Under the Equality Act (2010) trans people are entitled to freedom from discrimination when accessing healthcare. From the moment they come out as trans, trans people all ages are protected under the ‘gender reassignment’ characteristic. This also includes non-binary people.
It’s important not to make assumptions about your patients. Like anyone else, trans people may be disabled, neurodiverse, from a faith background, from a variety of ethnic and racial backgrounds, and have a range of sexual orientations.
Pronouns are the words used to refer to people’s gender in conversation – for example, ‘he’, ‘she’, or ‘they’. Be aware that a person’s pronouns may not align with the sex marker on their medical record. If you’re not sure about a patient’s pronouns, just ask them.
Only patients marked as ‘female’ on their medical records are automatically invited for cervical smears. Any trans man or non-binary person with a cervix should be given a reminder to have a cervical smear. Use the clinical data section on the HMR101 form to notify the lab that the patient has a cervix. The lab won’t release results directly to the patient, so make sure you follow up with the patient once the result is available.
After re-registering a patient’s gender as female, the cervical screening team should contact the practice to confirm that the patient doesn’t have a cervix. If they don’t, submit a cease request to CSAS. Be mindful that, although it is rare, trans women and non-binary people may be at risk of prostate cancer.
Be aware that any patients with breasts should be invited for breast cancer screening if they are 50 or older. This will include trans women who have started oestrogen treatment and may include some trans men and non-binary people.
It is good practice to maintain a list of eligible trans patients who will not routinely be invited for screening and to flag patient records when screening is due. Be aware that trans patients are at particular risk of not attending cancer screening, due to a number of barriers. These barriers can include fear of transphobia or of being misgendered.
More info: https://www.cancerresearchuk.org/about-cancer/screening/trans-and-non-binary-cancer-screening
You can refer patients to any Gender Dysphoria Clinic (previously the Gender Identity Clinic) in England. If your patient is able to travel, it is worth checking waiting times at different clinics. Waiting lists are currently several years long and you ought to be aware of a patient’s potential mental health needs during this waiting time.
You may be able to refer to a newer clinic: Indigo Gender Service in Manchester, CMAGIC in Merseyside, TransPlus in London, Sussex Gender Service in Sussex and the East of England Gender Service.
The clinic will ask you to enter into a shared care agreement and take responsibility for blood tests and prescribing.
Many patients seek private healthcare whilst waiting to be seen by an NHS clinic, it can be helpful to enter into a shared care agreement with the private provider.
More info: https://www.nhs.uk/live-well/healthy-body/how-to-find-an-nhs-gender-identity-clinic/
Under GMC guidelines, GPs are allowed to provide a bridging prescription. This is a prescription for hormone treatment to bridge the gap between the referral to a GDC and the trans person being seen by the GDC. Bridging prescriptions act as a ‘holding and harm reduction strategy’, to mitigate the effects of waiting to receive care from a GDC and the resultant risks of suicide, self-harm and self-medication.
Guidance for non-specialists on monitoring hormone treatment for trans patients is available at:
GMC guidance: https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare#mental-health-and-bridging-prescriptions
Some trans people registering as new patients at your practice may already have been accessing NHS prescribed HRT. As with any other patient, the ought to be able to expect continuation of their care. GMC guidance: https://www.gmc-uk.org/professional-standards/ethical-hub/trans-healthcare#Prescribing
See also: Prescribing HRT: Information for GPs
Supply issues with HRT are not uncommon. There’s guidance for GPs on alternative prescribing options if this impacts your patients. You can also speak to your patient’s Gender Dysphoria Clinic if they are registered with one.
https://gic.nhs.uk/gp-support/updates-on-physical-interventions/
Testosterone treatment does not act as a contraceptive, so it is important to talk to trans patients with a uterus about contraception. Some trans men and non-binary people choose to give birth, it’s important to use inclusive language when talking about their pregnancies.
Before starting hormone therapy, some trans people may wish to access gamete storage. NHS funding should be available through the ICB.
Whilst being trans is not a mental health condition, trans people are disproportionately impacted by mental health difficulties. Remember that not all trans people’s mental health difficulties are related to them being trans. Some patients will benefit from services designed specifically for trans people.
Details of trans inclusive mental health services: https://www.transactual.org.uk/transorgs
- ABC of LGBT+ Inclusive Communication A guide for health and social care professionals
- Cancer Research UK: I’m trans or non-binary, does this affect my cancer screening?
- GMC: Trans Healthcare Hub
- NHS Confederation: Leading for all: supporting trans and non-binary healthcare staff
- NHS England: Gender Dysphoria
- NHS England: Non-surgical care pathways
- NHS England: Surgical care pathways
- NHS England: Inclusive palliative and end-of-life care for lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) people e-learning course
- RCGP: LGBT Health Hub
- St George’s Hospital Medical School: Transgender Healthcare: Caring for Trans Patients e-learning course
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