The role of GPs in transgender care

This paper outlines the RCGP’s position on the GP role with respect to transgender people, those experiencing gender incongruence and/or questioning their gender identity, and recommendations to improve future care for these patients. The main body of this statement focuses on the provision of care to adults, with care for children and young people discussed separately in section 3 for clarity.

The RCGP recognises that language used in this area can be sensitive and contested. The common definitions of terms in this document are provided for explanation at annex A. All efforts have been made to ensure these are up to date and accurate.

1.1 Barriers to transgender health care

General practice remains the entry point to gain access to specialist health care for transgender people, those experiencing gender incongruence and/or questioning their gender identity, and the RCGP is aware that seeking health care for gender incongruence can be a challenging and frustrating process for patients and their families. A 2021 study identified key barriers in primary care for transgender people. Four barrier domains were identified; “structural (related to lack of guidelines, long waiting times, and shortage of specialist centres); educational (based on lack of training on transgender health); cultural and social (reflecting negative attitudes towards transgender people); and technical (related to information systems and technology)”.¹

The RCGP recognises that it is crucial that these barriers are urgently addressed and has therefore considered them, where applicable, in our policy recommendations (section 4).

1.2 Current training programmes, guidelines and evidence on gender incongruence

The UK lacks a nationally recognised training programme for gender identity healthcare. Although there are apprenticeship training models currently available in several specialist gender identity clinics (GICs) and guidelines are available from various organisations - such as the British Association of Gender Identity Specialists (BAGIS), the European Professional Association for Transgender Health (EPATH) and World Professional Association for Transgender Health (WPATH) - the workforce needs to expand rapidly to meet service needs.^2,3,4

In 2019, the Royal College of Physicians (RCP) was commissioned by NHS England (NHSE) to develop a range of credentials for clinicians working in GICs. RCP has subsequently developed three certificates for clinicians working in adult gender identity healthcare services.⁵

The RCGP eLearning site has a course on transgender care which is currently being updated. The module aims to expand the understanding of gender variance for primary care, covering patients who are transgender and non-binary. The module includes a wide range of issues including prescribing, the changing and expanding language in this area, and the need to treat patients openly, respectfully, sensitively and without bias.

There is limited quantitative research evidence for treatments and interventions which may be offered to transgender people, those experiencing gender incongruence and/or questioning their gender identity. The promotion and funding of independent research into the effects of various forms of interventions for gender incongruence is urgently needed, to ensure there is a robust evidence base which healthcare professionals can rely on when advising patients and their families. The RCGP would also encourage GPs to contribute to developing this evidence-base wherever possible. While recognising the need for more research and guidelines, it is important that service provision for transgender people, those experiencing gender incongruence and/or questioning their gender identity is urgently improved, and that the experiences and preferences of these patients are respected by GPs.

There may be additional challenges in supporting those who, having received treatment for gender incongruence, find their transition goals have changed. There are currently no guidelines available to support advising these individuals; this population often has unmet physical and mental healthcare needs and may not want to engage with the services that supported them to transition.⁶ This can put 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 subsequent doubts.

Further information on training and materials related to children and young people can be found in section 3.

1.3 System demand and capacity

The General Medical Council (GMC) advises that doctors promptly refer patients requesting treatment for gender incongruence to a specialist gender identity service.⁷ However it is unlikely that a timely referral will result in the patient being seen promptly given the long waiting lists for relevant specialist services. Most patients are currently waiting for many years without clarity on how long they are likely to wait. Under the NHS Constitution for England, the maximum waiting time for an initial specialist appointment following referral is 18 weeks.⁸ Despite this, at the time of writing waiting lists for GICs are many times this with many patients facing multi-year waits.^{9,10,11,12,13}

These long waiting times and uncertainty cause significant distress to patients and put pressure on primary care services as well as causing a disconnect between general practice and specialist services. It is important that patients on waiting lists are given regular updates by the relevant specialist service on their progress to a clinic appointment.

