Mental Health · Full case

Gender Dysphoria

GMC / GIC pathwayAffirming · GIC referralMental-health risk

Respect & affirmUse the person's correct name and pronouns, take their experience seriously, and provide respectful, non-judgmental care. Gender incongruence is not a mental illness; gender dysphoria is the distress that can arise from a mismatch between gender identity and sex assigned at birth. Affirming care reduces distress

The GP's role: refer & supportA GP does not need to be a gender specialist. Refer to NHS adult gender services when the person asks (in England, from 1 October 2026, via the National Adult Gender Referral Support Service, not directly to a Gender Identity Clinic) — you do not need a mental-health assessment first, and referral should not be gatekept or delayed. Meanwhile, support mental health and general health

Long waits → support meanwhileGIC waiting times are very long. The GP's continuity matters: support mental health, monitor risk, manage general healthcare, and signpost peer/third-sector support. Don't leave the person unsupported while they wait

Mental-health & suicide riskTrans and gender-diverse people have markedly higher rates of depression, anxiety, self-harm and suicidal thoughts — strongly associated with minority stress, discrimination and lack of support, alongside co-occurring conditions. Gender incongruence itself is not a mental illness. Assess and treat mental health and risk proactively and compassionately

Bridging & shared careWhere an adult is already self-medicating with hormones from an unregulated source, always offer harm reduction and monitoring. GMC advice says a GP may (but is not obliged to) issue a "bridging" prescription to mitigate self-harm/suicide risk, after seeking gender-specialist advice, within the GP's competence and following an individualised, specialist-informed plan; the RCGP (2024) does not regard initiating hormones as part of the core GP role. Engage in shared care with the specialist clinic rather than refusing to be involved

Don't forget routine healthcareTrans people need the same general healthcare as everyone — and organ-based screening: a trans man with a cervix still needs cervical screening; a trans woman may need prostate awareness; consider bone health and cardiovascular risk on hormones. Tailor screening to anatomy, not recorded gender

Young people: specialist pathwaysSince the Cass Review (April 2024), under-18s are referred via NHS paediatric or CAMHS services (not directly by the GP) to the NHS Children and Young People's Gender Service, which takes a holistic, cautious, multidisciplinary approach. Puberty blockers for gender incongruence are restricted indefinitely outside the PATHWAYS research trial. Involve the family appropriately and safeguard. Never initiate hormones or blockers in primary care

Avoid harm: don't gatekeep or pathologiseRefusing referral, demanding proof, misgendering, or treating the person's identity as a problem to be solved causes harm and erodes trust. So does conversion practices (unethical and harmful). Provide affirming, person-centred care within your competence, and refer for specialist input

📋 Clinical Stem — Gender Dysphoria

A 24-year-old trans man, anxious about being dismissed, asking for a referral to a gender clinic — and quietly disclosing low mood, self-harm and that he's started buying testosterone online

Sam Okoro, 24 (he/him), assigned female at birth, attends asking to be referred to a gender clinic. He has felt a persistent mismatch between his gender identity and his body for years, with significant distress, and has socially transitioned. He's braced to be questioned or refused. As trust builds he discloses low mood, episodes of self-harm, and — hesitantly — that he has recently started buying testosterone online because the waiting list is "years long" and he couldn't wait. He has no regular contact with mental-health services. He is registered as female and is overdue cervical screening. He fears being judged, misgendered, or told he needs to "prove" anything.

This stem tests the ability to deliver respectful, affirming, person-centred care: using the correct name and pronouns; understanding the GP's role is to refer on request to NHS adult gender services (via the national referral service, not direct to a clinic) (without gatekeeping, demanding a mental-health assessment first, or pathologising the identity); to proactively assess and support mental health and suicide/self-harm risk (driven by minority stress, not by being trans); to respond safely to self-medication with online testosterone — recognising the harm-reduction issues, considering specialist advice and (per GMC guidance) the possibility of bridging prescribing and shared care, and arranging monitoring — rather than simply refusing involvement; to address general healthcare and anatomy-based screening (a trans man with a cervix still needs cervical screening); and to signpost support during the long wait. The SCA challenge is building trust with someone braced for rejection, and balancing affirming care with safety.

Scenario A — Referral + risk + self-medication (this stem) Affirming care; direct GIC referral without gatekeeping; assess/treat mood & self-harm; harm reduction + consider bridging/shared care & monitoring for online testosterone; anatomy-based screening; signpost support.

Scenario B — Straightforward referral request Person wants a GIC referral; refer via the national referral service, support general & mental health, signpost peer support, manage the wait.

Scenario C — Shared care on established treatment Person on specialist-initiated hormones; GP monitors per shared-care protocol (bloods, BP, bone/CV health), continues general care.

Scenario D — Mental-health crisis Active suicidality/self-harm → urgent mental-health assessment & safety plan, alongside affirming support.

Scenario E — Young person / family Child/adolescent with gender incongruence → specialist young-people's pathway, holistic/multidisciplinary, family involvement, safeguarding; avoid primary-care-initiated interventions.

Key variables to adapt for Adult vs young person; referral (don't gatekeep) vs shared care vs crisis; mental-health/suicide risk; self-medication & bridging/harm reduction; anatomy-based screening & general health; hormone monitoring (bone/CV); social support & minority stress; respectful language throughout.

Steps:

Step 1

History — Affirming Opening · Their Goals · Risk · Self-Medication · ICE

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The consultation opens by establishing respect — correct name and pronouns — and by understanding what the person wants (here, a referral) rather than interrogating their identity. Then, with trust built, sensitively assess mental health and risk (high in this group, driven by minority stress), uncover any self-medication, and address general healthcare. The GP's job is to refer, support and keep the person safe — not to gatekeep or to "assess whether they're really trans".

🎓 SCA framing — affirm, don't gatekeep

"Thanks for coming, Sam — and just so you know, I'm happy to make that referral to the gender clinic today; you don't have to prove anything to me. I'd also like to understand how you're doing in yourself and make sure you're supported while you wait, because the waits are unfairly long."

Sam is braced for rejection. Affirming his identity, committing to the referral up front, and using his correct name/pronouns is what builds the trust needed to then explore risk and the online testosterone safely.

1A — Goals, experience, risk and self-medication

Question	Why it matters	Impact on plan	Changes what?
🟢 OPEN QUESTION"Tell me what you'd like from me today, and what would feel most helpful for you."	Centres the person's goals. Sam wants a GIC referral and support. The GP's role is to provide these — to refer on request (via the national referral service) and support general/mental health — not to put the person through a gatekeeping "assessment" of their identity. Establishing the agenda respectfully sets the tone.In SCA: leading with respect and the patient's goals (referral + support), rather than questioning the validity of their identity, is the core skill.	Sets the agenda: referral + support, led by the patient.	Request → direct GIC referral (no gatekeeping)
Their experience & what's helped"How long have you felt this way, and what's been helpful or hard so far?"	Understanding the person's history and social transition supports holistic care and the referral letter — gathered with curiosity and respect, not as a test. It also surfaces sources of distress (minority stress, discrimination) and support.	Holistic understanding → tailored support + referral.	Support tailored to the person
🚩 Mental health & risk"How's your mood been? Have you harmed yourself or had thoughts that life isn't worth living?"	Proactive and compassionate. Trans people have markedly higher rates of depression, anxiety, self-harm and suicide — driven by minority stress and lack of support, not by being trans. Sam discloses low mood and self-harm. This needs assessment, treatment and a risk/safety plan, and may raise urgency.	Low mood/self-harm → assess/treat; safety plan; urgent if active risk.	Active risk → urgent mental-health support
🚩 Self-medication / hormones"Are you taking any hormones or anything you've sourced yourself? Tell me honestly — I'm not here to judge, just to keep you safe."	A harm-reduction issue. Sam is buying testosterone online because the wait is years. Refusing to engage drives concealment and risk. Seek specialist advice, arrange monitoring (bloods/BP) and give harm-reduction advice whatever you decide about prescribing. GMC advice permits, but does not oblige, a GP to consider a bridging prescription in narrow circumstances (see 7D); the RCGP (2024) regards initiating hormones before specialist assessment as outside the core GP role unless the GP has extended expertise.	Self-medication → harm reduction; consider bridging/shared care + monitoring; specialist advice.	Self-medication → bridging/monitoring (GMC)
General health & anatomy-based screening"Can we also make sure your general health is looked after — including any screening that applies to you?"	Trans people need the same general healthcare plus organ-based screening: Sam (trans man with a cervix) still needs cervical screening, often complicated by being recorded as male/female on systems. Tailor screening to anatomy, not recorded gender; consider bone/CV health on hormones.	Anatomy-based screening (cervical for Sam); bone/CV on hormones.	Cervical screening; bone/CV monitoring
Support & social context"Who's around you for support — family, friends, community? How are things at work/college?"	Social support buffers minority stress; isolation and discrimination worsen mental health. Signposting peer/third-sector support is part of the plan, especially during the long wait. Safeguarding considerations apply for young people.	Isolation → signpost peer support; address discrimination/stress.	Signpost peer/third-sector support

