This information page is for GPs who have a trans patient with a letter from an NHS Gender Clinic asking for them to be prescribed hormone replacement therapy (HRT).
The NHS Gender Clinics have a contract with the NHS which devolves the provision of prescriptions to Primary Care.
The HRT medications used for trans people are the same HRT medications used for men and women who aren’t trans. You will be familiar with prescribing this medication for peri and post-menopausal women and for men with low testosterone levels.
The report or letter your patient gives you from their NHS Gender Clinic will have details about the medication type, the dosage and frequency of blood testing. You may also find NHS Wales’ Endocrine management of gender incongruence in adults: Prescribing guidance for non-specialist practitioners useful.
If you require further reassurance or have additional questions, contact the NHS Gender Clinic that provided the initial letter to ask them for more information.
You can find further information about prescribing, including guidance from other NHS gender clinics and local NHS organisations, on our Health professionals: prescribing page.
The GMC offers guidance on the provision of HRT prescriptions for trans people. It states:
“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:
- Leeds Gender Identity Service: Shared Care Interim Guidance: Leeds GIS
- Tavistock and Portman Gender Identity Clinic: Shared Care Guidance – Treatment of Gender Dysphoria In People Assigned Female at Birth Transitioning to a Masculine Gender Identity
- Tavistock and Portman Gender Identity Clinic: Shared Care Guidance – Treatment of Gender Dysphoria in People Assigned Male at Birth Transitioning to a Feminine Gender Identity
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.
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.
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.
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.
You can learn more about prescribing for trans people on our Health professionals: prescribing page.
For more general information for GPs and GP surgeries, take a look at our Primary care: supporting trans patients page.
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