Trans healthcare

How to make your practice more inclusive 

Gender dysphoria

If your patient requests treatment for gender dysphoria, referring them to a Gender Identity Clinic (GIC) or an experienced gender specialist without delay will likely be the best option. An experienced gender specialist will have evidence of relevant training and at least two years’ experience working in a specialised gender dysphoria practice such as an NHS GIC.

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.

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).

Keeping your professional knowledge and skills up to date

If you feel you lack knowledge and experience about the healthcare needs of trans people you should ask for advice from an experienced gender specialist and address your training need. An experienced gender specialist will have evidence of relevant training and at least two years' experience working in a specialised gender dysphoria practice such as an NHS GIC.

Related resources

The House of Commons Women and Equalities Committee highlighted significant concerns about doctors’ lack of awareness and consideration in treating trans patients in their first report.

NHS choices website gives an overview of the treatments, symptoms and guidelines for gender dysphoria.

Government guidelines

National protocols and guidelines support the referral process in each country of the UK:

• England
• Scotland
• Northern Ireland
• Wales

Learning points

1. Take care to address your patient by their preferred name and title.
2. Respect a patient’s request to change the sex indicated on their medical records; you don’t have to wait for a Gender Recognition Certificate or an updated birth certificate.
3. Don’t disclose a patient’s gender history unless it is directly relevant to the condition or its likely treatment. It’s unlawful to disclose a patient’s gender history without their consent.
4. You may sometimes need to take extra care when speaking to – and recording information about – trans and non-binary people.

Use the patient’s preferred name and title

The way you address patients who are transitioning or have transitioned is extremely important. Taking care to use the right (i.e. the patient’s preferred) name and title shows that you are treating them with respect. If you are not sure how you should address someone, ask them:

• “how do you prefer to be addressed?”
• “what pronouns do you prefer people to use when referring to you?”

Employers have a responsibility to ensure that all staff are trained to understand trans issues. Trans women's voices can sound masculine on the phone.

Sometimes ‘misgendering’ a person is a genuine mistake. If you do misgender someone, just apologise.

Receptionists, practice nurses as well as doctors need to consider the long-term effects on mental health and wellbeing of trans people, if those they turn to for help don’t treat them with respect.

A bad experience could make patients reluctant to seek healthcare at all.

Medical records: changing name, title, sex, NHS number

Disclosing gender history

It is unlawful to disclose a patient's gender history without their consent.

When communicating with other health professionals, gender history doesn't need to be revealed unless it is directly relevant to the condition or its likely treatment.

The gender status or history of trans and non-binary people should be treated with the same level of confidentiality as any other sensitive personal information.

However there will be circumstances where it is appropriate to disclose this information - with your patient's consent - so that the service you are referring to is aware that your patient may have specific needs.

For example, if you are referring a trans man for treatment to a gynaecology service, letting the clinic know in advance should allow them to make sure that clinical, administrative and support staff respond appropriately to your patient and care for them in a manner that respects their dignity.

Learning points

1. You can prescribe unlicensed medicines following the steps set out in our guidance.
2. You must take care to discuss the risks and benefits of treatment with your patient.
3. You will need to collaborate with experienced colleagues to provide care that best serves your patient’s needs.

Unlicensed medicines

Most of the medications used for the treatment of gender dysphoria are not licensed for this specific indication, although GPs will be familiar with their use in primary care for other purposes. Our guidance allows for prescribing outside the terms of the licence ('off-licence') where this is necessary to meet the specific needs of the patient, and where there is no suitably licensed medicine that will meet the patient's needs.

Discussing side effects, complications and other risks

As with any proposed treatment you must give your patient clear, accurate information about the side effects, complications and other risks of the treatment options, and so help them to make informed decisions about their care.

Working collaboratively with colleagues

If you're a GP you should collaborate with a Gender Identity Clinic (GIC) and/or an experienced gender specialist to provide effective and timely treatment for your trans patients. This may include:

• prescribing medicines on the recommendation of an experienced gender specialist for the treatment of gender dysphoria, and
• following recommendations for safety and treatment monitoring.

An experienced gender specialist will have evidence of relevant training and at least two years’ experience working in a specialised gender dysphoria practice such as an NHS GIC.

If you are unsure whether a specialist working outside the NHS is suitably qualified, you are not obliged to follow their recommendations. As Good medical practice says – you must only prescribe drugs if you are satisfied they serve the patient’s needs. 

It would not, however, be acceptable to simply refuse to treat the patient. Discuss your concerns with your patient, carefully assess their needs, seek to understand their concerns and preferences; consult more experienced colleagues and provide care in line with the guidance in Good medical practice. 

Learning points

1. Be aware of the risk of self harm and suicide, and discuss mental health support with any trans patient who may be distressed.
2. Encourage your patient to be open with you about using medicines purchased online, and talk to them about the risks of self-medicating.
3. If your patient is self-medicating, consider issuing a bridging prescription as part of a harm reduction approach. Seek the advice of an experienced gender specialist.

Mental health support

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.

Self-medication

Some trans people can 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 of self medicating
• do your best to understand your patient's views and preferences and the adverse outcomes they are most concerned about.

‘Bridging prescriptions’

It may be that the risk of harm to your patient of self-medicating with hormones bought from an unregulated source is greater than the risk of initiating hormone therapy before the patient is assessed by a specialist.

A harm reduction approach is advocated by the Royal College of Psychiatrist’s current guidelines and it would be in line with our guidance if judged it to be of overall benefit to your patient. We have highlighted the most relevant parts of guidance, for you to consider when making this judgement, in the related guidance section of this page.

But you should only consider issuing a bridging prescription in cases where all the following criteria are met:

• the patient is already self-prescribing or seems highly likely to self-prescribe from an unregulated source (over the internet or otherwise on the black market)
• the bridging prescription is intended to mitigate a risk of self-harm or suicide, and
• the doctor has sought the advice of an experienced gender specialist* and prescribes the lowest acceptable dose in the circumstances.

*An experienced gender specialist is someone who will have evidence of relevant training and at least two years' experience working in a specialised gender dysphoria practice such as an NHS GIC.