Waiting times to be seen at any gender identity clinic in the UK at present are extremely long due to steadily increasing numbers of referrals. We understand this puts even more pressure on you as a GP, nurse or healthcare professional to find ways to support people seeking treatment for gender dysphoria and gender identity issues. The information below is aimed at improving your knowledge, and provides details of ways you can help support and signpost your patients while they wait to be seen.
General things to note
Gender Dysphoria is not a psychological disorder
However, many people with gender dysphoria do suffer from mental health issues, and these can and should be treated concurrently through referral to local mental health teams. You don’t need to delay referral to the Gender Identity Clinic.
Not all people seeking help for gender identity issues will identify as the binary male/female. It is important to acknowledge and respect this, and check how the person would like to be addressed. For example, non-binary people may wish to use gender neutral pronouns such as ‘they/them’ or ‘ze/zem’ instead of ‘he/him’ or ‘she/her. If you get it wrong, just apologise and correct yourself.
Autistic Spectrum Conditions
Many people we see have an autistic spectrum condition. There is some useful information and a tool to aid people with autism communicate about their gender: http://network.autism.org.uk/knowledge/insight-opinion/gender-dysphoria-and-autism-challenges-and-support
Transgender people in later life
Hormone therapy will usually be lifelong and hence ongoing monitoring is required, taking into account any age related conditions. AGE UK has a very good fact sheet: https://www.ageuk.org.uk/globalassets/age-uk/documents/factsheets/fs16_transgender_issues_and_later_life_fcs.pdf
Support needed before referral or in the early stages of referral:
This is an extremely important part of managing gender dysphoria. It’s really important to stress to your patient the importance of making a social gender role change into whatever role best suits them; and to encourage them as far as possible to let their family, friends and workplace know. We need to see evidence that the person is committed to their gender identity and able to cope with the challenges of transitioning. There are many resources and support groups to help social transitioning (see info and support section of website).
We encourage people to make their name change via deed poll (this is completely free https://freedeedpoll.org/). When they do so please update your patient’s name and gender marker on your practice records.
It is of paramount importance that you urge your patient to quit smoking. Anyone seeking hormone therapy (likewise for surgery) must have completely quit smoking for 3 months, due to increased cardiovascular and thromboembolic disease risks. We will not endorse hormones for anyone that is smoking and may have to stop or reduce therapy if they return to smoking.
Please strongly urge patients to consider their fertility before commencing hormone therapy. Discuss options including gamete storage and support and refer to fertility clinics as needed. At present, NHS funding for this is dependent on the local area and you will have to apply to your CCG or Primary Care Organisation. We hope this will change in the future.
The NHS Interim Gender Dysphoria Protocol 2013 highlights that transgender patients receiving gamete storage should be treated using similar protocols as with those receiving radiotherapy, chemotherapy, and other gamete damaging procedures. If you need to seek further clarification, please contact the local CCG / Primary Care Organisation directly. Please see the Human Fertilisation and Embryology Authority website for more information regarding local fertility clinics: www.hfea.gov.uk
We strongly advise against internet-sourced hormones. With regard to private gender specialists – we advise GPs to be discerning and check credentials. We are unable to endorse hormone therapy or take over management until we have assessed the patient ourselves. We can however discuss concerns with GPs upon request.
Support needed once referred or being seen at the GIC:
It’s important that anyone planning to commence treatment for gender dysphoria is as physically healthy as possible. As GP you can help in the following ways:
- Long-term conditions: Ensure any significant or long term conditions are under good control – e.g. diabetes, COPD, heart conditions.
- Venous Thromboembolism: If your patient has had a previous thromboembolic event they will need to be lifelong anti-coagulated before starting oestrogens so may need referral to an anti-coagulation clinic.
- Diet, exercise and wellbeing: The process of addressing gender dysphoria and transitioning can be stressful and there can be many challenges – doing all you can to support your patients’ wellbeing is crucial. The physical health risks of hormone therapy are increased in people that are overweight or have health issues such as hypertension, hypercholesterolaemia and diabetes. Please advise your patient on healthy diets and exercise and refer to support services where needed.
- Surgery: Genital reconstructive surgery will be delayed until BMI is lower than 31, with a waist measurement of less than 102cm. This is because surgical risks are increased if you are very overweight and surgical outcomes and healing are likely to be impaired.
- Cholesterol: It is very important for people on hormone therapy to manage their cholesterol levels. Please help patients to follow a healthy lifestyle to manage their cholesterol and consider medication if necessary, guided by cardiovascular risk assessments as per your normal practice.
- Bone health: Many of the patients we see have a low baseline vitamin D level, and making changes to hormone levels can further impact on bone health. We aim for a baseline vitamin D level greater than the lower end of the reference range for the local laboratory, and advise treatment of lower levels. If the patient is on low dose hormones, stops taking therapy for any reason, or there are any significant concerns about bone health, monitoring with DEXA scanning should be considered.
- Health screening call ups: If your patient has made a name change and changed their gender identity on your system, it may be that they miss call ups for health screenings that they need, such as breast screening, cervical smears and AAA screens. Please flag up this issue on your notes system if you can, and encourage patients to be aware of making appointments for health screenings as they may not get automatically called up. Read or download Public Health England’s guide, which is very useful
As well as the national screening programme list, transmasculine people that have been on testosterone for two years and retain their uterus will need two-yearly pelvic ultrasound scanning to monitor for endometrial hyperplasia. Where possible the transabdominal approach is preferred rather than transvaginal approach which may worsen dysphoric feelings.
Sexual health – please promote sexual health and use of contraception irrespective of whether patients are taking hormones.
With transgender patients, the same as with any patient, it is important not to assume sexuality.
For male bodied people who have sex with male bodied people it is of increased importance to advise use of condoms, HIV testing, hepatitis A and B vaccine and consideration of PrEP (Pre-Exposure Prophylaxis, for HIV).
Hormone therapy is NOT a contraceptive method. Pregnancy can still occur so precautions must be taken.
CliniQ in London is a sexual health service specifically for transgender and non-binary people https://cliniq.org.uk/. There may be other similar clinics nearer to the patient, under a more local sexual health service.
Please urge patients not to seek surgery outside of the care of gender specialists. It is a non-reversible step to take and it is much better to wait until settled in social transition and established on hormones, with the expertise and support of the GIC.
Deed poll, and change of documents such as passport, driving license, professional registrations can be done before referral to GIC.
DBS – transgender people are NOT obliged to include details indicating a previous gender. Email firstname.lastname@example.org
Link to our referral document to the Gender Identity Clinic: https://gic.nhs.uk/referrals/
Link to the NHS England care pathway for Gender Dysphoria: https://www.england.nhs.uk/wp-content/uploads/2013/10/int-gend-proto.pdf
Link to GMC guidance: https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare