Advice for issues related to trans healthcare

This page includes advice for common problems arising with seeking gender affirming healthcare via your GP, including issues with GPs:

• not giving a referral to a Gender Identity Clinic (GIC)
• misunderstanding the care that GICs provide
• not issuing bridging prescriptions
• not entering shared care agreements with NHS GICs or private providers

For each problem we provide some advice on what you can do to try and resolve it.

You can find tips and resources on advocating for yourself with your GP here, share tips and advice on what worked for you here, and see and contribute to our trans friendly GP map here.

You can also find advice on problems with trans admin here, and on complaints and poor treatment here.

GIC Referrals

Problem

My GP won’t give me a referral to be added to the waiting list for an NHS GIC, is delaying the referral, or is requiring additional evidence from me about my transition before they will refer me.

Advice

To access any Gender Identity Clinic (GIC) in Scotland you will need to be referred by your GP. You should arrange an appointment with your GP and ask to be referred.

GPs are not responsible for undertaking any kind of assessment for gender dysphoria as part of this referral, and therefore it would be extremely rare for a GP to have any legitimate reason to refuse a referral to a GIC. Any potential complexities should be assessed by the GIC when a person is seen by them.

If your GP is refusing to make a timely referral, here are a few things you could do:

• Ask your GP to look up your local health board’s policy on referrals to GICs, and to outline their reasons for refusing to refer you with regards to this policy. Ask for this to be done in writing.
• Ask your GP to look at Healthcare Improvement Scotland’s Gender Identity Healthcare: Adults and Young People Standards, and to outline their reasons for refusing to refer you to specialist services in line with the standards. Ask for this to be done in writing.
• Ask to see a different GP within your practice, or change the GP practice which you are registered to. See our complaints advice page for information on this, and our friendly GP map page.
• Get in touch directly with the GIC you would be referred to and explain your situation. Their contact details can be found online.

Misunderstanding What GICs Do

Problem

My GP doesn’t understand the care that GICs actually provide, believes that they should be handling all aspects of my healthcare, or is withholding referrals to other specialist services because they believe that the GIC provides all specialist care.

Advice

GPs often misunderstand the role that GICs actually play in trans and non-binary people’s healthcare. This can lead to GPs telling trans and non-binary people to see their GIC about health issues when what they actually need is to be referred to other specialist support services.

A GIC’s role is to assess a person’s need for gender affirming care, and then support their access to it. This includes hormone replacement therapy (HRT), surgeries, speech and language therapy etc.

Healthcare that is unrelated to a person’s transition should be provided by NHS services that treat everyone. There may be times when a specialist service needs to consult with a GIC, but this shouldn’t mean that a referral has to be made to a GIC prior to one being made to a specialist service. This is especially the case for those still on waiting lists to be seen by a GIC, as this could otherwise delay their access to specialist care by several years.

The Gender Identity Service Standards clearly state that GP’s should:

“Understand when to refer to the gender identity service and when a referral to another service may be more appropriate [and] listen to and involve people in decisions about referrals”

If you think your GP has referred you to a GIC when you should have been referred to another service, you could:

• Explain clearly to your GP that GICs only provide services related to a person’s transition and that the care you need is not related to your transition. Explain that if the service that you need to be referred to needs support from the GIC, that they can seek that support themselves. It may be helpful to show them this flow chart, that outlines the services a GIC offers (p.11)
• Show them the Gender Identity Services standards, and explain that it is important that they make appropriate referrals for you to the right place.
• Tell you GP that you have a right to access the services you need and that if they refuse to refer you to a service because you are trans and non-binary, they may be discriminating against you under the Equality Act.
• Explain to your GP that many NHS GICs have very long waiting lists for first appointments, and/or that it can be months or years between appointments even for those who are being seen, and therefore that waiting to be seen by a GIC for the issue may significantly delay your care and potentially worsen the issue.
• Contact the service you need to be referred to directly and explain the situation.

Bridging Prescriptions

Problem

My GP won’t provide a bridging prescription for hormone replacement therapy while I am on an NHS GIC waiting list, and/or while I am currently receiving hormones from a private provider or self-administering them. My GP doesn’t understand how long GIC waiting lists can be, and doesn’t see bridging prescriptions as providing harm reduction.

 

Advice

If you are on the waiting list for a GIC and your GP believes that it is quite likely that you will be prescribed hormones by the GIC when you are seen by the service, then they may be willing to prescribe you with a “bridging” prescription for hormones in the meantime. GPs give bridging prescriptions as a form of harm reduction, usually to patients who are self-sourcing hormones (e.g. buying them online) or patients who are at risk of self-harm or suicide.

