The Trans Lady’s Guide to Getting HRT in the UK

(or, “If you can’t make your own oestrogen, store bought is fine!”)

v1.0, March 2021

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Introduction

Congratulations on deciding to transition medically! When you start out it can be very overwhelming trying to figure out how the system works (or doesn’t work, as is often the case). This guide will help you better understand the options you have.

Trans healthcare in the UK is in crisis, and even if it was functioning perfectly the design is absolutely barbaric and woefully outdated. Until we have an informed consent system of medical transition we’re going to have to face a lot of unnecessary barriers. Hopefully this guide will prepare you for them and maybe even figure out how to skip a few. It’ll also tell you a bit about self-medding and in the interests of harm reduction it’ll tell you how to do it safely if you are resolved to take that option.

Limitations of the Guide

This guide was composed based on one white, middle-class, binary trans woman’s experiences in the South of England transitioning in 2020. I didn’t have access to one of the new community-operated clinics that have since sprung up; I started my transition with a combination of private and NHS care. I also haven’t had surgery at time of writing, so this is basically a guide to obtaining HRT on the NHS. Gender-based healthcare across the UK varies a lot depending on where you live; the NHS is divided into lots of separate regional trusts, some of which fund certain procedures and some of which don’t. Some of the advice might not apply to your situation, but hopefully at least some of it will be useful!

The Way Things Are Supposed to Work

The way it’s supposed to go is like this. You make an appointment with your GP and say, “I’m trans, I want to medically transition.” Your GP then refers you to a Gender Identity Clinic (GIC). The experts at the GIC give you some assessments, chat to you, and if their psychiatrists are satisfied they give you a formal diagnosis of Gender Dysphoria, which is not officially a mental illness. After that they write to various specialists to recommend you be given whatever treatments they decide are appropriate. Take hormone replacement therapy for example: after you get your Dysphoria diagnosis you get referred to an endocrinologist who can write a letter of recommendation for HRT. You then take that letter back to your GP ‒ yes, the same GP you started with ‒ and they prescribe you the hormones.

The Way Things Actually (Don’t) Work

As mentioned above, this system would be absolutely barbaric even if it functioned, which it doesn’t. From the bottom up it’s built on discrimination. Riddle me this: if a cis woman goes through menopause and wakes up thinking, “Ugh, my body feels bloated and awful, I feel mannish, I feel anxious and depressed all the time!” she can go to her GP and her GP can prescribe her with hormone replacement therapy. If you wake up feeling very much the same and go to the same GP to request the same medicine, you can’t get it because you’re trans. Instead you have to see a psychiatrist who will ask you about a bunch of irrelevant things like your childhood or your sexual fantasies, and they will diagnose you with Gender Dysphoria if they’re satisfied. Technically Dysphoria is no longer a mental illness, however since you have to be diagnosed with it by a psychiatrist to get treatment it might as well be. If that cis woman wakes up feeling like crap because of menpause, is that Dysphoria? If a bald man wants finasteride, a testosterone blocker, to fight hair loss, is that Dysphoria? If a girl gets teased for having hair on her upper lip and it makes her feel like a man so she decides to get it lasered off, is that Dysphoria? There is no proper answer to these questions because Dysphoria, at least in medico-legal contexts, just means, “That thing trans people have that makes them different and allows us to discriminate against them.”

Even at GICs, a lot of people report having no real control over their own transition. GICs often have very rigid, outdated ideas about what transition should look like ‒ a lot of nonbinary people in particular report having to pretend to be more binary than they really are because doctors don’t understand enbies. That’s how we end up with people who get pushed into things they aren’t sure about and are pressured to consent to things they maybe don’t want because if they say, “No” it’s back to square one.

You probably already know that waiting lists for GICs are several years long ‒ the system does not function. The reason for this is discrimination. In an ideal world they would all be closed and we could get our healthcare the same way cis people can without having to wait. We don’t live in that world ‒ yet!

