This guidance document advises General Practitioners against shared care agreements with unregulated providers in relation to hormone medication to children and young people under 18 as a response to gender incongruence / gender dysphoria.

• a GP must refuse to support the private prescribing or supply of GnRH analogues when used for the purpose of puberty suppression unless the course of treatment concerned began before 3rd June 2024
• a GP should refuse to support an unregulated provider in the prescribing or supply of alternative medications that may be used to suppress pubertal development
• a GP should refuse to support an unregulated provider in the prescribing of exogenous hormones
• a GP should always be prepared to refer their patient for an appropriate non-routine investigation under an NHS contract where there is a concern that the child or young person may come to harm as an outcome of a medication from unregulated sources

In all cases, safeguarding measures should be considered where the administration of a medicine from an unregulated source presents an immediate safety risk.

How do I approach the scenarios in primary care?

In all cases, your patient is under 18 years of age.

In all cases, safeguarding measures should be considered where the administration of a medicine sourced from an unregulated source presents an immediate safety risk.

Scenario: an unregulated provider asks you to agree a shared care approach to the supply of GnRH analogues for the purpose of puberty suppression, for gender incongruence or gender dysphoria, where the relevant course of treatment did not begin before 3rd June 2024.

You must decline the request. Such private sale or supply of GnRH analogues for the purpose of puberty suppression for gender incongruence or gender dysphoria is banned through Government legislation.

• advise the patient and the family against taking medications sourced from unregulated providers
• following consultation with the family, you may determine that a referral to the NHS CYP Gender Service is appropriate
• you should always be prepared to refer your patient for an appropriate non-routine investigation under an NHS contract where there is a concern that the child or young person may come to harm as an outcome of a medication from unregulated sources

Scenario: an unregulated provider asks you to agree a shared care approach to the supply of alternative medications that have the purpose of suppressing puberty, as a response to gender incongruence or gender dysphoria.

You should decline the request. The request raises clinical risks in respect of medicines which are not indicated for this purpose and may represent an attempt to evade the aims of Government legislation that prevents the private sale or supply of puberty suppressing hormones for gender incongruence or gender dysphoria. The request is also contrary to the aims of NHS England clinical policy that has removed puberty suppressing hormones from the NHS pathway of care.

• advise the patient and the family against taking medications sourced from unregulated providers
• following consultation with the family, you may determine that a referral to the NHS CYP Gender Service is appropriate
• you should always be prepared to refer your patient for an appropriate non-routine investigation under an NHS contract where there is a concern that the child or young person may come to harm as an outcome of a medication from unregulated sources

Scenario: a formal shared care agreement is already in place as you have previously agreed to a request by an unregulated provider for the supply of GnRH analogues for gender incongruence or gender dysphoria.

You may have previously agreed to take on continuation of prescription of gonadotropin-releasing hormone analogues to maintain continuity of care, following the Government’s legislation in 2024, where your patient met certain criteria (including the requirement that your patient had been issued with a prescription in the 6-month period before 3 June 2024).

You may decide to continue the shared care agreement if you conclude that continuation is in the best interests of your patient.

If you decide to discontinue the shared care agreement:

• the young person and family should be advised to withdraw from the medication, and the risks of ongoing administration explained to them
• inform the unregulated provider and the young person and family in writing that the shared care agreement is no longer in place
• where the young person or family decide to continue with the medication contrary to your advice, you should arrange for a final set of test results to be sent to the provider that is prescribing, with a written request for that provider to establish alternative means of regular monitoring and testing
• consider the individual’s need for further professional support, such as a referral to children and young people’s mental health services and / or to the specialist NHS gender pathway

Scenario: an unregulated provider asks you to agree a shared care approach to the supply of exogenous hormones for gender incongruence or gender dysphoria.

You should decline the request.

• advise the patient and the family against taking medications sourced from unregulated providers
• following consultation with the family, you may determine that a referral to the NHS CYP Gender Service is appropriate
• you should always be prepared to refer your patient for an appropriate non-routine investigation under an NHS contract where there is a concern that the child or young person may come to harm as an outcome of a medication from unregulated sources

Scenario: a formal shared care agreement is already in place as you have previously agreed to a request by an unregulated provider for the supply of exogenous hormones for gender incongruence or gender dysphoria.

