Disclaimer
This ethical hub topic shows ways in which our professional standards can be applied in this area of care and signposts to relevant resources. It does not set new professional standards and is not intended to replace the formal guidance. This ethical hub topic does not apply to children and young people in this area of care. Page last reviewed: 30 January 2024.
Every patient has the right to high-quality and inclusive healthcare.
This page gives advice on how you can apply the principles in our guidance when caring for transgender and gender diverse adults. We also signpost to external resources from a range of organisations to help you improve your knowledge, skills and find out more information. We have used the term ‘transgender and gender diverse’ throughout this page. However, we recognise that gender identity and associated terminology is personal and subject to interpretation.
This advice applies to doctors treating adults. It does not apply to the treatment of children and young people in this area of care.
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Trans healthcare
You have a responsibility to make your practice inclusive and provide high quality care to all patients.
This section sets out practical advice for doctors, including:
- How to make your practice more inclusive
- The importance of providing good general medical services to transgender and gender diverse people, including supporting their mental health
- Information on referring your patient to a specialist service provider
- How to keep your professional knowledge and skills up to date
In addition, see our resource on providing inclusive care to transgender and gender diverse patients, which sets out five key points for doctors drawn from the information on this page.
How to make your practice more inclusive
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NOTE: the process for changing medical records differs across the UK – for external guidance and resources about this, visit our medical records and screening tab.
Good medical professionals are competent, keep their knowledge and skills up to date and provide a good standard of practice and care. They strive to develop and improve their professional performance. They reflect regularly on their standards of practice and use feedback and evidence to develop personal and professional insight
(Good medical practice, Domain 1: introduction)
The approach and attitude of a medical practitioner can have a lasting impact on a patient. Treating patients with kindness, compassion and respect can profoundly shape their experience of care. Good medical professionals recognise that patients are individuals with diverse needs, and don’t make assumptions about the options or outcomes a patient will prefer. They listen to patients and work in partnership with them. 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.
Providing good general medical services to transgender and gender diverse people
While transgender and gender diverse people may have specific health needs in relation to gender dysphoria or gender incongruence – their general health needs are the same as anyone else’s. As with any patient, it’s important that you provide general care to meet their healthcare needs. Evidence shows that LGBT+ people experience worse health outcomes and experiences of healthcare.
Specialist gender identity services only provide treatment and care for issues directly relating to gender dysphoria or gender incongruence. They do not provide general medical care. Transgender and gender diverse patients shouldn’t be referred to these services for unrelated health issues.
Supporting patients who may be questioning their gender identity
In line with professional obligations, we support clinicians using evidence-based and ethical practices when working with patients who wish to explore, experience conflict with, or are in distress regarding their sexual orientation or gender identity.
So-called conversion therapy practices are inconsistent with our standards. As set out in our response to the UK government’s consultation on the development of legislation for banning conversion therapy, we would take very seriously any allegation about a doctor engaging in this practice.
19. You must treat patients fairly. You must not discriminate against them or allow your personal views to affect your relationship with them, or the treatment you provide or arrange. You must not refuse or delay treatment because you believe that a patient’s actions or choices contributed to their condition.
(Good medical practice, paragraphs 19)
56. You must not abuse, discriminate against, bully, or harass anyone based on their personal characteristics, or for any other reason. By ‘personal characteristics’ we mean someone’s appearance, lifestyle, culture, their social or economic status, or any of the characteristics protected by legislation – age, disability, gender reassignment, race, marriage and civil partnership, pregnancy and maternity, religion or belief, sex and sexual orientation.
58. If you witness any of the behaviours described in paragraphs 56 or 57 you should act, taking account of the specific circumstances. For example, you could:
a check in and offer support to anyone targeted or affected by the behaviour, and/or let them know that you feel that the behaviour you witnessed is unacceptable
b challenge the behaviour by speaking to the person responsible – either at the time, if safe to do so, or at an appropriate time and place
c speak to a colleague and/or consider reporting the behaviour in line with your workplace policy and our more detailed guidance on Raising and acting on concerns about patient safety. Before you report the behaviour you witnessed, try and make sure that the person who was targeted is aware of, and supports, your intention to report it.