How You Can Use the System to Get the Healthcare You Need

You might have spotted that the whole point of the GIC system is to get the exact same GP you started with to prescribe you some very common medicines that other people get very easily. Because you’re trans, in order to get that prescription you need multiple other pieces of paper ‒ dysphoria diagnosis, letters of recommendation, and on and on… but what if you got those pieces of paper from somewhere else?

You don’t actually have to get them from an NHS GIC; you can do a combination of private and NHS care!

Doing your transition entirely through the NHS will take years, possibly decades, and is extremely gruelling. But doing it entirely privately is hugely expensive. So a strategic blend of private and public, with a little luck and persuasion, could provide a balance of cost and speed. The time between my coming out to myself and my starting NHS-funded hormones was six months. In a country with decent trans healthcare this would be horrific. For Britain it’s practically a speedrun! I did this by blending private and public options, and the whole thing cost me less than £1,000.

Changing Your Name By Deed Poll

A lot of cis people have a bizarre fetish for paperwork, so having some on your side is a useful thing. Changing your name is free ‒ you do not need to pay to do it, all you need is one witness signature on the piece of paper. Here’s the really cool part: you do not have to register that change of name anywhere just yet. If you want to you can rip it up the next day and it’s like it never happened! So I would advise changing it early. I would also advise that you create about five original copies on thick glossy paper; having multiple will come in handy later if you want to change passports and so on ‒ that’s when your name change starts getting permanently registered on systems.

Here’s a pro tip: like a lot of us, you may well have started thinking about transitioning long before the date you decide to actually sign the deed poll. So feel free to backdate it a little and give yourself some extra time. Now have paperwork saying that you started transitioning a while ago, which can come in very handy if you ever want things like a Gender Recognition Certificate. Don’t take the piss with it, obviously, and be aware that this is technically fraud, but if you want to give yourself a few extra months on the clock you can, so long as your witnesses are on board and you’re OK with the small legal risk. You can get a deed poll for free at this website: https://freedeedpoll.org.uk/

Psychiatrists

You can pay a private psychiatrist to assess you for gender dysphoria. This is probably the single most expensive part, ranging from £200 to £500. You can find a list of options at https://transhealthuk.noblogs.org/covid-19-private-clinics/, and many of them will do video consultations. Some psychiatrists are nicer than others. The nice ones ask you irrelevant questions about your childhood. The more gruelling ones ask how you masturbate. They will also ask what seem like irrelevant questions about your mood, what day it is, can you remember a list of five words or shapes or something? That’s just to test that you aren’t having a breakdown and you’re ‘in your right mind.’ Again, in a decent country you wouldn’t be subjected to this ‒ are cis women given psychiatric evaluations before they get HRT? No, because the desire to be comfortable in your body after menopause isn’t deemed adjacent to madness! If you’re worried about bad psychiatrists, ask around other trans people about their experiences with different psychiatrists to make a good choice.

The appointment isn’t fun, but grit your teeth and you’ll get through. Officially they aren’t supposed to look at things like how you dress and present when you arrive, but they will mention it on your report. If you have clothes from your real gender, if you’ve been practicing your voice or your makeup (you can learn a lot on YouTube for free) then it won’t hurt to bring out those skills during the appointment. The psychiatrist will also ask if you’ve changed your name by deed poll and if you are out to friends, family, and coworkers. You don’t have to, but they will ask, and this creates a bit of pressure whereby you might feel you have to come out to certain people before you’re really ready.

While you’re there, ask them for a letter stating that your transition is likely to be permanent ‒ this is so you can change the gender marker on your passport. Contrary to popular belief you don’t need a Gender Recognition Certificate to do that, you just need your deed poll and that letter! Some trans people wait to get their passport, but I would advise getting it as early as possible. Most people attach a lot of symbolic importance to passports because this country is obsessed with borders and being racist, so if you have one in your correct gender they’ll defer to that. The only downside is you’ll need a new picture and you might not feel delighted about having to do that so early, but hey ‒ nobody likes their passport photo and hardly anybody ever sees it so it doesn’t really matter.