You should weigh the risk to the young person of ending the shared care agreement with the risk of ongoing administration of the medicine.

You should always be prepared to refer your patient for an appropriate non-routine investigation under an NHS contract where there is a concern that the child or young person may come to harm as an outcome of a medication from unregulated sources.

Introduction

In its role of direct commissioner of specialised services for gender incongruence / gender dysphoria, NHS England has received requests from Integrated Care Boards, General Practitioners (GP) and other primary care professionals for advice on how to respond to requests that are made by unregulated providers for a shared care approach to the prescribing, administration and monitoring of hormone interventions as a treatment option for gender incongruence or gender dysphoria.

The hormone interventions are (see Appendix A):

• gonadotrophin releasing hormone (GnRH) analogues and other medications that may be used to suppress pubertal development
• exogenous hormones (testosterone / oestrogen) used for the purpose of masculinisation or feminisation

An unregulated provider is one that is not registered with, or regulated by, a UK health regulator such as the Care Quality Commission or Health Inspectorate Wales.

Advice

This advice reaches to any unregulated provider operating in the field of gender dysphoria / gender incongruence for children and young people, including online providers. GPs are specifically cautioned against a shared care agreement with two unregulated providers who have published statements that oppose the restrictions that have been put in place by NHS England and, separately, the Government around the supply of gonadotrophin releasing hormone analogues to children and young people under 18 years of age:

• GenderGP
• Anne Transgender Healthcare Ltd

Reasons for the advice

Unregulated healthcare services pose a risk to patient safety as they are not subject to the same level of scrutiny as registered services.

It is well established that a prescribing professional is responsible for the prescriptions they sign and for their decision and actions when supplying and administering medicines. If a clinician prescribes at the recommendation of another, they must satisfy themselves that the prescription is needed, appropriate for the patient and within the limits of their competence. The clinician should question any recommendation which is considered unsafe.

When engaged in a pathway of care of a patient jointly with an unregulated provider, a GP has a professional obligation to verify the safety of care that an unregulated provider or unregulated health professional provides to that patient. For example, the General Medical Council requires a GP to ensure that they are confident that systems are in place to verify the safety and quality of the care when making a referral of their patient to an unregulated service. Diligence in this regard is also essential for patient safety when an unregulated provider or unregulated healthcare professional seeks to delegate responsibility for prescribing or monitoring a medication to a GP.

Recent advice to dispensing professionals from the General Pharmaceutical Council is equally relevant to GPs who are asked to agree a shared care arrangement:

Recently, the NHS and the Government have taken steps to curtail access to  medical interventions for children and young people under 18 years of age with gender incongruence or gender dysphoria because of the lack of evidence about safety, risks, benefits and outcomes. The use of gonadotrophin releasing hormone analogues is prevented through routine use in the NHS Children and Young People’s Gender Service through NHS clinical policy, and the Government has placed indefinite restrictions on private sale and supply. 

Additionally, from 9 March 2026, the NHS has paused the initiation of new prescriptions for exogenous hormones in the NHS Children and Young People’s Gender Services pending the outcome of a public consultation on the evidence base.

Subject to the outcome of this consultation, NHS England has proposed that exogenous hormones should not be prescribed to children under 18 years of age for gender dysphoria because of the limited evidence about safety, risks, benefits and outcomes.

It is within this context that GPs and other prescribing professionals are cautioned against a shared care approach with unregulated providers who continue to offer access to – or facilitate access to – endocrine intervention to children and young people under 18 years of age as a response to gender dysphoria or gender incongruence.

GPs may wish to familiarise themselves with the background to the Cass Review and the recent Government legislation (Appendix B).

NHS England’s interim service specification for NHS Children and Young People’s Gender Services (June 2023; for revision in 2025) is clear on the approach to unregulated providers:

GenderGP

GenderGP is a private online service providing gender affirming interventions to individuals in the UK. It offers a remote diagnostic service across all age ranges.