A report on transgender equality published by the House of Commons Women and Equalities Committee in January 2016 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’.¹⁴ The Committee noted the uneven geographical distribution of GICs, meaning that people need to travel long distances to access treatment. The importance of training in general practice to support improvements to patient experience and health outcomes was also emphasised. The situation has not improved since 2016, and in 2023, a briefing from the Parliamentary Office of Science and Technology 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’.¹⁵

2.1 The core role of the GP in providing care to adults

As expert generalists, the specialist skills required to assess and provide care to address specific needs related to gender incongruence do not fall within the remit of a GP’s education and training. The RCGP curriculum does, however, include the need to provide ‘high-quality, holistic and comprehensive care to…transgender people’.¹⁶ As such GPs should seek to gain as much knowledge and understanding as possible in order to deliver this holistic care. 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 of exploring their gender identity.

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

• To provide a holistic approach, contextualising a person’s presentation of gender incongruence alongside an individual’s physical, psychological and social health status within the broader environment.
• To provide appropriate primary care related to gender incongruence. This may include the use of non-oestrogen hormonal contraception to manage distressing periods in those who are assigned female at birth.
• To provide appropriate signposting to patients presenting with social or medical issues alongside gender incongruence. 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 recognise that the family members of a patient experiencing gender incongruence may also face significant challenges and refer these family members to further support services where appropriate.
• To liaise and work with specialist gender identity services in the same way as with any other specialist service. This includes consideration of prescribing under a collaborative or shared care arrangement.

2.2 Prescribing for adult patients

Further to the core role outlined above, GPs may be asked to be involved in prescribing for transgender adults and adults experiencing gender incongruence and/or questioning their gender identity in two main ways:

• initiating prescriptions for those on a waiting list for a specialist gender identity service.
• continuing prescriptions under a collaborative or shared care agreement with a specialist service.

Although some GPs may have developed additional expertise in this area and therefore may feel competent to initiate prescriptions for adults who are on the waiting list for specialist assessment and treatment, many GPs will not feel confident or competent to assess whether or not a prescription is appropriate, and to initiate it if so, without specialist input and advice. However, 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.

The RCGP advises that primary care prescribing should only be considered as part of a holistic assessment taking into account all conditions that may be present and the interplay of these conditions in the presenting features. This is important as a prerequisite before any prescribing can take place.

The GMC has published extensive advice on their ‘Trans healthcare’ hub, most recently updated on 30 January 2024.⁷ This includes information about prescribing on the recommendation of a specialist and on establishing shared care. Additionally, it includes information for doctors about ‘bridging prescriptions’ (referring to initiating a prescription for a patient on a waiting list for a specialist gender identity service) that ‘is aimed at reassuring doctors who wish to prescribe for their transgender and gender diverse patients that it wouldn’t be against [their] 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’. If a GP does decide to initiate a prescription for a patient on a waiting list for a specialist gender identity service, the GMC states that they should ‘consult local policy, where it exists, and seek advice from a specialist service provider or an experienced colleague'.

2.2.1 Initiating prescriptions for adult patients

With regard to assessing whether or not a prescription is appropriate and initiating it if so, the RCGP recognises that some GPs have particular expertise, beyond the levels of competence set out in the GP curriculum, in the area of transgender care and supports them to act in their patient’s best interests, within the limits of their competence and while considering the risks and benefits to the patient. We would also support GPs who wish to upskill themselves by pursuing further training and development in this area.

However, for GPs, without this additional expertise or extended role, the RCGP considers that the GP role would not include initiating prescriptions prior to a patient being seen by a specialist gender identity service. When a patient’s needs cannot be met by their GP, they will need to be signposted to a suitable care provider.

In the context of specialist waiting lists of several years, the risks associated with long term prescribing without specialist team support need to be carefully considered when deciding whether initiating prescribing of hormones by the GP would be in the best interests of the patient. Transgender patients, those experiencing gender incongruence and/or questioning their gender identity deserve a full, multi-disciplinary assessment by a specialist team. It is unreasonable for patients to have to rely on cumulative prescriptions from the same or different prescribers as a mitigation to excessive waiting times to see and obtain care and prescriptions from a specialist gender identity service.

However, it is important to note that in instances where patients have been initiated and established on medications, their prescriptions should not be abruptly stopped, as this could result in adverse physical and mental health effects. As above, a holistic assessment would be required taking into account the full context, risks and benefits. This may present additional complexities if, for example, a patient has been initiated on hormones by a private overseas clinic, where the clinical considerations and decision-making process may vary. The RCGP would expect that clinical judgment would be applied to these individual situations.

Transgender people, those experiencing gender incongruence and/or questioning their gender identity should have access to gender identity specialists in a timely way alongside the usual care of their GP. Until waiting lists are shorter, patients are likely to continue to fall between service gaps and it is incumbent upon commissioners to take urgent action to address this.

2.2.2 Prescribing for adult patients under collaborative or shared care arrangements

In common with other conditions, collaborative or shared care arrangements can be used for shared delivery of specialist care for those with gender incongruence. NHS bodies need to ensure that collaborative and shared care arrangements and locally commissioned services are adequately funded to support the ongoing care and treatment of patients. The RCGP would expect that any such collaborative or shared care arrangements would always include specialist involvement and clearly define the role of the GP. When responsibility for ongoing medical monitoring and prescribing is assumed by a GP in the context of a collaborative or shared care agreement, the limitations of this need to be recognised and mitigated. Collaborative or shared care for gender incongruence should follow the same lines as for any other condition wherein it takes place by arrangement and agreement. There should be a document that describes the nature, responsibilities and boundaries of the collaborative or shared care agreement in the patient’s notes.

Guidance on shared care is provided by both the GMC and NHS England.^17,18 In line with NHS England’s “Responsibility for prescribing between Primary & Secondary/Tertiary Care” guidance, which has been endorsed by RCGP, such care for any condition should only be carried out if:

• It is in the best interest of the patient: ‘the agreement and preferences of the patient should be at the centre of any shared care agreement and their wishes followed wherever possible.’
• ‘The patient or their carers […] have the opportunity to ask questions and explore other options if they don’t feel confident that shared care will work for them.’
• If the ‘specialist considers a patient’s condition to be stable or predictable.’
• ‘[T]he GP feels clinically competent to prescribe the necessary medicines.’
• ‘[T]he GP has agreed to this in each individual case, and the […] specialist will continue to provide prescriptions until a successful transfer of responsibilities. The GP should confirm the agreement and acceptance of the shared care prescribing arrangement and that supply arrangements have been finalised.’
• ‘[Adequate training and educational support is in place for the primary care multidisciplinary team, e.g. […] administration of the medicine etc. Information on how to access this support should be provided in the shared care prescribing guidelines.’
• ‘[T]he resources and capacity to ensure consistent delivery [are] determined before any such shared care prescribing is implemented.’^17,18

GPs are responsible for the prescriptions they sign and are accountable for their decisions and actions when supplying or administering medicines. The RCGP’s wider guidance on the interface between primary and secondary care explores this area further.

The RCGP would not consider the GP role to involve sharing care with the private sector, unless the GP practice has made their own decision to take this on and considers that it is safe.

2.3 Blood testing

Transgender people, those experiencing gender incongruence and/or questioning their gender identity who are prescribed hormones are likely to require blood tests to initiate, titrate and monitor these prescriptions.

The RCGP’s guidance on the primary-secondary care interface sets out that secondary care clinicians should avoid ‘asking GPs to undertake any tests that are required by secondary care as part of their diagnostic and treatment pathway, unless locally agreed and part of a clear pathway of care that benefits the patient’.²¹ In the context of care for transgender people, those experiencing gender incongruence and those questioning their gender identity, GPs should not be required to carry out blood tests on behalf of specialist services or make decisions about how those blood tests affect hormone doses, unless there is an urgent medical reason to do so, or by mutual agreement with a specialist service (who then take responsibility for the interpretation of the results).

Specialist gender identity services should be responsible for managing issues of distance by liaising with the patient’s local trust/phlebotomy services directly. Patients should not be required to travel long distances for blood tests from specialist services, and where this is an issue, commissioners should take urgent action to identify and resource appropriate local provision.

2.4 Challenges with IT systems

GPs also face difficulties with current IT systems in relation to referrals and screening. For example, a trans male may not be recalled for cervical screening on the national recall programme, despite possibly still having a uterus.

Up-to-date IT systems and associated IT training are needed to enable GPs and other healthcare professionals to treat transgender patients, those experiencing gender incongruence and/or questioning their gender identity 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 and 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 providers).