The other reason it may be very useful to have a passport with your correct gender marker is in case you get arrested and have to deal with police and prisons. Contrary to popular myth you can’t simply self-ID as trans in jail and expect better treatment ‒ in fact if you do get sent to prison and tell them you’re trans they will almost certainly not believe you unless you have some kind of documentation to back it up. Officially, they are supposed to make an individual assessment in each case based on your “risk”, and good documentation might help you get into a safer situation. A Gender Recognition Certificate is obviously the gold standard, but they’re rare as hen’s teeth: some ID or evidence from a doctor that you’re being treated would also come in handy. If you’re stealth and self-medicating when you’re arrested, as a lot of us have to be because the waiting lists are so long, you’re shit out of luck because they’ll take your medicine off you and force you to detransition, so get that deed poll, get that letter from the psychiatrist, and get that passport.

Letters of HRT Recommendation

So now you have a psychiatrist’s diagnosis of Mad Tran Disease (aka Dysphoria), a made up mental illness that doesn’t exist but which cis people think is terribly important. Time for the next step: a letter of recommendation for hormones. A letter of recommendation is not the same thing as a prescription; it’s what you give to a doctor who will then decide whether or not to prescribe. Again, if you wait for a GIC you’ll be waiting years. If you go private you can get that letter of recommendation much faster. Strictly speaking you don’t need a diagnosis of gender dysphoria before you do this bit: having that diagnosis will come in handy later though.

GenderGP is a private trans healthcare service that you can join for about £30 a month. You have to pay for every month you’re with them, which covers some services, but they also charge extra for more, like extra therapy. They’re very nice, although there is one potential drawback ‒ they are getting a lot of negative press attention and they are based outside the UK, so there’s a risk the government might turn around and say, “Letters of recommendation from them don’t count anymore.” They worked for me though, for now. You may want to shop around and see if you can find a private service within Britain.

Before you go in you’ll need a blood test: they need to see where your hormone levels are at before they start messing around with them. It has to be within 3 months of your appointment date. You might be able to get one from your GP, however this means showing your cards to them slightly before it might be best to do so. A private blood test will cost you anywhere between £100 and £200; you might need to shop around. It’s an added cost, but it allows you to wait to bring in your GP until your hand is strongest.

An appointment with one of Gender GP’s doctors will cost you about £200. It’s not as gruelling as the psychiatrist; they’ll just talk you through the different options for HRT and inform you about the risks and potential side-effects. Always do as much research as you can before you go ‒ you want to be an informed patient!

Afterwards they’ll take some time to consider your case with their whole team, typically a week or so, and then write you a letter of recommendation for HRT. If you have infinite money you can get them to prescribe also, though you’ll be paying through the nose for your prescription every time. However if you’re brave and clever and lucky enough, you might be able to get your GP to do it…

Before You See the GP

At this point, if you’ve done everything the way I did it, your GP won’t know you’re trans yet. You’ve got your Dysphoria diagnosis and your letter of recommendation, i.e. the two things that you would have got from the GIC. Now you have to convince your GP to prescribe. There are a couple of little tricks you can use to help!

Coincidentally I moved flats right at this stage, so I had to register with a new GP. The registration form only had two boxes, ‘Male’ or ‘Female’ so I decided “Fuck it” and ticked ‘Female.’ In hindsight this was an absolute stroke of genius because now everyone working there including the doctors sees my real name and ‘Female’ on the paperwork and are psychologically primed to accept me as a woman before I even walk in the door. Remember, cis people love paperwork! If you can make the paperwork work for you that can really come in handy! (It also means I get automatic letters from the NHS asking me to attend cervical cancer screenings, which makes me laugh every time.)

Speaking of paperwork, the NHS has official guidelines in place for prescribing HRT to trans people who obtain letters of recommendation privately. Your GP has almost certainly never read these guidelines and probably doesn’t even know they exist: they will flat out tell you to your face that they are not allowed to do things that they are not only allowed but required to do.

