Trans healthcare - advice based on GMC guidance

Trans and non-binary people experience the same health problems as everyone else and have very few differing needs. If a health problem is unrelated to gender dysphoria or its treatment, you must assess, provide treatment for and refer trans patients the same as your other patients.

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Trans health

How to make your practice more inclusive 

Watch this film for some practical tips on putting our guidance into practice and respecting the rights of trans patients. 

  1. Patients need good doctors. Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity and within the law.
     
  2. Good doctors work in partnership with patients and respect their rights to privacy and dignity. They treat each patient as an individual. They do their best to make sure all patients receive good care and treatment that will support them to live as well as possible, whatever their illness or disability.
(Good medical practice, paragraphs 1 and 2)

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).

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

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

(Good medical practice, paragraph 15)

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 as a part of your continuing professional development. 

Related guidance

Good medical practice
The duties of a doctor
Paragraph 1–2
Paragraph 9
Paragraph 11
Paragraph 15
Paragraph 46–48
Paragraph 54

Confidentiality
Paragraph 12
Paragraph 27–28

Consent
Paragraphs 29–36

Good practice in prescribing and managing medicines and devices
Paragraph 22–24
Paragraph 41
Paragraphs 67–70

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.

Government guidelines

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

Confidentiality and equality

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.

46. You must be polite and considerate.

47. You must treat patients as individuals and respect their dignity and privacy.

48. You must treat patients fairly and with respect whatever their life choices and beliefs.

54. You must not express your personal beliefs to patients in ways which exploit their vulnerability or may cause distress.

(Good medical practice, paragraphs 46, 47, 48 and 54)

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 pronoun 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.

Angela's story

"I called the GP's surgery to make an appointment.

The receptionist asked me to repeat my name twice. I said Angela - twice.

The receptionist sort of sniggered and turned to the other receptionist and said, quietly, but loud enough for me to hear:

'he says he's Angela - what do I do?'

I did get my appointment, but my stomach was churning. I felt terrible. That feeling comes back every time I need to make an appointment."

28. You must make sure that anyone you disclose personal information to understands that you are giving it to them in confidence, which they must respect. All staff members receiving personal information in order to provide or support care are bound by a legal duty of confidence, whether or not they have contractual or professional obligations to protect confidentiality.

(Confidentiality, paragraph 28)

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

Name and title

Both electronic and paper medical records should clearly indicate your patient’s preferred name and title.

Sex

A patient’s request to change the sex indicated on their medical records should be respected; they do not have to have been granted a Gender Recognition Certificate or have acquired an updated birth certificate for this to be changed.

NHS number

If your patient is to be issued with a new NHS number which has no reference to their sex at birth, you should explain to them that they will not automatically be contacted regarding current or future screening programmes associated with their sex at birth, and discuss the implications of this. Decisions about screening should be made with patients in the same way as any other decisions about their health.

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.

12. You must make sure that any personal information about patients that you hold or control is effectively protected at all times against improper disclosure.

27. You must respect the wishes of any patient who objects to particular personal information being shared within the healthcare team or with others providing care, unless disclosure would be justified in the public interest. If a patient objects to a disclosure that you consider essential to the provision of safe care, you should explain that you cannot refer them or otherwise arrange for their treatment without also disclosing that information.

(Confidentiality, paragraphs 12 and 27)

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.

Prescribing

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.

67. The term ‘unlicensed medicine’ is used to describe medicines that are used outside the terms of their UK licence or which have no licence for use in the UK.

68. You should usually prescribe licensed medicines in accordance with the terms of their licence. However, you may prescribe unlicensed medicines where, on the basis of an assessment of the individual patient, you conclude, for medical reasons, that it is necessary to do so to meet the specific needs of the patient.

69. Prescribing unlicensed medicines may be necessary where…There is no suitably licensed medicine that will meet the patient’s need.

(Good practice in prescribing and managing medicines and devices, paragraphs 67-69)

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.

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A significant risk for trans patients is that hormone therapy may have irreversible effect on their reproductive capacity. You may want to ask a patient to consider the storage of eggs or sperm before beginning treatment.

