Working with GP’s

Barriers to Care

Training

At the time of writing this guide there is no formal structure of clinical training for the treatment of transgender individuals in the UK, for any clinician. There is little structured training at medical school, foundation or postgraduate level and there is an urgent need for improvement in this area.

Much training in the field remains psychiatrically focused and is gained in an experiential manner, lacking standardisation.

Concerns regarding the treatment of trans patients

There is a lot of fear around the treatment of trans people, particularly those under the age of 18. Individuals can be scared to come forward for help and there is also fear on the part of the doctor, who might feel under prepared.

Research

Although it is often cited that more research in this area is needed to inform future care, there is an abundance of research that confirms that access to gender-affirmative care allows trans people to live their lives more easily.

Outcome measures such as mental health scores, employment and school attendance rates, as well as life satisfaction scores have all been shown to increase when a person has the right support in their gender identity.

The importance of affirmation

Outdated and flawed research has hampered the care of trans people for many years. Studies followed very young children who were experimenting with gender behaviour, but did not turn out to be trans. This was interpreted as a high incidence of regret, when actually these individuals were never trans in the first place and would never have qualified for medical intervention.

Current expert opinion is that people with longstanding feelings of gender incongruence that persist into puberty and adulthood are extremely unlikely to change their mind. They may change the path they wish to take, but for the majority, their feelings of gender variance will persist – however these feelings might manifest.

Although it is very tempting to ask patients whether they are ‘sure’ about their feelings, trans people will have done a huge amount of soul searching before presenting for medical help and care needs to be taken to ensure the language used is respectful.

How might you broach the subject?

Real life experience (RLE)

Real life experience, known as RLE, describes the situation where a trans person is expected to live in their gender role in order to somehow prove a commitment to their gender identity. Understandably, many find it insulting and degrading to have to prove themselves in this way.

Some providers / practitioners will still insist on this before allowing access to medical care or support for name changes on legal documents.

As there is no rule book or standardisation of RLE it remains highly subjective as to whether or not it can be considered as having been ‘satisfied’. Unless the specialist practitioner is fully conversant with all aspects of gender expression, there are times when complaints of “hoop jumping” are justified, as are doubts surrounding the efficacy of such practices.

Additionally, there are many facets to a journey of gender transition, and there may be social reasons at home, or work, why the time might not be quite right for someone to change their name or clothes or external gender appearance. That does not make a person’s gender identity any less valid.

Many trans people feel that they are unable to confidently present to the world as their true gender, without the help of the physical effects of hormones, and yet they are often required to do so in order to access the treatment they need. This can cause a great deal of anxiety.

There is more to be gained from the medical practitioner listening to the patient, hearing their experiences and encouraging them to share their journey, rather than expecting them to “prove” their gender variance by conforming to a list of preconceived expectations of what it means to be a man or woman.

In order to be approved for gender confirmation surgery, one criterion is that the person has to have lived in that gender role for a period of time. This aims to prevent “regret” should it ultimately prove to be too difficult to live in their authentic gender role rather than prove their identity.

However, fixed criteria such as this are problematic for some patients who feel that they are better placed than anyone, to be able to govern their own stages of transition. Current studies indicate that quality of life for trans patients wishing to undergo surgery improves after sex reassignment surgery.

Patient Groups

Adults

Adults who have not yet presented for treatment, will have gone through the puberty directed by their birth-assigned sex. This means they may require the alteration of primary and secondary sex characteristics associated with their assigned birth sex.

Their appearance may appear to be less well aligned with their true gender identity meaning they are more prone to social stress and be more at risk of abuse and hate crimes. Subsequently, their mental health scores may be lower, particularly if they are then denied access to attempts at validating their gender identity.

Belief and support are vital for this group, and many patients ask their GP to provide simple medical care in the form of hormones as used with hormone replacement therapy in cisgender people. Hormones can give patients tremendous confidence to face the world in their real gender identity.

Older people

Many people suppress their gender feelings all their life, in the firm belief that it is easier to live their life in accordance with their birth sex, than face discrimination.

Many factors may contribute to this suppression, however, as age advances these may start to reduce. Factors including the death of elderly parents, relationships breaking down, children leaving home and the approach of end of life may precipitate an older person presenting in later life with the mission to realise their true gender before they die.

