The NHS is failing trans people because a system designed for rare conditions has never been updated to reflect how many people now need gender-affirming care. Around 30,000 people are on waiting lists, facing waits of up to seven and a half years, while their bodies continue to change in ways they did not choose. The fix is straightforward: bring this care into general practice, where it belongs.
How does the NHS model actually work?
The NHS is built on a beautifully logical structure. Your GP handles the conditions that can be managed in a surgery. When something is beyond that, you get referred to your local hospital, where a consultant takes over. And when the condition is genuinely rare or complex, you travel to a tertiary centre: a specialist hospital in Birmingham, Oxford, Manchester, or London, staffed by people who spend their entire working lives on that specific condition.
That model works. It makes sense. You cannot expect a GP to know everything about every rare disease, and nobody is suggesting they should. The system routes people to the right level of expertise, and for most conditions it does that well.
Gender-affirming care was slotted into the tertiary tier because, for a long time, it genuinely was rare. Fewer than 500 people a year were coming forward, which meets the threshold for highly specialised medicine. There were seven gender identity clinics across England, and that was considered sufficient. For a while, it was.
What changed after 2010?
From around 2010 onwards, the number of people seeking gender-affirming care began to rise sharply. This was not a fad or a phase. It was visibility. As trans people became more present in public life, as language developed, as communities formed online, people who had spent years quietly wondering whether their experience had a name began to come forward. People who had been hiding came out into the open. That is not a crisis; that is progress.
But the system did not adapt. The seven specialist clinics remained. The classification remained. The referral pathways remained. And so the waiting lists grew, and grew, and kept growing. Today there are around 30,000 people on NHS waiting lists for gender care. Seven specialist clinics, designed for a few hundred patients a year, are simply not able to serve them.
The honest answer to the question of why the NHS is failing trans people is that nobody in charge made the decision that needed to be made: this is no longer a rare condition. It needs to be reclassified, and care needs to move into the tier of medicine that already has the capacity and the reach to provide it.
What does a seven-and-a-half year wait actually cost someone?
People hear "seven and a half years" and perhaps imagine it as inconvenient, frustrating, a long time to wait for something you want. It is not like that. It is actively harmful, in ways that cannot be undone.
If someone is referred to a gender clinic at twenty and does not get their first appointment until they are twenty-seven, their body has not paused in the meantime. The hormones they wanted to change have kept working. Skeletal changes have taken place. Facial structure has continued to develop. Voice, body hair, fat distribution, muscle mass: none of it waits. Every month of an unwanted puberty is a permanent physical change, and seven years is a very long time.
And that is only the physical cost. By the time someone is ready to come forward for care, they have usually already spent years, sometimes a decade or more, quietly working through all of this on their own. Is it real? Will it go away? What will happen to my relationships, my job, my family, if I do this? All of that internal questioning, that private waiting, happens before the NHS waiting list even starts. So when a person finally says I am ready, I know who I am, I want to move forward, the response is: yes, and now wait another seven and a half years. The cruelty of that is difficult to overstate.
Why can't GPs just do this?
They can. That is the short answer, and I mean it.
GPs are told that gender care is too specialised for general practice. I understand where that belief comes from, but it does not hold up. Managing hormones is not exotic territory for a GP. Contraception, hormone replacement therapy, prostate cancer management, breast cancer treatment: GPs are manipulating sex hormones all the time, in significant ways, for large numbers of patients. They already have that knowledge. They already have those prescribing skills.
There are genuinely conditions that do require specialist management in general practice. Severe acne requiring isotretinoin is one: that is a drug with complex monitoring requirements and real risk, and it makes sense to have consultants running that. But gender-affirming hormones, prescribed carefully and monitored with routine blood tests, do not fall into that category. This is not difficult medicine. It is medicine that GPs are already doing, for other patients, every day.
There is something else worth saying about GPs, something I genuinely believe. A GP knows a family. They know the patient, and they know the grandmother, and the partner, and the difficult father, and the worried mother. They know the context in which a person lives. Trans healthcare is not only about hormones: it is about family support, about navigating relationships and workplaces and schools, about the whole life around the medical care. GPs are extraordinarily well placed to support all of that. They are, in my view, the ideal clinicians for this work.
So why aren't GPs doing it?
Fear, mostly, not contempt.
The political climate around trans healthcare in the UK has been genuinely frightening for clinicians. The Cass Review, which has since been widely discredited internationally, created an atmosphere in which doctors who wanted to help trans patients felt exposed. Rather than a wave of GPs coming forward to say this is a patient group I want to support, the effect was the opposite: a retreat, a drawing back, a collective decision that this was not a safe area to work in.
Clinicians who previously worked in gender services have sometimes continued applying old policies and protocols, even after those services closed, rather than updating their practice to reflect current international guidelines. The Endocrine Society guidelines, the WPATH Standards of Care, the extraordinary work done by clinicians such as Michelle Telfer at the Royal Children's Hospital in Melbourne: evidence-based, research-led, built around what actually helps patients. That is the guidance we should be following. It exists. It is clear. What is missing is the will, and the safety, to use it.
GPs who say they do not have time deserve an honest answer: I know how stretched you are, and I know the pressures on general practice are enormous. But you have trans patients. They are already in your list. And right now, many of them are not getting care from anyone. "I don't have time" cannot be the end of that sentence when the consequence is ongoing, preventable harm. The answer has to be: make time, get the training, and treat your trans patients as you would treat any other patient whose needs fall within your clinical reach.
What would better actually look like?
It would look like gender-affirming care being reclassified out of the tertiary tier and brought into general practice, with proper education and support for GPs doing that work. It would look like the international guidelines being adopted as standard, rather than being treated as suspect. It would look like waiting lists that are measured in weeks, not years. It would look like a trans person being able to walk into a GP surgery, have a conversation, and begin a process that supports them, in the same way that any other person with a hormonal or endocrine need would be supported.
None of this is radical. It is what good medical care looks like. The trans community has waited long enough for it.
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