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All Wales Therapeutics and Toxicology Centre

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This prescribing guidance document is intended for non-specialist practitioners engaged in supporting the prescribing and monitoring of medical therapies used in the management of gender incongruence in adults (over 18 years old).

(Published - November 2019)

(Updated - August 2023 - update included renaming the document from 'Endocrine management of gender dysphoria in adults'; the 'Updates' section of the document summarises all other changes that have been made).

(Updated - October 2024 - the 'Updates' section of the document summarises changes that have been made).

This guidance refers to the Directed Enhanced Service for 'Hormone treatment for adult patients with gender dysphoria'; more details on this can be found one the Welsh Government website.

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Endocrine management of gender incongruence in adults

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This prescribing guidance document is intended for non-specialist practitioners engaged in supporting the prescribing and monitoring of medical therapies used in the management of gender incongruence in adults (over 18 years old).

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See the document named: The Endocrine and Fertility Preservation guidance

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You may also be interested in the following Public webpages:

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Spotlight: An Interview with Lee Onysko | Graphic Medicine

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Lee Onysko (they/them) is the creator of In Transition, reviewed by Soph here. This is the transcript of an interview Soph Myers-Kelley conducted with Lee Onysko on December 11, 2024. It has been revised for clarity and shortened for readability. Soph What compelled you to write this piece (In Transition), that’s really personal, about your gender journey? Lee The first 3 pages of the book are actually the first pages that I’d ever drawn. I’d always been interested in comics, but I hadn’t done a lot of them because I went to school for animation. After... Read More

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Engage with three characters through a series clinical interactions and observe their lived experiences

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The Pelvic, Obstetric and Gynaecological booklets listed below are available to view and download for free. This change was made in July 2019 to benefit patients and professionals.

Should you wish to purchase booklets in professional paper copy then you can do so by viewing the booklet price list and order form below.
Booklet price list and order form
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To make sure that the content of any POGP publication remains as up to date as possible there is a review process in place. The POGP education subcommittee is responsible for overseeing the review of a POGP publication and relies on POGP members volunteering to assist in the process The booklet review programme also includes evaluation from the general population.

The ESC wishes to acknowledge both members and its user's generosity in supporting this process
QR codes
Each booklet has a QR code that can be downloaded and shared to link to each booklet.

The below QR code links to this page.

Please download or share this QR code to link to this page.

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The Pelvic, Obstetric and Gynaecological booklets listed below are available to view and download for free. This change was made in July 2019 to benefit patients and professionals. Should you wish to purchase booklets in professional paper copy then you can do so by viewing the booklet price list and order form below.

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Introduction

This repository includes a range of knowledge about older LGBTQ+ people - about their lives, needs and their experiences with social care. This is a constantly evolving field of knowledge with some gaps, but this compendium will direct you to the key knowledge currently available in the UK.

Context

Older people (65+ years) are the largest age group accessing adult social care services ( Kings Fund, 2019) and as such also make up the largest LGBTQ+ group engaging with these services. Issues of sexual orientation and gender identity (SOGI) are often missed by social care workers ( WEC, 2019) or, if perceived, are not engaged with because of a lack of knowledge or concerns of morality ( Schaub et al, 2017; Bradbury-Jones et al, 2020). Our knowledge about LGBTQ+ people contains significant gaps; one prominent area is about their social care interactions. While some research has explored the public service experiences of LGBTQ+ individuals (see below), there is little research exploring how social care workers engage with and understand the needs of LGBTQ+ people needing care and support ( Abbott, 2017; Moriarty and Manthorpe, 2016).

LGBTQ+ Older Adults Social Care Assessment

Findings from the LOASCA study

Some of the main concerns for LGBTQ+ people when interacting with health and social care professionals are:

The knowledge base is not comprehensive, as we have less understanding about several groups, including black and other ethnic minority LGBTQ+ people, bisexual, and trans/non-binary people. These three groups are significantly under-represented in research, meaning we need detailed studies with these groups to improve our understanding of their lives and needs ( Jones, 2018; King et al., 2019a, King et al, 2019b; Kwong-Lai Poon, 2011).

Older LGBTQ+ people have particular needs and challenges when accessing social care. There is some evidence that older LGBTQ+ people experience anxiety when engaging with social care services because of discrimination by professionals and lasting effects of historical experiences.

Here are some key elements:

Older LGBTQ+ individuals anticipate concerns about receiving personal care services in their homes and the imperative to 'de-gay' their home environments and remove signifiers of non-normative sexualities and gender identities (Willis et al, 2018).

Older trans adults report their concerns about the anticipation of transphobic responses from staff and residents in care settings, alongside worries about losing personal autonomy over everyday presentation and bodily care (Willis et al, 2019; 2020).

Older LGBTQ+ people 'dread' accessing care services and, as a result, avoid planning for the care they will need in later life (Jandrić 2020).

In response to hetero/cisgenderism LGBTQ+ older people often seek social support from within the LGBTQ+ groups and networks (Alba et al., 2020).

References

Schaub J., Willis P., and Dunk-West, P. (2017), Accounting for self, sex and sexuality in UK social workers' knowledge base: Findings from an exploratory study, The British Journal of Social Work, Volume 47, Issue 2, March 2017, pp.427-446

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Changing gender, title, CHI in NHS (Scotland)

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Changing gender, title, CHI in NHS (Scotland)

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Request

All information regarding the administrative requirements for processing a change of gender and title for a patient. Specifically:

What evidence is required before a request for change of gender can be processed.

What process must be followed by the GP in order to change the gender and title of a patient.

Who can the patient contact if the GP is unwilling to change the gender and title.

Any information related to the issuing of a new CHI number for patients who have changed gender and how this will be updated throughout the NHS.

Response

This response is based on the based on how the Community Health Index (CHI) is updated and the link to NHS Screening systems which NHS National Services Scotland is responsible.

None of the following information is dependent on the patient changing their gender formally under the Gender Recognition Act 2004.

No evidence is required; the patient simply needs to advise either their GP practice or Practitioner Services (a business unit within NHS National Services Scotland) that they wish to change their gender. This is often accompanied by a change of name being requested by the patient.

The GP practice will amend their data held on their practice management computer system which will be received electronically by Practitioner Services. Whilst any name change can be processed automatically by CHI, a change of gender requires manual intervention by one of our trained staff to update CHI.

Most of our computer systems do not hold a title field rather it is the gender and marital status which determine title.

As GP practices are independent primary care contractors any dissatisfaction by a patient may be raised as a complaint and should be referred to the practice in the first instance and then the NHS Board in the area the practice is contracted to, if the complaint is not resolved by the practice.

In order to provide a better understanding of the context, it would be helpful to explain the current challenges within NHS National Services Scotland in relation to change of gender. Many of NHS Scotland's health screening programmes are gender specific e.g., breast and cervical for females and AAA (Abdominal Aortic Aneurysm) screening for male patients.

Whilst there is an enhancement to CHI which has been developed to allow for patients' CHI records to be marked to be included for screening if their gender does not match the gender usually associated with that particular programme e.g. a trans male who had previously had cervical screening in their former gender, the CHI record in the future will be able to record that the patient should be included in the screening programmes - the enhancement is not yet ready to be implemented.

When a patient asks Practitioner Services to change their gender, we alert them to the current clinical risks if they are undergoing a gender specific screening programme or follow-up treatment as a result of this we also advise the patient to discuss the clinical risks with their GP practice.

Practitioner Services will contact the patient to establish if they want a new CHI number and possibly a new NHS number. The new CHI number is communicated electronically to the registered GP practice.

All changes to CHI, including the issuing of a new CHI, number are notified to computer systems within NHS Boards who hold the previous CHI number for that patient to advise them to update - this previous medical records with reference to gender reassignment treatment and subsequent medication cannot be deleted.

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FOI - 000084 Requirements for processing a change of gender and title (HTML) | National Services Scotland

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Freedom of Information request related to requirements for processing a change of gender and title.

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New guidance seeks to support medical and dental students from a faith background

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Key services in West Sussex offering support, information and advice.