It is never too late for gender affirmation, and many people medically and surgically transition even though they have co-existing morbidities. Of course it is a balance of risk versus benefit, and that is a discussion between doctor and patient to come to the best decision given all the facts.

Towards the end of life

As people get older, issues such as autonomy, independent living, capacity to make informed decisions and death all begin to rise to
the surface. Many trans people fear their identity may cease to be recognised as they become older, will their true gender identity be respected in a place of care and on their death certificate? It can help significantly to make advanced life planning decisions so that everyone is aware of a person’s wishes for when they may not be able to communicate them effectively. The protected characteristics under The Equality Act 2010 are lifelong and must be respected whatever the situation. This may produce challenges for care giving organisations and clear policies must be in place to avoid discrimination and poor treatment.

Children

Prepubertal children do not need any hormonal intervention to affirm their gender. Medical intervention is not needed until puberty starts.

At home and school they may receive support to socially transition, ie use names, pronouns, clothes and affects that reflect their gender identity.

Forcing a trans child to express the gender they were assigned at birth can be extremely distressing.

Research and anecdotal evidence shows that children who are supported to explore and express their gender have better outcomes in terms of happiness, school success and social relationships.

A parent may bring their child to the doctor for advice. Current thinking is that for the best mental health outcomes, children should be listened to and believed when they are expressing ideation that their gender differs from that assigned at birth.

Support from their healthcare professional is essential, and no harm can come by ‘affirming’ the child and allowing them to express their feelings in a safe environment.

An early referral to NHS specialised services is warranted as waiting lists are long. The NHS young person’s service is able to help the child and family explore all the ideas around gender identity and what it means for them. Not all patients will seek medication, but for those that do, it is important that they can be supported in a timely manner so that intervention can begin at the onset of puberty.

Not all young people are supported by their families and they can find it difficult to get the help they need. They may present for medical help without the consent of their parents or guardian and their wishes must be taken into account as an individual who can make informed decisions.

Adolescents

As children approach adolescence they may or may not be aware that their natural puberty will bring with it some significant body changes. Young trans children, who are very well socially transitioned, may lose sight of the fact that the puberty they experience is going to reflect the gender they were assigned at birth, rather than their gender identity.

Others, however, are more than aware that, if nothing is done, the secondary sex characteristics of their birth-assigned gender will develop. This can be extremely distressing and is only avoidable with the use of hormone blockers (GnRH analogues). This is the same treatment that has been successfully used for many years to suspend precocious puberty.

There are early intervention programmes at the NHS specialist children’s service, the Tavistock and Portman, but in reality only a handful of adolescents are able to access this at the beginning stages of puberty, and it may well occur that parents and young teens ask their GP to help in the interim period.

A young person who is given puberty blockers at the right time will not have to go through the ‘wrong’ puberty. Their subsequent hormonal treatment will then enable them to develop some secondary sex characteristics that are in line with their gender identity. It also means that they will not have to undergo so many ‘rectifying’ surgeries or be as identifiable as trans in the future.

Although many doctors fear intervening with medication in young people, the act of ‘watchful waiting’ is not a neutral option. Puberty brings irreversible changes to the body that may ultimately require surgery to reverse, or will act to identify that person as trans for the rest of their life. This can be very distressing, and potentially dangerous for them.

Stonewall’s ‘Trans Report’ provides an overview of the profound impact that violence and discrimination is having on the quality of life of trans people in Britain today.

Despite much emotive public debate on the matter, puberty blockers are reversible and puberty resumes as normal on stopping them. They buy time for that young person to explore their gender identity and the journey that lies ahead of them. With such high levels of suicidal ideation by young trans people, often due to intense feelings of gender dysphoria, their use can be life-saving. With waits for a first appointment with specialist child and adolescent NHS services of more than two years. (as at date of publication), many parents and young trans teens want to be able to ask their doctor to prescribe and administer this medication.

In the UK, young people are able to be involved in decisions about their healthcare at a young age, as long as they have capacity to understand. Once the criteria for gender dysphoria are met and capacity to make decisions on medical intervention assessed through Gillick competency protocols, there is no reason why a well-informed doctor, nurse or pharmacist cannot prescribe for this patient group.

