Working with doctors Working for patients

Treatment pathways

From Good medical practice
  1.  

  2. 15. You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

     

    1. b. promptly provide or arrange suitable advice, investigations or treatment where necessary
    2. c. refer a patient to another practitioner when this serves the patient’s needs.

Referral to a Gender Identity Clinic (‘GIC’)

If your patient requests treatment for gender dysphoria, experts agree the best way to meet their needs is to refer them to a Gender Identity Clinic (GIC) or gender specialist without delay. Click on the tab at the bottom of the page for details of your nearest GIC.

All GPs in England, Northern Ireland and Scotland may refer their patients directly to a GIC and do not need to refer them to a mental health service for assessment beforehand. GPs in England don’t need to seek prior approval from their Clinical Commissioning Group (CCG).

This is supported in England and Scotland by NHS service protocols.

And in Northern Ireland by the guidelines for GPs developed by Royal College of GPs Northern Ireland:

The Welsh government published a Trans Action Plan (pdf) in March 2016, emphasising a commitment to develop and implement an NHS Wales Strategy for Wales, which will include a care pathway and guidance for healthcare practitioners, to be progressed as a priority. Any service realignment required to support the pathway should begin during 2016/17.

In the meantime the Welsh Health Specialist Service Committee (WHSSC) policy is for GPs to refer first to a local psychiatrist who assesses the patient and can recommend they are referred for assessment and treatment in England at the West London MHT GIC: Welsh Health Specialist Service Committee policy on Specialised Adult Gender Identity Services (pdf).

NHS Wales has recently launched a dedicated Gender Dysphoria website which includes a useful links page, listing a range of organisations who can provide support and advice to trans people and their families.

Every patient’s treatment journey will be different and GICs aim to provide care packages tailored to individual need. By focusing on your patient’s priorities and concerns and exploring with them the options available, you can collaborate with GICs to provide effective care and a positive experience for your patient.

If you feel you lack knowledge and experience about the healthcare needs of trans people you should ask for advice from a gender specialist and address your training need as a part of your continuing professional development (see the CPD section). E-learning is freely available on the RCGP website. The resource carries CPD points.

Tackling the risk of harm: ‘bridging prescriptions’

Patients may face a long wait before their first appointment with a gender specialist. This can be very distressing and their mental health may suffer as a consequence. The risk of self-harm and suicide for trans people is much greater than in the general population, and delay in accessing medical care substantially increases these risks. If your patient is distressed, or you believe them to be at risk from self-harm, you should offer them support and consider the need for referral to local mental health services.

Some trans people – after many years of suppression, and facing continued deterioration in their mental health while waiting for a specialist appointment – become desperate for medical intervention and may turn to self-medication with products bought on-line from an unregulated source, without prior medical assessment or supervision.

If your patient is self-medicating in this way, you should speak to them about the risks in line with our guidance on consent.

Do your best to understand your patient’s views and preferences and the adverse outcomes they are most concerned about. It may well be that the risk to your patient of continuing to self-medicate with hormones is greater than the risk to them if you initiate hormone therapy before they’re assessed by a specialist.

The harm reduction approach is recommended, and endorsed by the UK Good Practice Guidelines For The Assessment And Treatment Of Adults With Gender Dysphoria (RCPsych Report CR181, October 2013) (see box). 

From the UK Good Practice Guidelines For The Assessment And Treatment Of Adults With Gender Dysphoria (RCPsych Report CR181, October 2013).

These guidelines were developed by a multidisciplinary panel, including patient representatives. They are endorsed by:

  • British Association of Urological Surgeons,
  • British Psychological Society,
  • Royal College of General Practitioners,
  • Royal College of Obstetricians and Gynaecologists,
  • Royal College of Physicians and
  • Royal College of Surgeons.

The guidelines state, “…the GP or other medical practitioner involved in the patient’s care may prescribe ‘bridging’ endocrine treatments as part of a holding and harm reduction strategy while the patient awaits specialised endocrinology or other gender identity treatment and/or confirmation of hormone prescription elsewhere or from patient records” (page 25) and, “A bridging prescription may be appropriate, and blood tests and health checks are undertaken to screen for contraindications” (page 28).

After assessing the risk and screening for medical contraindications to hormone therapy use, you should seek advice from a GIC or gender specialist to find a hormone therapy regimen that has the lowest risk for your patient. 