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Pride prejudice A scoping review of LGBTQ medical trainee experiences

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Pride prejudice A scoping review of LGBTQ medical trainee experiences

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Pride prejudice A scoping review of LGBTQ medical trainee experiences

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Fertility preservation (Pt info leaflet)

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Fertility preservation (Pt info leaflet)

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Gender Recognition Act Reform 2022 - Scotland

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Gender Recognition Act Reform 2022 - Scotland

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Timeline
2022
3rd March: Gender Recognition Reform Bill published

21st March: Stage One (written evidence) begins with call for views on the Bill

16th May: Call for views closes after four weeks

17th May: Stage One (oral evidence) begins with the Scottish Parliament's Equalities, Human Rights and Civil Justice Committee taking evidence from a range of stakeholders

28th June: Oral evidence finishes after the committee hears from 39 witnesses with a range of perspectives and areas of expertise across 8 public sessions

2nd July: Scottish Parliament enters summer recess until 4th September, meaning no Committee or Chamber sessions

6th October: The Equalities, Human Rights and Civil Justice Committee releases its report, summarising evidence collecting and recommending by a majority that MSPs support the bill

27th October: MSPs debate the principle of the Bill in Scottish Parliament, and a vote on the Bill passes with 88 for, 33 against, and 4 abstains

28th October: Stage Two of the bill begins, meanings MSPs can submit amendments to the Bill to the Equalities, Human Rights and Civil Justice committee for them to approve or deny

22nd November: Final vote is held by the EHRCJ committee on Stage Two amendments, with only minor changes made to the Bill after over 150 amendments are considered

23rd November: Stage Three of the bill begins, the final section of the Bill's progress where all MSPs can suggest and vote on amendments, followed by a final vote on whether the Bill will pass or fail

20th December: After over 140 amendments were submitted, the first debates and votes of Stage Three Amendments begin. Debating and voting over amendments stretches on for three days, with Scottish Parliament meeting well into the early hours of the morning. Few amendments pass, making minor changes to the Bill, but nothing which alters its core function.

23rd December: After closing remarks, a final vote is held on the Bill, which passes with an overwhelming majority of 86 votes for to 39 against, with supportive votes from members of all five parties.
2023
16th January: Secretary of State for Scotland announces that the UK Government will use a Section 35 order under the Scotland Act to block the Bill from gaining royal assent, as they believe it will negatively impact their ability to carry out reserved equalities duties.

12th April: The Scottish Government announces that they will lodge a petition for legislative review of the Section 35 order, meaning they will take the UK Government to court over the legality of the order's use.

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Gender Recognition Act Reform 2022 - Scottish Trans

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2022 3rd March: Gender Recognition Reform Bill published 21st March: Stage One (written evidence) begins with call for views on the Bill 16th May: Call for views closes after four weeks 17th May: Stage One (oral evidence) begins with the Scottish Parliament's Equalities, Human Rights and Civil Justice Committee taking

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Supporting transgender and gender diverse medical students

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Supporting transgender and gender diverse medical students

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Supporting transgender and gender diverse medical students

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We use cookies to help provide and enhance our service and tailor content and ads. By continuing you agree to the use of cookies.

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LGBT inclusive mental health services – good practice guide | Mental Welfare Commission for Scotland

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LGBT inclusive mental health services – good practice guide | Mental Welfare Commission for Scotland

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LGBT inclusive mental health services – good practice guide | Mental Welfare Commission for Scotland

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We protect and promote the human rights of people with mental illness, learning disabilities, dementia and related conditions.

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MSC Active inclusion Challenging exclusions in medical education December 2021

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MSC Active inclusion Challenging exclusions in medical education December 2021

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https://www.medschools.ac.uk/media/2918/active-inclusion-challenging-exclusions-in-medical-education.pdf

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A specific recording of a Grand Rounds talk from February which has been highlighted as an accessible CPD resource re inclusivity. Hopefully you can get a chance to watch the recording if you weren’t in attendance!

Description: ‘NHS Tayside FY1 doctors Suzie Gordon and Cato Prowse kick off the 2022 LGBTQAI+ month presentations with a discussion of the inequalities faced by the LGBTQAI+ community, and what we can do on an individual and institutional level.’

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Dundee University and NHS Tayside Grand Rounds

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LGBTQAI+ Month 2022 - Suzie Gordon and Cato Prowse: LGBTQAI+ Inclusivity and Inclusion in Healthcare

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LGBTQ+ Inclusive Medical Education Alliance (LIMA)

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LGBTQ+ Inclusive Medical Education Alliance (LIMA)

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ABOUT LGBTQ+ INCLUSIVE MEDICAL EDUCATION ALLIANCE

We are a network of medical students, doctors and service users campaigning for better LGBTQ+ teaching for medical students and doctors to improve healthcare professionals' Medical Curriculum and queer patients' experiences. Our vision is for teaching on LGBTQ+ health to be a requirement across UK Medical Schools, in order to sufficiently equip medical students to treat LGBTQ+ patients in their future practise

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Home | LGBTQ+ Inclusive Medical Education Alliance (LIMA)

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ABOUT LGBTQ+ INCLUSIVE MEDICAL EDUCATION ALLIANCE We are a network of medical students, doctors and service users campaigning for better LGBTQ+ teaching for medical students and doctors to improve healthcare professionals' Medical Curriculum and queer patients' experiences.

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ABOUT LGBTQ+ INCLUSIVE MEDICAL EDUCATION ALLIANCE

We are a network of medical students, doctors and service users campaigning for better LGBTQ+ teaching for medical students and doctors to improve healthcare professionals' Medical Curriculum and queer patients' experiences. Our vision is for teaching on LGBTQ+ health to be a requirement across UK Medical Schools, in order to sufficiently equip medical students to treat LGBTQ+ patients in their future practise

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Home | LGBTQ+ Inclusive Medical Education Alliance (LIMA)

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ABOUT LGBTQ+ INCLUSIVE MEDICAL EDUCATION ALLIANCE We are a network of medical students, doctors and service users campaigning for better LGBTQ+ teaching for medical students and doctors to improve healthcare professionals' Medical Curriculum and queer patients' experiences.

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Not Seeing Myself in the Medical Curriculum with Ethan Wilson

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Carving my own path as a queer doctor with Duncan Shrewsbury

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Diane Goodman Consulting

Diversity ● Inclusion ● Equity ● Social Justice

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Trainer, consultant, professor, speaker, author, and activist, Diane Goodman has been addressing issues of diversity and social justice for over 30 years.

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Grand Rounds have facilitated a series of LGBT+ themed lectures doing LGBT history month on an annual basis. The series can be found here

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Dundee University and NHS Tayside Grand Rounds - YouTube

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Dundee University and NHS Tayside Grand Rounds

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Share your videos with friends, family, and the world

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Supporting the reproductive and psychosocial needs of people with variations in sex characteristics: healthcare policy and practice recommendations

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Supporting the reproductive and psychosocial needs of people with variations in sex characteristics: healthcare policy and practice recommendations

Reprofutures project is a co-produced and collaborative study involving people with variations in sex characteristics, support and community group facilitators, activists, and campaigners. Our work addresses the psychosocial support needed with reproduction, fertility, relationships and parenting for people with variations in sex characteristics (VSCs). These policy and practice recommendations have been produced as a result of our two-year project, in consultation with 28 people with VSCs, and are intended for healthcare practitioners in the UK.

If you require a version in a different accessible format, please get in touch.

Healthcare recommendations by Dr Charlotte Jones (Wellcome Centre for Cultures and Environments of Health, University of Exeter), Anis Akhtar, Paul Dutton, Sara Gillingham, Rachel Purtell, Magda Rakita, Tabitha Taya, Kaz Williams and Alex Woodward.

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Supporting the reproductive and psychosocial needs of people with variations in sex characteristics: healthcare policy and practice recommendations Reprofutures project is a co-produced and collaborative study involving people with variations in sex characteristics, support and community group facilitators, activists, and campaigners.

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Contraceptive Choices and Sexual Health for Transgender and Non-Binary People

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Contraceptive Choices and Sexual Health for Transgender and Non-Binary People

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FSRH CEU Statement: Contraceptive Choices and Sexual Health for Transgender and Non-Binary People (October 2017) - Faculty of Sexual and Reproductive Healthcare

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Breast screening is a test for breast cancers that are too small to see or feel.