1B — Red flags / things not to miss

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Red Flags — safety and harm to avoid

Red flag	Why it matters	Action
Active suicidality / self-harm	Markedly raised in trans/gender-diverse people (minority stress).	Risk assessment; urgent mental-health support; safety plan
Unmonitored self-sourced hormones	Health risks without monitoring; concealment if the GP refuses to engage.	Harm reduction; specialist advice; consider bridging/shared care; baseline & monitoring bloods/BP
Gatekeeping / refusing referral / pathologising	Causes harm, erodes trust, delays care.	Refer on request via the national referral service; affirming, person-centred care
Missed anatomy-based screening	Trans man with a cervix still at risk of cervical cancer; recorded-gender errors miss invitations.	Tailor screening to anatomy; ensure cervical/other screening offered
Child / young person	Needs specialist, holistic, cautious multidisciplinary care; safeguarding.	Specialist young-people's pathway; family involvement; avoid primary-care-initiated interventions
Conversion practices / misgendering	Unethical, harmful, damages trust and mental health.	Never; provide affirming care; use correct name/pronouns

1C — ICE

💭 Ideas

"What's your understanding of how the referral and treatment work?"

Sam may expect to be questioned or refused, or be unclear about the pathway and waits. Clarifying it honestly — referral via the national service (no self-referral), long wait, support meanwhile — sets realistic expectations and shows you're on his side.

😟 Concerns

"Has anything worried you about coming today — being judged, perhaps?"

His central concern is being dismissed, misgendered or made to "prove" himself. Naming and dispelling this directly is what builds the trust needed to discuss his mood, self-harm and the online testosterone safely.

🎯 Expectations

"What would make today feel like it went well for you?"

He wants the referral and to be respected. Meeting that — and adding proactive support for his safety and health — lets him leave feeling helped and trusting the GP, which matters hugely given the long road ahead.

1D — Psychosocial context

Many trans people approach healthcare expecting to be misgendered, questioned, gatekept or dismissed — and these experiences, alongside discrimination and isolation (minority stress), are the main drivers of the high rates of distress, self-harm and suicide in this group. The single most powerful clinical act is to be a respectful, affirming ally: use the right name and pronouns, make the referral without gatekeeping, support mental health and general health proactively, respond to self-medication with harm reduction rather than refusal, and keep the person supported through long waits. Trust, once earned, is protective.

🗣️ Respectful language

Correct name/pronouns; ask, don't assume.

"I want to make sure I get this right — can you tell me the name and pronouns you'd like me to use? I'll update your records too."

🚪 No gatekeeping

Commit to the referral up front.

"You don't need to convince me of anything — I'll refer you to the gender clinic today. My job is to support you, not to put hurdles in the way."

🆘 Harm reduction on hormones

Engage, don't refuse, around online testosterone.

"I understand why you couldn't wait years. Rather than you doing this alone and unmonitored, let's talk about keeping you safe — I can seek specialist advice about a bridging prescription and arrange some blood tests."

🧠 Mental health matters

Address distress proactively and compassionately.

"The distress and self-harm you've described are real and important — and they're often about how the world treats people, not about who you are. Let's get you some support for that too."

1E — Psychosocial context: the person behind the referral

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Sam's life outside the consulting room — support, safety, work, money and the long wait

A referral letter can be written in five minutes, but the waiting list for an adult Gender Dysphoria Clinic (GDC) is measured in years. What decides how Sam gets through that wait is his social context: who supports him, whether he is safe at home and at work, whether he can afford to keep buying hormones online, and whether he has anyone to talk to. Ask about these areas with curiosity, not as a checklist, and ask permission before exploring the more personal ones. Each one leads to something you can act on.

👨‍👩‍👧

Family and relationships

Family acceptance protects mental health, and rejection is one of the strongest associations with poor outcomes in trans people. Sam describes "variable" family support. Find out who knows, who is supportive and whether anyone is hostile. A partner may be a key source of support, or the relationship may be under strain.

Never share information about Sam's gender history with family members without his consent. That applies even when a relative phones the practice asking about him.

"Who in your life knows how you feel, and how have they responded? Is there anyone you can lean on when things get hard?"

💼

Work, study and discrimination

Gender reassignment is a protected characteristic under the Equality Act 2010. It covers anyone proposing to undergo, undergoing or having undergone a process of changing their sex, and does not require any medical treatment. Workplace harassment, being outed, and problems with facilities or dress codes are common sources of stress.

A fit note is appropriate if Sam's mental health is affecting his ability to work. Occupational health and Acas guidance can help with reasonable workplace adjustments.

"How are things at work? Has anyone made it difficult for you because of your transition?"

💷

Money, housing and online sourcing

Buying hormones online costs money. Some people take on debt, ration their doses or stop suddenly when they run out. Housing insecurity is also more common in trans people, particularly young adults who have left an unsupportive family home.

Ask how Sam pays for the testosterone and what he would do if he could no longer afford it. Financial pressure can push someone towards riskier sources or, rarely, towards exploitative situations. Treat any hint of that as a safeguarding question.

"Buying testosterone online must be expensive. How are you managing that, and are things okay with where you're living?"

🌐

Community, peer support and online spaces

Peer and community groups (local LGBTQ+ centres, trans-led support groups and national helplines) reduce isolation, which is a key driver of distress. Online communities can be a real source of connection. They can also be where unregulated hormone suppliers and unverified dosing advice circulate.

Ask where Sam gets his information and help him weigh it up. Don't dismiss it.

"Where have you found support or information so far? Some online advice is good and some isn't, so I'm happy to go through anything you've read."

🧩

Co-occurring conditions

Depression, anxiety, eating disorders and autism or other neurodivergence are more common in people with gender dysphoria than in the general population. The Cass Review (2024) emphasised a holistic assessment of these alongside gender-related distress. Their presence is a reason to offer extra support. It is not a reason to delay or refuse the GDC referral.

Asking about them respectfully also helps the specialist service plan his assessment.

"Alongside the referral, I'd like to understand anything else that affects how you're feeling, like anxiety, eating or sleep, so I can support you with those too."

🛡️

Safety: abuse, harassment and hate crime

Trans people experience high rates of harassment, domestic abuse and hate crime, and often don't report it. Ask directly and privately. Domestic abuse pathways, MARAC and adult safeguarding apply exactly as for any other patient. Hate crime can be reported to the police or through third-party reporting services.

"Some people I see have been hurt or threatened because of who they are. Has anything like that happened to you, at home or anywhere else?"

🗂️ Records, names and confidentiality: practical facts to get right

Issue	What the GP needs to know
Changing name and title	An adult can change their name and title on the GP record on request. A Gender Recognition Certificate (GRC) is not needed, and neither is a deed poll for the practice record.
Changing the gender marker (adults)	The practice submits a gender re-assignment request to PCSE. No GRC is required. This normally creates a new NHS number and a new record. PCSE guidance (updated 2025) lets the person choose whether clinical history is copied across and whether to keep their existing NHS number. Explain the consequences first: possible loss of history, screening and recall gaps, and possible loss of places on waiting lists.
Under-18s	After the Sullivan Review (2025), the Secretary of State directed that the PCSE process for changing NHS number and gender marker for under-18s must stop. Practices should not start it for children and young people. Name and preferred pronouns can still be recorded and used.
Gender Recognition Act 2004, s.22	It is an offence for someone who learns in an official capacity that a person has applied for or holds a GRC to disclose it, or to disclose their gender history. The Disclosure of Information Order 2005 exempts disclosure to a health professional for medical purposes, where the discloser reasonably believes the person has consented or cannot consent. Whether or not a GRC is held, disclosing trans status without consent breaches confidentiality under GMC guidance and UK GDPR.
Anatomy in the record	With consent, code the organs present (for example "cervix present") so that screening, lab reference ranges and clinical decisions stay correct whatever the gender marker is.

