NHS accused of favouring men changing gender over women with medical needs for breast surgery

[NotSoLittle]

Telegraph article " NHS accused of favouring men changing gender over women with medical needs for breast surgery Report says NHS has 'facilitated greater access' to surgery for gender dysphoria patients whilst services are cut for women in pain"
archive.today/bRJd3

I've had another look at the figures because 88,750 still looked like a very large number of admissions for aesthetic surgical procedures, but it turns out that 88,750 is the total number of admissions for all breast surgery.

"Over the last decade, the volume and percentage of all breast surgery admissions for gender reassignment has increased from 0.06% (53 admissions) in 2008/09 to 0.40% (355 admissions) in 2017/18."

The report also mentions the total number of operations per year is about 102,000 and adds:

"Volumes of admissions are slightly lower than volumes of operations, as a patient may have more than one operation in a single episode of care (for example, if the patient has operations on each breast simultaneously, this may be counted as two operations for the purposes of recording activity and workload.)"

So there are around 88,750 admissions in total for breast surgery, of which 0.4% (355) are for procedures related to gender reassignment and 2.84% (2520) are for aesthetic procedures other than for gender reassignment. This means that about 12% of admissions for aesthetic procedures are for gender reassignment.

@OldCrone
Oops yes, I had an extra zero in there when I converted 0.4% to 0.0004 when it should have been 0.004.

Can you explain how you arrived at “This means that about 12% of admissions for aesthetic procedures are for gender reassignment.” ? I can’t see how you calculated this?

Also where did you read this
”and 2.84% (2520) are for aesthetic procedures other than for gender reassignment.” ? Can’t find this.

Oh I see, you misquoted the study. It’s 2.84% of admissions are for aesthetic breast surgery procedures deemed to be of low clinical value….not all aesthetic breast surgery procedures for other than gender reassignment.

p12
“The case for aesthetic breast surgery for congenital, developmental and acquired anomalies
Having identified areas of unnecessary surgery, we have also looked at a subset of breast surgery which is becoming harder to access: aesthetic breast surgery for congenital, developmental and acquired anomalies. This broad category includes various procedures, which have been deemed of ‘limited clinical value’, with predictable consequences for the patients. In 2008/09, the procedures now bracketed as being of limited clinical value accounted for 7.78% of all breast surgery admissions; by 2017/18 that proportion had dropped to 2.84%.”

Not all aesthetic breast surgery is in the low clinical value bracket, ie corrective and reconstructive surgery post cancer removal and surgery to reduce the risk of breast cancer are also under the aesthetic breast surgery umbrella (see p74).

So not all aesthetic procedures other than gender reassignment fall into the low clinical value bracket, in fact per the report only these three do (p76):

• congenital breast developmental problems, resulting in minimal breast growth or significant breast asymmetry;


• breast overgrowth in females, known as developmental hyperplasia; and


• breast overgrowth in males (gynaecomastia) caused by medical conditions or treatment for prostate cancer.

Oh I see, you misquoted the study. It’s 2.84% of admissions are for aesthetic breast surgery procedures deemed to be of low clinical value….not all aesthetic breast surgery procedures for other than gender reassignment.

I was trying to use the same terminology as in the report itself. The 2.84% refers to the procedures covered in the section starting on p74 entitled "Access to aesthetic breast surgery". Throughout the rest of the report it refers to reconstructive surgery following treatment for breast cancer as 'reconstructive surgery', not 'aesthetic surgery', even though this is clearly for aesthetic purposes. But you're correct that on p74 it does say "corrective aesthetic breast surgery has been clearly acknowledged as essential to facilitate high-quality recovery and survivorship after breast cancer surgery", which I missed on my earlier reading.

It should have been clear from the context that I was referring to the procedures covered in that section of the report only. Of those procedures, the gender reassignment procedures constitute about 12% of the total.

Hi ladies, I am the woman referred to in the article. Unfortunately this policy was introduced by stealth years ago - incidentally when gender dysphoria was still clinically recognised as a mental illness by the WHO. Go figure.