So make sure you know the guidelines! This is crucial; it’s the most important thing you can do! In England, there are two documents you should read:

    • NHS England’s Specialised Services Circular in  regards to Prescribing HRT to Patients who Have Letters of Recommendation from Private Online Providers [e.g. GenderGP] https://www.dpt.nhs.uk/download/VjSSV5TQVv

These two documents are your friends! (For other UK nations, see https://transhealthuk.noblogs.org/navigating-uk-trans-healthcare/ for some more documents, but the England ones may still be helpful.) Before you go to your GP, print them out and know them and highlight the relevant sections. When your GP says, “Oh, um, I’m not sure about this, I think you need to be referred to a GIC…” you can whip them out and go, “Oh, well I have the NHS guidelines here, they say you can prescribe?”

The Appointment

The moment of truth! The GP appointment is where your charisma and charm will be tested. It’s the final hurdle. Again, if you have clothes and makeup and skills, now’s the time. Your GP will almost certainly know nothing about trans healthcare and be reluctant to learn; you’ll have to manage their expectations and ego (especially if they’re a man) to guide them towards giving you the healthcare you need. They may well ask you some more irrelevant questions or even just be blatantly transphobic to you. (One GP deadnamed me right out the gate and then asked, “Are you pre-op or post-op?” I had to take it on the chin and sweetly be like, “Hah, well I’m actually here to talk about HRT today! So, did you get a chance to read the paperwork I sent you?”) The central problem for them is that they’re being asked to prescribe you medicines “off-label,” i.e. ‘This isn’t what the paperwork says this medicine is officially for.’ They’re generally trained not to do that, so you’ll have to reassure them. They will almost certainly ask you about the private doctors you got the letter of recommendation from: they want to know that they are qualified and safe.

They may try to steer you towards being referred to a GIC: you don’t want that, that’s them getting you out the door so they don’t have to think about anything ‒ you can sweetly and politely make it clear to them that a GIC would just give you a diagnosis of gender dysphoria and a letter of recommendation, both of which you have already obtained privately! Draw their attention back to the regulatory paperwork, which says they can prescribe on that basis. They may also try to steer you towards being referred to local mental health services ‒ again, you can sweetly and politely tell them, “I’d be happy to talk about my mental health another time, but in this appointment I’d like to get a prescription for the HRT I need ‒ did you have a chance to read the NHS Guidelines on prescription yet?” Stay on message and always bring them back to the paperwork. If your GP tells you something that you know isn’t true, speak up! If they say, “I can’t prescribe you HRT without approval from an NHS Gender Identity Clinic,” (as mine did, wrongly) you are allowed to say, “Oh? I’m sorry, I don’t quite understand why not, because I have the NHS guidelines here and they say you can?” Again, cis people love paperwork! Make sure you can give them chapter and verse.

You are allowed to take a trusted friend or advocate with you ‒ depending on where you live there may even be trained LGBT volunteers who can do the job. I didn’t do that and I don’t think the GPs I saw would have reacted well if I had, but your mileage may vary.

Your GP may well decide to take time to think about it and call someone to check (especially if you’ve just caught them out saying something that contradicts the regulations they’re supposed to abide by). That’s okay ‒ but make sure to leave the paperwork with them! If your GP says they are going to do something like call somebody or check with somebody, follow up with them every week until they do it. The squeaky wheel gets the grease! I once had a GP tell me she was going to refer me to a specialist and I should wait: I found out three months later she had never sent the letter. This experience is common. You are Andy Dufresne in The Shawshank Redemption: write to them (politely!) once a week for as long as it takes!

Here’s a pro tip: doctors are simple creatures, so ask for one thing at a time. If you want HRT, voice coaching, and hair removal, don’t ask for them all in one appointment. In this case study I’ve focused on HRT cause it’s the hardest to get and there’s no free option, whereas if you want voice coaching you can achieve a lot with free tutorials online. When you book your appointment tell them you want to talk about prescribing HRT, email the clinic with your Dysphoria Diagnosis, your letter of HRT recommendation, your blood test results, and the guidelines with the relevant sections highlighted. Send a follow up email to check that they got them. Despite this, your GP will almost certainly not have read any of it by the time you get there.