NHS systems must ensure that patients can be safely recalled for the appropriate screening according to the organs that they have, and that patient safety is not jeopardised because clinicians are not aware of a patient’s sex assigned at birth. NHS bodies must find a solution to this which allows for the recording of sex assigned at birth as well as gender, while ensuring appropriate confidentiality and compliance with the Gender Recognition Act.²² Similarly, it is important that systems are in place to ensure that changes made to records do not adversely affect care by disrupting waiting list placement or resulting in loss of past records of care.

Children and young people experiencing gender incongruence or questioning their gender identity should receive care openly, respectfully, sensitively and without bias as any other child or young person accessing health services. Children and young people will often have complex problems that require a holistic and person-centred approach to be adopted, to better understand the patient’s needs.

In April 2024, the final report of the Cass independent review of gender identity services for children and young people was published (Cass Review). 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.

The College welcomed the final report of the Cass Review and broadly supports the model the report recommends. The Cass Review specifically outlines the GP role as consisting of the following (numbering as per the Cass Review for reference):

• 19.9 'Initial consultation should be with the GP, who should make an initial assessment as they would with any other adolescent. They will have a record of any relevant past medical history and of family context.'
• 19.10 'If they consider that the young person may need to be referred to a Regional hub, they should make a referral in the first instance to a secondary Centre service. If the young person reaches the referral threshold for Children and Adolescent Mental Health Services (CAMHS), with mental health problems, they should be referred to that service, or otherwise they should referred to paediatrics. This should have an immediate effect on reducing the length of time children and young people are waiting to be seen by NHS services.'
• 19.11 'The GP should also share weblinks to trusted NHS information sources with the child or young person. In the longer-term these sources should be overseen by the National Provider Collaborative. In the interim, MindEd (2023) provides initial information for frontline staff, parents and teachers.'⁶

To support the establishment of new children and young people’s gender services, NHSE commissioned the Academy of Medical Royal Colleges (AoMRC) to design and deliver induction training for non-specialist clinical staff working in these gender service centres. Additionally, NHS Specialised Commissioning have commissioned AoMRC to develop training materials aimed at specialist clinicians who will be seeing patients in these new gender service centres across England.

For the care for children and young people, the College advises following national guidance and drawing on the recommendations highlighted in the Cass Review.^23,6 As well as the provision of holistic, context specific, personalised and respectful care as set out above, the RCGP considers the role of the GP in relation to children and young people to include promptly referring, where appropriate, to the appropriate secondary care paediatric or mental health services. The RCGP does not consider that the GP role in relation to children and young people would include prescribing gender affirming hormones to address gender incongruence in a patient aged under 18.

3.1 Safeguarding

In relation to safeguarding the Cass Review notes: “As with all health care provision, when working with children and young people safeguarding must be a consideration.”⁶

The RCGP recognises the importance of adequate safeguarding and has published comprehensive safeguarding standards and supplementary toolkit which supports GPs in their decision making.^24,25

3.2 Gonadotrophin-Releasing Hormone Analogues

A permanent ban on the sale and supply of Gonadotrophin-Releasing Hormone Analogues (puberty blockers) to under-18s came into force on 1st Jan 2025, following an earlier emergency order. This restricts the private sale and supply of these hormones.²⁶

Prior to this, in March 2024, NHS England took the decision not to commission the routine use of puberty blockers for the treatment of gender incongruence - informed by an evidence review conducted by the National Institute for Health and Care Excellence.

As such GPs should not prescribe puberty blockers to under-18s. However, NHS patients who are already receiving these medicines for gender incongruence can continue to access them, as can patients receiving the medicines for other uses.

To support the provision of high quality, joined-up, person-centred and evidence-based care for transgender people, those experiencing gender incongruence and those questioning their gender identity, the RCGP calls for the following changes at national level:

1. To review the service specification, the model of provision, and identify issues related to service delivery and best practice for adult specialist gender identify services:
   • As part of this, to ensure that the commissioning of gender identity services is sufficient to address the backlog and support current and future demand for services for patients, and advice and good communication to GPs.
   • This should also include support for development of follow through gender services for 17-25 year olds.
   • The RCGP would suggest exploring innovative models to provide care from local clinics supported by GPs with Extended Roles (GPwERs) with supervision from a consultant specialist in the field, where suitable for the local population. The RCGP would be open to exploring the creation of a framework for a GPwER for care of adults in this area.

2. To ensure that gender identity services for adults and children and young people take a holistic approach, considering neurodiversity, adverse childhood experiences and mental health issues.
3. To ensure that patients who present to their GPs with gender incongruence have access to appropriate timely psychological therapy within the community, whilst waiting to be seen in a specialist gender identity service or as stand-alone therapy for those who do not wish to be referred to a specialist gender identity service. This should include adequate resourcing of CAMHS and other primary and community services to support those who are not referred or those on long waiting lists.
4. To ensure that collaborative or shared care arrangements are adequately funded at both primary care and secondary/tertiary care level to support the ongoing care and treatment of patients.
5. To fully implement the provisions of the NHS England commissioned Cass Review in England and adopt the principles for the care for children and young people 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 specialist gender identity services.
6. To develop evidence-based guidelines to support health professionals in supporting transgender people, those experiencing gender incongruence and those questioning their gender identity, including specifically addressing the needs of individuals and their families if their transition goals change.
7. To review IT systems with safety concerns in mind. NHS systems must ensure that patients can be safely recalled for the appropriate screening according to the organs that they have, and that patient safety is not jeopardised because clinicians are not aware of a patient’s sex assigned at birth:
   • NHS bodies must find a solution to this which allows for the recording of sex assigned at birth as well as gender while ensuring appropriate confidentiality and compliance with the Gender Recognition Act.
   • 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.
8. There must be appropriate standards of care, principles of oversight, audit and ongoing review of outcomes, and regulation applied to all providers of gender identity services, whether they work in the NHS or privately.

Collaborative care: This term is used to refer to locally agreed arrangements which may not fully reflect the pathways typical of shared care protocols.²⁷ Collaborative care is available for a variety of conditions and is not exclusive to gender incongruence. It is well suited to define care within the context of local integrated services. Collaborative care for gender incongruence should follow the same lines as for any other condition wherein it takes place by arrangement and agreement. There should be a document that describes the nature, responsibilities and boundaries of the collaborative care agreement in the patient’s notes. Such arrangements must always include specialist involvement and clearly define the role of the GP. In England, such arrangements have been adopted within some ICSs, setting out specific boundaries for specialist and primary care roles.^28,29

Gender (WHO): 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.³⁰

Gender dysphoria (Diagnostic and Statistical Manual of Mental Disorders): A marked incongruence between one’s experienced/expressed gender and assigned sex, 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.³¹

Gender identity (Office for National Statistics): 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.³⁰

Gender identity clinic / gender dysphoria clinic (GDC) (NHS): 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. In Wales the provision is named the ‘Welsh Gender Service’.^32,33

Gender incongruence of adolescence and adulthood (International Classification of Diseases 11th revision, (ICD-11)): 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.³⁴

Gender incongruence of childhood (ICD-11): 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.³⁵

Sex (World Health Organization (WHO)): refers to the different biological and physiological characteristics of females, males and intersex persons, such as chromosomes, hormones and reproductive organs.³⁶

Sex assigned at birth: this language is used in order to be consistent with the language predominantly used within the NHS in this context. The NHS digital service manual on inclusive content notes: 'We use the phrase "sex assigned at birth" when we're talking about trans health and gender dysphoria, as this is the language our audience uses. In other cases, we use "the sex someone was registered with at birth" because user research shows that most people understand this better as it refers to an actual event'.37

Transgender/Trans (NHS England): An umbrella term to embrace the diverse range of identities outside the traditional male/female definitions. These include transgender, gender fluid and non-binary.³⁸

