Transgender healthcare in the UK is in crisis. Average waiting times for a first appointment at a specialist gender identity clinic (GIC, sometimes referred to as a GDC) vary between three and five years after GP referral. As of November 2021, there are currently 10,142 people languishing on the often closed waiting lists, with only 46 first appointments offered last month.
Alongside well-documented institutional transphobia and the decimation of the NHS at the hands of successive governments since the early 2000s, the situation is unquestionably bleak. The system is fundamentally broken; the GICs need to go and must be replaced by the informed-consent model used in other countries.
This guide offers up some strategies for trans people seeking the most common form of gender-affirming healthcare, hormone replacement therapy (HRT), in the face of the UK’s outdated and punitive healthcare system. It draws on personal experience and the work of flourishing online trans healthcare communities, especially the comprehensive Trans Health UK blog and its guide on HRT. Further resources are linked below the article.
The guidelines vs. the reality.
While the path that NHS guidelines dictate appears somewhat straightforward, the process itself is arduous.
In theory, it works like this: after informing your GP that you are trans and would like to medically transition through HRT, your GP refers you to a GIC. The GIC carries out an assessment and provides you and your GP with an official diagnosis of gender dysphoria. They then pass you over to an endocrinologist, who writes a letter of recommendation to your GP regarding hormones. After that, your GP – the same GP you spoke to on day one – prescribes you your hormones. Simple right?
The reality is vastly different. Patients are subjected to intolerable waiting times of four years or more for their first appointment at a GIC. The GIC assessment is undertaken by psychiatrists with definitions of transition from archaic textbooks – and that’s without mentioning the fact that so many health professionals have been shown to be transphobic, ignorant of the guidelines, clueless about trans health, or even outright transphobic (as the long-running Twitter hashtag ‘#TransDocFail’ makes clear).
The situation is even worse for black, Asian and minority ethnic trans people, as medical racism intersects acutely with institutional transphobia. The standards of care that trans people receive from medical institutions is shocking. This may well be exacerbated throughout your medical transition, but there is a framework in place, and you have the right to insist on it being followed.
Essentially, the process can be boiled down to gathering two documents and presenting them to your GP. This guide is designed to help you take advantage of this fact, showing you how to selectively access private options in order to build up as strong a ‘case’ as possible before you see your GP in an attempt to sidestep the GIC.
Doing so is unavoidably expensive, costing somewhere between £600 and £800. That said, if you are able to raise the funds, either personally or through a trans healthcare fund such as We Exist, then this method should prevent you from having to wait up to a decade on a GIC waiting list, while remaining much cheaper than going entirely private.
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Getting your dysphoria diagnosis.
Psychiatrists shouldn’t be playing a role in whether or not you receive the gender-affirming care you need, but they currently do. This step is expensive if you are unable to wait years on a GIC waiting list, and invasive and demeaning either way.
‘Gender dysphoria’ is a term describing the distress that can accommodate a mismatch between someone’s gender identity and the sex they were assigned at birth. It is not considered a mental illness, and yet it is treated like one in all but name by the healthcare system. The role of the psychiatrist that diagnoses it is to be an expert on not just gender but your gender, in particular, acting as a patriarchal gatekeeper of gender roles while perpetuating the idea that being trans is some kind of disorder.
Being trans is a health issue in much the same way as being pregnant is a health issue; the patient isn’t sick, but they need care. The obsolete GIC takes its model of care not from the sexual health centre but from the psychiatric unit, and so it’s no surprise that many countries around the world replaced them in the last couple of decades. Not Britain, though.
A signed letter from a cis person stating that you are authentically trans is both completely absurd and wildly degrading, but it is something the UK system requires. It doesn’t need to be a GIC psychiatrist, though, if you want to avoid the waiting list and the drawn-out, multiple appointments; you can pay a private psychiatrist between £200 and £500 for an assessment and diagnosis.
Unfortunately, you have to be prepared to live up to the gender expectations of the psychiatrist, a sad constant of trans healthcare for many decades, whether at the GIC or a private practice; they will be paying close attention to how you dress and present, for example, even if they’re not supposed to. Treat this as a painful but temporary procedure, because it is, and get that certificate!
Changing your name and your passport can help.
One useful document that’s worth obtaining early is a change of name by deed poll. This is free to do, and doesn’t require actually registering the change of name anywhere. It has no material impact, yet you can use this document as important evidence for time spent living in your preferred gender (an ambiguous and regressive requirement that psychiatrists will still want to see).
It’s also important to ask the psychiatrist for a letter stating that your transition is likely to be permanent: in combination with the deed poll, it’s all you need to change the gender marker on your passport. A correctly-gendered passport is the next-best thing to the highly inaccessible gender recognition certificate, and will make your life much easier when dealing with any kind of bureaucracy. The British are obsessed with passports and tend to defer to their authority in most situations.
