This is a guide for trans people going to the GP to tell them you are trans and to initiate any treatment or referrals you will need as a trans person. This information and guidance is based on my experience as a non-binary trans person within the NHS (UK) specifically the North West of England. I believe this advice can be applied and used for any trans person in a GP appointment, but what you want out of the appointment will vary on your personal transition needs.
I have tried to make this guide as accessible as possible, the most important sections are in bold. If you have any suggestions or feedback on how to make this guide more accessible please contact me at firstname.lastname@example.org
Here is a link from a Leeds based charity called TransLeeds, this link will lead you to a webpage titled ‘Guide for GPs Treating Transgender Patients’. I suggest you print this and take it to your appointment, the more information you can provide your GP with the more they will see you are well informed on the topic and know your rights within the NHS and what treatment you should be given access to. If you do not have access to a printer you can take along the webpage link and ask the doctor to google it and print it themself.
Here is a link for a rating website which shows Trans friendly doctors: https://transfigurations.org.uk/trans-friendly-doctors
(you can also rate your own GP)
In my experience many doctors are not well educated in trans issues or what treatment the NHS can actually provide transgender patients with. As your doctor it’s their responsibility to educate themself as that GP will be eventually responsible for monitoring their patients transition and administering hormone treatment after assessment by the Gender Services (If that’s a route you want to take). You should stress this responsibility to the doctor.
If a doctor is rude to you or dismissive, although it may seem stressful you can easily switch doctors and you should. You should also file a complaint if you think a GP has treated you badly or inappropriately. You deserve respect and fair treatment, your gender identity is not a hassle and you should not be made to feel that way. These appointments can be so nerve wracking and emotionally exhausting to think about because of expected negative reactions, hence being put off booking the appointment.
Here’s some quick tips for prep:
- Take a friend(s) or advocate with you to the appointment. If physical and emotional support is needed it’s okay to bring people with you to back you up or even speak for you. Try reaching out to local trans charities if you have nobody you can bring with you to an appointment, even ask in a private Facebook trans group and ask a trans user to come with you in solidarity (obviously be safe when meeting people off the internet).
- When making the appointment tell the receptionist / doctor it’s for a GIC Referral in advance so they have time to read up on the process and familiarise themselves with the referral forms.
- If your anxiety is too much to speak you can pre-prepare a letter and read from that or directly give it to the GP to read.
- Write a list or document in the week leading up to the appointment how your dysphoria affects you (Mentally, Physically, Socially, Sexually, Relationships)
E.g My dysphoria stops me from being able to leave the house, get dressed, look in a mirror which then affects my mental health, I become extremely anxious and depressed, isolated which can lead to suicidal thoughts.
Everyone’s mental health intersects in different personal ways, this is just an example but it is important you can vocalise how your gender dysphoria effects you in these areas so your GP can note down how it affects you on file so this information can be shared with the GIC and reflected upon when thinking about desired routes to help you.
- Say you have been living in your ‘acquired gender’ for as long as possible including pronouns, the longer the better. They don’t check to my knowledge or require evidence. This shows them you are ‘serious’ about your gender which is a bullshit standard to have to submit to and extremely gatekeeping which is a sad reality of the current medical view of trans patients identities. If factors like safety and not being out to family, jobwise or socially play into you being unable to be openly living in your gender identity that’s fine, tell the doctor this. You are not less trans because you are not socially out.
- You can change your name on the GP Practices System. Ask for your name to be changed from your deadname. You can also choose the title (MR/MS/MX). This is doable without a legal name change via deed poll I did it very easily. This should make going to appointments less stressful as the staff won’t deadname and misgender you.
- Listen to your favorite music and get pumped before the appointment, you are transgender and it’s okay, your identity is valid and you deserve to be respected by a GP and to start your journey whatever that entails.
TEMPLATE FOR GP APPOINTMENT
TELLING YOUR GP YOUR TRANS
I [insert name here] am transgender, I use [pronouns] and want to be referred to [insert preferred GIC if you have one] Gender Identity Clinic.
My gender dysphoria effects me in these ways:
[list effects on your mental health / physical health / relationships and social interactions]
Discuss your aims and needs and how you want to progress through the NHS as a transgender person.
Remember to ask for your name and title to be changed on the GP system. You do not legally have to have changed your name to have it changed on the system.
The doctor should request for your bloods to be tested if you are requesting hormones (for the GIC) a bridging prescription or are already illegally on hormones.
A doctor should not judge you or your gender identity based on how you present physically, you are not less legitimately trans if you are for example a trans man and present femme do not let these regressive views deter you from getting the help and access to services you need. Doctors should also be aware that non-binary is included and recognised by the GIC.
What to ask for :
If you are wanting to medically transition you need to be referred to the GIC (Gender Identity Clinic). Medically transitioning can include having hormone treatment or gender reassignment surgeries.
