Bridging Hormones

In 2016, there was excitement as the healthcare magazine ‘GP Online’ proudly announced that ‘GPs should consider prescribing ‘bridging’ hormone treatment to transgender patients attempting to self-medicate while they await specialised gender identity treatment, GMC guidance recommends.’

With waiting times for specialist appointments increasing rather than decreasing, this was real positive news for trans people.

In 2020, the GMC advice continues to make the following recommendation to doctors:

‘Bridging prescriptions’

It may be that the risk of harm to your patient of self-medicating with hormones bought from an unregulated source is greater than the risk of initiating hormone therapy before the patient is assessed by a specialist.

A harm reduction approach is advocated by the Royal College of Psychiatrist’s current guidelines and it would be in line with our guidance if judged it to be of overall benefit to your patient. We have highlighted the most relevant parts of guidance, for you to consider when making this judgement, in the related guidance section of this page.

But you should only consider issuing a bridging prescription in cases where all the following criteria are met:

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

*An experienced gender specialist is someone who will have evidence of relevant training and at least two years’ experience working in a specialised gender dysphoria practice such as an NHS GIC.

Many feel that this guidance is still limiting, and doesn’t supply the patient with the full scope of care that they are entitled to on the NHS, but for many it was seen as a potential lifeline. Now, it appeared, there was a safer option than the black market.

Of course every doctor, when interpreting advice, should take the overall health and wellbeing of their patient into consideration, as well as acknowledging one of the key ‘Duties of a Doctor’ laid out by the GMC: ‘Make the care of your patient your first concern.’ 

So, how many doctors are following the guidance? How many are prescribing Bridging Hormones, how many trans people feel that their doctor makes the care of their trans patient their primary concern?

In July we asked you to share the response you received on asking your doctor to prescribe for you while waiting for the NHS specialist services. Even we were shocked at the results.

Of those who responded in the affirmative to the question have you asked your GP to prescribe bridging hormones for you, this was the response they received…

There has to come a time when GPs are held accountable for their own actions. They can refuse to help their trans patients, but not without good reason, and not without making the care of their patient their first concern.

We need to stand together and raise the expectation that GPs put some time aside to read guidance for Primary Care doctors. There is ample information available, such as the excellent Guidelines from the University of San Francisco and California.

We need to raise our expectations: GPs should not be able to refuse to provide basic hormone therapy to patients who are fit and healthy, without concurrent health problems that could raise cause for concern, without very good reason. Trans people need to know their rights and they need to push for the care they are entitled to.

By refusing to follow the guidelines, which are so clearly set out by the GMC, GPs are either stating that they are unwilling to accept that their patient is trans, or that they cannot do so without a specialist clinic validating that person’s gender. Or, worse, they are saying they haven’t got the time (or inclination) to learn and increase their knowledge in this area. Neither of these options would be acceptable in any other avenue of healthcare and it should not be acceptable when it comes to supporting people with their gender.

To put this in perspective, for those who are reading this article and are still not confident that they should be able to access their healthcare via their GP, picture this scenario:

Mary Foster tells her GP that she has all the symptoms of diabetes. The GP, an educated medical professional, can see that based on Mary’s symptoms this looks like it may indeed be the case. The GP refers Mary to the specialist diabetic clinic. Three years later, Mary gets an appointment. The clinic agrees, in line with the patient and the GP’s suspicions, that Mary does indeed have diabetes and recommends she has insulin injections for the rest of her life. The GP is not sure about his knowledge of diabetes and refuses to prescribe for her. The specialist clinic does not have a policy in place for prescribing, only advising, so Mary goes without her treatment for her diabetes.