Research shows that about half of all trans people have a care demand sooner or later. There are several options and possibilities in the field of transgender care. Not all trans people find all steps necessary to feel good in/with their gender identity and body. The trajectory that a trans person takes therefore differs greatly from person to person.

To make all possible steps in the transition process clear, the Ministry for Health, through the Gender Wellbeing Clinic (GWC), developed the transgender care pathway aimed at developing trans-inclusive healthcare system, using a person-centred individualised approach to maximize overall health and psychological wellbeing.

The importance of the individual’s self-determination of making informed choices and the value of harm reduction approaches are emphasised. Moreover, a core multidisciplinary clinical team has been established to care for the needs of transgender persons, composed of nominated clinicians working within the public health services.

This care path includes a general overview of the services available throughout the entire transition processes, based on the latest version of the Standards of Care (SOC 7) issued by the World Professional Association for Transgender Health (WPATH).

The Point of Entry to Service

Any person seeking gender affirmative healthcare may be referred to the GWC through a designated referral form. This form may be duly filled by a General Practitioner, or a social worker, or psychologist of the client’s choice. Once filled, a soft copy can be emailed to [email protected]. Alternatively, a hard copy can be left at Mater Dei Hospital reception.

The Gender Wellbeing Clinic’s Address is: A3 Towers, Arcade Str, Paola.

The Initial Assessment

Once a referral form is received at the GWC, an appointment for an initial assessment will be sent to the client by post in the indicated address. In this visit, a needs assessment will be carried out by the clinic specialised nurse along with the social worker and/or psychologist. The scope of this initial meeting is to gather background information, as well as to map out an individualised care pathway in line with the identified client’s needs, wants and expectations. In this assessment, the nurse will also be able to provide information about available services and clarify any queries that the person may have.

Psycho-Social Support

If a need for further psycho-social support is identified and agreed with the client in the initial meeting, the person will be referred to the respective psycho-social professional. This may include individual meetings with a counsellor or psychologist; support to the client’s family and/or significant others by the family therapist; and/or social support by a social worker. The client has the option to carry out these sessions either physically or online.

There is also the possibility for a review with a clinic psychiatrist who can assist in support of any existing mental health challenges and follow-ups, and for further determining the client readiness for an informed consent provision prior to irreversible treatments and interventions. The existence of psychiatric problems is not used as an exclusion criterion for accessing gender affirming care. In contrast, prominence is chiefly placed improving the client’s holistic wellbeing and facilitating better functioning in one’s daily activities.

Endocrinology

Should the client wish to start and/or continue feminising or masculinising hormonal therapy, in accordance with one’s preferred gender identity, a referral to the clinic endocrinologist will be done. The client may be able to obtain the prescription for hormonal treatment available on the government formulary, through the Pharmacy of Your Choice (POYC). A consent form​ needs to be signed by the client prior to hormonal therapy whereby one is informed of both the risks and the benefits of therapy. Periodic follow up by the endocrinologist at the GWC is very important to monitor general health status and overall wellbeing, as well as to detect any potential health issue at the earliest possible time.

Communication Therapy

If the client wants to develop vocal characteristics and non-verbal communication patterns that support their desired gender identity, a referral to the clinic’s speech language pathologist (SLP) can be made. These sessions take place within community clinics and the client has the option to carry out these sessions either physically or online.

Surgical procedures

In view of the irreversible nature of the surgical interventions, a detailed psychosocial assessment and psychiatric review is recommended prior to surgery. These are done in close collaboration with the GWC multidisciplinary team. Currently, the available surgical procedures include the removal of the uterus and ovaries (hysterectomy and salpingo-oopherectomy) in transmasculine persons, the removal of testicles (orchidectomy) in transfeminine persons, and chest surgeries. Surgeries are done at MDH.

Fertility preservation

Fertility preservation options are discussed with the clients regardless of stage of transition, but particularly prior to initiating any gender-affirming hormonal treatment or intervention which may potentially effect fertility potential and outcomes. The client is informed about the possibility to be referred to ART clinic at Mater Dei Hospital , whereby gamete preservation may be opted for.

Gynaecology

Transmasculine persons who wish a gynaecological review or consultation, including the possibility of pap smear, are referred to a designated clinic for transmasculine persons within the community.

The clinic is carried out by a designated gynaecologist and the clinic specialised nurse of the GWC clinic team, ensuring dignity and comfort.

Children under age 16

All referred clients aged 16 and over are channelled through the adult services. On the other hand, children under 16 years of age wishing to start puberty blockers are referred to the paediatric endocrinologist at MDH, who works in close collaboration with the GWC team. Psychosocial services are available for the child and family through the GWC. Once a client turns 16, a transitioning process will take place in which handing over to GWC team will take place, ensuring seamlessness and continuity of care in the transition process and holistic needs of the respective client. Partly or fully irreversible treatment are only be considered after the age of 16 years.

The complete Transgender Health Policy, in English and Maltese language, can be accessed here.

A schematic overview of this care pathway may be accessed here.