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.
Referring to a Gender Dysphoria Clinic
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. Several pilot clinics have been launched and are now accepting referrals. GPs in Manchester can refer trans patients to the Indigo Gender Service, in Merseyside GPs can refer to CMAGIC, and TransPlus is available to some patients in and around London. 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.
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:
Fertility and contraception
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 CCG.
Mental health support
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
Sources of CPD and further reading on trans inclusive practice in the GP surgery
Royal College of General Practitioners
- LGBT health hub https://elearning.rcgp.org.uk/mod/page/view.php?id=9380
- E-learning module https://rcgpportal.force.com/s/lt-event?id=a1U1i000001ROrrEAG&site=a0d0Y00000AeOP6QAN
- Position statement https://www.rcgp.org.uk/representing-you/policy-areas/transgender-care#
General Medical Council
- Trans healthcare hub https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare
- Gender dysphoria https://www.nhs.uk/conditions/gender-dysphoria/
- Non-surgical care pathways https://www.england.nhs.uk/publication/service-specification-gender-identity-services-for-adults-non-surgical-interventions/
- Surgical care pathways https://www.england.nhs.uk/publication/service-specification-gender-identity-services-for-adults-surgical-interventions/
LGBT+ sector organisations
- TransActual https://www.transactual.org.uk/healthcare
- CliniQ https://cliniq.org.uk/
- GIRES https://www.gires.org.uk/e-learning/
- The Clare Project https://clareproject.org.uk/resources/
- Pride in Practice https://lgbt.foundation/prideinpractice