your guide to gender-affirming healthcare in the uk
From first appointments to hormone therapy, here’s everything to know according to experts and people who've been through it first-hand
From first appointments to hormone therapy, here’s everything to know according to experts and people who've been through it first-hand
Navigating gender-affirming care as a trans person in the UK can be a minefield, but it’s not impossible. The system is undeniably flawed – long waitlists regularly make headlines – but trans-led collectives and services work tirelessly to create vital resources, and there are regulatory bodies like the General Medical Council (GMC), whose guidelines can – and should – be used to ensure you’re getting the best possible care.
First, a few disclaimers. The term “gender-affirming care” is extremely broad, and often contested. According to the World Health Organisation (WHO), it includes “any single or combination of a number of social, psychological, behavioural or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity.”
Kathleen Egan, Communications Manager at the Gender Hormone Clinic, describes it as a “broad range of access needs,” which spans everything from medical and mental healthcare, to cosmetic procedures such as styling services, and even words of affirmation online. Basically, it’s care which makes you feel more affirmed in your gender. That might a cis man taking testosterone gel for low testosterone levels, or a hair transplant, to treat male pattern baldness. It might mean a cis women with PCOS taking medication like spironolactone (which blocks testosterone) to treat increased hair growth. Not everyone agrees what it means, but there’s definitely a case to be made that cis people need it, too.
This guide will focus primarily on medical care, but also on gender-affirming procedures like laser hair removal and voice therapy, as well as trans-inclusive mental healthcare. Basically, anything that requires extra steps or advice to navigate. Some trans people want these services, others don’t. Every trans person is valid, whether they’re seeking medical transition or not.
Led by experts, this guide will break down the basics of gender-affirming care for adults. This age limit ranges based on country, but that means 16+ in Scotland, 17+ in England, and 18+ in Wales. It should go without saying, but given the clickbait headlines, it’s worth reiterating: trans youth can’t access gender-affirming surgeries. After lengthy, well-documented legal battles, NHS England recently announced an “interim policy” to only prescribe hormone blockers to young trans people under exceptional circumstances, although they are still available in Scotland. The UK’s trans healthcare model for under-16s is changing frequently, due in no small part to high-profile court cases and right-wing lobbyists, whereas gender-affirming care for adults – which this piece focuses on – is comparatively stable, although the likes of the British Medical Association (BMA) acknowledge that many trans people are being failed by the system.
If you’re looking to access gender-affirming care on the NHS, the first thing you’ll need to do is talk to your GP and get a referral to a GDC (Gender Dysphoria Clinic). According to the NHS website, these are run by a “multidisciplinary team of healthcare professionals, who offer ongoing assessments, treatments, support and advice.”
This can feel daunting, but there are plenty of trans-led resources out there to help: Action for Trans Health has a database of Trans-Friendly GPs with reviews from trans folks, and Trans Healthcare Intel has a similar database, but in the form of detailed maps of England, Scotland and Wales. You can also search for GP surgeries trained by Pride in Practice, a programme offered by the national charity the LGBT Foundation, which works with medical professionals to ensure they’re delivering inclusive care.
Here, the internet is your friend! Use forums, social media, local community groups – whatever you need to gain first-hand insight from other trans people. It's worth saying, though, that crowd-sourced reviews and advice will not have been monitored and will vary in accuracy so do exercise caution.
If your GP – for whatever reason – is uncooperative, you don’t have to stay with them. You can change your GP at any time without giving a reason, but if you do want to complain, community-led resource TransActual has an in-depth breakdown of how to do so and how to escalate it to the General Medical Council, if needed. GMC guidelines unequivocally state that GPs should be offering this care to adults; if they aren’t, you are within your rights to hold them accountable.
Getting a diagnosis
The next step is to get a diagnosis of gender incongruence, or gender dysphoria, which you’ll need in order to access hormones, surgeries and other gender-affirming care. These diagnoses are similar, but according to a Patient article, “dysphoria” describes “clinically significant levels of distress”, whereas gender incongruence simply outlines a difference between someone’s sex assigned at birth and gender identity. Increasingly, it’s acknowledged that not all trans people experience dysphoria – in this sense, some see the language of “gender incongruence” as a step forward in diversifying medical understanding of trans experiences.
This is easier said than done. Waiting lists at GDCs across the country are long; according to Gender Construction Kit, as of April 2023, waitlists are between 3 and 82 months. You can do your own research and request a certain clinic if their waitlists are shorter, and there are services that can help in the interim, too.
You don’t have to go with your local clinic if you can afford to travel to somewhere with a shorter waiting list – and Egan reiterates that GPs shouldn’t gatekeep if you ask to go further afield – and GPs won’t necessarily recommend the nearest. Simon*, who agrees to speak pseudonymously, was based in Birmingham when he spoke to his GP back in January 2016, but was referred to a clinic more than a hundred miles away, where he had his first appointment, 18 months later. There are new pilot schemes in Liverpool, London, Manchester and Nottingham, which treat trans and non-binary people who are already on a waiting list for an NHS gender clinic, rather than taking new referrals. These are intended to alleviate long waiting lists, but their criteria can be strict and their capacity limited.
Questions asked during the diagnosis procedure have been criticised in the past; when (now) 27-year-old Simon went through the procedure back in 2017, he says he was asked “intrusive” questions about masturbation habits and porn preferences. These questions seem to have changed. Private service GenderGP provided a “gender questionnaire” to woo, which offered some insight into what lines of questioning to expect. Notably, GenderGP is run by Dr. Helen Webberly, who, in March this year, successfully appealed a tribunal decision to suspend her from practising medicine. The diagnosis questionnaire outlines that the general aim is to get to know the patient, figure out what steps they’ve already taken to affirm their gender, ascertain the supportiveness of their network and outline their “dreams and wishes” – basically, what would transition look like to you?
