate application?

A.We support trans/non-binary people’s right to self-determination. However, the current process for obtaining legal gender recognition in the UK requires an application for a Gender Recognition Certificate in accordance with the Gender Recognition Act 2004. See the Government site here: UK website for further details.

Should you choose to apply, your application requires a report from a:

  • Doctor registered with the General Medical Council (GMC)
  • Psychologist registered with the Health and Care Professions Council

We are able to provide a medical report which is compliant with the following guidance: https://www.gov.uk/government/publications/form-t452-guidelines-for-registered-medical-practitioners-and-registered-psychologists-to-facilitate-completion-of-the-medical-report-proforma-for-g

Please request the report at one of your appointments or contact the CMAGIC Administration team.


Q: How can I give feedback or make a complaint about the service?

A: Please share your compliments or feedback on any areas that could be improved as your views can help us shape and develop our services and allows us to deliver the best possible care. If you would like to share feedback or talk to us about a problem or complaint please contact our Patient Advice and Liaison service (PALS)

Or you can contact the Patient Advice and Liaison Officer by calling: 0151 471 2377 or Freephone 0800 328 2941.