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"I'll refer you to the gender clinic today — you don't have to prove anything." — affirming, no gatekeeping.

"Have you harmed yourself or had thoughts life isn't worth living?" — proactive risk assessment.

"Rather than do this alone, let's keep you safe — I can seek advice about a bridging prescription." — harm reduction.

Deductions

Misgendering; gatekeeping/refusing or delaying referral; pathologising identity
Not assessing mental health/self-harm risk
Refusing to engage with self-medication (no harm reduction)
Missing anatomy-based screening (cervical)

🔴 Red

Misgenders; gatekeeps/refuses referral; no risk assessment; refuses to engage with hormones; screening missed

🟠 Amber

Respectful; refers; some risk assessment; self-medication noted but no harm-reduction plan; screening/support partial; ICE partial

🟢 Green

Affirming language; referral on request (no gatekeeping); assesses/supports mood & risk; harm reduction + considers bridging/shared care; anatomy-based screening; signposts support; ICE all three

Step 2

Triage — Crisis (Risk) · GIC Referral & Bridging · Ongoing Support

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Triage by safety: active suicidality/self-harm needs urgent mental-health support now; the referral to specialist gender services and any harm-reduction/bridging decision proceed in parallel; and ongoing general/mental-health support continues throughout the long wait.

🔴 Urgent

Same day / soon

Risk

Active suicidality / self-harmUrgent mental-health assessment; safety plan
Acute distress / crisisSupport; crisis services
Unsafe self-medicationHarm reduction; specialist advice promptly

🟠 Specialist

Refer / share care

GIC

GIC referral (adult)Direct, on request — no gatekeeping
Bridging / shared careWith specialist advice; monitoring
Young person (<18)Refer via NHS paediatrics/CAMHS to the CYP Gender Service

🟢 Ongoing

GP continuity

During the wait

Mental-health supportTreat mood/anxiety; monitor risk
General & anatomy-based screeningCervical for Sam; bone/CV on hormones
Peer/third-sector supportSignpost

🎓 SCA Checkpoint — Step 2Tasks

Triage rationale

"I'll refer you to the gender clinic today, and because of the self-harm I want to get you some mental-health support now too — and we'll sort out keeping the testosterone safe while you wait."

Deductions

Not escalating active risk
Delaying/gatekeeping the GIC referral

Step 3

Assessment — Mental State & Risk · Hormone Effects & Monitoring · General Health

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"Examination" here is a mental state and risk assessment, attention to the effects/safety of any hormones being taken, and general physical health and anatomy-based needs — all delivered respectfully.

🧠 Mental state & risk

Domain	What to assess
Mood/affect, anxiety	Depression/anxiety; distress related to dysphoria & minority stress.
Self-harm / suicide risk	Ideation/plans/acts; protective factors; safety plan.
Support & coping	Social support, isolation, discrimination.
Capacity & goals	Informed, person-led decisions.

⚕️ Hormones & general health

Check	Why
Hormone effects / dose	If self-medicating — what, how much, source; effects/side effects.
BP, weight, CV/bone risk	Monitoring on hormone therapy.
Anatomy-based needs	Cervical screening (trans man with cervix); other organ-based screening.
General health	Same routine care as anyone; vaccinations; smoking (CV risk with hormones).

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Demonstrating the formulation

"My assessment: gender dysphoria with significant distress, low mood and self-harm needing support, currently self-medicating with testosterone that needs monitoring and safety, and overdue cervical screening — with a direct GIC referral the priority."

Deductions

No risk assessment / safety plan
Ignoring hormone monitoring / anatomy-based screening

Step 4

Investigations — Baseline & Hormone Monitoring · Screening · Mental Health

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Investigations support safety on hormones (baseline and monitoring bloods, BP), anatomy-based screening, and mental-health assessment — gender dysphoria itself is a clinical diagnosis made by specialist services, not a lab test.

🧪 Hormone & baseline

Test	Why
Baseline bloods (FBC/LFTs/U&E/lipids/glucose)	Before/with hormone therapy; CV/metabolic risk.
Hormone levels (per protocol)	Monitoring testosterone/oestradiol where on treatment.
Haematocrit (testosterone)	Polycythaemia risk on testosterone.
BP, weight, bone health	CV and bone monitoring on hormones.

🔬 Screening & mental health

Test	Why
Cervical screening	Trans man with a cervix (Sam) — anatomy-based. Sam is still registered female so will be invited; if he changes his gender marker to male, invitations stop and the practice must opt him in via the Cervical Screening Administration Service.
Other organ-based screening	Breast/prostate as anatomy dictates.
PHQ-9 / GAD-7	Track mood/anxiety severity and response. Do not use risk-assessment tools or scales to predict suicide or decide who gets treatment (NICE NG225) — assess needs and make a safety plan.
BBV / sexual health	As indicated.

🎓 SCA Checkpoint — Step 4Tasks

Key reasoning

"Since you're on testosterone, I'll do some baseline bloods and check your blood count and blood pressure, and we'll arrange your cervical screening — which still matters for you."

Deductions

No monitoring for self-administered hormones
Not arranging anatomy-based screening

Step 5

Formulation — Needs, Risks & the GP's Role

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The "diagnosis" is a needs-and-risk formulation that clarifies the GP's role: refer to specialist services, support mental health and general health, and respond safely to self-medication — not to make or contest the gender-identity diagnosis (a specialist task) and not to gatekeep.

Element	Detail
Gender dysphoria / incongruence	Persistent distress from a mismatch between identity and sex assigned at birth; not a mental illness — specialist (GIC) assessment for gender-affirming care.
Mental-health needs	Depression, self-harm, suicide risk — driven by minority stress; need support/treatment.
Self-medication / safety	Online testosterone unmonitored — harm reduction, bridging/shared care, monitoring.
General & screening needs	Anatomy-based screening (cervical), CV/bone health on hormones, routine care.
The GP's role	Refer, support, keep safe — not gatekeep or pathologise.

🚩 Refer, support, keep safe — without gatekeeping

Sam's formulation: gender dysphoria with significant distress, comorbid low mood and self-harm (minority stress), currently self-medicating with online testosterone, and overdue anatomy-based (cervical) screening. The GP's plan is to make a direct GIC referral today (no gatekeeping), proactively support and treat his mental health with a safety plan, respond to the self-medication with harm reduction and consideration of bridging/shared care and monitoring (with specialist advice), arrange his cervical screening, and signpost peer support — all with affirming, respectful care.

🎓 SCA Checkpoint — Step 5Tasks

Explaining the plan

"My role isn't to assess whether you're trans — that's for the specialist clinic, and I'll refer you today. What I can do is support your mental health, keep you safe on the testosterone while you wait, and look after your general health."

Deductions

Treating identity as something to diagnose/contest in primary care
Not clarifying/owning the supportive GP role

Step 6

Referral — GIC · Mental Health · Shared Care · Peer Support

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Referral is the GP's core action: a referral on request to NHS adult gender services via the National Adult Gender Referral Support Service; mental-health services for risk/comorbidity; shared-care/specialist advice for hormones and bridging; and signposting to peer and third-sector support — with specialist young-people's pathways for under-18s.

Referral	Who / when	Urgency
Gender Identity Clinic (GIC)	Adults (18+) — GP referral on request to NHS adult gender services; no gatekeeping/mental-health pre-assessment required. A single national waiting list was introduced in 2026, and from 1 October 2026 referrals go to the National Adult Gender Referral Support Service (Gender National Referral Support Service, GNRSS) rather than to individual clinics (self-referral is not accepted), so check the current form and route. Some forms ask for baseline information such as bloods and BMI; sending these should not delay the referral.	On request
🔴 Mental health / crisis	Active suicidality/self-harm; comorbid depression/anxiety.	Urgent if risk
Specialist advice / shared care	Bridging prescription, hormone monitoring, established treatment.	As needed
Young-people's specialist pathway	Under-18s — since 1 Sept 2024 referrals to the NHS Children and Young People's Gender Service must come from NHS paediatric or CAMHS services, not primary care; GP refers to local paediatrics/CAMHS, supports family, safeguards.	Via paediatrics/CAMHS
Peer / third-sector support	Community/peer support during the wait.	Signpost

🎓 SCA Checkpoint — Step 6Tasks

The key action

"I'll write the referral to the gender clinic today. I'll also seek specialist advice about your testosterone and shared care, get you mental-health support, and point you to some peer support while you wait — and I'll be here throughout."

Deductions

Not referring to the GIC / adding barriers
Refusing shared care / specialist advice on hormones

Step 7

Management — Expectation · Goals · Non-Drug Support · Who Prescribes · Drug Cards · Psychosocial · Follow-Up · Monitoring · Safety-Netting

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Management is affirming, continuity-based care: make the referral, support and treat mental health with a safety plan, respond to self-medication with harm reduction and (per GMC) consideration of bridging/shared care with monitoring, deliver anatomy-based screening and general health, signpost support — and keep the door open throughout the long wait.

🤝 Refer & support

Element	Detail
GIC referral	Direct, today, no gatekeeping; explain the pathway/wait honestly.
Mental health & safety	Treat mood/anxiety; safety plan for self-harm; mental-health referral; monitor risk.
Peer/third-sector support	Signpost community support during the wait.
Affirming care & records	Correct name/pronouns; update records sensitively.

🆘 Safety & general health

Element	Detail
Self-medication / bridging	Harm reduction; specialist advice; consider bridging prescription & shared care; baseline/monitoring bloods/BP.
Anatomy-based screening	Cervical screening for Sam; other organ-based screening.
Hormone monitoring	Haematocrit/CV/bone health on testosterone.
General health	Same routine care, vaccinations, smoking/CV risk.
Continuity / review	Regular review; keep the door open; coordinate with GIC.

7A — Address the patient's expectation first: validate → explain → negotiate

🤝

Sam expects to be refused or questioned, and he wants testosterone. Meet the first expectation in full, and be honest and supportive about the second.

Validate: name both expectations

Sam came for a referral, expecting a fight. He may also hope you will take over prescribing his testosterone. The first can be met completely and straight away. The second needs an honest conversation. Name both so he doesn't feel you are side-stepping the one that matters most to him right now.

"You came in for a referral and I'm doing that today, no conditions. I also get the sense you're hoping I can help with the testosterone itself. That's a fair thing to ask, so let's talk it through properly."

Explain: what a GP can and can't do

Gender-affirming hormones for adults are normally started by the specialist GDC and then shared with the GP under a shared-care agreement. GMC advice says a GP may issue a bridging prescription in narrow circumstances, but is not obliged to. Those circumstances are: the person is already self-medicating from an unregulated source (or is highly likely to), it is intended to reduce a risk of self-harm or suicide, and gender-specialist advice has been sought. The dose should follow an individualised, specialist-informed plan — "lowest acceptable dose" is not a substitute for one — and the GP must be competent to prescribe and monitor. The RCGP (2024) says initiating hormones before specialist assessment is not part of the core GP role unless the GP has extended expertise. Explain this openly, without hiding behind it.

"Usually the gender clinic starts hormones and then I take over prescribing with their support. Because you're already taking testosterone and things have been hard, I'm going to ask a gender specialist today what the safest option is, including whether I can prescribe for you in the meantime."

Negotiate: what Sam leaves with today

Whatever happens with prescribing, Sam leaves with a lot: the referral sent, blood tests and a blood pressure check, harm-reduction advice, a safety plan, mental-health support, a cervical screening plan he feels comfortable with, and a named follow-up date. Monitoring does not depend on whether you prescribe.

"Today: the referral goes off, I'll check your bloods and blood pressure so we know the testosterone is safe, we'll make a plan for the difficult days, and I'll see you again in a week. You're not doing this on your own any more."

Key principle: The referral is a right, not a reward. Monitoring is harm reduction, not approval of the online source. A bridging prescription is a decision for the individual GP, made after specialist advice. Keep these three separate, so that declining one never means withholding the others.

7B — Why treatment matters: goals tailored to this patient

Treatment goals for Sam

GDC referral sent today; Sam has a copyNamed GP and planned reviews through the wait Self-harm reduced; written safety plan; crisis numbers knownDepression treated (talking therapy ± SSRI, NICE NG222) Baseline bloods, haematocrit and blood pressure done; product and dose documentedSpecialist advice sought and recorded; bridging decision documented Cervical screening opted in, with adjustmentsContraception and fertility discussed (testosterone is not a contraceptive)

Motivational language, tailored to Sam

"You've already done the hardest bit, which is telling me. Looking after your mood and checking your bloods doesn't slow the gender clinic down at all. It means you arrive there well."

"Testosterone can thicken the blood, and the only way to know is a blood test. I'm not checking up on you. I want the thing that's helping you to stay safe."

46% · 12%

Trans respondents who had thought about suicide / attempted suicide in the past year (Stonewall "LGBT in Britain: Health", YouGov survey, 2018)

>40,000

Adults waiting for a first GDC appointment in England, March 2025 (Levy review, NHS England, Dec 2025)

1 week

Review after starting an antidepressant at age 18–25 or with suicide risk: Sam is 24 (NICE NG222)

No risk scales

Don't use risk tools to predict suicide or decide who gets care (NICE NG225, self-harm)

×2

Annual GDC referrals have roughly doubled since 2022/23 (Levy review, 2025)

0.5%

262,000 people aged 16+ in England and Wales said their gender identity differs from their sex registered at birth (Census 2021, ONS; ONS has flagged quality caveats)

Hct >0.50 / >0.54

Common action / withhold thresholds for haematocrit on testosterone in local UK shared-care protocols (thresholds vary, and some pause at >0.50, so follow yours)

2027

Scheduled review of the indefinite UK restriction on puberty blockers for gender incongruence in under-18s (DHSC, Dec 2024)

Sept 2024

Since then, referrals to NHS Children and Young People's Gender Services have had to come from NHS paediatric or mental-health services, not the GP (NHS England)

7C — Non-medication management: mechanism + evidence + tailored advice

Most of what helps Sam during the wait isn't a prescription. It is psychological support, a safety plan, connection with others, practical help with social transition, and looking after his physical health. NICE NG222 (depression) and NG225 (self-harm) apply to Sam exactly as they would to any other adult.

🆘

Collaborative safety plan

Target: written plan today; reviewed at every contact

Mechanism

A safety plan works out, in advance and with the person, their warning signs, coping strategies, people and places that help, professional contacts, and how to make the environment safer. It gives structure to a crisis when thinking is hardest. NICE NG225 favours this kind of needs-based, collaborative approach over risk-scoring.

Practical

Write it together and give Sam a copy (paper or phone). Include his own coping strategies, trusted people, the crisis team or NHS 111 (mental health option), Samaritans (number on their website), and 999 or A&E for immediate danger. Discuss safer storage of medicines and prescribe limited quantities if you start an antidepressant. Ask about self-harm wound care.

NICE NG225: needs-based assessment and safety planning; not risk prediction tools

🧠

Psychological therapy

Target: referral or self-referral this week

Mechanism

Evidence-based talking therapies (CBT, behavioural activation, counselling) treat depression and anxiety whatever their cause. For Sam they also build coping with minority stress. Therapy should support him. It should never aim to change or suppress his gender identity, which would be a conversion practice.

Practical

NHS Talking Therapies accepts self-referral. With recent self-harm and moderate to severe symptoms, consider a referral to community mental-health services. Some areas have LGBTQ+-affirming counselling services. Therapy is never a precondition for the GDC referral.

NICE NG222: psychological therapy as first-line option for less severe depression; combined with SSRI for more severe

🤝

Peer and community support

Target: one named group or contact before next review

Mechanism

Minority stress theory suggests that social connection and community belonging buffer the effect of discrimination on mental health. Isolation during the wait is one of the main things that makes it harmful.

Practical

Signpost local LGBTQ+ centres, trans-led peer groups, national LGBT+ helplines and the local GDC's patient information. Most GDC websites list support organisations. Check anything you give out is current, and let Sam choose.

Social support consistently associated with lower depression and suicidality in trans cohorts (observational evidence)

💳

Practical support with social transition

Target: records updated today if Sam wants

Mechanism

Being called by the wrong name or title, or being sent letters that out someone, adds to distress every time it happens. Getting the practice's own systems right is a quick, concrete way to reduce harm.

