Health professionals: prescribing

The information on this page is intended for healthcare professionals. You can find information for trans patients on our How to access medical transition page.

Prescribing guidance

Key resource

NHS Wales: Endocrine management of gender incongruence in adults: Prescribing guidance for non-specialist practitioners

Shared care agreements

The GMC Trans healthcare ethical hub states that:

“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.”

It also states that

“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:

  • Consult more experienced colleagues or service leads and provide care in line with the guidance in Good medical practice
  • Discuss your concerns with your patient and carefully assess their needs
  • Seek to understand their concerns and preferences”

Some gender clinics have produced guidance around shared care agreements with their clinic:

If you have been asked to enter into a shared care agreement with a private gender service, read our Private services and shared care page for more information.

Endocrinology support

If you are working with an NHS gender clinic as part of a shared care arrangement, you should be able to contact the clinic to get endocrinologist support for prescribing.

Contact details for each clinic can be found on their websites. Some clinics have specific contact instructions for GP queries:

Bridging prescriptions

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 gender clinic and the trans person being seen by the gender clinic. Bridging prescriptions act as a ‘holding and harm reduction strategy’, to mitigate the effects of waiting to receive care from a gender clinic and the resultant risks of suicide, self-harm and self-medication.

The GMC have provided detailed advice on bridging prescriptions on on the GMC Trans Healthcare Ethical Hub. You can find detailed guidance for non-specialist prescribers on this page.

When making a decision whether to offer a bridging prescription, you might want to consider:

  • potential positive effects: studies have found that access to hormone therapy for trans people is associated with improvements in quality of life and a reduction in depression and anxiety 
  • likely wait time to be seen on the NHS: wait times at many gender clinics are in excess of five years and there is a subsequent significant wait between appointments before prescribing commences. You can find details of current waits on the website of each gender clinic, and details of the gender clinics and their wait times can be found on our Gender Clinics page.
  • negative impact of waiting: in our Transition Access Survey in 2022, respondents told us how waiting to access hormone therapy had negatively impacted their mental health (78%), physical health (78%), personal relationships (61%), home life (63%), and work life (63%). Patients who access private care while waiting for NHS care (54%) incur significant financial costs.
  • risk of self-medication: in our Transition Access Survey in 2022, 25% of respondents indicated that they had accessed hormone therapy by self-medicating, buying and using unprescribed and unregulated medication over the internet. If you are concerned that there is a risk of your patient self-medicating, bridging prescriptions can be used as part of a harm reduction approach.
  • whether you feel confident to prescribe: GMC guidance states that “you must recognise and work within the limits of your competence”. You can find detailed guidance for non-specialist prescribers on this page. Using this information, you must make your own decision about whether you feel competent to prescribe; you may wish to consult with your colleagues to make this decision.
  • whether formal diagnosis has been made: if a patient has not yet been seen by an NHS gender clinic, they may have received a formal diagnosis in the private sector, or not have any diagnosis. You will need to make your own assessment of whether the patient has gender dysphoria. You should also make the patient aware you are not able to offer a specialist diagnosis, and that as a result there is risk involved.
  • prescription type: you should consider what types of medication you would prescribe and in what dosages. Some guidance relating to bridging prescriptions suggests prescribing the lowest possible dose as a strategy to reduce risk.

You can find detailed advice on bridging prescriptions from:

Supply issues and shortages

Supply issues with HRT are not uncommon. The information on prescribing sent to your by your patient’s specialist endocrinologist normally has information about alternative medications that can be used. You can also speak to your patient’s gender clinic if they are registered with one.

Some gender clinics have created specific guidance on this subject:

Complications

Information about managing common complications can be found in the NHS Wales Endocrine Management guidance.

Continuity of care

Some trans people registering as new patients at your practice may already have been accessing NHS prescribed HRT. As with any other patient, they ought to be able to expect continuation of their care. 

The GMC Trans healthcare ethical hub explains:

“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.”

Paragraph 65 of Good medical practice states that:

“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.”