Breast screening doesn't prevent cancer but can detect cancer early and reduce the number of women who die from it. Breast screening saves 130 women's lives each year in Scotland.

The most effective way of testing for breast cancer is using breast X-rays (mammograms).

Eligibility

Breast screening is offered every 3 years to all females aged 50 to 70 as the risk of developing breast cancer increases with age.

Trans women

If you're a trans woman and taking hormones, the development of breast tissue means that you may be at risk of developing breast cancer.

You'll be automatically invited for breast screening every 3 years if:

you're between the ages of 50 and 70

you've changed your CHI number to reflect your female gender

You won't be invited if you haven't changed your CHI number to reflect your female gender. However, you can still have breast screening by arranging an appointment with your local breast screening centre.

Trans men

If you're a trans man and haven't had your breasts removed you may be at risk of developing breast cancer.

You'll be automatically invited for breast screening every 3 years if:

You won't be invited if you've changed your CHI number to reflect your male gender on or before 14 June 2015. However, you can still have breast screening by arranging an appointment with your local breast screening centre.

Breast removal surgery (mastectomy)

If you're a trans man and have had a bi-lateral mastectomy (both breasts removed):

you're less likely to develop breast cancer as there'll be little breast tissue left

you won't be eligible for breast screening

You should remain breast aware and contact your GP if you notice any unusual changes.

If you decide not to have screening

If you decide not to have screening, even when eligible for it, you should let the screening centre know in plenty of time. You'll be invited for screening again in 3 years. If you don't want to be invited again, ask the screening centre for a disclaimer form so that your name can be removed from the system.

Further information

Our breast screening section has more information about this screening service, including:

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Breast screening is a test for breast cancers that are too small to see or feel. Breast screening doesn't prevent cancer but can detect cancer early and reduce the number of women who die from it. Breast screening saves 130 women's lives each year in Scotland.

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Clinical guidance document - gender identity - FINAL-EDITABLE

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News

Published on 29 March 2022

University of Dundee researchers have won a Generations Working Together Award for a project that brought together an intergenerational group of LGBTQ+ people to discuss their experiences and perspectives

'Citadel Love Stories: Exploring Life-time LGBT2QI+ Love and Relationships' was led by Dr Mei Fang and Professor Judith Sixsmith (School of Health Sciences) and Professor Michael Gratzke (School of Humanities and Director of the Doctoral Academy) along with partners at the Citadel Youth Centre in Edinburgh.

The project was funded by the Institute for Social Sciences Research (ISSR) and brought participants together in a virtual space where they conveyed a strong sense of shared love and relationship experiences.

The storytelling focus of the project provided the opportunity to explore health and social outcomes associated with younger and older peoples' LGBTQ+ experiences. These stories are contained in a zine, which participants received as a record of their experience that they could share with friends and family.

Citadel Love Stories won the Social Justice and Dignity category of the Generations Working Together Awards. A short film sees participants and researchers share their experiences of the project, while more information can be found here.

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News Published on 29 March 2022 University of Dundee researchers have won a Generations Working Together Award for a project that brought together an intergenerational group of LGBTQ+ people to discuss their experiences and perspectives 'Citadel Love Stories: Exploring Life-time LGBT2QI+ Love and Relationships' was led by Dr Mei Fang and Professor Judith Sixsmith (School of Health Sciences) and Professor Michael Gratzke (School of Humanities and Director of the Doctoral Academy) along with partners at the Citadel Youth Centre in Edinburgh.

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Holden, C. and Shrewsbury, D. (2021) 'The transgender patient in primary care', InnovAiT, 14(12), pp. 750-756.

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NHS Tayside LGBT+ support organisation

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Transgender Patients: What Radiologists Need to Know

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Transgender Patients: What Radiologists Need to Know

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Transgender Patients: What Radiologists Need to Know : American Journal of Roentgenology
: Vol. 210, No. 5 (AJR)

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OBJECTIVE. The purposes of this article are to examine a few of the barriers the transgender population faces in achieving equitable health care, to suggest ways radiologists and radiology staff ca...

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I AM THEY - A Non-Binary Transgender Documentary (Part 1)

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I AM THEY - A Non-Binary Transgender Documentary (Part 1)

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I AM THEY - A Non-Binary Transgender Documentary (Part 1)

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How covid-19 has exacerbated LGBTQ+ health inequalities

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How covid-19 has exacerbated LGBTQ+ health inequalities

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How covid-19 has exacerbated LGBTQ+ health inequalities

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Despite inadequate monitoring of health in the LGBTQ+ community, the data we have suggest a disproportionate effect of the covid pandemic and its control measures, writes Callum Phillips "Wherever you meaningfully look for LGBTQ+ health inequalities, you find them," says Michael Brady, national adviser for LGBT health at NHS England.

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"When I announced the formation of the LGBTI Inclusive Education Working Group to Parliament back in 2017, I said we all have a responsibility to support our children and young people to be confident and proud of who they are, to know that they are valued and loved, and to know that they will be treated equally and fairly.

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GLADD is the UK's only organisation that unites and represents LGBTQ+ doctors and dentists from all over the country.

We open our membership to any doctor, dentist, medical or dental student who supports the values and constitution that GLADD stands for.

We run events in London and through our regional networks around the country. Highlights include our AGM dinner, summer and New Year parties, Pride and socials with other LGBTQ+ professional groups.

While we are disappointed that this year's Pride in London is not taking place due to ongoing COVID concerns, as medical professionals we understand and support the decision to prioritise the health and safety of our community.

Read more here about how COVID has worsened inequalities experienced by LGBTQ+ communities, particularly health inequalities.

GLADD has a respected national voice in LGBTQ+ health activism and education, working with leading figures such as the British Medical Association, General Medical Council, Royal Colleges and Parliament. We collaborate with universities and the NHS to further research into LGBTQ+ health issues and deliver training aimed at empowering those working in and studying healthcare to tackle discrimination in support of their LGBTQ+ colleagues and patients.

You can keep up to date with what GLADD is doing on Facebook and Twitter. If you would like to get involved with our current projects or have an idea of how we can support your work, please get in touch. Whether you would like to help deliver LGBTQ+ teaching locally, run a research project or have seen an opportunity for improving LGBTQ+ health & healthcare, we'd love to hear from you.

Students make up a significant proportion of our GLADD membership and there are opportunities all year round for you to get involved with our work and community.

Find out more about our mentoring programme, which is open to all members.

Our support pages include general information, resources and articles as well as specific LGBTQ+ Health, Bisexual, Trans and Religious support.

You can contact GLADD via the form below and one of our committee members will get back to you as soon as they can.

The committee are all working professionals and full time students so please allow a minimum of 5 days for your query to be answered. All messages received remain strictly confidential and are only seen by the member(s) of the committee responding to you.

Please note that GLADD is unable to provide medical and dental advice or recommend LGBTQ+ practitioners. LGBTQ+ patients may find the GMC's Guide for LGBT Patients useful. Your GP or dentist is often the best first contact for health advice.

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The association of LGBTQ+ Doctors and Dentists. GLADD is the UK's only organisation that unites and represents LGBTQ+ doctors and dentists from all over the country. We open our membership to any doctor, dentist, medical and dental student who supports the values and constitution that GLADD stands for.

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Find resources near you

Our Community Outreach team, with the help of our wonderful volunteers have put together a list of organisations, support groups and other charities that can provide more support.

Awards and Nominations

Winner of "Charity & Community Initiative Award 2019"

Nominated "British LGBT Award 2020"

Nominated "National Diversity Award 2019 and 2020"

Awarded "One of the Top UK LGBT+ podcasts"

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Our Community Outreach team, with the help of our wonderful volunteers have put together a list of organisations, support groups and other charities that can provide more support.

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Reale, C., Invernizzi, F., Panteghini, C. and Garavaglia, B. (2021) 'Genetics, sex, and gender', Journal of Neuroscience Research, n/a(n/a). DOI: https://doi.org/10.1002/jnr.24945.

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New BJGP paper inc updated WHO definition

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New BJGP paper inc updated WHO definition

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INTRODUCTION

'The expression of gender characteristics, including identities, that are not stereotypically associated with one's assigned sex at birth is a common and culturally diverse human phenomenon (that) should not be judged as inherently pathological or negative.'