Practical

Update name, title and pronouns, and add an alert so reception use them. Discuss whether and when to change the gender marker, and explain the effects on NHS number, screening and waiting lists first. Record the organs present with consent. Don't make assumptions about what Sam wants.

Equality Act 2010: services must not discriminate on the basis of gender reassignment

🌬️

Smoking, alcohol, weight and exercise

Target: smoke-free; alcohol within guidance

Mechanism

Smoking adds to the higher haematocrit and cardiovascular risk that testosterone can cause, and to the VTE risk of oestrogen. Alcohol and drug use are often ways of coping with distress and make self-harm risk worse. Exercise helps mood but can be difficult for trans people who find changing rooms unsafe.

Practical

Offer stop-smoking support (NICE NG209). Take an alcohol history using AUDIT-C. Suggest ways to exercise that feel safe for Sam, such as home workouts, running, or inclusive sports groups.

Smoking cessation is the most important modifiable CV and thrombotic risk factor on hormone therapy

👕

Chest binding: safer practice

Target: no binding with bandages or tape; regular breaks

Mechanism

Many trans men bind their chest to reduce dysphoria. Binding too tightly or for too long can cause pain, skin damage, shortness of breath and rib discomfort. Improvised binders (elastic bandages, duct tape) carry the highest risk.

Practical

Ask without judgement. Advise a purpose-made binder of the right size, taking it off to sleep and exercise, taking breaks, and never using bandages or tape. Assess and treat any skin or musculoskeletal problems. Binding helps Sam's wellbeing, so support safe binding rather than discouraging it.

Harm reduction supports wellbeing while reducing physical complications (observational evidence)

7D — Prescribing guide: who initiates what (NHS England service specifications · GMC · RCGP · BMA · UK legislation)

In gender care, what matters most for the GP is who is responsible for prescribing. Specialist services initiate gender-affirming hormones. The GP prescribes and monitors under shared care, handles any bridging decision within strict limits, and treats co-occurring conditions exactly as for anyone else. For under-18s, the legal and commissioning rules have changed a great deal since the Cass Review (April 2024). The GP's role there is referral, support and safeguarding, never prescribing.

Situation	Position and source	GP action
Adult on GDC-initiated hormones	Under the NHS England adult service specification, the specialist GDC assesses and diagnoses, then recommends endocrine treatment (and in some services initiates it). Prescribing and monitoring are then usually shared with primary care. The BMA advises GPs to approach shared care with gender specialists as they would with any other specialist. The Levy review (NHS England, Dec 2025) recommended that GDCs manage the first year of hormone treatment before transfer, and that NHS England and ICBs set up sustainable local prescribing and monitoring arrangements, including a GP with Extended Role in gender medicine.	Shared care per the GDC protocol; raise specific concerns with the service rather than refusing outright
Adult self-medicating while waiting (Sam)	GMC advice for adults: issuing a bridging prescription is not against GMC guidance, and GMC guidance does not oblige a GP to do it. Consider it only if the patient is already self-prescribing from an unregulated source (or highly likely to), it is intended to reduce a risk of self-harm or suicide, and gender-specialist advice has been sought; prescribe only within competence, following an individualised, specialist-informed plan ("lowest acceptable dose" is not a substitute for one). RCGP position statement (2024): for GPs without extended expertise, the role "would not include initiating prescriptions" before specialist assessment. BMA: GPs should feel clinically competent, and it should follow local policy.	Harm reduction + monitoring always; seek specialist advice; the individual GP decides whether to bridge; document the reasoning
Under-18: puberty blockers (GnRH analogues)	NHS England stopped routine commissioning in March 2024 after the Cass Review. Emergency legislation in 2024 restricted private sale and supply for gender incongruence in under-18s. In December 2024, on advice from the Commission on Human Medicines, the government made the restriction indefinite from 1 January 2025, with a review in 2027. Patients already on treatment could continue. The only route is the NIHR-funded PATHWAYS trial (King's College London). It was paused in February 2026 on MHRA advice and resumed under a modified protocol (agreed June 2026) with minimum entry ages of 11 for birth-registered females and 12 for birth-registered males, and clearer safety stopping rules (bone health, cognition, vaginal bleeding). The High Court refused permission for a judicial review in July 2026, and recruitment was scheduled from 1 August 2026. Check the current status.	Never prescribe; do not support private/overseas supply; refer via paediatrics/CAMHS
Under-18: masculinising/feminising hormones	NHS England accepted Cass: not under 16. At 16–17 they are prescribed only by the NHS CYP Gender Service, with "extreme caution". In March 2026 NHS England consulted (9 March to 7 June 2026) on removing routine access for new under-18 patients and paused new starts during the consultation. Existing 16–17-year-olds may continue if agreed in writing. Check whether the final policy has now been published.	No GP initiation or shared care with unregulated providers (NHS England guidance to primary care, updated 2026)
Comorbid depression / anxiety	NICE NG222 (depression in adults) applies unchanged. Offer psychological therapy and/or an SSRI according to severity and preference. At 18–25 or with suicide risk, review 1 week after starting and be aware of early increased suicidality. NICE NG225: consider the toxicity of medication in overdose and prescribe limited quantities.	Treat now; never make it conditional on gender-related decisions
Contraception with a uterus, on testosterone	CoSRH CEU statement (2017): testosterone does not provide adequate contraception. Periods often stop, but ovulation and pregnancy can still occur, and testosterone is contraindicated in pregnancy (risk of virilisation of the fetus; SPC). Discuss contraception where there is any risk of pregnancy.	Offer effective non-testosterone contraception; ask about sperm exposure sensitively

If you are considering a bridging prescription: the checklist

GDC referral already sent; this is an adult (18+)
Already self-medicating from an unregulated source (or highly likely to), and bridging is intended to reduce risk of self-harm or suicide (GMC conditions)
Advice sought from a gender specialist or experienced colleague, with the reply or the attempt documented
Regulated preparation, with the product, route and dose agreed on specialist advice as an individualised plan, using a recognised local/shared-care protocol where available (dose per specialist / SPC)
Fertility preservation discussed before prescribing, and documented
Baseline bloods and BP done, and a monitoring schedule agreed
Check your ICB or local policy (many areas have one) and that you feel competent. If not, say so honestly and keep monitoring

If you decide not to bridge: what you still do

Explain your reasoning honestly, and don't frame it as a judgement of Sam
Offer the same monitoring bloods, BP and review schedule you would offer if you were prescribing
Harm-reduction advice: sterile single-use equipment, needle exchange, safe sharps disposal, no sharing, rotate injection sites, never double a missed dose, bring the product in so it can be checked
Offer BBV testing and hepatitis B vaccination if equipment may have been shared
Pass on the specialist advice when it arrives, and review the decision if Sam's risk changes
Document everything: the product, the dose, the advice given, the bloods and the plan

7F — Drug reference cards: gender-affirming hormones and related medicines (specialist-led; GP under shared care)

Testosterone (masculinising)

Long-acting IM testosterone undecanoate · short-acting IM testosterone esters · transdermal testosterone gel

GDC-initiated · shared careDose per GDC protocol / SPC

✓ Role

Masculinising hormone therapy recommended by the adult GDC; the GP continues prescribing under shared care once stable

Bridging (adults only): only within the GMC conditions and after specialist advice (see 7D)

✗ Contraindications / cautions

Pregnancy: contraindicated (risk of virilisation of the fetus)

Pre-existing polycythaemia or high haematocrit, uncontrolled hypertension, significant liver disease, thrombophilia or prior VTE, heavy smoking: seek specialist advice

⚠ Key counselling

Some changes are permanent (voice deepening, facial and body hair, clitoral growth). Fertility may be affected, so discuss preservation before starting

Not a contraceptive (CoSRH). Acne, scalp hair loss, mood changes and pelvic pain can occur. Transdermal gel: avoid skin contact transfer to others

Online supply: product, strength and sterility can't be verified. Bring it in to be checked

🔬 Monitor

FBC with haematocrit, LFTs, lipids, HbA1c, BP, weight, testosterone level (timing depends on preparation) at baseline and per protocol. Typically about 3-monthly in year 1, then 6–12-monthly. Act on a rising haematocrit as the protocol directs

SCA phrase: "Testosterone can make the blood thicker, which is why I'd like to check a blood count now and regularly from here on. That way it's the testosterone looking after you, not something we have to worry about."

Oestradiol (feminising)

Transdermal patches / gel · oral estradiol valerate or estradiol hemihydrate

GDC-initiated · shared careDose per GDC protocol / SPC

✓ Role

Feminising hormone therapy. UK GDC protocols use estradiol. Ethinylestradiol and conjugated oestrogens are not used because of higher VTE risk

Transdermal routes are generally preferred where VTE risk is higher (older age, smoking, obesity, previous VTE)

✗ Contraindications / cautions

Active or recent VTE, oestrogen-sensitive cancer: specialist decision

Smoking, migraine with aura, significant liver disease, thrombophilia, raised BMI, immobility or surgery (seek advice on peri-operative management)

⚠ Key counselling

VTE symptoms (calf swelling or pain, chest pain, breathlessness) need same-day assessment. Stopping smoking is strongly advised

Breast development is largely permanent. Fertility is reduced, so discuss sperm storage before starting

🔬 Monitor

Oestradiol and testosterone levels, prolactin, LFTs, lipids, HbA1c, BP and weight per the GDC protocol. Interpret against the target range the GDC sets, not the lab's sex-specific range

SCA phrase: "Patches or gel through the skin carry a lower clot risk than tablets, and stopping smoking is the biggest thing you can do to keep that risk low."

Testosterone suppression in adults

GnRH analogues (e.g. triptorelin, leuprorelin) · cyproterone acetate · (sometimes spironolactone or finasteride on specialist advice)

Specialist-recommendedDose per GDC protocol / SPC

✓ Role

Adults on feminising regimens where oestradiol alone doesn't suppress testosterone enough. GnRH analogues are commonly used by UK GDCs

The under-18 restriction on GnRH analogues for gender incongruence does not apply to adults under GDC care

✗ Contraindications / cautions

Cyproterone: contraindicated with current or previous meningioma. Dose-dependent meningioma risk (MHRA Drug Safety Update, June 2020). Use high doses only where alternatives are unsuitable

Cyproterone: hepatotoxicity (monitor LFTs), low mood. GnRH analogues: bone loss if sex hormones are not replaced

⚠ Key counselling

GnRH analogue depot timing matters, so don't let doses lapse. Warn about hot flushes and low mood if oestradiol is interrupted

🔬 Monitor

Testosterone and oestradiol levels, LFTs (cyproterone), bone health if there are long gaps in sex-hormone cover or after gonadectomy (consider DXA per specialist advice)

SCA phrase: "The injection that blocks testosterone works alongside your oestrogen. If one stops, the balance changes, so let's make sure your repeat dates are set up."

SSRI for comorbid depression / anxiety

Sertraline · citalopram · fluoxetine

GP-initiated (NICE NG222)Dose per SPC and local formulary

✓ Prefer when

Moderate to severe depression, or preference for medication, alone or with psychological therapy (NICE NG222)

Treat on the same basis as for any other patient. It is never conditional on gender decisions and never a reason to delay the GDC referral

✗ Avoid / caution

Citalopram: QT prolongation. Bleeding risk with anticoagulants or NSAIDs. Consider toxicity in overdose and prescribe limited quantities where there is self-harm risk (NICE NG225)

⚠ Key counselling

Takes 2–4 weeks to work. Agitation or suicidal thoughts can increase early on in people aged 18–25, so contact the practice straight away if this happens. Don't stop abruptly

🔬 Monitor

Review at 1 week (age 18–25 or suicide risk, NICE NG222), then regularly. PHQ-9 to track symptoms. Review the safety plan at each contact

SCA phrase: "Treating your low mood won't hold up the gender clinic at all. The two happen side by side. Because you're 24, I'd like to see you again in a week after starting."

Unregulated online hormones: what to ask

Testosterone vials or gels, oestradiol, antiandrogens bought online or from friends

Harm reductionDocument product, strength, dose, route, source

✗ Risks

Unknown content, strength or sterility; counterfeit or contaminated products

Injection site infection or abscess, BBV transmission if equipment is shared, supraphysiological dosing (polycythaemia, VTE), sudden stops when supply or money runs out

⚠ Key counselling

Sterile single-use equipment, needle exchange, safe sharps disposal, never share. Never double doses. Bring the product or packaging photos in. Report suspected fake medicines to MHRA Yellow Card

🔬 Monitor

Same bloods and BP as for prescribed hormones, whether or not you prescribe

SCA phrase: "I'm not going to tell you off. I'd just like to know exactly what you're taking and how much, so I can keep you safe."

7G — Psychosocial impact: work, driving, family, identity and the wait

🤝

Gender dysphoria and the wait: identity, safety, relationships and being believed

For many trans people, the hardest part of gender dysphoria is not the dysphoria itself. It is the years spent waiting for care, and what happens in the meantime: at work, at home, in public and in healthcare settings. The GP is often the only clinician who sees the whole of that picture.

💼

Work and education

The Equality Act 2010 protects against discrimination and harassment because of gender reassignment, with no requirement for medical treatment. If Sam's mood affects his work, a fit note is appropriate. Use neutral wording that does not disclose his gender history unless he agrees ("low mood and anxiety" rather than a gender-related diagnosis). Suggest adjustments such as time off for GDC appointments.

"Would it help if the fit note just says 'anxiety and low mood'? You decide what your employer knows."

🚗

Driving and DVLA

Gender dysphoria and gender-affirming hormones do not need to be reported to the DVLA. The mental-health rules apply as usual. DVLA guidance (Assessing fitness to drive) says that severe depression or anxiety with significant memory or concentration problems, agitation, behavioural disturbance or suicidal thoughts means the person must not drive and must tell the DVLA. Discuss this sensitively. Changing the name and gender on a licence is an administrative process, not a medical one.

"Nothing about being trans or taking hormones affects your licence. If your mood gets bad enough that you can't concentrate, or you're having thoughts of ending your life, you shouldn't drive until that improves."

👨‍👩‍👧

Family and relationships

Relatives may be supportive, confused or hostile, and a partner may need support too. Offer information, but never share Sam's gender history or medical details with them without his consent. If a relative contacts the practice, confirm nothing without Sam's consent.

"If it would help, you could bring someone you trust to an appointment. That's entirely your choice, and I won't share anything without your permission."

👤

Identity, body image and intimate examinations

Cervical screening, chest examination and some blood tests can cause significant dysphoria. Use Sam's own words for his body, explain why each examination is needed, offer choices (a smaller speculum, a clinician he chooses, a chaperone, stopping at any point) and self-sampling where it is available. Testosterone can cause vaginal atrophy. A short course of topical vaginal oestrogen before screening may help, but agree this with Sam and his GDC or specialist.

"I know this test might be really difficult for you. We can go at your pace, use whatever words you prefer, and stop whenever you want."

⏳

The wait: hope and anger

The Levy review found that more than 40,000 adults were waiting for a first appointment (March 2025), and some clinics estimated waits of over a decade for new referrals. NHS England accepted the recommendations: a single national waiting list was introduced in 2026, self-referral is no longer accepted, and from October 2026 GP referrals go through one national referral service. Anger about this is reasonable. Acknowledge it honestly, don't offer false timescales, and plan the wait actively rather than leaving Sam to wait passively.

"I'd be angry too. I can't make the list shorter, but I can make sure you're looked after properly while you're on it."

🏥

Trust in healthcare

Many trans people have had healthcare experiences where every symptom was put down to their gender identity or hormones (sometimes called "trans broken arm syndrome"), or where they were refused care. Investigate chest pain, headache or abdominal pain exactly as you would for anyone else, and take account of anatomy and hormones where they are relevant.

"Whatever you come in with, I'll look into it properly, the same as I would for anyone."

7H — Follow-up schedule

1 Week — Safety Plan and Mood Review

Self-harm since last seen? Safety plan used and still fits? If an SSRI was started, review at 1 week (age 18–25, NICE NG222) for agitation or increased suicidal thoughts. Mental-health referral or NHS Talking Therapies in progress? Specialist advice on hormones received? Baseline bloods and BP results (haematocrit, LFTs, lipids, HbA1c, testosterone level). Confirm the GDC has acknowledged the referral.