Excellent guidance for the treatment of gender diverse children and adolescents has been published by The Royal Children’s Hospital, Melbourne, Australia.

Learning disabilities

Gender expression is a natural part of human identity. We are all on the gender spectrum somewhere and while most of us will identify with the gender we are assigned at birth, others may not. Gender does not take into account learning ability, although the ability to express feelings of gender incongruence may be hampered in this group. There will be clues, verbal and non-verbal, that may give us the telltale signs that feelings of a mismatch exist, between how someone’s gender is perceived and how it is experienced. Nobody should be prevented from living their life authentically.

The Care Management Group have developed an easy to read guide about what it means to be transgender. Read it here

Autistic spectrum

There is a recognised overlap between the gender spectrum and the autistic disorder spectrum with the ‘dual diagnosis’ occurring more frequently than might be expected.

Although someone may be on the autistic spectrum this is not a reason to discount their gender identity. The individual’s human rights must be respected.

There is also an overlap in the presentation of people with personality disorder, post-traumatic stress disorder, autism and gender dysphoria.

Social difficulties and withdrawal, lower mental health scores, difficulties with relationships at school, work and home, are all more common in these groups. A key question is whether people are wrongly diagnosed as being on the autistic spectrum, when in fact they are really gender dysphoric.

Conversely, having gender incongruence is not currently completely socially acceptable in all circles, and many feel the need to suppress their feelings. Perhaps people on the autistic spectrum are less able or inclined to follow these social rules, and are more able to outwardly express their gender identity?

Whatever the reasoning, both ‘labels’ may co-exist and must be respected individually.

Considerations in Primary Care

General care

“Trans broken arm syndrome” describes the situation in which healthcare providers assume that all medical issues – from mental health problems to broken arms – are somehow related to a patient being trans.

The fact that a patient within a practice is trans should be irrelevant unless the condition with which they are presenting specifically requires the disclosure.

This is particularly important in modern day general care where patients often see a different GP every time they visit the surgery.

Unless absolutley relevant to the condition being presented, there is no reason to disclose the fact that a person is trans, and to do so may be in breach of their human rights.

However, if they have had a procedure that may influence their treatment then it may be necessary to bring this information to the attention of the medical practitioner. For example, someone who had had genital reassignment surgery being referred for abdominal pain, this would be a relevant past history to note.

How might you broach the subject?

Gender dysphoria

Some trans people may have acute discomfort with a part of their body or a personal feature that relates to their assigned sex at birth. This is known as gender dysphoria. The opposite is ‘gender euphoria’ which occurs when the physical appearence aligns with the gender identity. This is something which trans people describe they have felt after gender confirmation surgery.

For a trans woman, gender dysphoria may be caused by her voice, facial hair or stature, as it will be an unwanted reminder that she was assigned male at birth.

For a trans man, this may be breasts, periods, voice, or smaller stature.

It is important to note that gender dysphoria can change over time as people can focus on different parts of their body and gender presentation.

As everyone is different, the intensity of their gender dysphoria will also vary. Being trans is not a tick box exercise. What is problematic for one person, may not be an issue for another. Approach each person as an individual.

How might you broach the subject?

Initiating treatment

The waiting lists for NHS specialist Gender Identity Clinics are very long, and many people find these waits incredibly distressing. In addition to this, many trans people have very simple needs that can easily be addressed by their local primary care service. Many countries have used guidelines that are specifically designed for implementation in every day evidence-based primary care, but the UK has been slow to follow. Having said that, there is now increasing talk about a future where primary care plays a much more prominent role.

There are GPs that would like to help their patients but, due to a lack of clear guidance, many are unclear on exactly what their role can be. This is further complicated by the message that the care of trans patients is a specialised area of medicine.

Continuing care

Once a person starts hormone therapy, they may wish to maintain that treatment regimen for the rest of their life, and this will require the support and care of their GP.

There is clear guidance from NHS England on the role of the GP in the care of a patient who has been assessed and recommended for treatment by the GIC:

Doctors can feel confident in using their expertise in administering hormone therapy to provide ongoing treatment to their trans patients. Where additional support is required, gender specialist input can provide reassurance and guidance. This is the same way that GPs and specialists have worked together for years, and we must make this joint approach available to our trans patients.

