Continuing HRT after arriving in the UK
I recently returned to the UK after spending three years in North America. During my time abroad I medically transitioned. I have now been on testosterone for two years as well as having had top surgery over a year ago.
I was nervous about trying to continue my HRT after returning to the UK. Searching online for information, I found no accounts of trans people who had successfully continued their treatment after arriving in the UK. On the contrary, I found more than one Reddit threat started by people whose transitions had been thrown into reverse by systemic problems in the NHS. This is horrifying, and I absolutely wanted to avoid this situation.
I did a lot of research in order to figure out how best to approach the NHS on my return. This week I got my testosterone prescription without too much fuss, for which I am very grateful. I feel very lucky. I think part of the reason it went well is that I had the information I needed, thanks to resources made available by trans activists online. I want to share those resources in one place here, and share my own experience of navigating the NHS after transitioning abroad. Disclaimer: nothing in here is intended as medical advice. I don’t think it comes across that way, but it’s always worth pointing out.
How the NHS can fail newly-arrived trans patients
Many GPs lack any experience of treating trans people, and are therefore quick to refer new trans patients to a Gender Identity Clinic (GIC) for specialist attention. This on its own is quite sensible: nobody wants to be held responsible for decisions that they do not fully understand, and doctors may face career-ruining consequences if those decisions end up hurting people. This reaction is, superficially, in-line with the current NHS protocol on transgender health. The 2013 interim protocol document focuses on a flow chart that begins unilaterally with referral to a GIC, appearing to show no other option regardless of the patient’s circumstances.
The rest of the flow chart shows that the GIC assessment is focused on reaching a “yes-no-maybe” answer to the implied question, “is this person a good candidate for medical transition?” This seems overwrought for the case of someone who has already transitioned, but on its own would not be a huge problem. Presumably, if someone was to present themself for assessment and explain that they have already medically transitioned while overseas and are doing just fine and would just like to keep on taking hormones, the GIC would answer “yes”.
The problem is that gender identity services are extremely short-staffed. After receiving a referral, most people have to wait over a year before even getting their first appointment at a GIC. In a letter to uktrans.info, NHS England admitted that these wait times are illegal: “NHS England agrees that the people accessing gender identity services have a legal right under the NHS Constitution to be seen within 18 weeks of referral.” However, evidence presented to the recent parliamentary inquiry on trans rights suggests that it is going to take system-wide reforms to resolve this problem, and it is unclear whether or when these reforms will happen.
For someone coming to the UK who has already started HRT, this is a frightening prospect: if they are referred to a GIC so that their HRT can be monitored by specialists, they will probably not get their prescription renewed in good time, and consequently may have to stop taking medication that is vital for their well-being, or resort to acquiring it on the black market.
GIC referral is not necessary
NHS guidance does allow GPs to prescribe hormones, so that patients in urgent need of this care do not have to go without. This is true even if the patient has not yet been assessed by a gender specialist in any country. The Intercollegiate Good Practice Guidelines published by the Royal Society of Psychiatrists states,
“Where patients’ acute needs cannot be met by a specialist service within a reasonable and safe time frame, they may be referred as an interim measure to a local endocrinologist and for mental health support as appropriate, prior to being seen by a specialist gender identity clinic” (p. 17).
An addendum to the NHS Interim Protocol points to these Good Practice Guidelines as the authoritative source for any issues not covered by the Interim Protocol. On the prescription of hormones, the Interim Protocol itself states:
“The GIC physician, the patient’s GP or another medical practitioner involved in the patient’s care may prescribe “bridging” endocrine treatments as part of a holding and harm reduction strategy while the patient awaits specialised endocrinology or other gender identity treatment and/or confirmation of hormone prescription elsewhere or from patient records.” (p. 16)
On top of this, if the patient has already transitioned elsewhere, chances are they do not need to be assessed at all. There are no clear guidelines for what to do if the person has transitioned outside of the NHS system. However, according to a 2014 memo sent to NHS GPs, if a patient has transitioned within the NHS, then one year after the final medical intervention for gender-related care has been carried out (e.g. the last surgery that one wants for the time being) the GIC will discharge them and put them in the care of the GP, who is expected to prescribe hormones according to the GIC’s instructions.
“Once a patient has completed their episode of care with a GIC, typically twelve months after completion of the last planned intervention, they will be discharged by the GIC. As almost all patients will need to continue taking hormone therapy for the rest of their lives, the GIC will, at the time of discharge, provide their GP with written guidance for ongoing prescribing and monitoring.”(p. 4)
Key here is the fact that a gender specialist is giving instructions on how to monitor and prescribe the hormones, so that the GP does not have to take on the decision-making responsibility.
