Gender Incongruence and Bridging Prescription Policy

 

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Overview

Hormonal treatments for gender incongruence entail significant risks and require expert oversight, which is beyond the scope of NHS GPs' training and expertise.

As NHS GPs, we are very happy to work with NHS gender identity clinics when a shared care arrangement is in place and appropriate assessments have been conducted. However, we are unable to prescribe hormone treatments for gender incongruence unless they are part of a formal NHS shared care protocol. This includes requests from private practitioners and requests for “bridging” prescriptions.

Patients are strongly advised to avoid obtaining hormone medications from online sources without appropriate specialist guidance.

Patients may choose to seek care from private providers, but the practice will not assume the responsibility of prescribing on behalf of private clinics.

 

Context and Rationale

Our practice is dedicated to delivering the highest standard of primary care to all patients, including those who are transgender and dealing with gender incongruence, also referred to as gender dysphoria. We understand that transgender patients often face challenges that GPs are well-placed to assist with, both in terms of physical and mental health, as well as offering guidance or referrals to specialised services.

Unfortunately, gender identity clinics in the UK, such as The Tavistock and Portman in London and the Devon Partnership in Exeter, are overwhelmed with demand, resulting in long waiting times. These clinics play a crucial role in coordinating detailed psychological assessments required before starting medical treatments, including hormones and surgeries.

Consequently, GPs are encountering requests for "bridging" prescriptions while they await formal assessment, particularly those who have already begun self-administering medication or have sourced drugs online.  We understand the frustration many patients feel due to these delays, but it is essential to practice medicine safely and responsibly.

Hormonal treatments for gender incongruence are used outside of their licensed indications in the UK and require ongoing monitoring from specialist gender physicians or endocrinologists. These medications can have irreversible side effects, including changes to physical traits, fertility issues, and an increased risk of conditions like breast cancer and blood clots.

As registered medical professionals governed by the General Medical Council (GMC), we must adhere to the principles of GMC Good Medical Practice. Article 14 of the GMC's guidance emphasizes that doctors must work within their areas of competence. According to GMC guidelines, prescribing medications outside their licensed indications should only occur if the doctor is confident in their ability to manage the medication and counsel the patient thoroughly on potential risks and side effects. Furthermore, the GMC's “Trans Healthcare: Ethical Guidance 2019” defines an experienced gender specialist as ‘a physician with specialized training and at least two years of experience in a gender dysphoria practice, such as those within NHS Gender Identity Clinics.’

The Royal College of General Practitioners (RCGP) has published a statement about GP competences to prescribe hormones for gender incongruence including the topic of “bridging” prescriptions.

Read the statement on the Royal College of General Practitioners website

 

Our Approach to Prescribing Treatments for Gender Incongruence

As GPs, we are more than happy to discuss treatment options and offer support to individual patients. We can assist with aspects of mental and physical health, and help patients access other necessary services.

This includes contraception, sexual health, referrals for PrEP/PEP, cancer screening, managing long term conditions and mental health support.  If a patient is interested in pursuing medical (hormonal) or surgical treatments, we can facilitate initial discussions and make referrals to the relevant NHS gender identity clinics.

Once a patient has been assessed by an NHS gender identity clinic, our practice is open to discussing the possibility of continuing hormone treatment, provided that a proper “Shared Care Protocol” is in place. This protocol, produced by the specialist clinic, will outline the monitoring requirements and responsibilities. If the protocol is followed and safety measures are in place, we will be happy to assist in prescribing treatments under the guidance of the specialist, with the added safeguard of additional NHS gender specialist reviews should any complications or side effects arise.

In Bristol, our local gender Identity clinics are in London and Exeter, which are NHS-commissioned and follow established "Shared Care Protocols" together with the BNSSG prescribing formulary.

However, prescribing hormones outside of a rigorous “Shared Care Protocol” would be outside of our competence as GPs. This applies to where patients may be sourcing treatment themselves from the internet, from private providers and requests for unsupervised “bridging” prescriptions. It is outside of our expertise and competence to prescribe hormones for gender incongruence where proper assessments and care agreements have not taken place.

 

Considerations Regarding Self-Sourced or Private Prescriptions

The practice strongly discourages patients from obtaining prescriptions for hormones via online channels without first receiving specialist medical advice and assessment.  Medicines bought online are likely to be unregulated and may be contaminated and dangerous.

Patients who opt for assessments with private healthcare providers are free to do so at their own risk, expense, and discretion. However, our practice cannot recommend private healthcare providers, and will not be able to take on prescribing responsibilities for patients treated privately. 

 

Further information