Common scenarios

The following are common scenarios in General Practice and can all be managed appropriately in Primary Care using current knowledge and appropriate published guidance, such as that found at the end of this guide. Consider these scenarios and how you could best help the following patients:

NHS Gender Markers

All trans people have the legal right to be called by the correct name and pronoun. Many trans people report the hurt that is caused by being misgendered in their GP surgery. While this can cause considerable distress, it can be easily remedied.

It is a legal right for a person to change their name and gender on their NHS record and an individual would be able to bring a civil claim against any body refusing this request.

There is a simple process accepted by the Department of Health which changes the name and gender marker on GP and hospital records. There is no requirement for a legal change by deed poll or a gender recognition certificate, or a medical report to accompany this wish.

The process for changing gender marker

The process for changing gender marker on NHS records is relatively straightforward:

In order to obtain documents such as new passports, driving licences and Gender Recognition Certificates (GRC), GPs may also be requested to provide written evidence of a patient’s permanent transition and any associated treatments.

Gender Recognition Certificate (GRC)

In the case of the GRC, a substantial amount of detail is required by the Gender Recognition Panel, including dates of the start of the change in gender role, hormone therapy regimes, surgery dates and procedures. A template for the report from the doctor or psychologist is provided on the UK Government website.

Screening and diagnosis

It is important to remember that changing gender marker on medical records may affect the screening procedures that a patient is automatically called for. Screening should be offered in accordance with a person’s anatomy rather than their gender marker.

A trans man may still have a cervix.

A trans woman will have a prostate gland and this needs to be considered when presenting with urinary symptoms.

Both trans men and trans women may have breast tissue that requires screening mammography.

NHS Wales has developed advice on screening for trans individuals.

How might you broach the subject?

Referral to a Gender Identity Clinic

In the UK there are a few specialised centres that receive referrals for adults, these are known as Gender Identity Clinics (GICs). Centres specialising in the care of children and adolescents are called Gender Identity Development Services (GIDS).

Details on how to refer a patient to a GIC are found on the NHS website.

As time has gone on and as more and more people feel able to come forward for help and support with their gender, waiting lists for the specialised clinics have lengthened with some patients waiting up to four years to be seen.

While some trans people may have needs that require specialist input, and those who require surgery need to go down this Pathway, worldwide expert opinion recognises that much routine care for trans patients can be provided in a primary care setting. This approach is currently being rolled out in other countries, as well as being trialled in the UK. This represents a straightforward solution to what is, for many patients, becoming an increasingly unmanageable situation.

Patients do not need to be referred to mental health services in order to access gender services.

How might you broach the subject?

Due to the long waiting lists a number of trans people may turn to self medication or private providers. For those people who do enter into the GIC or GIDS services, a number of them may still feel that care is not well delivered.

Trans people are entitled to the same level of excellent care as any other member of society. If specialist centres are not matching up to the standards required, alternative provision of care, including via GP surgeries, is an obvious alternative.

Waiting times

It is well documented that waiting times to treatment on the NHS for trans patients are considerable and far exceed the 18 weeks laid out in the constitution.

In such cases, GPs are required to look for alternative providers to work alongside, this may include private services if that is the patient’s choice.

GenderGP can help in providing a shared care alternatives or additional support for GPs, where required.

Private Care

Many patients worry that if they access private services while waiting for the specialised gender clinics, they may be penalised.

As emphasis on patient choice within the NHS grows, it is increasingly recognised that patients are entitled to choose freely between NHS and private treatment, whether provided as a private service by an NHS body or by the independent sector, at different points in their overall care.

Going abroad for treatment

If a patient’s treatment cannot be provided on the NHS, within a time period that’s medically justifiable, then they may be entitled to NHS- funded treatment in another European Economic Area (EEA) country or Switzerland. There are certain qualifying criteria that need to be met, as set out on the NHS website.

The GP’s role is to support the trans patient if their choice is to explore surgery options outside of the UK, particularly given long waiting times.

Legal requirements when treating trans patients

Some GPs may feel they lack experience with treating trans patients. However, they must ensure that any personal beliefs they may have around gender variance, are put to one side. The treatment of the patient is paramount, as it would be with any other condition.

Gender reassignment is a protected characteristic under the Equality Act 2010. This gives anyone the right to have their gender identity acknowledged and respected.

