The role of the GP in transgender care

• WHO: World Health Organization
• ONS: Office for National Statistics
• DSM: Diagnostic and Statistical Manual of Mental Disorders
• ICD-11: International Classification of Diseases 11th Revision
• GIC: Gender identity clinic
• GDC: Gender dysphoria clinic
• CYP: Children and young people
• GIDS: Gender Identity Development Service
• CAMHS: Child and adolescent mental health services
• GAH: Gender-affirming hormones
• GPwER: GP with Extended Role

This paper outlines some of the background and recent changes that affect the care of patients who seek help to do with their gender. It updates the RCGP’s position on the GP’s role with respect to patients experiencing gender incongruence and recommendations to improve future care for this cohort.

In 2019, RCGP Council approved a position on transgender care; this updated statement draws heavily on that agreed position and does not seek to propose any new policies, rather to present the significant changes in the external environment since 2019. Our 2019 statement, while referring to children and young people, predominantly focused on provision of care to adults. This update looks to comprehensively include care for children and young people in the light of the Cass review for England. The RCGP fed into the Cass Review to ensure the GP voice was represented. The Cass recommendations can only be understood in the context of the history of gender care for children and young people in the UK, a brief explanation of which is included in this paper. While the Cass review is specifically related to the English context, it is understood that the review will be considered in order to inform changes to existing policy and service provision in Scotland, Wales and Northern Ireland.

This document will (apart from when using direct quotations from other publications) use the same terms as the Cass review, i.e. gender incongruence rather than gender dysphoria, and gender-related distress to describe the feelings that commonly arise or intensify during puberty and lead to a person seeking help from the NHS1.

• Sex (World Health Organization, WHO¹): refers to the different biological and physiological characteristics of females, males and intersex persons, such as chromosomes, hormones and reproductive organs.
• Gender (WHO²): refers to the characteristics of women, men, girls and boys that are socially constructed. This includes norms, behaviours and roles associated with being a woman, man, girl or boy, as well as relationships with each other. As a social construct, gender varies from society to society and can change over time.
• Gender identity (ONS³): Gender identity is a personal internal perception of oneself and, as such, the gender category with which a person identifies may not match the sex they were registered at birth. In contrast, sex is biologically determined.
• Gender dysphoria (DSM⁴): A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months’ duration, as manifested by at least two or more of the following:
  • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
  • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
  • A strong desire for the primary and/or secondary sex characteristics of the other gender
  • A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
  • A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
  • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)
  The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Gender incongruence of adolescence and adulthood (International Classification of Diseases 11th revision, ICD-11⁵): Gender Incongruence of Adolescence and Adulthood is characterised by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex, which often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual’s body align, as much as desired and to the extent possible, with the experienced gender. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.
• Gender incongruence of childhood (ICD-11⁶): Gender incongruence of childhood is characterised by a marked incongruence between an individual’s experienced/expressed gender and the assigned sex in pre-pubertal children. It includes a strong desire to be a different gender than the assigned sex; a strong dislike on the child’s part of his or her sexual anatomy or anticipated secondary sex characteristics and/or a strong desire for the primary and/or anticipated secondary sex characteristics that match the experienced gender; and make-believe or fantasy play, toys, games, or activities and playmates that are typical of the experienced gender rather than the assigned sex. The incongruence must have persisted for about 2 years. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.
• Transgender/Trans (NHS England⁷) An umbrella term to embrace the diverse range of identities outside the traditional male/female definitions. These include transgender, gender fluid and non-binary.
• Gender identity clinic (GIC)/gender dysphoria clinic (GDC) (NHS^8,9): A gender identity clinic (GIC) is an NHS facility where services for transgender patients are offered, for example the provision of hormones and surgery. NHS wording is inconsistent, with some websites using GIC and some using GDC (gender dysphoria clinic). In Wales the provision is named the ‘Welsh Gender Service’. For consistency, this document will use the term GIC throughout.
• Cass Review¹: A review about the care of children and young people (CYP) with gender-related distress in England. It does not relate to the care of adults. It was commissioned by NHSE and published an interim report in February 2022 and a final report in 2024. Significant changes in service provision have been recommended. As the review was commissioned by NHS England, decisions on services in the devolved nations will be made locally.