1. British Journal of General Practice (2021) Health professionals’ identified barriers to trans health care: a qualitative interview study
2. European Professional Association for Transgender Health (EPATH)
3. British Association of Gender Identity Specialists (BAGIS)
4. World Professional Association for Transgender Health (WPATH)
5. Royal College of Physicians. Professional Certificates for Gender Identity Healthcare Professionals. Accessed February 2025
6. Dr Hilary Cass (2024) Independent review of gender identity services for children and young people: Final report (The Cass Review)
7. General Medical Council (GMC) (2023) ‘Trans healthcare’, Ethical hub. Accessed February 2025
8. Department of Health and Social Care (2022) Consultant-led treatment: right to start within 18 weeks
9. Sheffield Health and Social Care Trust, NHS Foundation Trust. The Sheffield Gender Identity Clinic (aka. Porterbrook Clinic). January 2024. Accessed February 2025
10. Leeds and York Partnership, NHS Foundation Trust. Leeds Gender Identity Service. November 2023. Accessed February 2025
11. Welsh Gender Service (WGS), Cardiff and Vale University Health Board. Welsh gender service. November 2023. Accessed February 2025
12. Lothian Sexual Health, Chalmers Sexual Health Centre, NHS Lothian. Waiting times. Accessed February 2025
13. Brackenburn Gender Identity, Brackenburn Clinic, Belfast Health and Social Care Trust. Accessed February 2025
14. UK Parliament. House of Commons, Women and Equalities Committee (2016) Transgender Equality First Report of Session 2015–16 (HC 390). London: The Stationery Office Limited
15. UK Parliament. Parliamentary Office of Science and Technology (POST) (2023) POSTbrief 53: Factors shaping gender incongruence and gender dysphoria, and impact on health services
16. RCGP (2019) The RCGP Curriculum: Being a General Practitioner
17. General Medical Council (GMC) (2021) Professional standards: More detailed guidance. Good practice in proposing, prescribing, providing and managing medicines and devices
18. NHS England, Direct Commissioning Change Projects (2018) Responsibility for prescribing between Primary & Secondary/Tertiary Care
19. RCGP: Interface between primary and secondary care. Accessed February 2025
20. British Medical Association (BMA), GPC England (2023) General practice responsibility in responding to private healthcare
21. RCGP (2024) Primary-Secondary Care Interface Guidance
22. Gender Recognition Act (2004)
23. NHS England (2024) Referral pathway for Children and Young People’s Gender Services: Guidance for NHS Community and Hospital Paediatric Services
24. RCGP (2024) RCGP safeguarding standards for general practice
25. RCGP Safeguarding toolkit. Accessed February 2025
26. The Medicines (Gonadotrophin-Releasing Hormone Analogues) (Restrictions on Private Sales and Supplies) Order 2024, SI 2024/1319. Accessed February 2025
27. NHS England, Regional Medicines Optimisation Committees (RMOCs) (2022) Shared Care Protocols (SCPs). Accessed February 2025
28. NHS Nottingham and Nottinghamshire ICB, Nottingham Centre for Transgender Health (2022) Nottinghamshire Area Prescribing Committee Adult Transgender Collaborative Care Protocol: Hormone treatment for transgender adults. Accessed February 2025
29. NHS England, Sussex Partnership NHS Foundation Trust Area Prescribing Committee (2023) Sussex Gender Service (SGS) Collaborative Care Agreement (CCA) Hormone treatment for transgender adults. Accessed February 2025
30. Office for National Statistics (2020) Data and analysis from Census 2021. Measuring Equality: Gender identity. Accessed February 2025
31. American Psychiatric Association (2017) A Guide for Working With Transgender and Gender Nonconforming Patients: Gender dysphoria diagnosis. Accessed February 2025
32. NHS (2020) How to find an NHS gender dysphoria clinic. Accessed February 2025
33. NHS Arden and Greater East Midlands Commissioning Support Unit (Arden & GEM) (2024) National Referral Support Service for The NHS Gender Incongruence Service for Children and Young People. Accessed February 2025
34. World Health Organization (WHO), International Classification of Diseases 11th Revision (2024) ICD-11 for Mortality and Morbidity Statistics: HA60 Gender incongruence of adolescence or adulthood. Accessed February 2025
35. World Health Organization (WHO), International Classification of Diseases 11th Revision (2024) ICD-11 for Mortality and Morbidity Statistics: HA61 Gender incongruence of childhood. Accessed February 2025
36. World Health Organization (WHO) Health Topics: Gender and health. Accessed February 2025
37. NHS Digital service manual (2021) Inclusive content: Sex, gender and sexuality. Accessed February 2025
38. NHS England (2023) NHS population screening information for trans and non-binary people. Accessed February 2025