Jude Guaiatamacchi, a model, educator and campaigner, says this process can be difficult for non-binary people, due to a “lack of education” in clinical settings. “Several friends that went through NHS pathways informed me that doctors were less likely to offer gender-affirming care to non-binary people,” they explain. I speak off-record to one non-binary person, who presented androgynous for a GP appointment, and was refused a GDC referral for not looking “feminine enough.” Two weeks later, they went back in a sundress and landed the referral.
Again, speaking to trans people online can be invaluable – the more you know what to expect, the smoother your experience is likely to be. You can, of course, go private for a diagnosis, but costs vary hugely, so do your research. GenderCare’s fees range from £250 to £360 for appointments (as well as extra costs for reports); DPL Psychology charges £450 for a gender assessment, whereas the Northern Gender Network, the Gender Hormone Clinic and others will be able to provide lists of trans-affirming clinicians you can contact directly.
There’s a variety of masculinising and feminising hormones available on the NHS. These can cause gender-affirming changes, like breast growth and softer skin for trans-feminine people, or voice deepening and fat redistribution for trans-masculine people. Dosage can vary; you might choose to microdose for more gradual changes. Hormones are commonly taken in either transdermal – gel or patch – form, or they’re injectable. The method you choose will determine how often you’ll take them.
However, you’ll need a diagnosis first, and because the waitlists for GDCs are so long, it's not uncommon for GPs to issue bridging prescriptions (a temporary hormone prescription for those on GDC waiting lists) as a harm reduction measure.
The GMC recommends these be issued only when patients are self-medicating or “highly likely” to self-medicate, but you can – and should – advocate for your access to these prescriptions if you need them. “A lot of people don’t know that GPs can offer them,” explains Egan. If they refuse, Jude advises: “There are NHS guidelines which offer information on a GP’s duty of care when it comes to bridging prescriptions.” You can try other GPs if the first refuses.
If you do manage to get a bridging prescription, “you’re not going to get proper monitoring, and you’re not going to get one-on-one care from clinicians,” Egan continues, “but you will get hormones earlier, and you’ll normally be on a fairly stable system.” It’s worth noting that you usually don’t get a hormone prescription at your first GDC appointment, usually your second – and that means more waiting. If you get the diagnosis at your first appointment, you can then go to a private service to access hormones while you wait for a prescription through the NHS.
Taking gender-affirming hormones requires continuous care, such as regular blood tests to check hormone levels. If you’ve initially gone private for hormones, you can later switch to “shared care” – “essentially, an agreement between your GP and a private practice,” says Egan. “We'll monitor someone's care, as long as the GP will provide us with blood tests.” This means you can then get lower-cost hormone prescriptions through the NHS but receive care from a private practice.
You are entitled to shared care – and Egan says, optimistically, that more and more GPs seem comfortable with this agreement. “If GPs refuse, we’ll often ask if they can have a phone call with our lead clinician. If that fails, we can send resources to try and help the patient access shared care elsewhere.”
Laser hair removal
There are other affirming procedures you can access through the NHS, like laser hair removal. Setsuko Takeuchi, founder of Setsuko Beauty Clinic, a private hair removal service, explains that the NHS “might help to fund up to eight sessions of laser hair removal treatments,” but getting the funding requires “clinical diagnosis, lots of paperwork, and then funding approval from the local [integrated care system].”
Again, you can advocate for yourself – if your local integrated care system (formerly know as clinical commissioning group) does fund laser hair removal, encourage your GP to research this. You can also check what your ICS offers by accessing the contact information on their dedicated website and asking a representative.
You don't need a diagnosis or even a GDC referral to access voice therapy through the NHS. Your GP might not know this, but GenderGP has an in-depth breakdown of which clinicians accept NHS referrals, as well as which GDCs have voice therapists online, and which services have online resources for trans people to practise voice therapy themselves.
There’s a wide range of gender-affirming surgeries available to trans people. Some are available on the NHS, like ‘top surgery’ – double mastectomy – for trans-masculine people, but these usually come after at least two GDC appointments, and you need to have at least one letter from a clinician to be approved. Simon “waited it out on the NHS,” but was “very, very lucky that a new contract was signed for top surgery,” and that there was a cancellation. “It still took ages,” he says, “18 months from my second GDC appointment.”
Some surgeries – like facial feminisation surgery, or breast implants for trans-feminine people – aren’t available on the NHS at all. As a result, plenty of trans people are forced to crowdfund for private treatment. This at least means having a say on which surgeon you go to, and again, asking around online and reaching out to trans-led services for recommendations and advice will be the best way to go.
Finally, there’s a range of holistic, wide-ranging care out there - though often these are concentrated in the south of England. There are non-NHS services that can help: from CliniQ and 56 Dean Street in London, to Clinic T in Brighton, these vital organisations can offer everything from counselling, mental health support and help with hormone injections to cervical screening and liver function tests.
Everyone I spoke to for this article was happy to pass on their guidance and experience; Egan, in particular, says that they get regular emails asking for advice from non-patients, which they’re happy to answer. Activists continue to push for better gender-affirming care in the UK, but the GMC guidelines are there for a reason, and that reason is to ensure medical professionals aren’t defaulting on their duty of care to gender non-conforming patients.
You’ll have to advocate for and educate yourself, and likely for others, too, but with enough knowledge of bridging prescriptions, harm reduction and – if you can afford it – access to private healthcare, gender-affirming care is possible.
*Name has been changed.
If you require access gender-affirming care on the NHS, book an appointment with your GP in the first instance. You can read NHS information on the treatment of gender dysphoria here.