Adult gender services have been provided for patients from England, Scotland and Wales at the Tavistock and Portman clinic since 1966¹⁰. A multi-disciplinary approach is used, focusing biological, psychological and social aspects of gender.

Services to treat CYP with gender incongruence started in the UK in 1989 with the opening of the Gender Identity Development Service (GIDS). It saw around 10 patients per year, mainly those registered male at birth, with a focus on therapeutic work; a minority progressed to hormone treatment at age 16¹ and it was accepted that for most, gender-related distress would not persist long-term. Persistence rates of 10 – 33 % were noted with most of the CYP growing up to be same-sex attracted adults who were not transgender¹.

The focus of management changed in the 2000s after the Dutch protocol was published. This allowed for the use of puberty blockers in a small and carefully selected group of CYP, with the intention to buy time to think and improve future ability to pass as the preferred gender. To access this treatment, patients had to be at least 12, with life-long gender incongruence which had increased around puberty. They had to be psychologically stable, with no serious co-morbid psychiatric disorders and to have family support¹.

Puberty blockers were first used in the UK in 2011, as an uncontrolled research study. There was no consistent improvement in psychological well-being or other mental health outcome measures (a contrast to the original Dutch study) and 98% of the group given puberty blockers went on to use gender-affirming hormones (GAH). In 2014, puberty blockers were routinely made available in clinical care in the UK, a move which the Cass review describes as having ‘unclear…rationale’. The strict criteria of the original Dutch study were not followed, and a much wider group of patients were treated, included those with no history of gender-related distress before puberty, and those with complex presentations including neurodiversity and mental health co-morbidities. Clinical practice also deviated from the NHSE service specification under which the clinics should have been operating, which required that research protocol parameters be used. Clinical practice was ‘disconnected from the clinical evidence base’.¹

In this time period, referrals also increased significantly – in England and Wales, the number of referrals to child and adolescent GICs increased from 210 per year in 2011/12 to over 5,000 per year in 2021/22 and the proportion who are of the female sex has significantly increased¹¹. For adults, there was a 240% increase in the five years to 2018¹². Increases have also been seen in Scotland¹³ and Northern Ireland¹⁴. This has placed immense pressure on GICs to meet demand.

The Cass Review. Final report. April 2024. Used under the terms of the Open Government Licence.

Current provision for adults varies by country of the UK:

• In England⁸ there are seven NHS Gender Identity Clinics (GICs), and three providers of adult genital reconstruction surgery.
• There are four GICs in Scotland¹⁵, all of which take referrals from a defined geographic area; the Sandyford clinic also accepts adult self-referrals¹⁶.
• Welsh GPs can refer adults to the Welsh Gender Service¹⁷ which assesses and refers on to a local gender team to co-ordinate treatment, using the NHSE surgical network if required.
• The Brackenburn Clinic in Belfast provides a Regional Gender Identity Service for adults in Northern Ireland¹⁸.

CYP in Northern Ireland are seen by the ‘Knowing Our Identity Service’¹⁹ and those in Scotland are seen by the Sandyford clinic¹⁶. CYP in Wales are seen by child and adolescent mental health services and transferred to adult services at the age of 17¹⁷.

Services for CYP in England have changed recently; in 2022, following the interim Cass report²⁰, GIDS was closed and replaced with regional centres, administered by a national referral support service⁹. Group legal action against GIDS also began in 2022²¹. In April 2024, the final Cass report¹ recommended that a regional multi-site service network be developed as soon as possible, with referrals to local specialist services being accepted only from secondary care (paediatrics or CAMHS) who would provide an initial assessment before referring on to gender services if appropriate. GPs would therefore no longer refer directly to a GIC for CYP. Regional gender services will work as an operational delivery network, supporting integration with other services (such as those for mental health and neurodiversity, as well as fertility and endocrine opinions where appropriate), to provide a more holistic approach and ongoing therapeutic support.

Proposed service models and referral pathways for CYP. The Cass Review. Final report. April 2024. Used under the terms of the Open Government Licence.