However they are not obliged to do so, and finding a GP willing to do this can be difficult. While individual GPs may be willing to provide bridging prescriptions, sometimes practices themselves may also have policies against it.

If your GP refuses to prescribe you a bridging prescription, you could try:

• Booking an appointment or writing a letter to you GP to discuss the below guidance with them, outlining why you think a bridging prescription would reduce potential harm to your health and asking them to seek guidance from a specialist gender service. If they refuse, ask them to put the reasons why in writing.
• Change GPs to one who would be willing to prescribe you a bridging prescription. See our complaints advice page for information on this, and our friendly GP map page.

Examples of guidance on bridging prescriptions from medical institutions

Role of GPs in managing adult patients with gender incongruence, British Medical Association:

“The Royal College of Psychiatrists suggests that GPs may prescribe a bridging prescription to cover the patient’s care until they are able to access specialist services. The GMC advises that GPs should only consider a bridging prescription when:

the patient is already self-prescribing, or seems highly likely to self-prescribe, with hormones obtained from an unregulated source (online or otherwise on the black market), the bridging prescription is intended to mitigate a risk of self-harm or suicide, and the doctor has sought the advice of a gender specialist and prescribes the lowest acceptable dose in the circumstances.”

Good practice guidelines for the assessment and treatment of adults with gender dysphoria, Royal College of Psychiatrists

“Patients frequently find it difficult to confide their feelings of gender dysphoria to their GP, often because it is the family GP or practice, and fear of ridicule, guilt or shame as well as other pressing social factors prevent them from seeking help and treatment. These factors and the anticipated delay in obtaining treatment on the NHS have led to increasing numbers of people self-medicating. Hormones and hormone-blockers are readily available via the internet. The medical practitioner or specialist must consider the risks of harm to the patient by not prescribing hormones in these circumstances. The WPATH standards of care (World Professional Association for Transgender Health, 2011) suggest the prescribing of a ‘bridging’ prescription on an interim basis for a few months while the patient is referred to a gender specialist and an endocrinologist.”

Trans Healthcare Guidance, General Medical Council:

“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.

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.”

Shared Care Agreements

Problem

My GP won’t enter a shared care agreement, either with an NHS GIC or a private healthcare provider.

Advice

A “shared care agreement” is when a GP agrees to work with an NHS GIC or private healthcare provider to perform certain services (such as blood tests and prescriptions) to support a person’s transition. However, they are not obliged to do this, even with an NHS GIC. While individual GPs may be willing to enter shared care agreements, sometimes practices themselves may also have policies against it.

We have split our advice below into issues encountered around shared care with private providers and NHS GICs.

Shared care agreements with private providers

Some GPs may be willing to work with private providers to provide things like blood tests and prescriptions, especially if they recognise that a patient has only opted for a private provider because of the extremely long waiting lists for NHS GICs which they cannot endure any longer. However, there is no obligation for GPs to provide blood tests or shared care agreements with private providers.

If you want to ask your GP to enter a shared care agreement with a private provider, you could try:

• Booking an appointment to explain your situation to your GP, including the length of the waiting list, why you feel you cannot wait any longer, the cost of the private care, and asking them to provide blood tests or a shared care agreement.
• Send your GP a letter to explain this – GenderGP have produced a template letter here that you can base yours on, but theirs is for English services, so you may wish to edit it to make it relevant for Scottish services.
• Changing GP to one that is willing to provide shared care. See our complaints advice page for information on this, and our friendly GP map page.

Shared care agreements with NHS GICs

If you are already being seen by an NHS GIC, it is more likely your GP will enter into a shared care agreement with them, but unfortunately they are not obliged to. However, guidance from the General Medical Council encourages GPs to collaborate with gender specialist services to provide your care.

Trans Healthcare Guidance, General Medical Council:

“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, doctors 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.”

The Royal College of General Practitioners’ position statement on the role of GPs in transgender care also states that:

“Once adult patients are under the care of a specialist gender identity service, many GPs are likely to feel able to maintain prescriptions under a collaborative or shared care arrangement.”

If your GP refuses to enter a shared care agreement with the GIC, you could try:

• Booking an appointment with or writing a letter to your GP to explain the above guidance with them and why it would be beneficial to your care for them to enter a shared care agreement with an NHS GIC. If they refuse, ask them to put the reasons why in writing.
• Ask your GIC to contact your GP and explain why a shared care would be beneficial for your care and what would be involved.
• Changing your GP to one who would be willing to provide shared care. See our complaints advice page for information on this, and our friendly GP map page.
• If you live in the Lothian health board, ask your GP to read the Shared Care Agreement for the health board (Lothian is currently the only health board to have this agreement in place, but we very much hope to see other health boards replicate this)