HRT is used to treat Gender Dysphoria in trans people. It brings about changes that cause the trans person’s body to change in a way that acts to reduce their experience of dysphoria. Access to HRT has been demonstrated to reduce Gender Dysphoria in trans people and improve mental health outcomes. If a trans person’s HRT treatment is halted, some of the physical changes they’d experienced will reverse. This is likely to heighten the experience of Gender Dysphoria and may cause or exacerbate mental ill health.

Please be aware that any patient who has undergone an oophorectomy or orchidectomy (whether as part of other transition related surgeries or not) will require lifelong access to HRT. Without access to this, they will pass through menopause and experience the same increased health risks that a post-menopausal woman will.

For other common medications – such as a patient’s asthma inhalers – you would typically automatically continue treatment when a patient transferred to you from another GP. This practice of continuing existing prescriptions would normally include hormonal medications such as oestrogen therapy in menopausal women and testosterone in men with low testosterone. Your trans patient will expect their care to continue when they transfer GP to you, and failing to do so may be perceived as discriminatory by your patient and damage their trust in you and the NHS as a whole.

If your patient has moved from one UK nation to another, they will likely no longer be eligible or funded to be seen at their gender clinic. The patient’s current gender clinic will need to arrange a transfer of care to a new gender clinic – you may have to contact them to request this. In England, patients may wish to choose which of the gender clinics they are referred to, as some have considerably shorter wait times than others.

You can find detailed guidance on making decisions about whether to continue treatment for a patient on the Leeds Gender Identity Service website.

Patients who have moved to the UK from outside of the UK may have been prescribed medications that are not licensed or available in the UK, and they may need to be transferred to new medications. You can find details of the medications commonly prescribed on the NHS in the Medication type and dosing section of this page.

If you do not feel comfortable to continue their existing prescriptions:

  • you can contact your local NHS gender clinic for specialist advice.
  • if you choose not to continue their existing treatment you should make a referral to an NHS gender clinic. There are potential risks to your patient if their treatment is stopped, particularly of poor mental health. Patients who have had surgery to remove ovaries or testes and whose hormone therapy is stopped will have similar risks to post-menopausal patients (e.g. increased risks of osteoporosis).
  • your patient is able to access private services while they wait to be seen by an NHS gender clinic – details of the clinics available to them can be found on our Private Care page.

If your patient is a refugee or asylum seeker, they are likely entitled to NHS care. You can read more about their rights in the BMA Refugee and asylum seeker patient health toolkit.

Contraception

Detailed guidance on contraception has been provided by FSRH.

Key resource

FSRH Clinical Effectiveness Unit: Contraceptive Choices and Sexual Health for Transgender and Non-binary People

You can find information aimed at trans patients relating to contraception and sexual health on our Patient Information page.

Hormone replacement therapy does not act as contraception. It is possible for someone who is receiving testosterone therapy to become pregnant. In the event that someone who is receiving testosterone becomes pregnant, it is important that they stop testosterone therapy immediately to avoid harm to the foetus.

The Equality Act 2010

Trans people are protected under the Equality Act 2010 characteristic of gender reassignment. This applies to trans people at any stage of social or medical transition, whether or not they have a Gender Recognition Certificate. If the treatment of a trans patient is found to be detrimental when compared to the treatment of someone who isn’t trans, the practice may risk being found to have breached the Act.

You can learn more about your legal and ethical responsibilities to trans patients on our Your Responsibilities page.

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Disclaimer: TransActual do not provide medical, health, or legal advice. The content of this page is intended to be read by healthcare professionals and is for information purposes only. Use this information in conjunction with your professional judgement and expertise. Information on this page is not a substitute for advice from a legal professional, and we strongly suggest you consult a legal professional for specific legal advice about your situation. TransActual do not advocate or recommend the purchase of any specific product or paid healthcare service. We do not endorse or guarantee the credentials or appropriateness of any health care provider, any product or any provider of insurance and legal services.

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