Recently the World Health Organization has moved to re-define gender identity-related health and now uses the umbrella term transgender to describe 'a diverse group of people whose internal sense of gender is different than that which they were assigned at birth'.

This term is growing in familiarity globally and does not imply a medical condition. The term includes people living in accordance with their gender identity in the absence of medical treatment and those undergoing gender-affirmative health care to support and affirm their gender identity including those with non-binary gender identities.

PREVALENCE

Increasing numbers of people are either gender questioning or identifying as transgender. Accurate epidemiological data are not available on how many people globally identify as gender questioning or transgender but there is evidence that the number of patients accessing gender-affirming health services is increasing. This is particularly true for children and adolescents.

Recent studies suggest that the prevalence of a self-reported transgender identity in children, adolescents, and adults ranges from 0.3% to 2.7%, significantly higher than prevalence estimates based on adult clinic-based referrals., Furthermore, an expanded definition of gender variance results in higher prevalence estimates. However, cultural norms around gender expression may impact on self-report and most of the reported prevalence studies have been conducted in European countries.,

TRANSGENDER HEALTHCARE NEEDS

There is an increasing focus on the healthcare needs of transgender people.,, This patient group and their families have specific medical, social, and psychological needs that have not been adequately met by routine healthcare services including primary care.,

Transgender people experience high levels of discrimination, stigma, social exclusion, and harassment in many aspects of their lives including in healthcare settings. Access to specialist gender-affirming services is challenging with long waiting lists and lack of services in many regions. Many fear disclosing gender identity to their healthcare providers including their GPs, which may have a negative impact on healthcare provision.

Compared with their cis-gender peers, transgender people experience many health disparities including higher rates of HIV infection, sexually transmitted infections, substance use, mental illness, and suicide., Delays in accessing essential health-related support to enable transitioning can exacerbate these risks.

Studies have shown that healthcare providers struggle to provide appropriate and sensitive gender-affirming care to this group including the use of acceptable terminology. This deficit is often linked to inadequate knowledge and training of healthcare providers.,

There is also a recognised deficit of quality research on transgender issues that impacts negatively on our understanding of their healthcare needs.

IMPROVING TRANSGENDER HEALTH CARE IN PRIMARY CARE

The General Medical Council and GP professional bodies in Ireland and the UK have published guidance and training modules on transgender health.,,, However, many challenges remain in how to provide transgender people with timely and quality primary health care appropriate to their needs.

GPs play a critical role in providing a safe space for gender-questioning and transgender people (including children) to disclose their issues and get access to appropriate support and referral pathways., GPs are invaluable support to family members and other support networks who may struggle to understand gender identity and the appropriate terms to use. With a sensitive and non-judgemental approach to healthcare provision, GPs can help reduce the existing health inequities between this minority group and the rest of the population. Reassuring patients about confidentiality is also important.,

It is important that GPs and their staff are aware of the correct terminology to use, and that we seek and clarify with the patient their name, pronoun, and preferred anatomical terms., These should be documented in the patient's medical records with all practice staff aware of how to address the patient. Providing non-binary and free-text options on practice registration forms will send a message of acceptance.

It is also important that GPs know the basics of gender-affirming health care and are aware of referral pathways for support and specialist treatment services.,, While the management of routine health care for transgender people is similar to their cis-gender peers, there are some issues that are unique to transgender healthcare delivery., Some of these can be very sensitive and how we approach them will gain a sense of trust with our patients.,

These issues include:

physical examination, in particular chest and genital examination;

appropriate inclusion in national cervical and breast screening programmes;

prostate exams in trans women;

fertility and pregnancy care;

sexually transmitted infection (STI) screening;

management of cancer or genetic predisposition syndromes;

patient may source hormone therapy over the internet and present for care around its management (including when their source may be abruptly stopped);

patients may present for pre- or post-gender-affirming operative care; and

the use of puberty blockers in adolescents.

EXPANDING THE ROLE OF PRIMARY CARE IN TRANSGENDER HEALTH CARE

A number of transgender people will embark on social or medical transitions. In most jurisdictions, specialist services are hard to access, costly, and the time delay for patients can be particularly stressful.

There are conflicting views on the role of primary care in providing transgender health care. Some GPs believe that most transgender health concerns can, and should, be managed in primary care. The care of these patients is not simply limited to hormone treatment and surgery, but incorporates an appreciation of wider psychosocial and professional issues. The 'whole-person' approach of primary care makes it a good fit for addressing the health needs of transgender people.,

However, there are concerns about the level of competency needed to provide some aspects of the medical care that may be required (for example, hormone therapy, preand post-gender-affirming surgery care, and puberty blockers). Given the deficits in the availability of specialist services, many GPs are concerned that they may be left to fill this void without the necessary terminology, training, and skill set.

Both the Royal and Irish College of General Practitioners recognise the important role that GPs play in caring for transgender patients., Both colleges identify lack of training and the timely access to specialist services as major barriers to GP involvement in transgender health care and advocate for an urgent increase in specialist capacity and increased training needs for GPs.,

However, this existing position does not address the present needs of many transgender patients. Many are still accessing hormone therapies online and suffer great stress in not being able to access gender-affirming surgery options in a timely manner. There may be a need for a more blended approach to treatment provision with some GPs developing a special interest in the field and providing support to their primary care colleagues. This approach has been successfully developed by the Indigo project in Manchester.

This approach could be augmented by the remote access to specialist service. Primary care has already developed a similar model for community hepatitis C treatment and more recently in the remote management of COVID-19.

MEDICAL EDUCATION

There is an identified deficit in the amount of LGBT training in medical curricula, which impacts on the confidence and competence of doctors to provide gender-affirming care.,, It is recognised that educating healthcare providers about LGBT-related health is the most effective way to improve healthcare delivery to this population., It is a priority to incorporate more LGBT training into both undergraduate and postgraduate medical GP training and professional development. This may challenge some GPs to question their cis-normative and heteronormative assumptions that can negatively impact the care of their LGBT patients.

CONCLUSION

The care of transgender and gender-questioning people in primary care is of increasing relevance. It requires an open and non-judgemental approach, correct use of terminology, and knowledge of treatment and support services. Increasing specialist training on LGBT is critical to provide GPs with the skills and knowledge to provide appropriate care to this vulnerable group who suffer disproportionate levels of physical and mental health issues compared with their cis- gender peers. There is also an opportunity to review how specialist transgender treatment services are provided including the options of developing the role of GPs with a special interest and the use of remote models for specialist transgender healthcare delivery. Increased funding and research in the area is a priority.

Notes

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

REFERENCES

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'The expression of gender characteristics, including identities, that are not stereotypically associated with one's assigned sex at birth is a common and culturally diverse human phenomenon (that) should not be judged as inherently pathological or negative.'

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Working with older lesbian, gay and bisexual people

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Working with older lesbian, gay and bisexual people

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How do we improve medical education to deal with intersectionality among bame lgbtq+?

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Thank you for this lecture! It would be great if we could have more of these lectures, especially from year 1.

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Are there differences between interacting with a MtF and FtM trans person?

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Are there differences between interacting with a MtF and FtM trans person?

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Does it exclude people to say "LGBT" rather than the longer acronym?

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Does it exclude people to say "LGBT" rather than the longer acronym?

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How should we approach care for children and young people who are trans or non-binary 

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How should we approach care for children and young people who are trans or non-binary 

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Dr McConville, do you think GPs reluctance to prescribe hormone therapies branches from a medical lack of knowledge or simply the infamilarity?

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Do you have an issue with the use of the rainbow of a symbol for the NHS during Covid

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What is your opinion on the Tavistock and Portman NHS recent ban on under 16s receiving hormone blockers? Do you think it is poor care due to the studies showing that hormone blockers reduces suicidal ideation in trans youth. If you're comfortable answering, would you have taken hormone blockers if they were available to you pre-puberty?

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what to you think is the best way to ask a patient about their gender identity and anatomical reproductive parts so medical professionals don't miss diagnoses and opportunities for screening are given?

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what to you think is the best way to ask a patient about their gender identity and anatomical reproductive parts so medical professionals don't miss diagnoses and opportunities for screening are given?