The UK lacks a nationally recognised training programme for gender identity healthcare. Although there are apprenticeship training models in several specialist GICs and guidelines are available from various organisations such as the British Association of Gender Identity Specialists (BAGIS)²², the European Professional Association for Transgender Health (EPATH)²³ and the World Professional Association for Transgender Health (WPATH)²⁴, the workforce needs to expand rapidly to meet service need. Concerns have been raised about some of these guidelines, with the final Cass review¹ saying that the WPATH guidelines ‘were found…to lack developmental rigour [and]…cited…studies that were already deemed as low quality [and]…overstates the strength of the evidence [that gender-affirming interventions]…are safe and effective’. Guidelines in other countries including Sweden and Finland are much more cautious about the use of puberty blockers than the WPATH guidelines¹.

The Royal College of Physicians has been commissioned by NHSE to develop a range of credentials for clinicians working in GICs; these will involve submission of a portfolio of evidence²⁵.

Gender identity services are also needed for people who are uncomfortable or distressed by their biological sex or gender roles and behaviours assigned to them by society, and who may identify with a variety of gender types, but do not wish to access medical or surgical treatments.

The significant lack of evidence for treatments and interventions for CYP is a major issue which was investigated in depth by the Cass review¹. Findings included the following:

• There ‘are many unknowns about the impact of social transition…it is unclear whether it alters the trajectory of gender development and… [the]…impact on mental health’.
• The evidence base for the use of puberty blockers in CYP ‘had already been shown to be weak’ before the review started, and there continues to be ‘insufficient and/or inconsistent evidence about the effects of puberty suppression on psychological or physical health’. Attempts to improve the evidence base by following through the 9,000 patients who were seen by GIDS ‘have been thwarted by a lack of co-operation from the adult gender services’. Within a few days of the publication of the report, it was announced that the adult clinics will now share their data and so this evidence can now start to be gathered^26,27.
• One single Dutch study suggesting that ‘puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence’ was used as the basis for ‘the extension of this approach to a wider group of adolescents who would not have met the inclusion criteria for the original Dutch study’, with ‘some practitioners [abandoning] normal clinical approaches to holistic assessment’. Despite the fact that early studies on puberty blockers ‘did not demonstrate benefit [and showed] a lack of any positive measurable outcomes… puberty blockers moved from a research-only protocol to being available in routine clinical practice… the adoption of a treatment with uncertain benefits without further scrutiny is a significant departure from established practice’.
• Evidence for use of GAH in CYP is not of high quality, with ‘inconsistencies regarding suicidality and/or self-harm… moderate quality evidence that hormone treatment may improve psychological health in the short term [and] few studies that undertake long-term follow-up. Uncertainty remains about the outcomes for height/growth, cardiometabolic and bone health… evidence does not adequately support the claim that gender-affirming treatment reduces suicide risk’.
• The assessment process at GIDS has been criticised by the Cass review for having ‘a lack of… professional curiosity as to how the [CYP’s]… social circumstances may impact on their… decisions. Sexuality was not consistently discussed… notes rarely provided a structured history or physical assessment… it is not clear how fully and appropriately [ADHD and ASD] had been explored… the gender journey was rarely examined closely for…difficulty [or] regret or wishes to alter any aspect of their gender trajectory’. GIDS chose not to take part in the international survey done as part of the Cass review.

There are also no guidelines available to advise those who wish to detransition; this population often has unmet physical and mental healthcare needs and may not want to engage with the services that supported them to transition^1,28. This puts GPs in a very difficult position when trying to support patients and their families, either before referral, whilst on a long waiting-list, or if they present with regrets about their transition. The final Cass review has recommended that NHS England ensure provision for those who want to detransition¹.

The General Medical Council (GMC) advises that doctors promptly refer patients requesting treatment for gender dysphoria to a specialist gender service²⁹, however it is unlikely that a prompt referral will result in the patient being seen promptly.

Under the NHS Constitution for England, the maximum waiting time for an initial specialist appointment following referral is 18 weeks³⁰. Despite this, as of February 2024, one GIC in England were booking appointments for people referred in late 2018³¹ and as of April 2024, another clinic quoted 5,246 people on their standard waiting list³². The situation was better in Wales, with adult patients referred in Aug 2022 being seen in Nov 2023¹⁷, and in some areas of Scotland, with one clinic quoting a two-year waiting list³³, but worse in Northern Ireland where people referred in 2017 were being sent appointments in 2024¹⁸.