Advice regarding a standard regimen is available in the RCGP-GIRES Gender variance e-learning module.

Particular care is needed with patients who are already self-medicating and who have experienced improvement in their gender dysphoria. In these circumstances, sudden discontinuation of established hormone use may have unpredictable psychological consequences, and is not recommended.

In summary, a GP should only consider issuing a bridging prescription in cases where all the following criteria are met:

  1. a. the patient is already self-prescribing with hormones obtained from an unregulated source (over the internet or otherwise on the black market)
  2. b. the bridging prescription is intended to mitigate a risk of self-harm or suicide
  3. c. the doctor has sought the advice of a gender specialist, and prescribes the lowest acceptable dose in the circumstances.

Gender Identity Clinics (GICs) in the UK

England

  • Gender identity clinics in London and the southeast
    West London Mental Health NHS Trust Gender Identity Clinic
    179-183 Fulham Palace Road, London, W6 8QZ
    Telephone: 020 8483 2801

The West London clinic's website has an overview of information useful for anyone with gender identity needs, not just those in the area.

  • Gender identity clinics in the north
    Sheffield Health and Social Care NHS Foundation Trust Sexual and Relationship, Sexual Medicine and Transgender Services
    Porterbrook Clinic, Michael Carlisle Centre, Nether Edge Hospital,
    75 Osborne Road, Sheffield, S11 9BF
    Telephone: 0114 271 6671

The Sheffield Gender Identity Services website includes information about referrals, clinic opening hours, and links to eligibility criteria and the Porterbrook Clinic.

  • Leeds Gender Identity Clinic
    Management Suite, 1st floor, Newsam Centre, Seacroft Hospital, York Road, Leeds, LS14 6WB
    Telephone: 0113 855 6346

The Leeds clinic's website covers referrals and commonly used medications.

  • Northumberland Gender Dysphoria Service
    Benfield House, Walkergate Park, Benfield Road, Newcastle, NE6 4QD
    Telephone: 0191 287 6130

The Northumberland Gender Dysphoria Service website has a leaflet outlining eligibility and how to access services. 

  • Gender identity clinics in the Midlands
    Northampton Gender Clinic
    Danetre Hospital, London Rd, Daventry, Northamptonshire NN11 4DY
    Telephone: 01327 707200
    Email: genderclinic@nhft.nhs.uk

Visit the Northampton Gender Clinic's website for more information.

  • Nottingham Centre for Gender Dysphoria
    3 Oxford Street, Nottingham, NG1 5BH
    Telephone: 0115 876 0160

Visit the Nottingham Centre for Gender Dysphoria website for more information.

  • Gender identity clinics in the southwest
    The Laurels Gender Identity and Sexual Medicine service (Devon Partnership NHS Trust)
    The Laurels, 11-15 Dix's Field, Exeter, EX1 1QA
    Telephone: 01392 677077

The Laurels' website has information about the types of services on offer and the help available during transition.

Northern Ireland

Opening Hours for Telephone Contact 
9.00am – 5.00pm Monday – Friday.

Scotland

There are 4 gender specialist clinics in NHS Scotland and referrals can be made to these clinics to explore with the patient the options available to them.  

  • The main NHS Scotland Gender Identity Clinic is based at the Sandyford in Glasgow and accepts referrals from across Scotland. It is also possible to self-refer to the Sandyford clinic www.sandyford.org or 0141 211 8130.
  • The Sexual Problems Clinic within the Royal Infirmary of Edinburgh accepts patients from NHS Lothian Health Board area and also NHS Fife, NHS Borders, NHS Forth Valley, NHS Tayside and the North of England. The clinic can be contacted on 0131 242 2515.
  • NHS Grampian. Referrals are accepted from general practitioners of patients residing in Grampian, Orkney and Shetland. All referrals should be made to Dr John Callender, Royal Cornhill Hospital, Aberdeen AB25 7ZH.
  • NHS Highland Sexual Health Clinic based at Raigmore Hospital, Inverness accepts selfreferrals. The clinic can be contacted on 01463 704202. The clinic does not accept out of area referrals.

Wales

Wales does not currently have a gender identity clinic but in April 2015 Welsh Assembly members voted for an independent study to be carried out into the feasibility of opening a gender identity clinic in Wales.