BMJ 2016; 352 doi: (Published 30 March 2016) Cite this as: BMJ 2016;352:i1694

James Barrett, consultant psychiatrist, Charing Cross Gender Identity Clinic, and president, British Association of Gender Identity Specialists

Author affiliations

  1. Charing Cross Gender Identity Clinic, 179-183 Fulham Palace Road, London W6 8QZ

Conservatism in treating trans people in primary care is unacceptable

The need for treatment for gender dysphoria worldwide has never been higher. Tens of thousands of UK residents are transgender, and the combined waiting list for the United Kingdom’s 11 NHS gender identity clinics is at least 5000 people, NHS England has told me.

With early and prompt treatment at a gender identity clinic, improvement in quality of life can be huge and can be sustained in the long term. And NHS England says that, considered purely in terms of quality adjusted life years per pound spent or the extent of patient satisfaction, gender identity clinics rank highly (a result of NHS England’s prioritising process in 2014).

So it seems odd that such effective treatment was ever considered a low priority—or that access to it should have been delayed or made more administratively complex than access to less efficacious therapies.

Delayed access to treatment

Sadly, primary and secondary care often still delays access to treatment, including inappropriate and unnecessary referrals to community psychiatry. For patients established at a gender identity clinic, conservatism in primary care often complicates and delays access to hormone therapy.

Gender dysphoria has been safely treated with hormone therapy for nearly four decades,1 2 3 4 5 and the lack of a licence for all treatments except Sustanon (an injectable blend of four esterised testosterone compounds) reflects not safety concerns but the lack of commercial reward for manufacturers from low volume treatments.

With centralised NHS specialist services, a modern gender identity clinic may have a caseload of several thousand patients at any one time. It’s impossible for such clinics to prescribe for them because many live far away, and their hormone treatment will continue after discharge for the rest of their lives. Because hormone replacement therapy is safe, a practical solution is a joint care model in which primary care gives patients hormone prescriptions and gender identity clinic practitioners provide treatment endorsement and protocol, with easily accessible and informed treatment advice from gender specialists.

Currently, however, in the experience of those of us who work at gender identity clinics as many as one in five GPs won’t prescribe for people with gender dysphoria, even after expert advice from an NHS clinic. Reasons that GPs have given me for this refusal include concerns about it being dangerous (it isn’t), difficult (it isn’t), expensive (it’s not, particularly), and I’ve also heard disturbingly frank admissions that it was against “deeply held Christian beliefs” or that “we are trained to treat illnesses, not to change nature.”

NHS England’s guidance on specialised commissioning makes it clear that GPs are expected to care for people with gender dysphoria just as for any other group with an uncommon condition easily managed with a joint care model.6 The General Medical Council has made it clear that ethical or “principled” objections are not acceptable in gender dysphoria and that “inexperience in the field” should be remedied by prompt cooperation with a gender identity clinic.7

Not freaks

NHS care for transgender people can improve in other ways, too. Such patients are still often, offensively, referred to by their old title or legal sex, sometimes years after hormone treatment or gender reassignment surgery. They may be admitted to the wrong ward, checked in as the wrong sex, and instructed to use the wrong toilet or a disabled access toilet despite not having a disability.

Their transgender can be viewed as a psychiatric illness, which it never was, and can feature in every medical consultation and referral even if not relevant to the ailment in question, in a manner that would be unacceptable if the issue was that they were gay or black.

People with gender dysphoria aren’t freaks.8 They are teachers and accountants, police officers and doctors, parents and taxpayers, and—importantly—patients as deserving of respect and decent, routine NHS care as anyone else. It’s about time they started getting exactly that.


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.




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