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How do you feel about doctors/healthcare professionals being open and asking questions if they aren't sure vs how much they should already know to give their trans patients effective care?

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How do you feel about doctors/healthcare professionals being open and asking questions if they aren't sure vs how much they should already know to give their trans patients effective care?

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How has your experience been with health checks/screening tests? Is there ways to make this better for the LGBT+ community?

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What's the most important piece of advice you'd like to give us for when we encounter LGBT+ patients in our future careers?

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can you explain what you mean by this please? is this about difficulty finding drs who are supportive and don't judge you or about finding drs who are knowledgeable and well informed about the topic
?

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Have you any thoughts on the use of the rainbow flag for the NHS during COVID?

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should we be asking everyone about pronouns when they come in? 

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should we be asking everyone about pronouns when they come in? 

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Do you feel there is adequate support for you if you would like to report abuse/an unprofessional experience?

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Do you feel there is adequate support for you if you would like to report abuse/an unprofessional experience?

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What are the ways in which GP practices/clinics could make it a more comfortable place for you? Ie is it welcoming to see the pride flag etc/ pronoun posters?

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What are the ways in which GP practices/clinics could make it a more comfortable place for you? Ie is it welcoming to see the pride flag etc/ pronoun posters?

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what tips would you give us, as medical students/future doctors, for helping people who have gender dysphoria? Whether they present with this or if they are in to see you for an unrelated medical problem

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Have you heard any good stories about trans people's experience in healthcare? if so, what about it was good for that person and what did you wish other healthcare professionals would do too?

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what is the most important piece of advice you could give for us going forward as doctors for interacting with the trans community (and the wider LGBTQIA+ community)?

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what is the most important piece of advice you could give for us going forward as doctors for interacting with the trans community (and the wider LGBTQIA+ community)?

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LGBT Health Hub

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In July 2017, the Government Equalities Office launched a national survey of LGBT people which was open to anyone who identified as having a minority sexual orientation, gender identity or had variations in sex characteristics. It asked questions about people's experiences of living in the UK and in accessing public services and received more than 108,000 responses, an unprecedented number.

The survey highlighted that LGBT people's experience of healthcare in the UK is often not as good as those who are not from the LGBT community. This is often caused by the lack of knowledge of healthcare providers of the specific health needs of their LGBT patients.

This collection of eLearning modules, podcasts and screencasts aims to inform and update all members of the general practice team on particularly important aspects of primary care for LGBT people, to improve both experience and outcomes for our patients. It was produced with the help of a grant by the Government Equalities Office and with the guidance of the RCGP's LGBT+ steering group.

We encourage you to undertake all six modules, after which you can complete the LGBT Health post-learning assessment section at the bottom of the hub so we can evaluate the impact of these resources.

The LGBT Health Hub is free to access when you register for an RCGP account. For instructions on how to register and log in, please click here.

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In July 2017, the Government Equalities Office launched a national survey of LGBT people which was open to anyone who identified as having a minority sexual orientation, gender identity or had variations in sex characteristics. It asked questions about people's experiences of living in the UK and in accessing public services and received more than 108,000 responses, an unprecedented number.

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Helping gender-diverse kids, young people and their families since 1995

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A core component of the remit of Scottish Trans Alliance is to provide high quality training to public service providers in Scotland, to help mainstream transgender equality, rights and inclusion. To date, Scottish Trans Alliance has provided a wide range of training on good practice in ... Read More

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Scottish Trans Alliance - Trans equality in Scotland

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A core component of the remit of Scottish Trans Alliance is to provide high quality training to public service providers in Scotland, to help mainstream transgender equality, rights and inclusion. To date, Scottish Trans Alliance has provided a wide range of training on good practice in ... Read More

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Long term hormonal treatment for transgender people

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Long term hormonal treatment for transgender people

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1. Martin den Heijer , professor of endocrinology 1 2,

2. Alex Bakker , transgender man with 20 years of experience taking hormonal treatment,

3. Louis Gooren , emeritus professor in transgender medicine 2

1. 1Department of internal medicine, VU Medical Center, Amsterdam, Netherlands

2. 2Center of expertise on gender dysphoria, VU Medical Center, Amsterdam, Netherlands

Transgender people using hormone treatment need lifelong medical support and care. Hormonal treatment for gender dysphoria resembles hormone replacement therapy for people with hypogonadism.

Hormone treatment in transgender people is accepted to be safe and increases overall wellbeing in most people. The most common (though rare) side effects are venous thrombosis in trans women due to oestrogens and polycythaemia caused by androgens in trans men.

Some trans women will not have had their prostate removed and some trans men keep their ovaries. Be aware of the risk of cancer in these sites and think about the added risk of hormone supplementation.

Correspondence to M den Heijer m.denheijer{at}vumc.nl

What you need to know

The aim of hormone treatment in transgender people is to adjust their secondary sex characteristics to be more congruent with their experienced gender. Hormone treatment for transgender people is usually initiated by specialist gender clinics, but some people start hormone treatment of their own accord without a prescription. With growing numbers of transgender people presenting to healthcare services (estimated as 9.2 per 100 0001), general practitioners, general endocrinologists, and other doctors will become increasingly involved in their long term care, the prescription of hormones, and consideration of potential side effects. Several guidelines are available on the start of hormonal treatment2 3 4 5 6 7; the focus of this article is the long term hormonal care for transgender people who might no longer attend a specialist clinic. It is aimed at a more general readership of physicians occasionally seeing adult transgender people.

Transgender terminology

Language and terminology are sensitive. Some terms used in the past are no longer appropriate because they might have negative connotations.

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Long term hormonal treatment for transgender people

# data[].attributes.attachment_link.description
What you need to know The aim of hormone treatment in transgender people is to adjust their secondary sex characteristics to be more congruent with their experienced gender. Hormone treatment for transgender people is usually initiated by specialist gender clinics, but some people start hormone treatment of their own accord without a prescription.

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Communicating With Patients Who Have Nonbinary Gender Identities

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Communicating With Patients Who Have Nonbinary Gender Identities

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Abstract

The increasing visibility of transgender people and others who do not conform to traditional gender norms challenges us to think about gender in new ways, and to use new terminology when communicating with patients. People who describe themselves as nonbinary have a gender identity that is not exclusively girl/woman or boy/man. A small but growing body of research indicates they experience high levels of societal victimization and discrimination, and are misunderstood by health care clinicians. Using language that is inclusive of all gender identities can reduce these burdens and barriers. In this essay, we use a case scenario that illustrates ways to interact respectfully and affirmatively with nonbinary people throughout the patient care experience.

Case Scenario: Sam, aged 22 years: Sam is about to arrive for a new patient visit at a local health center. As a person with a nonbinary gender identity, Sam is nervous that the experience will not go well. Will the new primary care clinician accept Sam's gender identity or dismiss it as "confusion" like the last clinician did?

Increasingly, health care clinicians see patients like Sam who live openly as nonbinary-an umbrella term that encompasses any gender identity outside of the binary construct of girl/woman or boy/man. Gender identity refers to the inner sense of one's gender, while sex refers to the female or male designation assigned to a newborn based on external anatomy. Some but not all nonbinary people identify as transgender, a term that describes people whose gender identity differs from the one traditionally associated with their sex assigned at birth. While many transgender people identify their gender as solely girl/woman or boy/man, nonbinary people may identify as both, somewhere in between, something else, and/or reject the concept of gender altogether. Nonbinary people who have a fluctuating gender identity often refer to themselves as gender fluid.

As an underserved population at disproportionate risk for discrimination, victimization, and suicidal ideation, nonbinary people are especially in need of health care clinicians who affirm their gender identities. The medical literature on culturally sensitive care with racial/ethnic minorities as well as sexual and gender minorities recognizes language and communication as fundamental to engendering trust with patients, positively influencing patient satisfaction and adherence, and ultimately improving engagement in care and health outcomes. In this article, we aim to help bridge language and communication gaps between nonbinary people and their health care clinicians by explaining ways to use affirming terms and pronouns while avoiding assumptions about gender. Sam's case scenario illustrates approaches for communicating effectively with nonbinary people throughout the patient care experience.