A report on transgender equality published by the House of Commons Women and Equalities Committee in January 2016³⁴ found ‘serious deficiencies in the quality and capacity of NHS gender identity services’ and expressed concern about ‘the apparent lack of any concrete plans to address the lack of specialist clinicians in this field’. The Committee reports the uneven geographical distribution of GICs, meaning that people need to travel long distances to access treatment. Concern was also raised about the attitude of some GPs, with reference made to a lack of training. In 2023, a parliamentary briefing³⁵ noted that ‘waiting times are contributing to… distress’ and that ‘care on the waiting list is minimal…adults on the waiting list can, in some places, access peer or community support groups but there is significant geographical variation’.

Of the 108,100 respondents to the 2018 Government Equalities Office (GEO) National LGBT Survey³⁶, 13% of respondents were transgender. Of these respondents, 38% accessing general healthcare services reported a negative experience due to their gender identity. Some of the respondents specifically called for healthcare professionals to be trained in not making assumptions about their patients’ gender identity.

Of the 2,900 respondents who elaborated on their experiences of gender transition and gender identity services, the emerging overall view was of hard-to-access services, and a lack of knowledge among GPs about what services are available and how to access them. Of all the trans respondents who had tried accessing gender identity services, 80% said that access had not been easy, with the majority of these (68%) reporting that waiting times had been too long. The survey also found that 16% of trans respondents had gone outside the UK to pay for healthcare or medical treatment, and a further 50% were considering it.

The Cass review¹ spoke to a wide variety of patient and their families, including those who felt empowered by the decision to transition and those who deeply regretted it. The Review notes that some children and young people were ‘really clear that [they] want much better advice on the options available to [them] and the risks and benefits of different courses of action [and that] others…have said you just want access to puberty blockers and hormones as quickly as possible’. Similarly, among parents, ‘some have fought to get their children onto a medical pathway and have spoken about how frustrated they have felt to have to battle to get support. Others have felt a medical pathway was entirely the wrong decision for their child and have described their dismay about actions taken without their consent and in ignorance of the various other difficulties their child may have been through, such as loss of a parent, traumatic illness, diagnosis of neurodiversity and isolation or bullying in school’.

Bridging prescriptions

Patients who are not under the care of a GIC may request that the GP prescribe a ‘bridging prescription’ or offer blood tests to monitor hormones bought online. This is recommended in relation to adult patients by a 2013 Royal College of Psychiatrists (RCPsych) document³⁷. However, this guidance is due to be updated and may not reflect the latest context, including growing waiting times for specialist care. Notably, the current WPATH guidance suggests that bridging should be ‘a limited (1-6 month) prescription’ which does not fit with the UK context, where patients wait several years to be seen. More recently, the GMC has published extensive guidance in relation trans healthcare, most recently updated on 30 January 2024²⁹. This includes information about prescribing on the recommendation of a specialist and establishing shared care as well as a section on bridging prescriptions which ‘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’.² If a GP does decide to do this, they should ‘consult local policy, where it exists, and seek advice from a specialist service provider or an experienced colleague.’

Patients who are experiencing gender incongruence should not have to resort to self-medication without the advice of a gender identity specialist, but until waiting lists are shorter, this is likely to continue to happen. GPs should not be expected to fill the gaps in commissioned gender identity specialists and clinics.

The RCGP recognises that some GPs have particular expertise, or an extended role, in the area of transgender care. Such GPs may feel competent in providing bridging prescriptions and this document is not intended to stop them doing that, in line with the instruction in Good Medical Practice³⁸ that we work within the limits of our competence. However, most GPs will not have a special interest or have undergone training and so are unlikely to feel comfortable prescribing bridging prescriptions for patients who are on the waiting list for a GIC. We welcome the clarity on the GMC’s website, added since the first iteration of this position statement in 2019, that GPs are not required to prescribe. GPs are ultimately responsible for their prescribing and should not be pressured into prescribing where they feel it is unsafe or involves unacceptable risks.

Safeguarding

GPs face challenges in addressing the needs of children and young people under the age of 16 who are experiencing gender incongruence or are in the process of transitioning to another gender. These challenges include the vulnerabilities and wider mental health issues of young people and the lack of a robust evidence base for interventions. Parental and carer involvement in the care of these patients is crucial and adds another layer of complexity to the GPs role.