2–6 Weeks — Hormone Plan and Screening

Act on specialist advice: document the bridging decision either way and agree a monitoring schedule. Harm-reduction advice reinforced. Cervical screening opt-in submitted, with adjustments agreed. Contraception and fertility discussion documented. PHQ-9 trend. Peer support contact made?

Every 3 Months (Year 1 on Testosterone) — Monitoring Review

FBC and haematocrit, testosterone level, LFTs, BP and weight per protocol. Mood and self-harm reviewed. Injection sites and supply source checked. Smoking status. Any new symptoms investigated on their merits.

6–12 Monthly — Stable Phase and Shared Care

Monitoring interval extended per the GDC protocol once stable. Lipids and HbA1c yearly. Cardiovascular risk discussed (standard calculators are not validated for trans people, so treat modifiable risk factors on their merits). Screening programmes reviewed against anatomy. Record accuracy checked.

At GDC Contact and Beyond — Transition of Care

Share the monitoring history with the GDC. Agree a shared-care protocol when offered, and raise specific concerns with the service rather than refusing the whole arrangement. After surgery or gonadectomy, make sure sex-hormone cover is continuous (bone health) and update screening. Continuity with a named GP continues.

7I — Monitoring: safety on hormones, mental health and screening

Memory rule: "Mood, Blood, Pressure, Screen, Supply"

At every review: Mood (self-harm, suicidal thoughts, safety plan; no risk scores, per NG225); Blood (haematocrit on testosterone; LFTs, lipids, HbA1c and hormone levels per protocol); Pressure (BP and weight); Screen (by anatomy, not by the recorded gender marker); Supply (regulated or unregulated source, gaps, injection technique).

What	When	Action threshold / note
Haematocrit / Hb (testosterone)	Baseline; about 3-monthly in year 1; then 6–12-monthly (per GDC protocol)	Rising or >0.50: review dose, timing and smoking; seek advice (some local protocols pause testosterone at this level). >0.54 or thrombosis: withhold per protocol and get urgent specialist or haematology advice (thresholds vary between protocols)
Testosterone / oestradiol levels	Per protocol; timing relative to the dose matters	Interpret against the target range the GDC sets for the affirmed gender, not the lab's range for the recorded sex
LFTs	Baseline and per protocol	Rising transaminases: review product, alcohol and cyproterone; seek advice
BP, weight, lipids, HbA1c	Baseline; at least annually	Treat hypertension, dyslipidaemia and diabetes on standard thresholds. Be cautious with sex-specific CV risk calculators
VTE risk (oestrogen)	At initiation and whenever circumstances change (surgery, immobility, long-haul travel, smoking)	Symptoms of DVT/PE: same-day assessment. Peri-operative plan agreed with the specialist
Bone health	If gonadectomy with gaps in hormone therapy, long interruptions, or other risk factors	Consider DXA on specialist advice. Make sure hormone supply is continuous
Mood, self-harm, suicidal thoughts	Every contact	Active plan or intent: same-day crisis team. PHQ-9/GAD-7 track symptoms but don't predict risk (NG225)
Screening status	Annually and whenever the gender marker changes	Cervical opt-in (cervix present); breast and AAA request or opt-out as anatomy dictates (see table below)

🔬 NHS population screening for trans and non-binary people (GOV.UK / NHS screening programmes)

Programme	Registered as female	Registered as male
Cervical (25–64)	Trans men and non-binary people with a cervix are invited automatically. Trans women registered as female may also be invited, but don't need screening because they have no cervix (a neovagina is not screened). The practice can update the record so the invitations stop.	Trans men or non-binary people with a cervix are not invited automatically. The practice can opt them in to automatic invitations through the Cervical Screening Administration Service (NHS Cervical Screening Programme transgender and non-binary opt-in guidance).
Breast (50–71)	Invited, including trans women (the GOV.UK leaflet explains the options). Trans men who have had chest reconstruction are still invited and can discuss opting out, as some breast tissue may remain.	Not invited. Trans women taking oestrogen, and trans men who have not had chest reconstruction, can ask the GP to arrange screening.
AAA (men at 65)	Trans women are not invited but have the same risk as other people assigned male at birth and should request screening.	Trans men are invited. Their risk is low (similar to people assigned female at birth) and they can decline.
Bowel	Invited according to age regardless of gender marker.

7J — Safety-netting: exact phrases + medico-legal rationale

⚠ Three scenario-specific safety-nets: say these, then write them down

Why documentation matters here

Referral: "Referred to adult GDC on patient request; no preconditions; copy offered." This shows the referral was made without gatekeeping.

Risk: "Self-harm and suicidal thoughts explored; safety plan agreed and copy given; crisis numbers provided; review 1 week." Needs-based, per NG225.

Hormones: product, strength, dose, route, source; specialist advice sought (date, who); bridging decision and reasons; monitoring plan. This is what GMC advice expects.

Fertility and contraception discussed before any prescribing, and documented. This discussion can't be done afterwards.

Confidentiality: consent recorded for what can be shared, and with whom (family, employer, fit note wording). GRA 2004 s.22 applies where a GRC has been applied for or is held.

Screening: organs present coded with consent; cervical opt-in submitted; note added so future clinicians screen by anatomy.

1 WeekSafety plan; SSRI check if started; bloods and BP results; specialist advice

2–6 WeeksBridging decision documented; screening opt-in; contraception; therapy started

3-MonthlyHaematocrit, BP, mood and supply review until GDC care starts and beyond

💬 Key phrases

💭 Name and pronouns

"Can I check the name and pronouns you'd like me to use? I'll make sure they're on your record so everyone here gets it right."

😟 No gatekeeping

"You don't need to prove anything to me. I'm referring you today, and that doesn't depend on anything else we talk about."

🎯 Honest about bridging

"I can't promise to prescribe testosterone today. It isn't something GPs usually start, and I need a specialist's advice first. What I can promise is that I'll ask for that advice today and check your bloods regardless."

🤝 Minority stress

"A lot of what you're feeling makes sense given how hard the last few years have been. That's not a flaw in you, and there's help for it."

🔬 Screening by anatomy

"Because you have a cervix, screening still matters for you. I can set it up so the invitations come automatically, and we'll make the test itself as comfortable as we can."

📋 Continuity close

"I'll see you in a week. Anything before then, call and ask for me. The wait is long, but you're not waiting on your own."

🔴🟠🟢 RAG marking: all three domains

Tasks

🟢

Refers to GDC today without preconditions; proactive risk assessment and safety plan; baseline bloods, haematocrit and BP; specialist advice sought; bridging decision reasoned within GMC conditions; cervical opt-in; contraception and fertility raised; 1-week review

🟠

Refers and asks about mood, but no written safety plan; mentions bloods without a schedule; promises or refuses bridging without specialist advice; screening noted but not arranged

🔴

Delays referral pending "mental-health assessment"; no risk enquiry; refuses any involvement with hormones or monitoring; or prescribes without advice or fertility discussion; misses screening

Relating to Others

🟢

Correct name and pronouns throughout; commits to the referral early; non-judgemental about online testosterone; explores ICE; honest about the wait and GP limits; sensitive to dysphoria around examinations

🟠

Polite but hesitant; slips on pronouns and doesn't correct them; information-giving outweighs listening; ICE partly explored

🔴

Misgenders; questions whether Sam is "really" trans; lectures about the online source; Sam leaves feeling judged

Global Skills

🟢

Structured: affirm, then risk, then hormones, then screening, then plan; prioritises safety without losing the patient's agenda; clear follow-up and safety-net

🟠

Covers the content but runs out of time for safety-netting or screening

🔴

Disorganised; misses risk or hormones completely; no follow-up arranged

🚫 Danger zones

✗

Requiring a mental-health assessment before referral→ Adult GDCs accept referral on request. Mental-health needs are treated alongside the referral, not as a gate before it.

✗

Prescribing testosterone on the spot without specialist advice or a fertility discussion→ GMC conditions require specialist advice; prescribe only within competence, following an individualised, specialist-informed plan. The RCGP (2024) says initiation is outside the core GP role. Fertility must be discussed first.

✗

Refusing to monitor because the hormones are "not prescribed"→ Monitoring is harm reduction. Take bloods and BP, and document, whatever you decide about prescribing.

✗

Using a risk score to decide Sam is "low risk"→ NICE NG225: don't use risk tools to predict suicide or decide on care. Do a needs-based assessment and write a safety plan.