- You don’t need to know what dosages you want or if you want hormones yet.
- You don’t need to have decided if you want surgery yet.
- You do need to be referred to the GIC so you can talk to someone and have information about what is available through the NHS for transgender people.
- You can ask for a ‘Bridging Prescription’ for hormone treatment.
- You can ask for your name to be changed on the GP System and for your pronouns to be used and recorded on file.
Legally a doctor can prescribe a ‘Bridging Prescription’ which bridges the gap/wait time a patient faces before they are seen by the GIC to begin treatment for gender dysphoria. Many doctors are uncomfortable with prescribing bridging prescriptions as often they are not educated or knowledgable about prescribing hormones which puts doctors out of their comfort zone. If a doctor rejects you from getting a Bridging Prescription they legally have to refer you to an endocrinologist. Endocrinologists wait times are much shorter than the GIC wait times, in the North West currently (oct 2018) the wait times are 3-6 months. A standard UK GIC wait time is 18-24 months (oct 2018) from receiving the referral. You can get updated info on GIC wait times on the Gender Identity Clinic webpage under ‘appointments’ or via this link https://gic.nhs.uk/appointments/waiting-times/
Sometimes Reddit or Yahoo or social media will have updated GIC wait times from people on the waitlist but it is best to ask your doctor or use the official website for a estimate on wait times.
The endocrinologist can prescribe you hormones if they see it suitable to. Usually people have anything from 1 to a few appointments with the endocrinologist before receiving hormones. Please note the endocrinologist does not have to legally give you hormones.
SELF MEDICATION OF HORMONE TREATMENT
You can get and self medicate with hormones illegally but you must tell your doctor and by law they are required to monitor your blood levels. Do tell your doctor as it’s extremely dangerous to self medicate with hormones without having your blood levels regularly checked. The doctor cannot report you to the police for you self medicating illegally as it would breach patient-doctor confidentiality.
INFO TO TELL TO GPS ABOUT SELF MEDICATION IN SUPPORT OF PRESCRIBING YOU A BRIDGING PRESCRIPTION:
Royal College of Psychiatrists state: “Patients may opt to self-medicate with hormones and/or anti-androgens so it is useful to ask them directly about this as it can adversely impact on their health and wellbeing. They may ask you to monitor them for side effects including checking blood tests and this is something that should be negotiated between you and the patient. Under the Royal College of Psychiatrists guidelines patients presenting on illicit hormones can be issued a bridging prescription by their GP while they await assessment at a Gender Identity Service. Advice can always be sought from the Gender Service or Endocrinology”.
– Good practice guidelines for the assessment and treatment of adults with gender dysphoria [Royal College of Psychiatrists]. Source: TransLeeds ‘Guide for GPs Treating Transgender Patients’ http://transleeds.lgbt/guide-for-gps-treating-transgender-patients/
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.
A GP or other medical practitioner involved in the patient’s care may prescribe ‘bridging’ endocrine treatments as part of a holding and harm reduction strategy while the patient awaits specialised endocrinology or other gender identity treatment and/or confirmation of hormone prescription elsewhere or from patient records. Patients may face a long wait before their first appointment with a gender specialist. This can be very distressing and their mental health may suffer as a consequence. The risk of self-harm and suicide for trans people is much greater than in the general population, and delay in accessing medical care substantially increases these risks. If your patient is distressed, or you believe them to be at risk from self-harm, you should offer them support and consider the need for referral to local mental health services.
Some trans people – after many years of suppression, and facing continued deterioration in their mental health while waiting for a specialist appointment – become desperate for medical intervention and may turn to self-medication with products bought on-line from an unregulated source, without prior medical assessment or supervision. -From the UK Good Practice Guidelines For The Assessment And Treatment Of Adults With Gender Dysphoria (RCPsych Report CR181, October 2013).
These guidelines were developed by a multidisciplinary panel, including patient representatives. They are endorsed by: British Association of Urological Surgeons, British Psychological Society, Royal College of General Practitioners, Royal College of Obstetricians and Gynaecologists, Royal College of Physicians and Royal College of Surgeons.
How to initiate Hormone Therapy
Good practice guidelines for the assessment and treatment of adults with gender dysphoria –[ Appendix 4 – Royal College of Psychiatrists]
Patients should be encouraged to stop smoking, take regular exercise, have a sensible diet and consume no more than 14 units of alcohol per week.
Blood pressure, full blood count, urea and electrolytes, liver function tests, fasting blood glucose, lipid profile, serum free thyroxine T4, thyroid- stimulating hormone, testosterone, oestradiol (less than 100 pmol/l) and prolactin (50–400 mU/l).
On a 6-monthly basis for 3 years and then yearly depending on clinical assessment and results. Provision of prescription is contingent on patients understanding the risks and benefits that may result due to the need to take the following tests: blood pressure, full blood count, urea and electrolytes, liver function test, fasting glucose, lipid profile, testosterone, serum oestradiol 24 h after a tablet or 48 h after a patch (levels should be in the upper half of the normal follicular range, 300–400 pmol/l) and prolactin (less than 400 mU/l).