My condition is a congenital defect caused by breast disease that revealed itself at the onset of puberty. The resulting capsular contractor complication aside (as this is common for anyone who undergoes breast augmentation) is that the funding has been withdrawn at all; for thousands of women and girls who are born with a health issue that the health service is now choosing to ignore. That is the true scandal here, the prioritisation of treatment of sufferers of GD is a secondary grain of salt in that wound.

Naturally, I feel incredibly let down by a service that has effectively abandoned me in chronic pain and conveniently “re-branded” by condition as cosmetic. There is nothing cosmetic about struggling to put on a bra in the morning, to be unable to touch my breast in either a casual or sexual capacity, to be unable to breastfeed, or to be awoken at night with a sensation that I have an elastic band in my chest which is being pulled tighter with every given year that it is not treated. CC does not improve in time, it only gets worse until the scar tissue is surgically removed. Trans identified men and women do not experience this.

Should I compare this circus to any another part of the body where a prosthetic is required, it really does highlight the farce of my experience. Say if I went to A&E with a broken tibia bone:

Me: I’ve broken my leg, can I have a wheelchair?
NHS: Sorry, some of our wheelchairs are being used by people who don’t feel like walking
Me: But my leg is broken, my surgeon recommends a wheelchair
NHS: Looks cosmetic to us
Me: It hurts me to walk around on a broken bone every day
NHS: Ok, if it hurts so much - we can chop off your leg. You don’t need two legs. But you still can’t have a wheelchair…

And scene.

NHarding

I am so sorry that you have been treated this way. I am shocked that you have been left in this condition. Thank you for speaking up and I hope that you will get the medical care you need soon.

have you written to Baroness Nicholson? I wonder if she can assist.

Shocked I am! Shocked!

I notice the date on the report is February 2021 - why has it taken so long to report it, I wonder?

It also says "embargoed pending formal approval". It would be interesting to know if it's had that formal approval yet.

@NHarding I'm so sorry. Reading your case study in the report made me quite angry. If I've understood correctly, not only is this revisional surgery required because of a congenital abnormality of breast development but because of complications of the initial surgery done on the NHS, causing significant pain symptoms and difficulties in functioning. How they can say this is cosmetic is insulting! As is the suggestion that you instead just have the implant removed on the NHS. I hope the report's authors' comments and recommendations for improving access to aesthetic breast surgery for congenital, developmental and acquired anomalies will be implemented and that yours and similar cases will be treated as clinically necessary.

Could I have predicted a time where breast cancer survivors where lower priory for reconstruction surgery than biologically healthy trans people.

Unfortunately yes I could.

There is a final version of the report (Jul 21) with the same Feb 21 date and after a skim I can't see any differences that jump out at me. I can't link to the final version because you need an NHS log in to see it.

www.gettingitrightfirsttime.co.uk/girft-reports/

There are videos about the report, if that's any help.

www.gettingitrightfirsttime.co.uk/surgical-specialty/breast-surgery/

None of this addresses why the Telegraph is running the story now, of course.

The telegraph only became aware of the issue following my anonymous testimony on Twitter. My surgeon has applied for funding on my behalf for 6 years calendar years and it has always been denied.

There is a medical grading for Capsular Contractor called the Baker Scale (1-4) to indicate it’s severity. I am at the final end of the scale at grade 4 which is described as “hard, implant dislocation / deformation, breast is painful to the touch and appears abnormal. Requires surgical intervention”.

Essentially, I have run out of time. I am now saving and crowdfunding for the surgery.

That makes a lot of sense for the Telegraph running it (becoming aware of your testimony and the refusal of the IFR). I'm shocked it's been refused for 6 calendar years.

NHarding, I'm so sorry to read about this. It's an absolute outrage. Wishing you all the best with your case.

I didn't see this article posted:

lascapigliata.com/institutional-capture/female-patient-denied-nhs-funding-for-treatment-of-painful-breast-condition/

Also, if anyone would like to support the woman in question you can google the name in the article.