The NHS commissions services for transgender patients and these services include:

There is no option for a healthcare professional in the UK to refuse to make these services available to trans patients who request them. People are entitled to treatment by law as stated in the case of North West Lancashire Health Authority v A, D & G, Court of Appeal, 1999.

Doctors who feel personally unable to provide care must refer patients to a colleague who can help.

Prescribing and monitoring under shared care protocols with specialists can help to alleviate any concerns. However, GPs are uniquely positioned to provide a holistic view of the patient and should provide any relevant insights to the gender specialist regarding any medication currently being taken that may impact their care.

It is important to note that any disability or neuro diverse condition is not a reason, in and of itself, to refuse treatment.

Conversion therapy

In 2017, the Coalition against Conversion Therapy, launched a Memorandum of Understanding (MoU2) against conversion therapy with the backing of all major psychological, psychotherapeutic and counselling organisations in the UK.

The MoU2 was supported by the British Psychological Society (BPS), British Association for Counselling and Psychotherapy, and the UK Council for Psychotherapy in October 2017.

It was also supported by Stonewall, NHS England and NHS Scotland.

It is not possible, lawful or ethical to try and persuade someone that their identity is in any way unreal or can be reverted to their birth gender. However, many people report that they have been subjected to conversion therapy of some kind or another.

The practise is now banned in 18 US states, Malta and some parts of Spain with other countries set to follow suit.

Any attempt at encouraging a person to embrace a cisgender identity rather than a trasgender identity, can be regarded as an attempt to convert them to a ‘preferable’ identity. We should be aware of this when we exercise caution with patients. You can read more about this here.

Coercion

Gender identity is as innate as eye colour or sexuality, you cannot and should not try to pursuade anyone that they are anything other than what they percieve themselves to be.

There is a concern that youngsters are being influenced by information they find on the Internet. However, while much research is carried out by trans people as part of the process of understanding their gender identity, the act of developing this understanding is as much about giving a name to their feelings as it is about finding evidence that they are not alone.

Los Angeles based Darlene Tando, a specialist in the care of trans youth, makes the following analogy:

Medical Management

The medical needs of trans people can be both simple and complex. Acceptance, support and belief are fundamental to securing the wellbeing of the patient.

Hormone therapy

The principles of treatment are simple and the treatment itself is safe and well established.

The GnRH analogues (triptorelin, goserelin) are well known to GPs in their role in suppressing natal hormone production when used for precocious puberty, hormone impacted cancers and endometriosis. The same principle guides their use for trans patients, and they are excellent at suppressing hormone production in trans patients who are at tanner stage 2 or beyond. This is in accordance with the guidelines followed by GIDS.

Hormone replacement is vital for bone health, and for alleviating induced menopause and andropause caused by the GnRH analogues. Hormones are prescribed exactly as they would be for women and men who are finding that their natural hormone production has declined or is insufficient. The same dose of injection (Nebido, Sustanon) or patch (Evorel, FemSeven, Estradot) or pill (progynova) or gel (Oestrogel, Sandrena) is used and then the doses titrated so that the hormone levels match with age-related targets for that gender.

Robust guidance ‘Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People’ has been produced by the Centre of Excellence in Transgender Health at the University of San Fransisco.

This guidance succeeds in ‘equipping primary care providers and health systems with the tools and knowledge to meet the healthcare needs of their transgender and gender nonconforming patients.’ And provide detailed information on the management of trans patients.

Trans masculine people may prefer to have testosterone as their primary sex hormone rather than oestrogen. This can be achieved medically using the same preparations that are used when helping cisgender males who have low testosterone. In the UK, this is available as injections and gels with the aim of achieving blood levels within the male range.

Trans feminine people may wish to have oestrogen and progesterone, and this can be given as pills, patches and pesseries, or in some countries, injections and implants. The preparation, dosage and expected blood levels are identical to female hormone replacement therapy.

Trans women who cannot access GnRH agonists for whatever reason, can be prescribed other anti-androgens such as spironolactone or finasteride. This is required in order to suppress the natural testosterone so that the oestrogen therapy can take effect.

Some non binary people may wish to adjust their bodies with hormones to alleviate their dysphoria or to align themselves more closely with their gender identity. With informed discussion this can be made possible for them.