It would generally be expected that, for patients under the care of a consultant, any safeguarding issues noticed in secondary care would have been actioned, but this may not be the case for those who have been seen by GIDS. The Cass Review¹ acknowledges that there are a small number of cases in which ‘the child’s gender identity was consciously or unconsciously influenced by the parent’. It also reminds us that ‘safeguarding issues can be overshadowed or confused when there is focus on gender or in situations where there are high levels of gender-related distress’ and that ‘when the multi-professional review group (MPRG) began reviewing cases, the Tavistock team were unwilling to comply with MPRG safeguarding reporting requirements, but this situation has been partially resolved…however the MPRG continue to be very concerned about the GIDS teams lack of apparent professional curiosity or concern in relation to risk and safeguarding’. In 2021, GIDS was rated inadequate by the CQC, with concerns about risk management among other issues. GPs should not therefore assume that safeguarding issues have been addressed for patients who have been under the care of GIDS, and it remains important that GPs refer if there are any concerns.

Changes to the gender marker on the notes

GPs also face difficulties with current IT systems in relation to referrals and screening. For example, a trans male will not be recalled for cervical screening on the national recall programme, despite possibly still having female reproductive organs. The Cass review¹ has raised concerns that the need for a new NHS number when gender is changed ‘makes it more difficult to identify the long-term outcomes for a patient population for whom the evidence base is currently weak’ and suggests that ‘the NHS and the Department of Health and Social Care needs to review the process and circumstances of changing NHS numbers and find solutions to address the clinical and research implications’.

Up-to-date IT systems and associated IT training is needed to enable GPs and other healthcare professionals to treat trans patients and patients with gender dysphoria in a safe and respectful manner (for example, documenting generalist and specialist advice in writing as part of the patient record, maintaining safe access to screening programmes such as smears after a patient’s gender has been changed on records). NHS systems should record codes for biological sex as well as gender identity, while ensuring all patients are afforded the right to express their preferences for how they wish to be named and referred to by their GP and other healthcare professionals.

Concerns about conversion therapy

The RCGP is a signatory of the Memorandum of Understanding on Conversion Therapy (MoU)³⁹, the ‘primary purpose [of which is] a commitment to ending the practice of ‘conversion therapy’ in the UK’. The MoU defines conversion therapy as ‘an umbrella term for a therapeutic approach, or any model or individual viewpoint that demonstrates an assumption that any sexual orientation or gender identity is inherently preferable to any other, and which attempts to bring about a change of sexual orientation or gender identity, or seeks to suppress an individual’s expression of sexual orientation or gender identity on that basis’.

The Cass Review¹ makes it clear that ‘the intent of psychological intervention is not to change the person’s perception of who they are but to work with them to explore their concerns and experiences and help alleviate their distress… it is harmful to equate this approach to conversion therapy as it may prevent young people from getting the emotional support they deserve’. The British Psychological Society has also noted their concerns that a ban on conversion therapy may prevent identity exploration and stop professionals from providing ethical forms of therapy⁴⁷.

The Cass Review is in line with the MoU³⁹ which ‘supports therapists to provide appropriately informed and ethical practice when working with a client who wishes to explore, experiences conflict with or is in distress regarding, their sexual orientation or gender identity.’ The MoU is clear that it ‘is not intended to deny, discourage or exclude those with uncertain feelings around sexuality or gender identity from seeking qualified and appropriate help. This document supports therapists to provide appropriately informed and ethical practice when working with a client who wishes to explore, experiences conflict with or is in distress regarding, their sexual orientation or gender identity. Nor is it intended to stop psychological and medical professionals who work with trans and gender questioning clients from performing a clinical assessment of suitability prior to medical intervention. Nor is it intended to stop medical professionals from prescribing hormone treatments and other medications to trans patients and people experiencing gender dysphoria’ and notes that ‘for people who are unhappy about their sexual orientation or their gender identity, there may be grounds for exploring therapeutic options to help them live more comfortably with it, reduce their distress and reach a greater degree of self-acceptance. Some people may benefit from the support of psychotherapy and counselling to help them manage unhappiness and to clarify their sense of themselves. Clients make healthy choices when they understand themselves better’.

As a signatory to the MoU, the RCGP fully endorses the concept that therapists in primary and secondary care must be allowed to fully explore patient’s uncertainties, and any mental health co-morbidities or neurodiversity, without being accused of conversion therapy^1,40,41.