The rush to blame trans women was deafening.

And whose fault is that when the NHS insist on referring to some women as male?

But the fact remains that some people who are physically healthy are being given favourable treatment compared to others who are in pain or have other debilitating symptoms.

Just because the 'men' having breast surgery turn out to be women having mastectomies because they don't like being women doesn't make this NHS policy any less unfair for those women with a genuine physical need who are being denied surgery.

I'm overweight, and my gut is much bigger than my boobs. This doesn't make me feel very barbie like womanly.

Is there any chance I'd be offerred a minor breast augmentation to help me feel more womanly? Or would I have more luck pushing for a total mastectomy to affirm my non-womanly feeling?

Yes there was a lot of jumping to the assumption that it was MtF trans women getting breast implants even though the NHS does zero of those procedures. The report was actually very clear on that and it was mentioned in the article too that it was FtM mastectomy procedures.

There should be parity between physical and mental health medical conditions. The FtM transmen needing masectomies may be physically healthy, but they are not mentally healthy due to gender dysphoria- a recognised medical condition.

We can’t go so far as to say that the gender procedures are being prioritised over other aesthetic breast surgeries because to know what is being prioritised you’d need to know what % of referrals for each procedure are being denied. The report doesn’t have this data. The fact that 355 gender reassignment ones were done and it was an increase, whereas for three other procedures the numbers went down over the same period is not the right data to use to determine which procedure is being prioritised (if any are).

The only way to know is to look at what % of referrals were denied by procedure.
Hypothetical example:

Procedure A has on average 1,000 referrals per year. The % denied has gone up from 10% to 20% so the number of surgeries has decline from 900 to 800 per year.

Procedure B has on average 500 referrals per year. The % denied has gone down from 80% to 60% so the number of surgeries has increased (doubled) from 100 to 200 per year

But despite procedure A having a decline in referrals accepted and procedures, a higher % of total referrals are accepted- 80%. This then compared to procedure B’s 40% of referrals accepted means that in actuality Procedure A is prioritised twofold over Procedure B.

The report doesn’t have the data to say that anyone is being denied in favour of another for any procedure. The only thing clear from the report is that breast surgery is woefully underfunded because people are being turned away that should not be.

Hardly surprising given the language used. It is often difficult to work out who is who when sex based language is replaced with gender based descriptions.

Which was the point of much of the initial discussion here.

Yes there was a lot of jumping to the assumption that it was MtF trans women getting breast implants even though the NHS does zero of those procedures. The report was actually very clear on that and it was mentioned in the article too that it was FtM mastectomy procedures.

I've just read through the article in the OP again, and it doesn't mention at all that this refers to FtM mastectomy procedures. In fact it suggests that these procedures are mainly or exclusively breast augmentation procedures for males:

Breast augmentation for gender reassignment is also not routinely funded by NHS England and an application has to be made.

Draft Clinical Commissioning Policy guidance available online states that it should be given as a secondary service for trans women as “augmentation mammoplasty should not be confused with breast enhancement in natal women. It is a necessary and vital part of gender reassignment” for those who have not responded to hormones.

Where does the Telegraph article mention FtM mastectomies?

The report does say that breast augmentation in males is not routinely funded, but one of the quotes from the report included in the Telegraph article implies that some of this surgery for males is funded:

The report added: “It is striking to note how NHS Specialised Commissioning has facilitated greater access to gender reassignment surgery for gender dysphoria – even though some of the surgical procedures involved are the same as those used to treat e.g. congenital breast developmental issues.”

“We see it as both inconsistent and illogical that a procedure can be deemed of limited clinical value for one group of patients or medical condition, but acceptable for another, where there is no substantial difference in the surgical outcomes.”

Since most of the women affected by this are not seeking mastectomies, we can assume that the surgical procedures referred to as "the same as those used to treat e.g. congenital breast developmental issues” are those requested by males who want to be women.