Here’s another pro tip for talking to doctors: always open with the thing you want them to hear. Years ago I had a friend who needed to be taken to A&E for chest pains ‒ could have been very serious! She was a sweet thing and didn’t like to make a fuss, so when the doctors asked her, “Do you have pain in your chest?” she said, “No, not really, well just a little bit, sometimes, when I do this…” As a consequence they left her sitting on her ass in the corridor until I kicked up a fuss, and it’s a good thing I did because it turned out she was too polite to tell them how urgent her case actually was! I had to tell her, “Babes, when they ask if you have chest pains, just say ‘YES!’” Always open with the thing you want them to hear! For example, my GP asked if I had ever had any problems with my mental health. This is a classic irrelevant question: even if I had it would have no bearing on whether or not I needed HRT to transition, he was just looking for an excuse to push me onto the psychiatrists at a GIC or local mental health services. As a matter of fact I have had some serious mental health problems, but it was years ago, I feel much better now, and since I started transitioning my mental health had hugely cleared up! So I smiled and said, “No! I’ve been stable for several years now and since coming out I feel so much happier!” This was factually true ‒ it’s not often a good idea to straight up lie to your doctor ‒ but that doesn’t mean you have to accept their (often transphobic) framework for obtaining and processing information. If I’d said, “Well yes actually, a few years ago I tried to kill myself ‒ but I’m much better now!” He would have gone, “Hmm, well, I’m not sure…” But I opened with the word, “NO” cause that’s what I wanted him to hear.

In a similar vein, you should always lead with the thing you want them to do and stay firmly on message. For instance:

BAD: “I’ve been thinking about it a lot, Doctor. I’ve been depressed for a while, I haven’t felt right, my childhood was like XYZ, I think I’m trans, and I would really like you to consider prescribing me with Hormone Replacement Therapy.”

BETTER: “I’d like Hormone Replacement Therapy, please. I’m transgender. Here is my diagnosis of gender dysphoria and a letter of recommendation from my private doctors, and here are my blood test results. And in case you need them, here are the NHS guidelines for GPs on prescribing with the relevant sections highlighted.”

Here’s another protip ‒ it’s sad but it’s true, you are not going to convince your GP to prescribe by explaining the ways in which the system is institutionally transphobic. It is, but you won’t get them to agree to that. Just stay on message. Know the rules and above all know the paperwork and you can beat them at their own game.

Hopefully your doctor will prescribe you your HRT! If they do, send them and the entire GP’s surgery a thank you card. In it, briefly mention how grateful you are, and how getting healthcare is sometimes hard for trans people but you really appreciate them listening to you! Even if they were transphobic and getting healthcare was like pulling teeth, if you get the result you want always send a thank you card. Most cis people, in my experience, genuinely do want to be nice to us, they’re just shit at it and have an overpowering fetish for paperwork. If you send a card you leave them feeling positive and like good allies, and if you need to see them again later to adjust your dose (which you probably will) then you’re already a friend to them!

If they get back to you and refuse or try to pawn you off onto a GIC or some crappy mental health service with a six month waiting list that you don’t want or need, give them chapter and verse from the regulations. Quote directly from them down the phone if you have to ‒ I did, and it worked. You gotta be like a politician ‒ stay on message, lead with what you want them to do, and know the paperwork. If you end up having to make an official complaint to anybody, make sure you do it in as dry and legalistic a way as you possibly can ‒ know the regulations and cite them!

Self-Med

One last word on DIY hormones. I started self-medding shortly after seeing the psychiatrist because I just couldn’t wait any damn longer. When I saw GenderGP to get my letter of recommendation I told them I was self-medding, and when I saw my GP to get them to prescribe I told them too. This can work in your favour: it shows them you’re serious and, in your GP’s case, demonstrates a clear clinical risk to your health if they refuse to help you. (Which the NHS regulations say is bad.)

However, that’s a double-edged sword because there can be a clinical risk to your health. In rare cases you can do permanent damage, in particular to your liver with pills, if you get it wrong, and that’s assuming the meds you take actually are what they’re advertised as. (Again, that’s rare, but it does happen.) For me it was DIY or die: I’m an adult, it’s my body, and I judged that the risk of not doing it was greater than the risk of doing it because if I didn’t start transitioning I was going to throw myself under a train. If you are going to DIY there are ways you can minimise the risk.