When Sam arrives at the health center, the registration staff member greets Sam by saying, "Good morning. How may I help you?" Sam is pleased that the staff member does not use any gender-specific terms or identifiers, like "ma'am/sir" or "Ms/Mrs/Mr."

The registration staff member in Sam's case scenario demonstrates the practice of avoiding gendered terminology when speaking with new patients. It is impossible to know someone's gender identity or pronouns just by hearing their voice or looking at them. Some people wear gender nonconforming clothing and hairstyles, while others dress, speak, and act in ways traditionally associated with either femininity or masculinity. Therefore, by asking "How may I help you?" instead of "How may I help you, ma'am/sir?" the registration staff member reduces the likelihood of offending patients by incorrectly guessing their gender.

Sam is handed a registration form that asks for "name and gender on insurance," the "name on identification documents," and the "name you wish to be called during the office visit." Sam feels relieved to be asked these questions. Sam currently has neither the time nor funds to legally change their name from "Sherilynn" to "Sam." In addition, the form asks for the patient's pronouns, gender identity, and sex assigned at birth. Sam checks off "they/them/theirs" for pronouns, "genderqueer" for gender identity, and "female" for sex assigned at birth.

By collecting information from patients on names, gender identity, and pronouns, this registration form signals to patients of diverse gender identities that the health center's staff will make an effort to address patients in accordance with their wishes. Although Sam identifies as genderqueer, other nonbinary people may use a range of terms to describe themselves ( Table 1). The terminology for nonbinary identities varies from person to person; over time, new terms also emerge while others become outdated. For these reasons, organizations may want to provide patients with a list of gender identity terms as well as the option to write in a term. It is also recommended to offer patients an option to "choose not to disclose."

Using correct pronouns is essential for building a stronger patient-clinician alliance. While Sam's pronouns are they/them/theirs in the singular form, other people may have more traditional pronouns such as she/her/hers and he/him/his, or pronouns such as ze/hir/hirs that were developed specifically by and for nonbinary people. Some people do not have pronouns at all. Because speaking with unfamiliar (or no) pronouns may at first present a challenge, we developed a chart ( Table 2) as part of our guidelines from the National LGBT Health Education Center that lists pronouns along with phrases commonly used in clinical situations, to adapt for self-directed practice or as part of a workplace training.

Documenting patients' sex assigned at birth in addition to gender identity helps to ensure that insurance will cover screening and treatment related to sex characteristics. Some people may not feel comfortable including this information initially and may need to first build more rapport with their clinician.

Finally, the discrepancy between Sam's name and the name on their insurance is common for people with transgender and nonbinary identities. In situations when a person gives a name that does not match any records, staff can ask, "I'm sorry, could your insurance/chart/record be under a different name?" The challenge for health care organizations is to not only collect names, pronouns, and gender identity in registration forms, but also to ensure the electronic health record can harness and display this information in ways that are visible to relevant staff. Some software systems have fields already developed for this, while others need modifications. Once systems are in place, staff members will likely require training and practice in order to be able to consistently access and use the names and pronouns provided by patients.

Sam's new primary care clinician, Dr Shaw, refers to Sam as "transgender" while taking a social history. Sam corrects Dr Shaw, explaining that they are genderqueer and do not consider themselves transgender. Dr Shaw replies, "I'm sorry, I'm not familiar with the term 'genderqueer' and assumed it was the same as 'transgender.' I appreciate your patience while I learn. Would you be willing to tell me what being genderqueer means to you? If not, that's okay."

When communication missteps occur (early in the learning process, they almost inevitably do), most patients are understanding and show appreciation for the clinician's commitment to learning and practicing new terms and pronouns. In Sam's case, Dr Shaw demonstrates a best practice by offering a brief and sincere apology. Moreover, by asking Sam if they are willing to share more about their identity, Dr Shaw attempts to build rapport and better understand Sam without obligating Sam to act as a teacher. Occasionally, patients will become angry or distressed if called the wrong pronoun, name, or gender. These patients have likely experienced a heavy burden of discrimination in the past that contributes to this reaction. An empathic response could be: "I hear that you are very upset. I apologize, I didn't mean to disrespect you."

Dr Shaw's conflation of the terms genderqueer and transgender stems from the complex nature of gender identities and the nuanced array of related yet distinct terms for these. Nonbinary people may or may not think of themselves as transgender. Additionally, like transgender men and women, nonbinary people sometimes seek hormone therapy or surgeries to affirm their gender identity and to help them feel more aligned in their bodies.

After taking Sam's history, Dr Shaw asks Sam to prepare for the physical exam and says, "Please change into this robe, with the opening in the front. You can leave on your bottom underwear but it is better to not have anything covering your chest, as long as that is comfortable for you. If not, that is fine too."

By using terms that apply to all genders and anatomies, like underwear and chest, Dr Shaw affirms Sam's nonbinary gender identity and provides a safe and inclusive health care experience. In addition, Dr Shaw recognizes that Sam may not be comfortable enough with a new clinician to expose their chest, because this may trigger a sense of dysphoria. During the exam, Dr Shaw can ask Sam what terms they use for different parts of their anatomy, and then mirror those terms.

CONCLUSION

Our culture's increasingly nuanced understanding of gender brings a responsibility for all health care clinicians to support patients' self-definition of their gender identities. Best practices for all health care staff include avoiding assumptions about patients' gender identities, asking for information about name and pronouns in order to adopt these consistently throughout the clinical setting, and describing anatomy and related terms with gender-inclusive language. Through these communication approaches, health care clinicians can remain responsive to rapidly expanding concepts and terminology for gender identification and expression within our society, and can offer more patient-centered care that moves beyond binary gender concepts.

Footnotes

Conflicts of interest: authors report none.

To read or post commentaries in response to this article, see it online at http://www.AnnFamMed.org/content/16/6/559.

Funding support: The authors' work was supported by Grant U30CS22742 from the Health Resources and Services Administration Bureau of Primary Health Care and the Horace W. Goldsmith Foundation. The funders were not involved in the writing of the article or in the decision to submit the article for publication.

Received for publication June 20, 2018.

Revision received September 10, 2018.

Accepted for publication September 20, 2018.

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Communicating With Patients Who Have Nonbinary Gender Identities

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The increasing visibility of transgender people and others who do not conform to traditional gender norms challenges us to think about gender in new ways, and to use new terminology when communicating with patients. People who describe themselves as nonbinary have a gender identity that is not exclusively girl/woman or boy/man.

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British Association of Gender Identity Specialists

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British Association of Gender Identity Specialists

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The British Association of Gender Identity Specialists (BAGIS) was founded in 2014 for the purpose of promoting clinical research and exchange of knowledge of gender dysphoria and transgender health. It is an association of healthcare professionals, from a wide range of disciplines, committed to promoting excellence in clinical practice, clinical research, training and education in the field of healthcare for transgender and gender non-conforming people. The Association encourages and fosters the highest standards of practice amongst its members, based upon the best available evidence, and also advocates the adoption of similar standards amongst all health professionals in the British Isles.

SCIENTIFIC SYMPOSIUM 2019

This year's symposium took place in Durham on Thursday 3rd and Friday 4th October. MOre information will be available soon.

Fertility Preservation for Trans People

by James Barrett (Outgoing President of BAGIS)

This is probably the most delightful thing I have had to announce as President of the Association.

Rather more than two years ago the Association, driven by the concerns of members, complained to the Equality and Human Rights Commission that NHS England Clinical Commissioning Groups very often refused to fund the preservation of the fertility of trans people undergoing hormone treatment and surgery - in circumstances where the fertility of cis gender people was funded. We felt that this was discriminatory.

The Equality and Human Rights Commission noted that the Manchester LGBT Foundation had raised the same concerns and asked the Association to provide hard evidence. It was at that point that I wrote to you asking for just exactly that.

ean and stylish font favored by designers. It's easy on the eyes and a great go to font for titles, paragraphs & more.

And evidence there was ! The most egregious cases were passed to the Commission and I found myself spending many long hours consulting with lawyers. The heartening thing, though, was a preliminary legal opinion sought by the Commission that suggested a seventy-five per cent chance of success if the matter came to a hearing. I was advised that this is lawyer-speak for a very strong case.