There should be parity between physical and mental health medical conditions. The FtM transmen needing masectomies may be physically healthy, but they are not mentally healthy due to gender dysphoria- a recognised medical condition.

Why are people with a mental health condition with no physical symptoms being prioritised for surgery over women who suffer physical pain? Is surgery an appropriate treatment for a mental health condition?

As an aside do you realise that it is considered transphobic to refer to gender dysphoria as a mental health condition?

Stonewall make the fervent assertion that the trans community are not ill - hence the assiduous lobbying to the WHO in 2019 to remove it from being classified as a mental health disorder, together with their stance against conversion therapy.

This begs the question, if they are not ill - why are they being treated by the NHS at all?

@NHarding

What an absolutely wretched situation for you to be in. Have you tried contacting your MP? It does seem as if you’ve been misled about exactly what’s happening though (or else misquoted?) in that trans women cannot get breast implants funded at all. I very much hope your CCG will agree if another funding application is put in, though of course it shouldn’t take multiple individual funding requests. There also shouldn’t be any nonsense over querying its being aesthetic (rather than cosmetic) surgery, which seems to be part of the problem.

I hate to break it to you, but wheelchair services was probably the worst comparison you could have made there: broken leg? That’s one for the Red Cross. Need a wheelchair but your clinical needs don’t tick the right boxes? IF wheelchair services accept a referral, it will be a tank (if you don’t go with their suggestion to just buy your own). Need a powerchair but don’t live an a completely accessible property? Well it sucks to be you: can’t access the personal wheelchair budget because you haven’t met NHS criteria; you can give up the mobility part of your DLA/PIP to loan one, but it may not meet your needs & if they stop your payments they take your chair; you can set up a Go Fund Me (because who needs dignity); & you can do the rounds of the (few) charities who help fund wheelchairs.

Things are NOT helped by the fact there are a quite astonishing number of people out there who decide that they know far better than any & all of the people involved in their care & they just go off & get wheelchairs. So you’re going to be competing for that incredibly limited amount of funding - from both charities & any individuals outside your own circle who might be willing to help fund something like this - with people who do not, in fact, have a clinical need for a wheelchair & will make themselves more unwell by using one.) They’re not offering limb-chopping as an alternative; but NHS wheelchair services are desperately underfunded (& have been for decades, getting steadily worse); & the alternative funding routes wheelchair services actively push as many patients as possible into are crowded by people who’ve no clinical need for a chair forcing you to compete for woefully inadequate charity funds. So yes, wheelchairs are the bit of the NHS where they routinely say “oh yes, you absolutely need this but you can’t have it” 🤷‍♀️

As for this whole “ZOMG how very dare you bigots blame poor innocent trans women?!” posters 🙄 What you’re actually saying is “how dare you discuss the contents of an article in a broadsheet?!” - with the notable omission of people first expressing the desire to read the full report; provision of a link to the report; & the thread moving to discuss the report. You could monster posters precisely because of that diligence & the fact they didn’t simply assume the facts were indeed as presented in the article. “You absolute transphobes, making it clear that The Telegraph’s suggestion the NHS funds breast enlargement for trans women is incorrect! How could you possibly initially take (& comment on) an article from a reputable source in good faith like that?!” Genuinely embarrassed for people who are so SO desperate for MN to be a hotbed of transphobia they will try this on.

I can see that my attempt at being facetious re the wheelchairs was completely lost on you. Never mind. My point was the idiotic rationale of the NHS offering to completely remove a part of my body as opposed to offering a prosthetic. You could replace wheelchair with crutches, hip replacement, or any other aid etc.

I wish that I had been “misled” about my own care, which has spanned decades. However, I know for a fact that trans women (MtF) in my CCG have indeed received breast implants and this were prioritised over my needs. How do I know this? Because my surgeon performed many of them! He is equally as aghast at this situation as I am.

As I said in my original response, the trans issue is only a further grain of salt into a wound that exists due to funding cuts for women’s health.