The volume of clients with whom they have interacted during this time makes them the most experienced specialist gender counselling team in the UK.

All of our counsellors are qualified and registered with the BACP or equivalent, and work to the highest standards. They have regular supervision outside of GenderGP and are bound to the counselling ethical framework.

Furthermore, the specialist gender counselling team are heavily involved in advocacy work and actively seek out the trans community, frequently attending events and support groups.

Specialist gender counselling is the perfect place to start this exploration. Gender affirmation is a journey and having a counsellor in your back pocket to help when the ride gets a little bumpy can make all the difference. Counselling is not there to tell you who you are, it’s there to support you, whatever your gender identity, and to offer emotional support and exploration.

The Specialised Services Circular 1620: ‘Guidance for GPs, other clinicians and health professionals on the care of gender variant people’ states that, ‘GPs are usually at the centre of treatment for trans people, often in a shared care arrangement with other clinicians. GPs may prescribe hormones and make referrals to other clinicians or services, depending on the needs of the particular service user. Sometimes a GP has, or may develop, a special interest in gender treatment and may be able to initiate treatment, making such local referrals as necessary. Otherwise referrals may be made to a specialist Gender Identity Clinic (GIC) where there are multidisciplinary teams of professionals. Private treatment with a gender specialist may be preferred by the service user.’

1. The patient will be able to access timely and safe healthcare for their gender identity while waiting for access to NHS services which have very long waiting lists.
2. The patient will be able to reduce their own personal risks by eliminating the need to purchase medication from unregulated sources without proper monitoring.
3. It supports their GP in prescribing and performing and analysing blood tests until treatment that should ordinarily be available to them on the NHS becomes available, but under specialist supervision.
4. There is a two-way sharing of the patient’s medical history which leads to safer and more comprehensive care and better outcomes.
5. Once a diagnosis has been established the GP will be advised on which blood tests are necessary to safely monitor the treatment and medication, and at what intervals they need to be performed.

The NHS Specialised Services Circular 1620 dated 22 April 2016 confirms that there is extensive clinical experience of the use of the medications used in the treatment of gender dysphoria, which provides evidence of tolerability and safety comparable with their use for approved indications. https://www.parliament.uk/business/committees/committees-a-z/commons-select/women-and-equalities-committee/news-parliament-2015/transgender-inquiry-report-published-15-16

‘A number of trans and non-binary individuals access private on-line medical services, often because of long waiting lists into an NHS-commissioned Gender Identity Clinic. The online provider may make a diagnosis of gender dysphoria through remote contact with the patient and in such cases a private prescription may be issued, or the patient’s GP will be asked to issue a NHS prescription. Either way, it is likely that the patient’s GP will be asked by the online provider to assume responsibility for monitoring and testing and for passing the results of the monitoring and testing to the private on-line service.

‘A number of GP practice staff have asked NHS England to provide advice on the responsibilities upon an individual’s GP in such cases in regard to issuing the prescription, and for monitoring and testing.’

1. The NHS should not withdraw NHS care because a patient chooses to buy private care, nor should patients who access private care be placed at an advantage or disadvantage in relation to the NHS care they receive.
2. The NHS should continue to provide free of charge all care that the patient would have been entitled to had they not chosen to have additional private care.
3. Where the same diagnostic, monitoring or other procedure is needed for both the NHS and private elements of care, the NHS should provide this free of charge and share the results with the private provider.

The GMC Advice for doctors treating trans patients aims to help doctors see how the principles of Good medical practice apply in relation to trans patients and also to explain doctors’ duties under the Equality Act 2010 and other legislation.

The GMC’s advice was initially met with a variety of concerns from NHS GPs, and Dr Chaand Nagpaul CBE Chair, BMA General Practitioners Committee penned his concerns to the GMC raising the emotive points that this would, ‘make GPs undertake specialist prescribing, placing them in a difficult position and forcing them to prescribe outside the limits of their competence.’

Susan Goldsmith, acting chief executive of the GMC, replied with reassurances including that they expect GPs to, ‘acquire the knowledge and skills to be able to deliver a good service to their patient population’, which may mean undertaking training and that they don’t believe care for patients with gender dysphoria is a highly specialised treatment area requiring specific expertise.’

The medication for transgender care includes well-known oestrogen therapy used for treating female menopause (estradiol), injections that are given for women with endometriosis or men with prostate cancer (GNRH analogues), a diuretic used for heart failure (spironolactone), anti-androgens used in contraceptives (cyproterone acetate), medication for benign prostate hyperplasia (finasteride) and testosterone replacement therapy used for the management of the male menopause.

These are medications that are well known to GPs who are well-used to their side effects and monitoring needs. Although it is recognised that some of these medications are not currently licensed for use in these conditions, there is sufficient evidence of their efficacy and safety in the management of gender dysphoria.