We recognise some people may find it harder than others to speak up4 but everyone has a responsibility – to themselves and their colleagues – to do something to prevent these behaviours continuing and contributing to a negative, unsafe environment.
Supporting your patients’ mental health
As set out by the Royal College of Psychiatrists, being transgender or gender diverse is not a mental health disorder. However psychiatric disorders (particularly anxiety, depression and acts of self-harm) are more common in treatment-seeking transgender people.
If your patient is distressed, or you believe them to be at risk from self-harm, regardless of cause, you should offer them support and consider the need for referral to local mental health services. Alongside this, consider signposting patients to local, regional and national support organisations – Mind link to a range of mental health support for LGBTQIA+ people.
Referring your patient to a specialist service provider
If your patient presents with – or requests treatment for – gender dysphoria or gender incongruence, explore the options available, including prompt referral to a specialist gender service. All GPs in England, Wales, Scotland and Northern Ireland can refer adult patients directly to the relevant specialist gender service and do not need to refer them to any other services beforehand.
By focusing on your patient’s priorities and concerns, and by exploring with them the options available, you can work with specialists to provide effective care and a positive experience for your patient. This includes recognising that patients may be anxious at the prospect of attending a specialist appointment and undergoing an assessment. It may also include discussing with your patient the waiting times they’re likely to face before their first appointment at a specialist service provider, and how you can support them in the interim. Consider signposting them to advice and support services. Terrence Higgins Trust lists several UK-wide resources and organisations.
National protocols, guidelines and processes to follow are signposted below:
- England - NHS England provide a list of gender dysphoria clinics.
- Wales - you can also find contact details for Local Gender Teams in other Health Boards.
- Scotland - where NHS National Services Scotland are currently reviewing and updating the clinical protocol. Information is also provided by the National Gender Identity Clinical Network for Scotland.
- Northern Ireland
In England, the Care Quality Commission (CQC) provides information about what they expect from GP practices in terms of adult trans care pathways.
6. You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must work in partnership with them to assess their needs and priorities. The investigation or treatment you propose, provide or arrange must be based on this assessment, and on your clinical judgement about the likely effectiveness of the treatment
options.
7. In providing clinical care you must:
a) adequately assess a patient’s condition(s), taking account of their history, including
i. symptoms
ii. relevant psychological, spiritual, social, economic, and cultural factors
iii. the patient’s views, needs, and values
b) carry out a physical examination where necessary
c) promptly provide (or arrange) suitable advice, investigation or treatment where necessary
h) refer a patient to another suitably qualified practitioner when this serves their needs.
(Good medical practice, paragraphs 6 and 7a-c, 7h)
23. You must treat patients with kindness, courtesy and respect. This doesn’t mean agreeing to every request (see paragraph 7d) or withholding relevant information that may be upsetting or unwelcome (see paragraph 28). It means:
a) communicating sensitively and considerately, particularly when you’re sharing potentially distressing issues about the patient’s prognosis and care
b) listening to patients, recognising their knowledge and experience of their health, and acknowledging their concerns
c) trying not to make assumptions about what a patient will consider significant or the importance they will attach to different outcomes
d) being willing to explain your reasons for the options you offer (and the options you don’t) and any recommendations you make
e) recognising that patients may be vulnerable, even if they don’t seem it
f) being alert to signs of pain or distress, and taking steps to alleviate pain and distress whether or not a cure may be possible
28. The exchange of information between medical professionals and patients is central to good decision making. You must give patients the information they want or need in a way they can understand. This includes information about:
a) their condition(s), likely progression, and any uncertainties about diagnosis and prognosis
b) the options for treating or managing the condition(s), including the option to take no action
c) the potential benefits, risks of harm, uncertainties about, and likelihood of success for each option.
29. You must listen to patients and encourage an open dialogue about their health, asking questions to allow them to express what matters to them, and responding honestly to their questions.
32. You must take steps to meet patients’ language and communication needs, so you can support them to engage in meaningful dialogue and make informed decisions about their care. The steps you take should be proportionate to the circumstances, including the patient’s needs and the seriousness of their condition(s), the urgency of the situation and the availability of resources.
How to keep your professional knowledge and skills up to date
The first report from the House of Commons Women and Equalities Committee highlighted a lack of knowledge and understanding among those providing care for transgender patients.
Transgender and gender diverse people have the same general healthcare needs as any other group. Most doctors will provide care to someone who is transgender or gender diverse at some stage in their career. An understanding of the health inequalities they face is necessary to ensure high quality general medical care is provided and, where necessary, referrals are made to specialist services.
If you feel you lack knowledge and experience about the healthcare needs of transgender and gender diverse people, consider taking part in activities that will develop your competence. This could include seeking advice from an experienced colleague – it could also include contacting the specialist service provider.
The following organisations also provide training materials:
- The Royal College of General Practitioners (RCGP) provide a Gender Variance e-learning course for their members.
- Health Education and Improvement Wales (HEIW): Gender Diversity which is based on typical case studies that might present to a GP.
- NHS Education for Scotland: Gender reassignment
In addition to these courses, in England, the Royal College of Physicians have developed a range of professional certificates (credentials) for clinicians working in adult gender identity services.
1. You must be competent in all aspects of your work including, where applicable, formal leadership or management roles, research and teaching.
11. You must keep your professional knowledge and skills up to date.
13. You must take steps to monitor, maintain, develop, and improve your performance and the quality of your work, including taking part in systems of quality assurance and quality improvement to promote patient safety across the whole scope of your practice.
This includes:
a) contributing to discussions and decisions about improving the quality of services and outcomes
b) taking part in regular reviews and audits of your work, and your team’s work, and responding constructively to the outcomes, taking steps to address problems, and
carrying out further training where necessary
c) regularly taking part in training and/or continuing professional development
d) regularly reflecting on your standards of practice and the care you provide, including
i. reflecting on any constructive feedback available to you
ii. considering how your life experience, culture and beliefs influence your interactions with others and may impact on the decisions you make and the care you provide.
The advice on this page is written for doctors treating adult patients
Information and processes for treating and referring children and young people are signposted below:
- England - gender dysphoria treatment
- Wales - gender dysphoria treatment
- Scotland - Gender Identity Clinics
- Northern Ireland - gender identity service
You can also review our ethical guidance, which applies to all doctors across all specialties treating children and young people:
Useful links
UK-wide
- RCGP: Transgender care, which provides an overview of the key issues facing gender-questioning and transgender patients, general practice, and the broader health system
- British Medical Association (BMA): Managing patients with gender dysphoria and inclusive care of trans and non-binary patients
- World Professional Association for Transgender Health (WPATH)
England
- TransPlus: FAQs for healthcare providers
- Gender Identity Clinic (GIC): supporting your patients waiting to be seen at the GIC
- The Nottingham Centre for Transgender Health: Information for health professionals
Wales
Scotland
Northern Ireland
Confidentiality and equality
Respect your patients’ rights to privacy and dignity. If you have a leadership or management role, make sure the staff you supervise are equipped with the skills to ensure patients are treated with respect and that their personal information is protected.
This section sets out advice for doctors, including:
- The importance of using a patient’s chosen name and title
- Information on protecting the confidentiality of a patient’s gender history
Use the patient’s chosen name and title
The way you address transgender and gender diverse people is extremely important. Taking care to use the right name and title shows that you are treating patients with respect. A patient’s chosen name and title is defined by them. This may change with time, based on the patient’s experience and understanding of their own identity.
If you are not sure how you should address someone, you can refer to them by their name or using a neutral pronoun. Alternatively, you could ask them:
- “How do you like to be addressed?”
- “What pronouns should people use when referring to you?”
Sometimes ‘misgendering’ – using the wrong pronouns for – a person is a genuine mistake. If you do misgender someone, just apologise. You may see a colleague misgendering a patient, if you’re able to – and feel it’s appropriate – politely correct them.
Consider how electronic records can be used to record the correct name and title for your patients. This can avoid causing distress to patients when they’re encountering other healthcare professionals. For further information on changing medical records, see our tab on medical records and screening.