Self-medication

Many trans people who have faced long waits for care resort to buying medication for themselves, without a prescription. GMC guidance notes this as a criteria which may allow a GP to prescribe a ‘bridging prescription’ to provide interim care while a patient waits for specialised services.

Trans people who embark on their own unsupervised treatment regime would be better managed, and at considerably less risk of harm, if they were under the supervision of their GP. There is published guidance by the Endocrine Society in the Journal of Clinical Endocrinology and Metabolism, for the prescribing and monitoring of hormone therapy in Primary Care.

Unlicensed medicines

Very few medications are specifically licenced for the use in treatment of gender dysphoria. However, off-licence medications are frequently prescribed by GPs for medical conditions without issue, and competent physicians will be familiar with this practice and aware that it is known to be safe and effective when other medical options are not available.

Hormone therapies have been used, effectively, and safely for decades in the treatment of gender dysphoria. As with all medications, care should be taken to explain to patients what the treatment entails and any potential side-effects.

How might you broach the subject?

Side effects

What may be considered by a cis individual to be the ‘adverse side effects’ of gender affirming hormone treatment, are likely the very reason trans patients seek to have HRT prescribed.

Trans men prescribed testosterone will find that their voices break, facial hair will grow and their bodies will masculinise.

Trans women prescribed oestrogen will see breast development, a reduction of muscle mass and redistribution of body fat. Skin may soften and emotional responses may change.

Young trans people who receive medication to block their natural puberty and then continue on to gender-affirming hormone therapy, will develop secondary sex characteristics that match their gender identity. This gives trans youth the opportunity to have a ‘puberty with peers’ along with the chance to be unidentifiable as trans to the public observer as an adult.

As with cis patients, there is increased risk of certain health conditions in taking HRT and the benefits should be balanced against any risk, which is the case when prescribing any medication.

In practice, hormone therapies are very safe for trans people and the improvement in mental health has been shown to offset any negative side effects.

Informed consent

While healthcare professionals are experts in their own field, a course of treatment should only be embarked upon with the understanding and cooperation of the patient. Patients are the experts in their own feelings and bodies and how treatment may impact on their daily lives.

As with many other long-term healthcare condition, a collaborative approach between a healthcare professional and patient in developing a joint management plan is essential to produce the best outcomes.

Once a healthcare plan is agreed, consent forms can help protect patients and prescribers, and good templates are available.

When it comes to transition, the medical journey is not a simple one from A to B. Adjustments may need to be made as time progresses. Plans made around medical transition may alter, as may prescribed dosage, format and frequency. Treatment may be paused, or even stop altogether. Families, work environment, politics and the public may all impact a trans patient’s speed and direction of medical transition. Some patients may choose to stop treatment during times of personal stress, and then restart again later. This is all part of the journey, and in no way invalidates a trans person’s gender, or their continued wish to transition. As such, it is important that healthcare providers offer opportunities for discussion and the updating of healthcare plans.

Gender is a journey, sometimes people change direction, whatever direction they take, it is always a step forward.

An important note on physical examination

Many trans people find their genitals an extreme source of discomfort. There is no requirement to examine the genitals of a person who is presenting with feelings of gender variance, and no medical reason for doing so, prior to commencing hormone therapy.

Young people do not need to start any medical intervention until they reach tanner stage 2 of puberty. The onset of puberty and elevation of natal hormones can easily be diagnosed by taking a medical history and blood test, without any need for a potentially distressing physical examination.

If a physical examination is required for any medically valid reason, then sensitivity in the use of language, particularly in reference to gendered body parts, is vital.

How might you broach the subject?

Fertility

Hormonal and surgical therapy for gender affirmation may impair fertility in trans patients. The degree to which this may be the case is unknown, and it is best to counsel and advise on fertility preservation techniques early on in the patient’s journey.

The Human Fertilisation and Embryology Authority have information for trans and non-binary people seeking fertility treatment. Their advice is to store gametes wherever possible. This is not commissioned by NHS Gender Clinics, so it would be beneficial to the patient to be referred to their local fertility centre as soon as it is known that they are considering any hormonal intervention.