✗

Assuming screening will happen automatically→ Invitations follow the gender marker. Arrange by anatomy: cervical opt-in, and breast or AAA requests where relevant.

✗

Referring a young person directly to the CYP Gender Service, or supporting unregulated hormone supply→ Since September 2024 referrals come via NHS paediatrics or CAMHS. No GP prescribing or shared care with unregulated providers for under-18s (NHS England guidance).

✗

Disclosing gender history without consent→ This breaches confidentiality, and it may be a criminal offence under GRA 2004 s.22 if a GRC has been applied for or is held. Check consent for letters, fit notes and conversations with relatives.

🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills

A plan that scores

"So: I'll refer you to the gender clinic today, get you mental-health support and make a safety plan, seek specialist advice about a bridging prescription and do some monitoring bloods so the testosterone is safer, arrange your cervical screening, and give you some peer-support contacts. I'll keep seeing you throughout — you're not on your own with this."

Deductions

Referral only, with no mental-health/safety support
Refusing all involvement with hormones (no harm reduction)
Missing anatomy-based screening; not keeping the door open

(Guarded, expecting resistance) "Hi. I'm Sam — he/him. I've come to ask for a referral to a gender clinic. I'm guessing you'll want me to jump through hoops or tell me I have to see a psychiatrist first?"

Who you are

Sam Okoro, 24 (he/him), assigned female at birth. You've felt a persistent mismatch between your gender and your body for years, with real distress, and have socially transitioned. You're here to ask for a referral to a gender clinic and you're braced to be questioned, misgendered or refused. As trust builds, you'll disclose low mood and episodes of self-harm, and — hesitantly — that you've recently started buying testosterone online because the waiting list is "years long" and you couldn't wait. You're registered as female on the system and overdue cervical screening (which you find distressing). You most fear being judged or told you have to "prove" you're really trans.

Hidden concerns (reveal if explored)

Fear of rejection/gatekeeping (main): if the GP affirms you and agrees to refer without hurdles, you relax and open up.

Mood & self-harm: you'll disclose these if asked compassionately — you've not had support.

Online testosterone: you fear being told off or refused help; honesty depends on a non-judgmental approach.

Cervical screening: distressing/dysphoric for you; needs sensitivity.

Clinical details if asked

Persistent gender incongruence/dysphoria for years; socially transitioned; wants GIC referral
Low mood; episodes of self-harm; no current mental-health support; no active plan to end your life today
Recently bought testosterone online; taking it unmonitored; waiting list "years"
Registered female; overdue cervical screening; otherwise generally well
Some peer/online community support; variable support from family

Reactions at key moments

If misgendered or asked to "prove" yourself / refused referral: you withdraw, become defensive, lose trust.
On "I'll refer you today, no hoops": visible relief.
On compassionate risk questions: you open up about the self-harm.
On harm-reduction re testosterone (not a telling-off): relieved, willing to have monitoring.
Challenge line: "You're not going to refuse to refer me or report me for the testosterone, are you?"

"So are you actually going to refer me — without making me prove I'm 'really' trans — and are you going to give me a hard time about the testosterone?"

Resolution: Sam is well served if the GP: (1) uses his correct name and pronouns and provides affirming, respectful care, agreeing to refer him on request to NHS adult gender services via the national referral service — without gatekeeping, demanding a mental-health assessment first, or pathologising his identity; (2) proactively and compassionately assesses and supports his mental health and self-harm risk with a safety plan; (3) responds to the online testosterone with harm reduction — seeking specialist advice, considering a bridging prescription/shared care and arranging monitoring bloods — rather than refusing involvement; (4) arranges his (anatomy-based) cervical screening sensitively and maintains general health; (5) signposts peer support and offers continuity through the long wait. He disengages if misgendered, gatekept, judged about the testosterone, or left unsupported.

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Clinic Quick Reference

Gender Dysphoria — Clinical Decision Framework

Affirm · refer (no gatekeeping) · support · keep safe

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🤝 1 — The GP's role

Affirming care: correct name/pronouns; non-judgmental. Refer on request to NHS adult gender services via the National Adult Gender Referral Support Service (from 1 Oct 2026; no self-referral) — no gatekeeping, no mandatory mental-health pre-assessment. Support mental health (high suicide/self-harm risk from minority stress) and general health through long waits. Don't pathologise identity or use conversion practices.

🆘 2 — Safety & general health

Self-medication: harm reduction + monitoring always (haematocrit/BP/LFTs/lipids on testosterone); seek specialist advice; bridging only within GMC conditions and GP competence (RCGP 2024); shared care once the GDC is involved. Anatomy-based screening: trans man with a cervix needs cervical screening; tailor screening to anatomy not recorded gender. Young people: refer via NHS paediatrics/CAMHS to the CYP Gender Service; puberty blockers only within the PATHWAYS trial; no GP prescribing or shared care with unregulated providers; family support/safeguarding. Signpost peer support; provide continuity.

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SCA Quick Reference

Gender Dysphoria — Consultation Playbook

Affirm · refer · support safely

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🎯 The three pivots that pass this case

1 · Affirm & refer

Correct name/pronouns; refer on request via the national referral service — no gatekeeping or "proof". The GP supports, doesn't diagnose identity.

2 · Mental health & risk

Proactively assess/treat mood and self-harm (minority-stress driven); safety plan; signpost support through the wait.

3 · Safety & general health

Self-medication → harm reduction + bridging/shared care + monitoring; anatomy-based screening (cervical); routine care.

⛔ Don't misgender, gatekeep, demand "proof", or pathologise identity · Don't refuse to engage with self-sourced hormones — harm-reduce, consider bridging/shared care & monitoring · Don't miss the high mental-health/suicide risk · Don't overlook anatomy-based screening (cervical for a trans man) · Never use conversion practices; provide affirming, person-centred care

Gender Dysphoria · GP Clinical Reasoning Framework v2 · GMC ethical hub (trans healthcare; bridging prescriptions) · RCGP position statement (2024) · BMA — managing patients with gender dysphoria · NHS England gender service specifications (adults; children and young people) and guidance to primary care on unregulated providers · Cass Review (2024) · Levy review of adult GDCs (NHS England, 2025) · NICE NG222, NG225 · NHS population screening for trans and non-binary people · CoSRH CEU statement (2017) · MHRA DSU (June 2020) · Equality Act 2010 · Gender Recognition Act 2004

Provide affirming, respectful care (correct name/pronouns); gender incongruence is not a mental illness · The GP's role is to refer on request to NHS adult gender services via the national referral service (no gatekeeping/mandatory mental-health pre-assessment) and to support mental and general health through long waits · Proactively assess/treat the high rates of depression, self-harm and suicide (minority stress) · Respond to self-medication with harm reduction; consider bridging prescriptions & shared care with specialist advice and monitoring (GMC) · Tailor screening to anatomy (cervical screening for a trans man with a cervix); monitor hormone effects (haematocrit/CV/bone) · Young people via specialist holistic pathways; never use conversion practices

Teaching clinicians why each step matters — not just what to do · Always consult current GMC guidance and local gender-service pathways · Clinical judgement takes precedence over any framework

Gender Dysphoria

Red Flags — safety and harm to avoid

🗣️ Respectful language

🚪 No gatekeeping

🆘 Harm reduction on hormones

🧠 Mental health matters

Family and relationships

Work, study and discrimination

Money, housing and online sourcing

Community, peer support and online spaces

Co-occurring conditions

Safety: abuse, harassment and hate crime

Same day / soon

Refer / share care

GP continuity

🚩 Refer, support, keep safe — without gatekeeping

Validate: name both expectations

Explain: what a GP can and can't do

Negotiate: what Sam leaves with today

Work and education

Driving and DVLA

Family and relationships

Identity, body image and intimate examinations

The wait: hope and anger

Trust in healthcare

1 Week — Safety Plan and Mood Review

2–6 Weeks — Hormone Plan and Screening

Every 3 Months (Year 1 on Testosterone) — Monitoring Review

6–12 Monthly — Stable Phase and Shared Care

At GDC Contact and Beyond — Transition of Care

Memory rule: "Mood, Blood, Pressure, Screen, Supply"

⚠ Three scenario-specific safety-nets: say these, then write them down

Why documentation matters here

🎭 Patient actor brief — click to practise

Who you are

Hidden concerns (reveal if explored)

Clinical details if asked

Reactions at key moments