NHS England guidance (Specialised Services Circular 1620, April 2016) states that:

• General Practitioners should co-operate with the specialist Gender Identity Clinics and prescribe hormone therapy (feminising or virilising endocrine therapy) recommended for their patients by the Gender Identity Clinic. The specialists at the Gender Identity Clinic make recommendations for the prescription and monitoring of these therapies but they do not directly prescribe them, or provide physical and laboratory monitoring procedures for patients.
• The decision on whether or not to provide long-term feminising or virilising endocrine therapy requires the skills of a gender specialist physician, usually working within a Gender Identity Clinic.
• General Practitioners should collaborate with Gender Identity Clinics in the initiation and on-going prescribing of hormone therapy, and for organising blood and other diagnostic tests as recommended by the Gender Identity Clinics.
• General Practitioners are also expected to co-operate with Gender Identity Clinics in patient safety monitoring, by providing basic physical examinations (within the competence of General Practitioners) and blood tests and diagnostic tests recommended by the Gender Identity Clinic. Hormone therapy should be monitored at least 6 monthly in the first 3 years and yearly thereafter, dependent on clinical need.
• The Gender Identity Clinic is expected to assist General Practitioners by providing relevant information and support, including the provision of guidance regarding the interpretation of blood test results.
• With regard to prescribing drugs for the treatment of gender dysphoria, as described above:
  • 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 General Practitioner to prescribe treatment for their patient;
  • The gender specialist physician takes responsibility for overseeing the patient's care in collaboration with the patient's General Practitioner, and for their recommendation that the General Practitioners prescribe and monitor treatment;
  • The gender specialist physician will provide the patient's General Practitioner with the clear written guidance on prescribing and monitoring, be available to provide additional information on request, and answer questions regarding treatment and monitoring at reasonable notice.

More detailed advice is available from the NHS England Specialised Services Circular 1620 (April 2016).

Refer also to the Devon Partnership Trust prescribing guideline for gender dysphoria.

The following advice is taken from the NHS England Specialised Services Circular 1826 (January 2018):

A number of trans and non-binary individuals access private on-line medical services, often because of long waiting lists into an NHS-commissioned Gender Identity Clinic.

The online provider may make a diagnosis of gender dysphoria through remote contact with the patient and in such cases a private prescription may be issued, or the patient's GP will be asked to issue a NHS prescription. Either way, it is likely that the patient's GP will be asked by the online provider to assume responsibility for monitoring and testing and for passing the results of the monitoring and testing to the private on-line service.

Regulatory guidance and NHS England's current commissioning protocol supports a decision by a GP to accept a request made by a private on-line medical service to assume responsibility for prescribing, and for monitoring and testing, in cases where the GP is assured that the recommendation is made by an expert gender specialist working for a provider that offers a safe and effective service.

Where this is the case, GPs should also refer to "responsibilities in prescribing and monitoring hormone therapy for transgender and non-binary adults" above.

A GP may reasonably decline to accept responsibility for prescribing, monitoring and testing if the GP is not assured that the recommendation for prescribing has been made by an expert gender specialist, as long as the GP is also satisfied that declining responsibility would not pose a significant clinical risk to the individual. It is reasonable for the GP to ask the provider to demonstrate that it has the necessary expertise before responding to the provider's request.

All requests should be considered on a case-by-case basis.

More detailed advice is available from the NHS England Specialised Services Circular 1826 (January 2018).

For further guidance and information:

• GMC guidance on Trans Healthcare
• Royal College of General Practitioners e-learning on Long term hormonal treatment for transgender people
• DPT Prescribing Guideline for Gender Dysphoria
• DPT Gender identity information leaflets
• NHS England Specialised Services Circular 1826: Primary Care Responsibilities In Regard To Requests by Private On-Line Medical Service Providers to Prescribe Hormone Treatments for Transgender People (January 2018)
• NHS England Specialised Services Circular 1620: Primary Care Responsibilities in Prescribing and Monitoring Hormone Therapy for Transgender and Non-Binary Adults (updated) (April 2016)
• NHS England Gender Dysphoria Clinical Programme (includes service specifications and clinical policies)