29. In order to have effective discussions with patients about risk, you must identify the adverse outcomes that may result from the proposed options. This includes the potential outcome of taking no action. Risks can take a number of forms, but will usually be:

a. side effects

b. complications

c. failure of an intervention to achieve the desired aim.

Risks can vary from common but minor side effects, to rare but serious adverse outcomes possibly resulting in permanent disability or death.

31. You should do your best to understand the patient's views and preferences about any proposed investigation or treatment, and the adverse outcomes they are most concerned about. You must not make assumptions about a patient's understanding of risk or the importance they attach to different outcomes. You should discuss these issues with your patient.

(Consent paragraphs 29 and 31)

For information on 'bridging prescriptions' scroll back up this page and choose the 'mental health' tab.

Working collaboratively with colleagues

GPs must co-operate with GICs and gender specialists in the same way as they would other specialists, collaborating with them to provide effective and timely treatment for trans and non-binary people. This includes:

  • 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. 

A note about patients under 16

The advice on these pages is written with adult patients in mind. We are aware that some GPs are being asked to prescribe to children and teenagers under 16 in order to delay puberty or facilitate transition. 

The approach taken at the national Gender Identity Development Service (GIDS)when supporting children and young people is multidisciplinary, involving child psychiatrists, social workers, endocrinologists and local Child and Adolescent Mental Health Services or CAMHS. 

Close collaboration with experienced specialists is important for all trans patients, but will be particularly important when providing care for children and young people presenting with difficulties with their gender identity. 

'Work with colleagues in the ways that best serve patients’ interests.'
(Good Medical Practice, The duties of a doctor)

Did you know?

Once the patient has been discharged by a GIC or experienced gender specialist, the prescribing and monitoring of hormone therapy can be carried out in primary care without further specialist input. From the patient's perspective, management in primary care is far easier, and there is no specific expertise necessary to prescribe for and monitor patients on hormone therapy. It is reasonable for a GP to expect the GIC or specialist to remain available to provide timely support and advice where necessary.

We set out some general principles for managing shared care in our guidance Good practice in prescribing and managing medicines and devices (see paragraphs 35-43).

41. If you share responsibility for a patient’s care with a colleague, you must be competent to exercise your share of clinical responsibility. You should:

a. keep yourself informed about the medicines that are prescribed for the patient

b. be able to recognise serious and frequently occurring adverse side effects

c. make sure appropriate clinical monitoring arrangements are in place and that the patient and healthcare professionals involved understand them

d. keep up to date with relevant guidance on the use of the medicines and on the management of the patient’s condition.

(Good practice in prescribing and managing medicines and devices, paragraph 41)

Mental health

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.

22. You should encourage your patients to be open with you about their use of alternative remedies, illegal substances and medicines obtained online, as well as whether in the past they have taken prescribed medicines as directed.

(Good practice in prescribing and managing medicines and devices, paragraph 22)

‘Bridging prescriptions’

It may be that the risk to your patient of continuing to self-medicate with hormones is greater than the risk of initiating hormone therapy before they’re assessed by a specialist. In these circumstances sudden discontinuation of established hormone use may have unpredictable psychological consequences. A harm reduction approach is advocated by the Royal College of Psychiatrist’s current guidelines.

…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).
Royal College of Psychiatrists

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

  • the patient is already self-prescribing 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 will have evidence of relevant training and at least two years’ experience working in a specialised gender dysphoria practice such as an NHS GIC.

23. You should identify the likely cause of the patient’s condition and which treatments are likely to be of overall benefit to them.

24. You should reach agreement with the patient on the treatment proposed, explaining:

a. the likely benefits, risks and burdens, including serious and common side effects

b. what to do in the event of a side effect or recurrence of the condition

c. how and when to take the medicine and how to adjust the dose if necessary, or how to use a medical device

d. the likely duration of treatment

e. arrangements for monitoring, follow-up and review, including further consultation, blood tests or other investigations, processes for adjusting the type or dose of medicine, and for issuing repeat prescriptions.

(Good practice in prescribing and managing medicines and devices, paragraphs 23–24)