Getting your letter of HRT recommendation.
Hormone replacement therapy is something that you can either wait years to get from a GIC-referred endocrinologist, or you can obtain privately for around £200. GenderGP is the largest provider, but they are also the organisation with the most transphobic media attention and subject to the most vicious attacks – so it’s worth researching your options using the resources at the end of this guide.
You’ll need a blood test from within the last three months; you may want to wait until you have all your evidence gathered before talking to your GP about transition, who will need to know exactly what you want the blood test for before providing it, and so you might want to get this privately for a fee. GenderGP offers guidance about what kind of blood test you need. This should be your last cost before returning to the NHS, authoritative documents in hand.
The GP visit.
Time for the big day! The NHS has guidelines for prescribing HRT based on private letters of recommendation. Your GP may disagree, since they most likely have not read these guidelines and may not even know they exist. Help them out by printing off the guidelines from here and here, and bringing highlighted copies with you.
Much of the visit will be about you guiding and reassuring your GP, so expect irrelevant and invasive questions. Transition tends to be particularly confusing for GPs if your gender identity doesn’t align simply with their conception of male and female; non-binary people who wish to seek medical transition have an especially hard time of this.
I’m not suggesting you tell any especially big fibs, but maybe finesse your story into one that’s likely to be received with the least amount of confusion (and bear that in mind with the psychiatrists too). Trans people have been doing this ever since they first got access to medical textbooks and started passing them around before appointments to brush up on their lines, so you’ll be joining a storied lineage of creative trans memoirists. You’re not here to make friends, you’re here to get hormones. Don’t feel bad about it.
When they inevitably say they are going to refer you to a GIC, explain that the two things a GIC would offer you are things that you already have – a dysphoria diagnosis and a letter of recommendation – and are the only documents your GP requires to prescribe you hormones (as the guidelines you printed out make clear).
Stay away from mental health questions.
Another classic tactic of GP avoidance is to try referring you to local mental health services or, rather, referring you to the endlessly long waiting list of a local mental health service. Sure, as a trans person currently coming up against the confines of a system not fit for purpose, you probably are under a huge amount of distress. That’s not actually relevant to whether or not you can be prescribed HRT, as the guidelines make clear. Maybe point at the printout of the guidelines again if you haven’t handed them over already.
In general, try not to get sidetracked by irrelevant discussions regarding mental health, or discussions about the authenticity and history of your gender identity; your dysphoria diagnosis means those conversations have been had already. Keep things simple: you’re trans, you’d like HRT and you have the necessary documents.
Although your own persuasiveness is unfortunately often relevant to the appointment, by far the strongest weapon in your arsenal is referring your GP to the guidelines you’ve been waving around this whole time, which require them to prescribe. They may need time to call somebody or check with somebody, or read over the guidelines (which you should leave with them in physical form regardless), which is fine: make sure to keep following up.
Send a thank you card if it works, change GPs if it doesn’t.
If you do get a prescription, thank your GP afterwards, with a card (even if they were mostly awful!). This establishes a good relationship going forward in case you ever need to change your dosage. It also makes them feel like they’ve done the right thing and made a positive impact on someone’s life and health (which is why they’re there), and sets them up to be more accommodating to the next trans person who comes along.
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It’s also worth bearing in mind that changing your GP is relatively easy: just sign up at the new surgery and your records are transferred. It can often be a good option if you are struggling against a particularly unhelpful individual – and Action for Trans Health maintains a crowdsourced list of cooperative GPs here. There’s a lot of time to be wasted on persuading someone who won’t engage, so move on to someone who will if you can.
Solidarity, and good luck!
If you can make it, there’s an important demo happening tomorrow (Saturday 4 December), organised by Trans Action Bloc.
Here are some further resources for helping you in your transition journey:
Information and resources covering a wide variety of trans issues: https://www.transactual.org.uk
Information on trans-friendly GPs and private providers: https://www.transhealthcareintel.com/
Comprehensive information related to UK trans healthcare: https://transhealthuk.noblogs.org/
Open-source toolkit on all things transition-related: https://genderkit.org.uk/
Training, support and advocacy for trans and queer people in the UK: https://queercare.network/
Informative zines about trans healthcare (Power Makes us Sick): https://pms.hotglue.me/?resources
Donate to the We Exist trans healthcare fund: https://www.weexist.co.uk/healthcare
This piece has been amended to better reflect its reliance on the information and tactics outlined in Trans Health UK’s guide on HRT.
OS Warren is the author of the free resource Transgender Health in the UK: A Primer.