Doctors with extra responsibilities
A bad experience could make patients reluctant to seek healthcare at all. All staff need to consider the potential long-term effects on mental health and wellbeing, if those they turn to for help don’t treat them with respect.
The NHS Digital service manual provides an inclusive content style guide focused on sex, gender and sexuality. It is designed for anyone creating content for the NHS. NHS Inform also provide a style guide on inclusive language.
2. The primary duty of all doctors is for the care and safety of patients. Whatever their role, doctors must do the following.
- Engage with colleagues to maintain and improve the safety and quality of patient care.
- Contribute to discussions and decisions about improving the quality of services and outcomes.
- Raise and act on concerns about patient safety.
- Demonstrate effective team working and leadership.
- Promote a working environment free from unfair discrimination, bullying and harassment, bearing in mind that colleagues and patients come from diverse backgrounds.
- Contribute to teaching and training doctors and other healthcare professionals, including by acting as a positive role model.
- Use resources efficiently for the benefit of patients and the public.
Doctors with extra responsibilities
35. You should support staff you manage to complete learning and development activities identified by appraisals or performance reviews.
62. If you are responsible for supervising staff, whatever your role, you must understand the extent of your supervisory responsibilities, give clear instructions about what is expected and be available to answer questions or provide help when needed. You must support any colleagues you supervise or manage to develop their roles and responsibilities by appropriately delegating tasks and responsibilities. You must be satisfied that the staff you supervise have the necessary knowledge, skills and training to carry out their roles.
(Leadership and management for all doctors, paragraphs 2, 35 and 62)
Protect the confidentiality of a patient’s gender history
You should treat the gender status or history of transgender and gender diverse people with the same confidentiality as any other sensitive information.
If you are communicating with other health professionals, you don't need to disclose a patient’s gender history unless it's directly relevant to their condition or likely treatment. If you are sharing this information, keep disclosures to the minimum you need for the purpose and inform your patient why it's clinically important or necessary.
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 them to is aware that your patient may have specific needs. As set out in our confidentiality guidance, asking for a patient’s consent to disclose information shows respect, and is part of good communication between doctors and patients.
For example, if you’re referring a transgender or gender diverse person for gynaecology treatment, it may be useful to let the clinic know in advance. The clinic can then make sure that all staff respond appropriately to your patient and care for them in a manner that respects their dignity. For further information, see our guidance on Intimate examinations and chaperones. Another example may also be when a patient is undergoing a test for a particular health condition and their gender history has potential relevance to the test itself or the analysis or interpretation of the results.
Section 22 of the Gender Recognition Act 2004 makes it an offence for any individual who has obtained information about a person’s gender identity in an official capacity to divulge that a person has, or has applied for, a gender recognition certificate or do anything that would make such a disclosure. The Gender Recognition (Disclosure of Information) (England, Wales and Northern Ireland) Order 2005(2) and the Gender Recognition (Disclosure of Information) (Scotland) Order 2005 creates an exception to Section 22 for health professionals where:
- The disclosure is made to a health professional
- The disclosure is made for medical purposes (to include the purposes of preventative medicine, medical diagnosis and the provision of care and treatment), and
- The person making the disclosure reasonably believes that the subject has given consent to the disclosure or cannot give such consent.
10. When disclosing information about a patient you must:
- use anonymised information if it is practicable to do so and if it will serve the purpose
- be satisfied the patient:
- has ready access to information explaining how their personal information will be used for their own care or local clinical audit, and that they have the right to object
- has not objected
- get the patient’s explicit consent if identifiable information is to be disclosed for purposes other than their own care or local clinical audit, unless the disclosure is required by law or can be justified in the public interest
- keep disclosures to the minimum necessary for the purpose
- follow all relevant legal requirements, including the common law and data protection law.
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.
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, paragraphs 10, 12, 27 and 28)
75. You must act promptly if you think that patient safety or dignity is, or may be, seriously compromised.
- If a patient is not receiving basic care to meet their needs, you must act to make sure the patient is cared for as soon as possible, for example by asking someone who delivers basic care to attend to the patient straight away.
- If patients are at risk because of inadequate premises, equipment or other resources, policies or systems, you should first protect patients and put the matter right if that’s possible. Then you must raise your concern in line with your workplace policy and our more detailed guidance on Raising and acting on concerns about patient safety.
- If you have concerns that a colleague may not be fit to practise and may be putting patients at risk, you must ask for advice from a colleague, your defence body, or us. If you are still concerned, you must report this, in line with your workplace policy and our more detailed guidance on Raising and acting on concerns about patient safety.
Prescribing
If you are a GP, we recognise that you may have queries about prescribing in this area of care. To provide inclusive care to your transgender and gender diverse patients, consult and work together with experienced colleagues and specialist service providers to provide medicines if this meets your patient’s needs.
As with any treatment, our Prescribing guidance says that if you share responsibility for a patient’s care with a colleague, you must be competent to exercise your share of clinical responsibility.
This section sets out advice for doctors, including:
- Information on prescribing medicines outside their UK licence
- The need to discuss side effects, complications and other risks with patients
- Advice about prescribing on the recommendation of a specialist and establishing shared care and information about transferring care when a patient moves GP practice
- The importance of supporting patients who are waiting for an appointment with the specialist service provider
- Advice on what to do if your patient is self-medicating
- Information about ‘bridging prescriptions’
- A selection of useful links and resources for doctors across the UK
Prescribing medicines outside their UK licence
In our Prescribing guidance we are clear that it may be necessary for doctors to prescribe medicines outside the terms of their licence. Doctors may do this where, on basis of an assessment of the individual patient, they conclude, for medical reasons, that it’s necessary to do so to meet the patient’s specific needs.
As set out by NHS England in their service specification for Gender Identity Services for adults, most recommendations made by a specialist for GPs to prescribe will be for medicines to be used outside the indications approved by the Medicines and Healthcare products Regulatory Agency.
103. In this guidance, the term ‘unlicensed medicine’ is used to describe medicines, which are used outside the terms of their UK licence or that have no licence for use in the UK.28 Unlicensed medicines are commonly used in some areas of medicine, such as in paediatrics, psychiatry and palliative care. They are also used, albeit less frequently, in other areas of medicine.
104. 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.
105. Prescribing unlicensed medicines may be necessary in the following instances.
a. There is no suitably licensed medicine that will meet the patient’s need. Examples include – but are not limited to – where...
(Good practice in prescribing and managing medicines and devices, paragraphs 103-105a)
Discussing side effects, complications and other risks
Our Decision making and consent guidance says you must give patients the information they want or need to make a decision. This will usually include giving your patient information about the potential side effects, complications, and other risks of the treatment options. This will help them to make informed decisions about their care.
For example, a risk for transgender and gender diverse patients is that hormone therapy may have an irreversible effect on their reproductive capacity. You may want to ask a patient to consider the storage of eggs or sperm before beginning treatment.
The Human Fertilisation and Embryology Authority provides a range of information for trans and non-binary people seeking fertility treatment. As with any patient, do not make assumptions about someone’s reproductive plans. Explore what matters to them and give them the information they need or want to make a decision.
19. You must seek to explore your patient’s needs, values and priorities that influence their decision making, their concerns and preferences about the options and their expectations about what treatment or care could achieve.
23. You should usually include the following information when discussing benefits and harms.
- recognised risks of harm that you believe anyone in the patient’s position would want to know. You’ll know these already from your professional knowledge and experience.
- the effect of the patient’s individual clinical circumstances on the probability of a benefit or harm occurring. If you know the patient’s medical history, you’ll know some of what you need to share already, but the dialogue could reveal more.
- risks of harm and potential benefits that the patient would consider significant for any reason. These will be revealed during your discussion with the patient about what matters to them.
- any risk of serious harm, however unlikely it is to occur.
- expected harms, including common side effects and what to do if they occur.
Prescribing on the recommendation of a specialist and establishing shared care
If you're a GP, collaborate with a gender specialist service to provide effective and timely care for your transgender and gender diverse patients. This may include:
- prescribing medicines on the recommendation of a specialist service provider, and
- following recommendations for safety and treatment monitoring.