GPs are expert generalists; the provision of detailed advice about gender identity issues and associated treatments does not fall within the remit of a GPs education and training. The RCGP curriculum does however include the need to provide ‘high-quality, holistic and comprehensive care to…transgender people’⁴². The RCGP eLearning site has a course on transgender care, which is being updated in light of the Cass review⁴³. GPs should be aware that a patient may find the process of approaching a healthcare professional to discuss their gender identity to be difficult or distressing. GPs and their practice teams should approach these patients openly, respectfully and sensitively, with an awareness and understanding that a person’s outward appearance may not necessarily correspond to their gender identity, particularly at early stages of the person’s journey to exploring their gender identity.

The RCGP considers that the role of the GP includes the following:

• To provide a holistic approach, contextualising a person’s presentation of gender incongruence with other conditions and within their broader environment.
• To provide appropriate primary care related to gender-related distress or gender incongruence. This may include the use of non-oestrogen hormonal contraception to manage distressing periods in those who are transitioning from female to male.
• To provide appropriate signposting to patients presenting with gender incongruence alongside other social or medical issues. This may include referral to mental health services or engaging with social care, safeguarding, social prescriber or sexual health colleagues.
• To ensure that all patients can express their preferences for how they wish to be named and referred to and that these are respected.
• To promptly refer, where appropriate, to a GIC, or to the appropriate secondary care service if the patient is aged under 18.
• To liaise and work with GICs in the same way as with any other specialist. This includes consideration of prescribing under a shared care agreement (SCA). It is important that SCAs are agreed upon by all parties involved, with consent from all parties, given on a willing and informed basis⁴⁴, ensuring the appropriate levels of resource^44,45, competence and expertise are established, as informed by the patient’s level of medical risk. NHS bodies need to ensure that local shared care arrangements are adequately funded to support the ongoing care and treatment of patients. When responsibility for ongoing medical monitoring and prescribing is assumed by a GP, the limitations of this need to be recognised and mitigated. This is especially important for children and young people, where there is concern regarding the evidence of outcomes of some interventions¹. The GIC involved in the SCA should have access to the patient’s GP records and be accessible to provide specialist consultation to GPs to ensure the patient is being monitored correctly and the appropriate dosages of medication are being prescribed based on the progress of the patient. The RCGP supports those who feel that a lack of expertise or, given the significant existing workload challenges in general practice, a lack of resource preclude them from sharing care.
• To recognise that the family members of a patient experiencing gender incongruence also face significant challenges and refer these family members to further support services where appropriate.

The RCGP recognises that some GPs have particular expertise, or an extended role, in the area of transgender care and supports them to act in their patient’s best interests, within the limits of their competence. For the majority of GPs, without this expertise or extended role, the RCGP considers that the role of the GP does not include the following:

• Prescribing bridging prescriptions for those on the waiting list for a GIC.
• Prescribing puberty blockers for a patient aged under 18, even on a shared care basis, given the concerns about the evidence base in this area as well as the specialist expertise required to monitor dosage and side effects. The Cass Review¹ notes that ‘the Review has already advised that because puberty blockers only have clearly defined benefits in quite narrow circumstances, and because of the potential risks to neurocognitive development, psychosexual development and longer-term bone health, they should only be offered under a research protocol. This has been taken forward by NHSE and the National Institute for Health and Care Research (NIHR)’ and that ‘if an individual were to have taken puberty blockers outside the study, their eligibility may be affected’. This precludes GPs from ever prescribing puberty blockers, excepting any GPs working on clinical trials in this area.
• Prescribing gender affirming hormones for a patient aged under 18, even on a shared care basis, given the concerns about the evidence base in this area as well as the specialist expertise required to monitor dosage and side effects. The Cass Review¹ advises that ‘NHS England should review the policy on masculinising/feminising hormones. The option to provide masculinising/feminising hormones from age 16 is available, but the Review would recommend extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18’. In view of this, the RCGP view is that prescribing of gender-affirming hormones should generally only be done by specialists.
• For both puberty blockers and gender affirming hormones, no attempt should be made to persuade a GP to prescribe by citing, for example, distance between the patient and the clinic - it is up to the clinic to facilitate electronic prescribing or some other means of arranging prescriptions.
• Carrying out blood tests on behalf of secondary care or making decisions about how those blood tests affect hormone doses – NHSE advice⁴⁶ and primary/secondary care interface documents⁴⁷ make it clear that a clinician who wants to request a test should do it themselves. Again, it is up to the clinic to manage issues of distance by liaising with the patient’s local trust/phlebotomy services directly.
• Sharing care with the private sector⁴⁸, unless the GP practice has made their own decision to do so and feels that it is safe and resourced.