Fertility preservation may be harder for trans youth preparing to start hormone blocking medication. Many fertility clinics in the UK may not treat patients due to their age or developmental stage. However, while their fertility will be impared while taking hormone blockers, it will be returned once treatment is stopped. This allows for the possibility to pause treatment to preserve fertility at a future date. Careful counselling is needed to communicate the medical impact of blocking and hormone therapy, while balancing against the negative impact of dysphoria. The desire not to preserve fertility should not be used as a reason to deny treatment to a young person.

How might you broach the subject?

It is important to note that infertility is no longer a forgone conclusion when it comes to trans masculine individuals. There have been numerous cases of trans men who have gone on to give birth to healthy babies after pausing their testosterone treatment for the requisite period of time.

Psychological support

Many people associate being transgender with the need for psychological assessment and therapy. It is true that if someone is distressed for whatever reason, then the talking therapies can offer significant relief and support – this is true of everyone, not just members of the trans community.

Transition is fraught with challenges, impacting every facet of a trans person’s life as they know it. Psychological support and exploration can help a person to find their way and provide much needed support. However, care should be taken that psychological evaluations should not be used as a measurement tool to ‘confirm’ a patient’s gender identity, or to convince a trans person to continue or revert to a cisgender presentation.

The benefits of having a “counsellor in your back pocket” to call upon when life gets tough, or when there are tricky decisions to be made, is not a concept which is unique to someone with gender variance.

While counselling is not and should not be mandatory, it should be available as and when it is required.

Presenting in the authentic gender

If a person’s sex characteristics do not align with the gender with which they identity, they may wish to use methods to shape their body. Trans masculine people often use tight chest garments or binders to give the appearance of a flat chest and a male shape. They may additionally use a ‘packer’ in their underwear to alleviate dysphoria and present more closely as male.

Trans feminine people may ‘tuck’ their penis away so that it doesn’t cause an unwanted prominence, and may use padding in bras or around the hips to create a more feminine outline.

All of these devices can alleviate gender dysphoria for the user, but may have physical or medical side-effects with prolonged use. It is recommended that medical providers ask if any body altering methods are being employed by the patient, and offer appropriate medical support and advice.

Hair Removal

Facial hair can be an enormous source of distress to trans feminine people. As well as being a noticeable ‘male’ social marker, regrowth during the day causes issues with make-up and is a common cause of dysphoria.

Hair removal is one of the treatments funded by the NHS, although CCG funding policies vary from area to area. It is advised that GPs supporting a trans patient should familiarise themselves with their local CCG policy and signpost their patient accordingly.

There are two types of hair removal available to trans feminine people through the NHS – electrolysis and laser treatment. Assessment of the suitability of treatment needs to be carried out by a qualified person. However, many people find that what is offered by the NHS is inadequate so supplement this with private treatments. For trans patients living in an area where CCG funding is not available, private treatment may be the only option.

Voice therapy

Trans people can often have dysphoria around their voice as a result of misgendering. This can be particularly worrying for them when using the telephone, as there are no visual cues. Trans women who have not had access to surgery or vocal feminisation training may be regularly misgendered or identified as trans, based on their voice.

Voice therapy can help and services are available on the NHS as well as via private practitioners, there are also apps specialising in voice feminisation.

Note for reception staff. The sound of a patient’s voice over the phone may not align with what is anticipated based on the patient’s record. In such instances, reception staff should be respectful and follow patient verification protocols as they would with any other patient.

Surgery

For trans men, the most commonly requested procedure is ‘top surgery’, which removes any breast tissue to create a masculine chest. There are two different procedures available, which are chosen based on the amount of tissue to be removed.

Male genital surgery is less popular with trans men as it is extensive and requires several surgeries. Currently, there are three main surgical techniques that are used, however these are constantly being developed and improved upon.

Many trans men choose not to undergo genital surgery, due to the invasive nature of the procedures and the surgical outcomes.

For trans women, breast augmentation, facial feminisation and female gender affirmation surgery are popular. The uptake of genital surgery by trans women is much higher than trans men, as the surgical procedures are more advanced in their development and have less complications.

Some surgical procedures are available on the NHS, however, these can only currently be accessed via referral from an NHS GIC.

Trans people vary enormously in what, if any, surgery they desire. Many do not wish to have any surgery at all and this in no way invalidates their gender identity.