GPs in England, Wales and Scotland can work under Shared Care Agreements, or through an Enhanced service, set up between specialist service providers and practices to provide joint care for patients. This is set out by the Royal College of General Practitioners (RCGP) in their information on transgender care. However, it is reasonable for a GP to expect the specialist service provider to remain available to provide support and advice where necessary.
Where those working for a specialist service provider are unable to demonstrate that they are suitably qualified, you are not obliged to follow their recommendations. As Good medical practice, paragraph 7d says – you must only prescribe drugs if you are satisfied they meet the patient’s needs.
It would not, however, be acceptable to simply refuse to treat the patient. Instead, we would advise you to:
- Discuss your concerns with your patient and carefully assess their needs
- Seek to understand their concerns and preferences
- Consult more experienced colleagues or service leads and provide care in line with the guidance in Good medical practice
In Northern Ireland there is no locally agreed service for the shared care of prescribing hormones or blood monitoring of transgender patients in Northern Ireland. RCGP Northern Ireland confirm in their guidelines for the care of trans patients that hormone treatment is currently arranged and monitored by the gender clinic and endocrinology.
Work with colleagues in ways that best serve the interests of patients, being willing to lead or follow as circumstances require.
(Good medical practice, The duties of medical professionals registered with the GMC)
46. If a colleague who is sharing information with a patient on your behalf raises concerns about their competence to do this, you should offer support, supervision or training and/or make alternative arrangements.
(Decision making and consent, paragraph 46)
75. Shared care requires the agreement of all parties, including the patient. It’s essential that all parties communicate effectively and work together.
80. 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:
- keep yourself informed about the medicines that are prescribed for the patient
- be able to recognise serious and frequently occurring adverse side effects
- make sure appropriate clinical monitoring arrangements are in place and that the patient and healthcare professionals involved understand them
- keep up to date with relevant guidance on the use of the medicines and on the management of the patient’s condition.
81. In proposing a shared care arrangement, specialists may advise the patient’s GP which medicine to prescribe. If you are recommending a new or rarely prescribed medicine, you should specify the dosage and means of administration, and agree a protocol for treatment. You should explain the use of unlicensed medicines and departures from authoritative guidance or recommended treatments. You should also provide both the GP and the patient with sufficient information to permit the safe management of the patient’s condition.
82. If you are uncertain about your competence to take responsibility for the patient’s continuing care, you should ask for further information or advice from the clinician who is sharing care responsibilities or from another experienced colleague. If you are still not satisfied, you should explain this to the other clinician and to the patient, and make appropriate arrangements for their continuing care.
(Good practice in prescribing and managing medicines and devices, paragraphs 75, 80, 81, 82)
Transferring care when a patient moves GP practice
In England, Wales and Scotland, a new patient registering with your GP practice may have already been seen and discharged by a gender specialist service. If their previous GP had taken on their prescribing, the patient will expect this to continue at your practice. In this instance, seek to re-establish shared care with the specialist service provider or similar supported prescribing arrangement.
If you have specific questions regarding the patient’s treatment, contact the specialist service provider or gender identity clinic local to your area.
Avoid referring the patient back to a gender identity clinic as a new referral. This is unnecessary and will lead to a significant delay in the patient’s continuing care.
65. Continuity of care is important for all patients, but especially those who may struggle to navigate their healthcare journey or advocate for themselves. Continuity is particularly important when care is shared between teams, between different members of the same team, or when patients are transferred between care providers.
a You must promptly share all relevant information about patients (including any reasonable adjustments and communication support preferences) with others involved in their care, within and across teams, as required.
b You must share information with patients about:
i. the progress of their care
ii. who is responsible for which aspect of their care
iii. the name of the lead clinician or team with overall responsibility for their care.
c You must be confident that information necessary for ongoing care has been shared:
i. before you go off duty
ii. before you delegate care, or
iii. before you refer the patient to another health or social care provider.
d You must check, where practical, that a named clinician or team has taken over
responsibility when your role in a patient’s care has ended.