The RCGP calls for the following changes at national level:

1. To review the service specification for adult GICs and ensure that the commissioning of gender identity services is sufficient to support the demand for services for patients and advice to GPs. We would hope that emails from GPs would routinely be answered within two working days and that a phone line be available for urgent queries.
2. To ensure that services for adults and CYP take a holistic approach, considering neurodiversity, adverse childhood experiences and mental health co-morbidities. We would support innovative models including those which use a ‘hub and spoke’ model to provide care from local clinics run by GPs with Extended Roles (GPwERs) with supervision from a consultant in the field. The RCGP would be open to exploring the creation of a framework for a GPwER in this area.
3. To ensure that patients who present to their GPs with gender-related distress have access to appropriate psychological therapy within the community, whilst waiting to be seen in a GIC or as stand-alone therapy for those who do not wish to be referred to a GIC. As noted in the Memorandum of Understanding on Conversion Therapy to which the RCGP is a signatory, while there must be commitment to ending the practice of conversion therapy in the UK, there must also be appropriate support for therapists to provide appropriately informed and ethical practice when working with a client who wishes to explore, experiences conflict with or is in distress regarding, their sexual orientation or gender identity.
4. To ensure that SCAs are adequately funded to support the ongoing care and treatment of patients, and that the position of GPs who do not feel able or resourced to share care with either the NHS or the private sector is respected. To ensure that no clinic is allowed to ask for a commitment to acceptance of shared care as a prerequisite for referral.
5. To fully implement the provisions of the Cass review in England and adoption of the principles it identifies across the nations of the UK, including the change in structure of services for children and young people and the need for further research, with full co-operation from adult gender clinics.
   1. Specifically, implement recommendation 23, that ‘NHS England should establish follow-through services for 17-25 year-olds at each of the Regional Centres, either by extending the range of the regional children and young people’s service or through linked services, to ensure continuity of care and support at a potentially vulnerable stage in their journey. This will also allow clinical, and research follow up data to be collected’ and that ‘a follow-through service would benefit both this younger population and the adult population. This will have the added benefit in the longer-term of increasing the capacity of adult provision across the country as more gender services are established. This would be consistent with the other service areas supporting young people that are selectively moving to a ‘0-25 years’ service to improve continuity of care’.
   2. Specifically, implement recommendation 25, that ‘NHS England should ensure there is provision for people considering detransition, recognising that they may not wish to reengage with the services whose care they were previously under’.
6. To review IT systems with safety concerns in mind. NHS systems should record codes for biological sex as well as gender identity, so that patients can be safely recalled for the appropriate screening according to the organs that they have, without compromising their gender identity. The use of a new NHS number when the gender marker is changed should be reviewed, as this carries the inherent risk of loss of relevant information.
7. Educational and training bodies, commissioners and employers should provide training to support GPs and their teams. This training would help GPs to act as holistic generalists in this area and will not, in most cases, enable them to feel safe to initiate treatment for a patient who is not under the care of a GIC.
8. The fundamental standards of care and principles of oversight and regulation applied by the Care Quality Commission (CQC) in England and equivalent bodies in the devolved nations, should be applied to all providers of gender identity services, whether they work in the NHS or privately.

1. The Cass Review. Final report. April 2024
2. World Health Organization. Gender and health
3. Office for National Statistics. Gender identity. June 2020
4. American Psychiatric Association. Gender dysphoria diagnosis. November 2017
5. ICD-11 for Mortality and morbidity Statistics. January 2024. Gender incongruence of adolescence or adulthood 
6. ICD-11 for Mortality and morbidity Statistics. January 2024. Gender incongruence of childhood 
7. NHS England. NHS population screening information for trans and non-binary people. January 2023
8. NHS. How to find an NHS gender dysphoria clinic. May 2020
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