Aphrodites.shop is (at time of writing) the website that a lot of my trans femme friends use. I used them in 2020. It might seem dodgy, especially since you have to pay them up front and then email them proof of payment separately, but they came through for me. They ship you the hormones from Europe, from countries where trans people don’t have to resort to this sort of thing! They aren’t prohibitively expensive, either, maybe £30 for a month’s supply, when you start out? Any trans woman in the UK who is on progesterone is probably self-medding because the NHS refuses to give progesterone to us. Legally speaking you’re almost certainly in the clear ‒ oestrogen and the sorts of blockers you can get online aren’t controlled substances, and even if they were the police presumably have better things to do than search your mail for tiny quantities of personal medicines. All the same, don’t flash it around ‒ the possibility of backlash from TERFs leading to regulatory action means it’s better to keep these things discrete. You can find other options at hrt.cafe (at the time of writing), and you can always search for reviews in places like https://www.reddit.com/r/transdiy.

Obviously, before you order anything you need to research the potential side-effects and risks and possible interactions with other medicines you’re on! When they arrive, check to see the seals are all intact. Don’t take anything that comes loose in a baggie: the packaging will have the name of the medicine written on it so check that it is what you ordered. Before you start, write down on a piece of paper what you’re taking and what the dose is, and tell a trusted friend in writing. That way if something goes disastrously wrong and you’re unconscious, other people have a record of what drugs are in your system. (This is just a good idea generally: if the drugs work fine but you get hit by a bus the next day and you’re in a coma it’d be good to have that record.) Obviously start with a small dose ‒ just as you would if you were doing it under clinical supervision. You can look up online what a good starter dose would be: it depends on what exactly you’re taking.

The main issue with self-med is that you have to take whatever’s available: if they’ve sold out of the testosterone blocker you want for instance, you might have to switch to another, which isn’t ideal. Estrogen comes as patches, gels, pills and injectables, and different people get different strengths of results from different methods, though the general effects and side-effects are usually the same. Different blockers have different side-effects. Spironolactone, for instance, makes you piss like a racehorse and can also make you depressed. I started out on Bicalutamide as my blocker, which works but can damage your liver. It’s also a lot easier to get pills than injections: the really good and safe testosterone blocker is Decapeptyl but that’s an injection and it’s usually a very expensive cancer drug ‒ you pretty much have to persuade the NHS to give you that. Again, in a decent country that didn’t discriminate against us we wouldn’t have to take these risks! You can bet your ass that if Mums up and down the country started self-medding to deal with menopause there’d be a national outcry! (In fact there was not long ago ‒ it made the papers!)

I self-medded for about three months before I persuaded the NHS to give me the good shit. Some people have to self-med for years, and trans women have been doing this for decades. There are risks with self-medding, but we can find ways to mitigate them.

Afterword

I hope this guide was useful to you! With about £1,000 you might be able to sequence-break your GP and do a trans healthcare speedrun. Once you’re all set up you might find it useful, as I did, to request that your GP also refer you to a GIC ‒ just to be in the system. By the time I actually get to a GIC I will have fully transitioned years ago (hopefully by the time I get to a GIC they will have been abolished and we’ll have equal rights!) but it can’t hurt to be in the system. Cis people do love their paperwork.

One last general note: charisma and charm go a long, long way. One of the hardest parts of transition is having to persuade cis people to do the jobs they are literally paid to do, like, “I know the computer says this, but what I actually need is…” or “I know you usually do things this way, but in this case would you consider…?” Being good at talking to and persuading people, knowing what they want and how to make them feel like they’re getting it, making them think that helping you is their idea and they’re good, virtuous people for doing it, will come in very handy. Sadly this is a lot easier if you’ve got institutional privilege on your side ‒ if you’re white and skinny, neurotypical and well-spoken you’re starting with an advantage. Hopefully some of these tips about talking to doctors can help level the playing field a little!

Good luck!