“The gender specialist physician takes responsibility to assess the capacity of
the patient to give meaningful informed consent to use such treatment, to
explain its potential risks, benefits and limitations, to explain that the treatment is not approved for this indication and the implications thereof, and to obtain and document consent before making a recommendation to a GP to prescribe treatment for their patient.” (p. 4)
So, GPs are allowed to prescribe hormones, are advised to do so when there is a pressing need for it regardless of whether the patient has been assessed by a GIC yet, and are expected to do so when there is a letter from a gender specialist giving guidance on what exactly they should prescribe. Reading accounts from trans people who have not been able to continue HRT after coming to the UK, part of the problem seems to be that, despite this, many GPs are not comfortable prescribing hormones; in extreme cases, they are not even comfortable referring the patient to a GIC, for ideological reasons.
Therefore, as far as I can tell, there are two things that one needs in order to continue HRT on the NHS after transitioning elsewhere:
- A GP who is understanding of trans issues
- A letter from the doctor who originally prescribed hormones
Finding a transgender-friendly GP
Uktrans.info hosts a register of transgender-friendly GPs that is maintained by Transfigurations, a Devon-based support group. Before arriving in the UK, I used this register to find a doctor local to where I would be living, so that I would be approaching a GP who already has some experience treating transgender patients.
I registered with the surgery as soon as I arrived, having already prepared a large collection of paperwork: prescription details from my time abroad, my deed poll document and new passport so that they could update my details on the NHS system, and some doctors’ and psychologists’ letters from back when I was getting my referrals for top surgery and getting the gender changed on my passport, as well as the usual stuff you need when registering with a GP, such as my NHS number and the address of my previous GP from before I left the UK. I wrote a covering letter explaining my legal and physiological status, and requesting that they make sure that my details are recorded in the system so that I will continue to receive gynecological care while also being referred to with male pronouns. This was all quite time-consuming to prepare ahead of time, but I felt like it was worth the effort in order to make sure that registering with the GP was as smooth as possible.
The staff handled all of this very professionally. I think they must have had some concerns or confusion, but if they did they took it out of the room and discussed it in private, rather than asking me any embarrassing questions. They did not even visibly react when I first handed over the paperwork and explained that I am transgender. They correctly gendered me consistently as soon as they learned my preferred pronouns. Even at trans speciality clinics, people are not always this courteous and respectful, so I was very impressed to be made to feel so comfortable at an ordinary GP surgery.
Getting a letter from the HRT-prescribing doctor
Meanwhile, I wrote to the doctor abroad who had originally prescribed HRT, asking for a letter recommending that my new doctor renew the prescription. My goal was to make sure that this letter would be as close as possible to the kind of letter that a GIC would send to a GP in the UK. I sent her a link to the 2014 memo to GPs, and summarised from that memo the points that a GP expects to see in a letter from a gender specialist within the NHS:
Your role as a trans health specialist, and the dates during which I was your patient.
Confirmation that I have been taking HRT since [date], after being assessed under the WPATH standards of care guidelines.
Indication that I was monitored to ensure responsible oversight of gender-related treatment.
Recommendation for prescribing and monitoring of HRT going forward.
Confirmation that it is more than 12 months since my last “planned intervention” for gender dysphoria.
Once the doctor’s letter made its way over to the UK, I booked an appointment with the GP to ask for a prescription renewal. The GP was keen to make sure that a copy was made and kept with the rest of my records. Of all the paperwork that I had gathered together, I think this letter was the most important piece, and I do not know if I would be continuing my HRT right now without it.
Now I have my testosterone and I am able to continue my HRT without interruption! So, to summarise:
- Navigating the NHS as a trans person is always nerve-wracking at best, and coming in after transitioning abroad introduces a new set of challenges that are less commonly discussed online.
- GPs are allowed to prescribe hormones, but most GPs do not have the knowledge or experience to feel comfortable making that decision.
- Looking for a trans-friendly GP can really pay off.
- Giving the GP surgery some paperwork documenting everything possible about one’s transition abroad is important, especially getting a letter with clear instructions from the doctor who originally prescribed HRT.
NHS Interim Gender Identity Protocol 2013-14 https://www.england.nhs.uk/wp-content/uploads/2013/10/int-gend-proto.pdf
NHS England letter to uktrans.info, 8th January 2015 http://uktrans.info/18-week-confirmation
Oral Evidence given to Transgender Equality Inquiry, 8th September 2015 http://transinquiry.co.uk/oral-evidence/first-session
Royal Society of Psychiatrists, Intercollegiate Good Practice Guidelines, 20th October 2015 http://uktrans.info/medical/55-clinical-guidelines-for-trans-healthcare/4-good-practice-guidelines-for-the-assessment-and-treatment-of-adults-with-gender-dysphoria
NHS Specialised Services Circular, 26th March 2014 http://shsc.nhs.uk/wp-content/uploads/2014/08/NHS-England-Specialised-Services-Circular.pdf
Register of Transgender-friendly Doctors, August 2014 http://uktrans.info/medical/48-other-medical-resources/238-register-of-transgender-friendly-doctors-and-medical-centres-in-the-uk