Supporting patients who are waiting for an appointment with the specialist service provider
Transgender and gender diverse patients face long waiting times before their first appointment with a specialist service provider. According to a survey carried out by TransActual in 2022, nearly 87% of respondents said that the long wait to access hormone treatment negatively impacted their mental health.
There are a range of ways in which you can support your patient while they’re waiting for their appointment.
For example being aware of, and drawing their attention to, local support services. The London Gender Identity Clinic in England signposts to support groups and resources in the UK. The Welsh Gender Service signposts to the gender and sexual diversity charity, Umbrella Cymru.
In June 2019 the RCGP released a position statement about the role of GPs in caring for gender questioning and trans gender patients.
We support their call for a whole systems approach. We know that there continue to be challenges for patients and doctors in accessing specialist advice and treatment.
If the delay for specialist assessment is excessive, GPs do have a role as their patient’s advocate in making representation to the commissioning organisation to help ensure timely provision.
Role of GPs in managing adult patients with gender incongruence, British Medical Association
What to do if your patient is self-medicating
In their Transition Access Survey, TransActual demonstrate the increasing number of people self-medicating and emphasise the associated risks. One risk being that those who self-medicate are often unable to access a safe and reliable source of hormones and may not have access to blood testing.
If your patient is self-medicating in this way:
- encourage your patient to be open about their use of medicines they’ve obtained online
- discuss the risks of self-medicating
- do your best to understand your patient's views and preferences and the outcomes they are most concerned about
- if prescribing medication for something else and you know that your patient is self-medicating, be aware of the compatibility of these medicines
12. If you are unsure about interactions or other aspects of prescribing and managing medicines, you should seek advice from experienced colleagues, including pharmacists, prescribing advisers and clinical pharmacologists.
36. You should encourage your patients to be open about their use of alternative remedies, illegal substances and medicines obtained online or face to face, as well as whether or not they have taken prescribed medicines as directed in the past.
(Good practice in prescribing and managing medicines and devices, paragraph 12, 36)
Information about ‘bridging prescriptions’
One way in which you might consider providing support to your patient is by issuing a ‘bridging prescription’. This is a temporary prescription of endocrine treatment that can be issued by a GP.
Before issuing a prescription, consult local policy, where it exists, and seek advice from a specialist service provider or an experienced colleague.
In their guidelines for the care of trans patients, RCGP Northern Ireland state that advice on hormone bridging prescriptions can be sought from the Gender Service or Endocrinology.
This information is aimed at reassuring doctors who wish to prescribe for their transgender and gender diverse patients that it wouldn’t be against our guidance to do so, but it does not require doctors who do not feel that prescribing would be of overall benefit to a patient to go down a particular treatment route.
14. You must recognise and work within the limits of your competence.
(Good medical practice, paragraph 2)
39. You should identify the likely cause of the patient’s condition and which treatments are likely to meet their needs.
40. You should reach agreement with the patient on the proposed treatment, explaining:
- the likely benefits, risks and impact, including serious and common side effects
- what to do in the event of a side effect or recurrence of the condition
- how and when to take the medicine and how to adjust the dose if necessary,
- how to use a medical device
- the likely duration of treatment
- any relevant 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 39-40)
Useful links
UK-wide
- BMA: managing patients with gender dysphoria
- RCGP: Transgender care, which provides an overview of the key issues facing gender-questioning and transgender patients, general practice, and the broader health system
England
- NHS England: responsibility for prescribing between primary and secondary/tertiary care
- NHS England: Primary Care Responsibilities In Regard To Requests by Private On-Line Medical Service Providers to Prescribe Hormone Treatments for Transgender People
- CQC: adult trans care pathway: what CQC expects from GP practices
- The Gender Identity Clinic provide clinical information and guidance for hormone therapy
- The Nottingham Centre for Transgender Health – Information for health professionals
Wales
- The Welsh Government provides guidance on prescribing hormone therapy for trans adults
- All Wales Therapeutics and Toxicology Centre provide guidance on endocrine management of gender dysphoria in adults