All of our doctors, clinicians and therapists have many years experience of working with gender dysphoria, and follow strict International guidance for treatment protocols.

Gender specialists can come from any medical specialty. In the NHS Document “clinical models operated by England’s gender identity clinics” it states that, “Gender specialists may be from many different clinical backgrounds, some specialising in mental health: psychologists, psychiatrists, counselors or therapists, but they may also be GPs, endocrinologists, nurses etc

In the WPATH Standards of Care Version 7: “With appropriate training, feminizing/masculinizing hormone therapy can be managed by a variety of providers, including nurse practitioners, physician assistants, and primary care physicians (Dahl et al., 2006).”

• All of the health professionals that our patients are referred to for support and evaluation specialise in gender dysphoria and have vast and extensive experience in the assessment of management of patients who may have associated mental or emotional distress.
• All patients are evaluated by at least two gender specialists, one of which is a medically qualified doctor and only the doctor will make decisions regarding endocrine treatments.
• Our MDT meets regularly to discuss cases and management and to review and develop the service.

NHS England will, as part of the Gender Identity Development Service for Children and Adolescents, commission cross sex hormones for young people with continuing gender dysphoria from around their 16th birthday subject to individuals meeting the eligibility and readiness criteria.

The Endocrine Society 2017 Guidelines, and the WPATH Standards of Care Version 7 are internationally recognised as providing excellent guidance in the management of transgender patients.

All of our prescribing physicians have extensive knowledge and experience in endocrinology and are fully qualified to treat children and adults. Both NHS and private gender specialists come from many backgrounds, counselling, psychology, general practice, general medicine, psychiatry, endocrinology, paediatrics.

The WPATH criteria for mental health professionals working with children include:

• Meet the competency requirements for mental health professionals working with adults;
• Trained in childhood and adolescent developmental psychopathology;
• Competent in diagnosing and treating the ordinary problems of children and adolescents.

The Endocrine Society Guidelines 2017 advise the following ‘We advise that only MHPs who meet the following criteria should diagnose GD/gender incongruence in children and adolescents:

• training in child and adolescent developmental psychology and psychopathology,

• competence in using the DSM and/or the ICD for diagnostic purposes,

• the ability to make a distinction between GD/gender incongruence and conditions that have similar features (e.g., body dysmorphic disorder),

• training in diagnosing psychiatric conditions,

• the ability to undertake or refer for appropriate treatment,

• the ability to psychosocially assess the person’s understanding and social conditions that can impact gender-affirming hormone therapy,

• a practice of regularly attending relevant professional meetings, and

• knowledge of the criteria for puberty blocking and gender-affirming hormone treatment in adolescents.

and

• ‘We suggest that adolescents who meet diagnostic criteria for GD/gender incongruence, fulfill criteria for treatment, and are requesting treatment should initially undergo treatment to suppress pubertal development.

• ‘We suggest that clinicians begin pubertal hormone suppression after girls and boys first exhibit physical changes of puberty.

• ‘We recommend that, where indicated, GnRH analogues are used to suppress pubertal hormones.

• ‘In adolescents who request sex hormone treatment (given this is a partly irreversible treatment), we recommend initiating treatment using a gradually increasing dose schedule after a multidisciplinary team of medical and MHPs has confirmed the persistence of GD/gender incongruence and sufficient mental capacity to give informed consent, which most adolescents have by age 16 years.
• ‘We recognize that there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/gender incongruence, even though there are minimal published studies of gender-affirming hormone treatments administered before age 13.5 to 14 years. As with the care of adolescents ≥16 years of age, we recommend that an expert multidisciplinary team of medical and MHPs manage this treatment.’

Women and Equalties Report 2016:

‘We recognise that there are legitimate concerns among service-users and their families about the clinical protocols which the clinic operates regarding access to puberty-blockers and cross-sex hormones. Failing to intervene in this way, or unnecessarily delaying such intervention, clearly has the potential to lead to seriously damaging consequences for very vulnerable young people, including the risk of selfharm and attempted suicide.

‘There is a clear and strong case that delaying treatment risks more harm than providing it. The treatment involved is primarily reversible, and the seriously dangerous consequences of not giving this treatment, including self-harming and suicide, are clearly well attested.

‘Accordingly, we recommend that, in the current review of the service specification and protocol for the Gender Identity Development Service, consideration be given to reducing the amount of time required for the assessment that service-users must undergo before puberty-blockers and cross-sex hormones can be prescribed.’

WPATH: ‘Refusing timely medical interventions for adolescents might prolong gender dysphoria and contribute to an appearance that could provoke abuse and stigmatization. As the level of gender-related abuse is strongly associated with the degree of psychiatric distress during adolescence (Nuttbrock et al., 2010), withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents.