A practice in the East Riding of Yorkshire area

4. Ms U complains about the Practice’s decision not to prescribe hormone therapy treatment she required following gender reassignment surgery in May 2025.

5. Ms U says as a result of this decision, she has been left in a state of untreated hypogonadism since the surgery. She has ongoing risk of irreversible osteoporosis, increased risk of cardiovascular risk. She suffers with daily anxiety and distress knowing her health is deteriorating without treatment.

6. As a result of bringing this complaint to us, Ms U is seeking an apology and service improvements.

7. Ms U says she has been on the Gender Identity Service waiting list since August 2020 and has not yet received a gender dysphoria diagnosis.

8. Ms U underwent private vaginoplasty surgery (surgical procedure that creates or reconstructs a vagina and vulva) on 14 May 2025 and made her GP aware of this on 28 May 2025. Ms U saw the GP on 30 May 2025, and the GP requested a copy of the surgery discharge letter to send to Urology for a referral to remove the catheter. The letter stated Ms U needed to start hormone treatment 3 weeks post-surgery, but they had not issued any hormone treatment as a private provider.

9. Ms U saw her GP again on 24 June 2025 and the GP agreed to write to the Gender Identity Service advising of recent surgery and asking for follow up NHS shared care.

10. The Gender Identity Service replied on 9 July 2025 to say they cannot enter an NHS shared care agreement due to long waits for their hormone appointments and she could not been seen by them until she had been through the Gender Identity Service.

11. The Gender Identity Service suggested reaching out to the local endocrinology service to ask if they could see Ms U. The GP contacted the endocrinology service on 15 July, and it replied on 17 July 2025 advising it is not commissioned to provide the service. The consultant at the endocrinology service mentioned they had a private clinic and could offer the prescribing and monitoring under this if she wanted a referral, but it would be payable and the GP made her aware of this option.

12. The GP partners held a meeting on 4 August 2025 to decide whether they could prescribe. They decided they would not able prescribe competently without an NHS shared care agreement and joined up care provision and let Ms U know this.

13. Ms U complained to the GP Practice on 7 August 2025. The Practice sent its final response on 22 January 2026. Ms U brought the complaint to us on 16 October 2025.

17. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any indications that something has gone wrong.

18. Ms U says in denying her the hormone therapy treatment, the Practice chose to ignore the principle of preventative medicine, which dictates treating a known deficiency before irreversible damage occurs She says it did this, in favour of a reactive "monitoring" approach, waiting for her bones to deteriorate before intervening and she feels this contradicts all standard medical practice.

19. Ms U says as a result she has been left without a safe, regulated NHS pathway. Due to the profound physical risks confirmed by specialists and the severe mental health collapse caused by the GP's refusal to treat her, she has been left feeling abandoned by the NHS and placed in a dangerous clinical condition.

20. In its complaint response, the Practice says it cannot prescribe the requested hormone treatment without a shared care agreement in place with prescribing initiated by the Gender Identity Clinic. It says the GP Partners are not qualified to consult on gender reassignment therapy.

21. The Practice says it has showed its duty of care by reaching out to separate specialist departments to try and facilitate NHS shared care for her. It says as it was not consulted prior to the private surgery and was therefore unable to make her aware of any obstacles she may face when returning to the UK post-surgery.

22. We asked our adviser what a shared care agreement is. Our adviser explained sometimes the care of a patient is shared between two doctors, usually a GP and a specialist. There should be a formalised written agreement/protocol setting out the position of each, to which both parties have willingly agreed, which is known as a ‘shared care agreement’.

23. The NHS England website section about responsibility for prescribing between primary and secondary care explains it is important patients are involved in decisions to share care and are clear about what arrangements are in place to ensure safe prescribing. In some cases, a GP may decline to participate in a shared care agreement if he or she considers it to be inappropriate. In such circumstances the consultant would take full responsibility for prescribing and any necessary monitoring.

24. The GMC guidance on trans healthcare says one way in which you might consider providing support to your patient is by issuing a ‘bridging prescription’. This is a temporary prescription of endocrine treatment that can be issued by a GP. Before issuing a prescription, consult local policy, where it exists, and seek advice from a specialist service or provider or an experienced colleague. Advice on hormone bridging prescriptions can be sought from the Gender Service or Endocrinology.

25. The BMA’s Managing patients with gender dysphoria guidance suggests that GPs may prescribe a ‘bridging prescription’ to cover a patient’s care until they are able to access specialist services. However, advises GPs should only consider a bridging prescription when the patient is already self-prescribing or seems highly likely to self-prescribe with hormones from an unregulated source. The bridging prescription is intended to reduce a risk of self-harm or suicide and is on the condition the doctor has sought the advice of a gender specialist and prescribes the lowest acceptable dose in the circumstances.

26. Our adviser says due to the long waiting list for the Gender Identity Service, there would be a considerable delay in which case the prescription becomes less bridging and more permanent. We can see Ms U was not self-prescribing at that time but had previously sought treatment from a private service.

27. From the records we cannot see any suicide or self-harm ideation when she first went to the Practice after the surgery although she did the present to the GP with this in November 2025. It is not clear this is directly related to not receiving hormones and was already under the psychiatry team for severe depression with bipolar spectrum on lithium and aripiprazole which are two specialist medications.

28. The psychiatry letter from November 2025 notes Ms U’s frustration with not being prescribed hormones but did not appear to be the sole cause for her mental health deterioration. The Practice reached out to the Gender Identity Service again for advice and we can see the letter it sent back dated 23 December 2025 suggested the Practice seek advice from the local endocrinology service, which it had already tried to do by this point.

29.The GMC’s Good Medical Practice guidance says doctors must recognise and work within the limits of their competence and only prescribe drugs or treatment when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs.

30. Our adviser said the Practice was within its rights not to prescribe hormone treatment if they were not comfortable to do so. GPs are not obligated to prescribe medication if they feel they do not have the required expertise as they carry the responsibility as the prescriber. In this case, Ms U is seeking hormone treatment for gender dysphoria which GPs have very limited knowledge of.

31.Our adviser says this is usually started by specialists and then only transferred to GPs under a shared care agreement once the patient is stabilised on the medication. Even if a shared care agreement is received, GPs are still not obligated to prescribe if they are not comfortable.

32. In this case, Ms U has not yet been reviewed by an NHS gender clinic and so there is no confirmed diagnosis. Ms U decided to undergo private surgery abroad without the GP agreeing to prescribe hormones following this. We can see that in line with the BMA guidance and GMC trans healthcare guidance, the GP tried to seek support with the gender identity service and endocrinologist, but these services could not help.

33. We understand how important access to hormone therapy can be and how impactful this situation would have felt for Ms U. After carefully reviewing the circumstances, we consider the Practice acted appropriately and in line with the GMC Good medical Practice guidance in their decision not to provide Ms U the hormone therapy treatment directly as it did not feel qualified enough to prescribe this.

34.We consider the Practice followed the BMA guidance and GMC trans healthcare guidance in trying to support Ms U by reaching out to the Gender Identity Clinic and Endocrinology services for advice, to try to ensure she received the right care. We also do not consider that she met the criteria for a ‘bridging prescription’ as she was not self-prescribing or at risk of self-harm or suicide as a result of this.

35. We appreciate this has been a very difficult time for Ms U as she has been unable to get the treatment she needs. As we have seen no indications of failings, we will not investigate this complaint any further.

36. Complaints give us a valuable insight into the organisations we investigate, and we recognise this has been a very distressing time for Ms U. We would like to thank her for sharing her experience with us.

1. We have carefully considered Ms U’s complaint about the Practice’s decision not to prescribe hormone therapy treatment. We were sorry to hear of the impact this has had on Ms U.

2. We have seen no indication the Practice was incorrect to decline prescribing this treatment.

3. We thank Ms U for bringing her concerns to our attention. We hope reading the following consideration reassures her we have considered this matter fully and carefully before reaching our decision to take no further action on this complaint. We hope reading this statement does not cause undue upset, as this is not our intention.