The response of NHS England was a robust rebuttal, and a court date was set for the 27th of March, just before what was then thought to be Brexit day.

I'm pleased to say that the matter settled out of court the day before the hearing was due to start. NHS England are now reissuing their guidance to Clinical Commissioning Groups. NHS England cannot, it seems, actually order Clinical Commissioning Groups to fund gamete storage for trans people but instead has advised them that were they to refuse they would be very likely to be open to legal challenge.

I am so grateful for the help I got from all the members of the Association. In the middle of all the legal wrangling it's sometimes easy to forget that there are real people involved. The human side was brought sharply to my attention, just a month ago. I was talking to a collection of fertility specialists, as I often end up doing. A much greater proportion than I have ever seen before had preserved the fertility of trans people; all thought that there would be even more in the future. For the very first time in my experience, though, one of the specialists reported a trans person who had come back, looking well, happy, thriving in life, with a settled relationship and wanting to have children using gametes stored five years earlier. Brought a lump to my throat, I have to say.

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The British Association of Gender Identity Specialists (BAGIS) was founded in 2014 for the purpose of promoting clinical research and exchange of knowledge of gender dysphoria and transgender health. It is an association of healthcare professionals, from a wide range of disciplines, committed to promoting excellence in clinical practice, clinical research, training and education in the field of healthcare for transgender and gender non-conforming people.

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For the first time we are publishing a What Your Patient is Thinking article by a group of people. These transgender authors share their experiences of healthcare and the important messages they would like doctors to know

Put simply, you can't tell my medical needs by looking at me. Of course that's true for any patient, but trans people have particular difficulties because we challenge the pervasive myth that people come in two basic types-"male" and "female"-and that you can always tell which someone is just by looking. That's why a group of us has written this piece together-there is no one "trans experience," but there is trans inclusive medicine, which fosters respect, cooperation, and the best experiences and outcomes.

I could be any one of your patients: we come in all shapes and sizes, with all kinds of reasons for coming to see you. Maybe I'm open about being trans-or perhaps it's just a 40 year old footnote on my medical records, with little relevance to who I am today. Some appointments will be about referring me to a gender identity clinic, or about hormones. Others will be what anyone else comes for-tonsillitis, back pain. Please don't bring up my trans status if it's not relevant to the consultation.

What you call me matters

You probably aren't an expert in trans issues-that's OK. You don't need to be an expert to treat me with kindness and compassion: something as simple as the name you call me makes a huge difference. If how you refer to me draws unnecessary attention it can leave me feeling vulnerable or agitated, or even put me in danger.

"One clinic called people in for appointments by putting names up on a big screen. I sat there shaking, because I didn't know what would happen. In the end, they had my name right, but my title was still Mr. When I got up to go in and meet the doctor, I could feel everyone in the room looking at me and wondering."

Some terms might be unfamiliar-I might tell you that I use the gender neutral title "Mx" (pronounced like a cross between "Miks" and "Muks") or the gender neutral pronoun "they." Although these ideas might seem new, that's not the case. I've always been here, as your trans patient; it's just I'm not hiding any more.

Given that history, and the evidence I've seen about some people's beliefs and attitudes, I can be nervous about talking to you about my trans identity. You can make that easier by making your positive attitude obvious. Let me know that you understand that everyone is the expert on their own identity, and check in occasionally: "how would you like me to talk about you?" Please respect my preferences and be consistent in referral letters, medical records, and when you talk about me to colleagues. (Please respect my identity even when I'm not there.)

"One of the first things I did on meeting my new GP was tell him that I'm trans, and use gender neutral pronouns. Eighteen months later he was reading his notes out to me as he typed them up (as usual) and he used a gendered pronoun for me-then immediately corrected himself and apologised. He'd been getting it right all along, and I hadn't even noticed. It was a lovely surprise, and I trust him even more."

I might need you to use my old name when sending letters to my home, however: this could be vital to keep me safe, or just because I'm not ready to tell everyone yet. Please check with me, respect my decision, and keep my trans status confidential-it can, in fact, be illegal to break that confidence.

Thinking outside the "M/F" tickbox

You'll need to think outside the tick-box about what's relevant for my body: is a smear test really necessary for all women (and only women)? Or is it for everyone with a cervix? The same goes for prostate and breast screening, and for any aspect of medicine where there's a distinction between how you'd treat a "male" and how you'd treat a "female." Those categories have never been the whole story-trans and intersex people have always been here-but the medical literature often oversimplifies, to our detriment. Knowing that I'm trans doesn't tell you anything about my primary and secondary sexual characteristics; but then neither does knowing-or assuming-that I'm not. If you need to ask, check whether I prefer to talk about my body in a particular way to minimise discomfort-I might want to avoid certain words, for example. Although I might be comfortable talking about my breasts, or going to get a routine prostate screening, it's also possible that I might want you to talk about my "chest" instead, or help me find ways to engage with the men's health unit that won't cause me tremendous distress.

"I know it's good to get regular sexual health screens, but it's always stressful: I usually pretend to be cis. In the past, when I've mentioned a sexual partner who is trans, I've been asked upsetting and intrusive questions; it feels like that would get even worse if I admit that I'm trans, too. Visiting a trans-centred clinic was a revelation. They had to list me as female so that the system would accept a smear sample from me, but they apologised, explained, and scribbled out the gender marker on my label. I felt safe, and I felt seen. I'm definitely going back."

I probably won't fit the stereotypical trans narrative, of making a "full medical transition" from my "birth sex" to an "idealised opposite acquired gender." I might not feel entirely like the labels man or woman fit me-hence "Mx" and "they." I might be distraught about my genitals and other gendered characteristics-voice, stature, (lack of) body hair-equally, I might be ambivalent or even comfortable with some aspects.

"The first medical professional I came out to was the gynaecologist I was seeing for endometriosis. It wasn't until well after I'd got the diagnosis-and started seeing him without my mum in the room-that I felt able to come out as gender queer. We had a pretty good rapport by this stage, but I was still scared about his reaction. What he did though was tell me that meant we might want to consider androgens sooner than we otherwise would. And then he cheerfully said, "So you won't mind if I neuter you, then?" I'd been warned in advance that he didn't have much by way of bedside manner-I can see how this [that comment] might upset someone else, but it was perfectly pitched for me and it was such a relief."

Please follow my lead with how I talk about and relate to the gendered parts of my body. Just as a disability isn't caused by the wheelchair, but by the stairs-sometimes my dysphoria isn't caused by my body, but by how the rest of the world regards what and who I am.

Social marginalisation means I'm more likely to experience anxiety, depression, substance misuse, or violence. I'll need the same support with that as anyone else, and it certainly shouldn't be a barrier to referring me to a gender specialist-sometimes, gender specific treatment is the only thing that will help.

Trans-specific care

I might come to you for help with medical transition. Most likely this will just mean routine prescription and management of my hormone therapy; but sometimes it'll be my first disclosure. It's okay if you're not familiar with the care pathways: but you should know that they exist and where to find them, and take steps to move me onto them swiftly.

"It took me ages to get up the courage to tell my doctor that I thought I might be trans. I think I was scared of being laughed at. In the end she was really matter of fact about it: I was so grateful to be taken seriously. She told me that I had to be assessed by the local mental health team, but I later found out that they can't diagnose gender dysphoria. I think she wanted me to be sure about my identity, but it's the gender clinic's job to check that-it just meant my transition was delayed. I feel like I lost two years of my life."

Speed is particularly important if I'm just starting puberty, when even the slightest delay can have disastrous effects as I'm forced to live with permanent changes caused by inappropriate hormones, and through the turmoil of adolescence while those changes are happening.

Be aware that NHS gender services are hugely over-subscribed, and the current long waiting times-sometimes years-can be excruciating; but if you stay engaged with the process and keep me updated, you'll help me to avoid some of that pain. In fact, you'll be supporting me to access specialist treatment with one of the highest satisfaction rates of any branch of medicine.

We are your trans patients. We are one in 100 of your patients. You won't always know who we are-two of us have written for this series before, when our trans status wasn't relevant, so we didn't bring it up. We know it's difficult sometimes when your systems struggle to include us, or the literature you rely on doesn't tell you how to treat us. But we're here, we exist; and we're counting on you.