In the first instance, a specialist clinician will provide the prescription or, if the GP is in agreement with collaborative care prescribing and the patient attends a gender specialist service, this will be supervised by the gender specialist who has obtained valid consent. Typical prescriptions would be for:
oestradiol (1–6 mg orally daily)
oestradiol gel (two to four measures daily) or patches (50–150 mcg, two to three times per week), particularly for patients over 40 years (lower risk of thrombosis). Dosage of oestrogen depends on the results of monitored circulating oestradiol levels (see p. 34);
goserelin 3.6 mg implant subcutaneously once every 4 weeks or 10.8 mg implant once every 12 weeks, or an alternative gonadotrophin- releasing hormone agonist – inhibits secretion of pituitary gonadotrophin and testosterone secretion.
Additional therapies, which may be helpful, include:
cyproterone acetate (50–100 mg orally daily) – it is much less satisfactory than goserelin;
Dianette (1 tablet daily for 21 days; repeat after 7 gap days), which contains cypoterone acetate and an oestrogen;
spironolactone (100–400mg orally daily) may be required for additional androgen receptor blockade – long-term use associated with liver dysfunction and possibly hepatoma risk (animal data);
progesterone is not usually indicated since no biologically significant progesterone receptor sites exist for biological males.
Medroxyprogesterone acetate (100mg orally twice daily) or dydrogesterone (10mg orally twice daily) has been used;
finasteride (5 mg orally daily) – blocks conversion of testosterone (which may derive from adrenal androgens in the absence of secreting testes) to the more active dihydrotestosterone. It can discourage male pattern hair loss and testosterone-dependent body hair growth.
Patients should be encouraged to stop smoking, take regular exercise, have a sensible diet and consume no more than 14 units of alcohol per week.
Blood pressure, full blood count, urea and electrolytes, liver function tests fasting glucose, lipid profile, serum free thyroxine T4, thyroid-stimulating hormone, prolactin (less than 400mU/l) and serum oestradiol and testosterone.
On a 6-monthly basis for 3 years and then yearly if well, depending on clinical assessment and results. Provision of prescription is contingent on patients understanding the risks and benefits that may result due to the need to take the following tests: blood pressure, full blood count (haemoglobin and haematocrit), urea and electrolytes, liver function tests, fasting glucose, lipid profile, serum oestradiol (for adequacy of suppression less than 70pmol/l) and prolactin (less than 400mU/l).
Serum testosterone should be at or below lower end of normal range (<10nmol/L) just before next dose is due to avoid accumulation or inadequate dosage. If on oral testosterone, measure dyhydrotestosterone levels 3–4h after a dose.
Goserelin 3.6mg implant subcutaneously once every 4 weeks or 10.8mg pellet subcutaneously once every 12 weeks.
Testosterone enantate or Sustanon (mixed testosterone ester) 250–500mg intramuscularly every two to six weeks depending on serum testosterone levels (see above).
Testogel (50mg/5g gel once daily – occasionally two doses are required), rubbed into the shoulders or loins after shower or bath.
Testosterone undecanoate 120–160mg/day orally or 1g intramuscularly every 3 months.
**This Royal College of Psychiatrists guide does not include non-binary / gender fluid / agender people and is very binary when referring to trans identities and I apologise for that. If you identify yourself as one of the above not mentioned identities you can align yourself with whatever treatment option fits you above.
GENDER IDENTITY CLINIC REFERRAL
Once you have stated to your doctor you are transgender and want to start medically transitioning your doctor should refer you to a Gender Identity Clinic (GIC) there are currently eight GIC’s in the UK (oct 2018). Most likely your GP will refer you to your closest GIC. You can request a specific GIC, most people will request the GIC with the current shortest wait time. Beware the GIC wait times can fluctuate and you need to take into account travel costs when selecting a GIC.
- Charing Cross Gender Identity Clinic, London
- Leeds Gender Identity Clinic, Leeds
- Northampton Gender Identity Clinic, Daventry
- Northern Region Gender Dysphoria Service, Newcastle
- Nottingham Centre for Gender Dysphoria, Nottingham
- Porterbrook Clinic Gender Identity Service, Sheffield
- The Laurels Gender Identity Clinic, Exeter
- The Tavistock & Portman NHS Foundation
Here is a link to the locations and addresses of the current UK GIC’s: https://www.gires.org.uk/nhs-gender-identity-clinics-england/
I will update this PDF as I continue on my journey as a trans person through the NHS. I am currently awaiting my first endocrinologist appointment and I’m on the waiting list for Sheffield GIC. I hope this guide has been informative and helpful.
Sending solidarity and love to all of my trans siblings.
Written by Eli Flint 16/10/18