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For the first time we are publishing a What Your Patient is Thinking article by a group of people. These transgender authors share their experiences of healthcare and the important messages they would like doctors to know Put simply, you can't tell my medical needs by looking at me.

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Gender Identity Research & Education Society 

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Gender Identity Research & Education Society 

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GIRES is a UK wide organisation whose purpose is to improve the lives of trans and gender diverse people of all ages, including those who are non-binary and non-gender.
GIRES is a professionally managed membership charity supported by volunteers that, in collaboration with other groups in its field, hears, helps, empowers and gives a voice to trans and gender diverse individuals, including those who are non-binary and non-gender, as well as their families.

We use evidence from individuals' lived experiences, combined with scientific research into gender identity development, to educate all those who are able to improve trans and gender diverse individuals' wellbeing. We contribute to policy development regarding equality and human rights for individuals, especially in healthcare.

We also deliver training, e-learning and information to public and private sector organisations, including supporting trans and gender diverse employees or students.

Please download our leaflet, Information and support for trans, non-binary and non-gender people (PDF, 525KB), for a starting point of discovery.

News

World Professional Association for Transgender Health (WPATH) Releases the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

20th September 2022

East Dundee, Illinois - Following five-years of rigorous scientific effort by more than 120 health care clinical and academic professionals across the globe, the World Professional Association for Transgender Health (WPATH) has released the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (SOC8). Building upon the Standards of Care Version 7, which were released in 2012, the SOC8 provides clinical guidance for health care professionals to assist transgender and gender diverse (TGD) people with safe and effective pathways to achieve lasting personal comfort with their gendered selves, and to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, hormonal or surgical treatments, gynecologic and urologic care, reproductive options, voice and communication therapy, and mental health services (e.g., counseling, psychotherapy), among others.

GIRES General Manager

3rd August 2022

Dr Harriet Hutchinson, is the new GIRES General Manager. She leads strategic activity across the organisation and promotes the conversion of
evidence-based research into real-world policy.

Harriet has a strong history of fundraising and campaigning, including on climate and energy, before shifting her focus to trans issues. She is the co-founder of Action for Trans Health Durham, and has worked to advocate, campaign and affect policy change at a local and national level. She has coordinated community responses to Gender Recognition Act reform, advised on changes to local primary care policies, and spoken at the House of Commons Women and Equalities Committee.

Her academic background as a multidisciplinary engineer led her to Research Development for universities in the North East where she convened and supported interdisciplinary research consortia in securing grant-funded project work. She now uses these skills to improve the lives of trans and gender diverse people.
Contact Details
Being Ready

15th June 2022
Being Ready: trans, intersex and gender diverse experiences of dying, death and bereavement
GIRES new project aims to make end of life, palliative, death, funeral, memorial and bereavement services trans and intersex inclusive in England & Wales. We believe these communities should always be treated with dignity and respect during all stages of life, death and grief.

The project is led by GIRES, in collaboration with Hospice UK and Stonewall.

Ban Conversion Therapy

14th June 2022

Yesterday, MPs from across the political spectrum spoke up in defence of trans people and to #BanConversionTherapy for all LGBTQ+ people. 🏳️‍🌈🏳️‍⚧️

Here are just a few:@LukePollard @Gibbo4Darlo @aliciakearns @LaylaMoran @NadiaWhittomeMP @KateOsborneMP @JacobYoungMP @kirstenoswald pic.twitter.com/0cNzfFx71C

- BanConversionTherapy (@BanCTorg) June 14, 2022

An LGBT+ Sector As One: #BanConversionTherapy
5th April 2022

As a member of both the LGBT+ Consortium, and the Ban Conversion Therapy Alliance, we support wholeheartedly Stonewall's decision to withdraw all support for this Summer's UK Government-led Safe To Be Me conference. The UK Government's plans to scrap legislation outlawing conversion practices were abhorrent. What made the situation worse was a quick U-turn that actively excluded our trans siblings, and we refuse to stand by and let this happen. Trans rights are human rights and we stand shoulder to shoulder with every trans organisation and every trans person on this matter. The UK Government's own data shows that Trans people are more likely to be subjected to so-called conversion therapy, with data showing even higher risk for Black Trans people. A ban that excludes Trans people is unacceptable and we as an LGBT+ sector must have our voices heard on this matter and stand as one in solidarity.

#BanConversionTherapy #TransRightsAreHumanRights

GIRES joins major LGBTQ+ organisations to spark international review of the EHRC

11th February 2022

Recent devastating public statements from the Equality and Human Rights Commission (EHRC) are not just a betrayal of LGBTQ+ people and a specific attack on trans people. They fundamentally undermine their core purpose of regulating, promoting and upholding human rights.

Recent revelations, if true, show that the EHRC is planning to restrict trans people's long-established rights through draft guidance that limits trans people's rights to spaces and services that match their gender.

Celebrating Infinitely Diverse Gender Expressions

A few of GIRES' friends colleagues and supporters.

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Gender Identity Research & Education Society

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GIRES is a UK wide organisation whose purpose is to improve the lives of trans and gender diverse people of all ages, including those who are non-binary and non-gender.

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LGBT Centre for Health and Wellbeing Response to the Royal College of Psychiatrists Draft Good Practice Guidelines for the Assessment and Treatment of Gender Dysphoria

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LGBT Centre for Health and Wellbeing Response to the Royal College of Psychiatrists Draft Good Practice Guidelines for the Assessment and Treatment of Gender Dysphoria

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A research report representing the largest survey of its kind in Europe, providing groundbreaking data on trans people's mental health needs and experiences, explored in the context of daily life, social/support mechanisms and when accessing healthcare and mental health services.

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1. Jessica Salkind , ST1 paediatric trainee, , academic clinical fellow in paediatrics , teaching lead for LGBT+ , health module 1 2 6,

2. Rosanna Bevan , CT2 core psychiatry trainee, , volunteer youth worker 3 7,

3. Donna Samuels , general practitioner 5,

4. Gayle Hann , paediatric consultant, lead for paediatric emergency, named doctor for child protection, , project lead for IBSc Paediatrics and Child Health 1 6

1. 1North Middlesex University Hospital NHS Trust, London, UK

2. 2Imperial College London, London, UK

3. 3East London Foundation Trust, London, UK

4. 5NHS Enfield Clinical Commissioning Group, London, UK

5. 6University College London Medical School, London, UK

6. 7Gendered Intelligence, London, UK

The LGBT+ population is diverse and it is important not to conflate sexual orientation with gender identity

LGBT+ adolescents have higher rates of self harm and suicide than the rest of the adolescent population, linked to potentially serious safeguarding risks at home, school, online, and elsewhere

Establish rapport with a non-judgmental and inclusive approach

Avoid unnecessarily gendered language and do not give a young person a label that they have not given themselves

Take risks seriously and seek support from child and adolescent mental health services, local child protection teams, or social services, particularly in a young person presenting with self harm or suicidal ideation

A 14 year old girl attends the emergency department after taking a paracetamol overdose at home. She explains she has felt really hopeless since telling her mother she identifies as bisexual and has a girlfriend. Her mother told her "I would rather you were dead" and has organised an exorcism through the local church.
Correspondence to J Salkind jessica.salkind{at}nhs.net

What you need to know

Recent years have seen political and social progress for people who identify as LGBT+ (lesbian, gay, bisexual, and transgender; the "+" indicating inclusion of other minority sexual and gender identities). Yet international evidence shows ongoing health and social inequalities in this group, many of which emerge during adolescence and represent unique safeguarding risks.1 2 3 4 5 6 7 This article offers an overview of these risks, which include increased rates of self harm, suicide, and family rejection or abuse. The article is aimed at all healthcare professionals who care for young people, including within paediatrics, general practice, emergency medical and surgical settings, and child and adolescent mental health services (CAMHS). We suggest a management strategy based on clinical experience and testimony from LGBT+ young people and organisations. Some suggestions assume legal protection and support services for LGBT+ people that ...

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What you need to know A 14 year old girl attends the emergency department after taking a paracetamol overdose at home. She explains she has felt really hopeless since telling her mother she identifies as bisexual and has a girlfriend. Her mother told her "I would rather you were dead" and has organised an exorcism through the local church.