GenderGP is outside the reach of the UK health regulators as the company is registered overseas and its relevant activities are performed overseas. GenderGP may either ask the patient’s GP to initiate prescribing or, more usually, has used prescribers overseas who issue prescriptions directly to individuals for dispensing by pharmacies in the UK. In either case GenderGP may ask the patient’s GP to accept responsibility for regular monitoring. It is known that many GPs refuse a shared care agreement with GenderGP because of its unregulated status and because of uncertainties about clinical expertise.

Past regulatory action and judicial rulings suggest that the activities of GenderGP may present an ongoing safety risk to children and young people in the UK:

• in 2018 Health Inspectorate Wales successfully prosecuted through the Magistrates Court one of the founders of GenderGP (Dr Helen Webberley, a medical professional) for illegally providing online gender healthcare services which required registration by the Care Standards Act 2000. The prosecution followed a period in which the doctor had refused to stop providing relevant services to patients. The business was subsequently registered outside of the UK, beyond the jurisdiction of Health Inspectorate Wales or the Care Quality Commission
• in response to the Government’s legislation that places restrictions on the supply of GnRH analogues, GenderGP has promoted the administration of synthetic testosterone to natal girls from 8 years of age, as an alternative drug for the purpose of puberty suppression. This is contrary to the NHS England clinical commissioning policy that prohibits the prescribing of exogenous hormones to children under 16 years of age because of the very limited evidence about the effects, harms and outcomes to young people under 16 years, though compromised fertility is a known likely outcome. GenderGP also promotes the use of raloxifene for pre-pubescent girls while noting that this is “an oestrogen blocker that hasn’t been widely tested in young people”

In a published judgment in May 2024, the President of the Family Division of the High Court stated the following, in a case concerning testosterone treatment offered to a 16-year old, and prescribed, by GenderGP:

Recent advice to dispensing professionals from the General Pharmaceutical Council is equally relevant to GPs who are asked to agree a shared care arrangement:

Recently, the NHS and the Government have taken steps to curtail access to medical interventions for children and young people under 18 years of age with gender incongruence or gender dysphoria because of the lack of evidence about safety, risks, benefits and outcomes. The use of gonadotrophin releasing hormone analogues is prevented through routine use in the NHS Children and Young People’s Gender Service through NHS clinical policy, and the Government has placed indefinite restrictions on private sale and supply.

Anne Trans Healthcare Ltd

Anne Trans Healthcare Ltd is a UK based company, though its clinical team is based overseas. It is not registered with the Care Quality Commission.

It describes itself as “a subscription service which coordinates therapeutic and medical support for individuals experiencing gender incongruence through referrals to healthcare professionals”. It offers access to overseas healthcare professionals, and its website states that it offers services which include “puberty blockers for individuals of all ages, including those under 18.”

As has been noted above, and subject to narrow exceptions, the sale or supply by private prescription of GnRH analogues to children and young people under 18 years for the purposes of puberty suppression and as a treatment for gender incongruence and/or gender dysphoria contravenes the Government’s restrictions on their prescription and is contrary to the aims of the NHS clinical policy position.

The company’s published terms and conditions has the disclaimer that “Anne is not responsible for the quality of care, advice, or any prescriptions or medication provided to you/the Minor (if applicable) by any Independent Healthcare Professional”. Nevertheless, the company’s website suggests that GPs may be approached to support patients in the monitoring of these medicines through a shared care approach: “we are very happy to work with GPs who are open to shared care agreements”.

Individuals who are sourcing unregulated medicines and who are seen by the NHS Children and Young People’s Gender Service will be advised to discontinue the medicine. The NHS Children and Young People’s Gender Service will not accept prescribing responsibility or enter into a shared care agreement with a private provider.

Summary

As a general principle, a GP should consider each request for shared care on a case-by-case basis to satisfy themself that the request is from a reputable company that provides a safe and effective service; and that the circumstances of the request for the particular individual meets the general principles of the General Medical Council’s “Good Practice in Prescribing and Managing Medicines and Devices”. A GP may decline to accept responsibility for prescribing, monitoring and testing if the GP is not assured that the provider offers a safe service.

Suppression of pubertal development

A GP must refuse to support the private prescribing or supply of GnRH analogues. It is a criminal offence for a healthcare professional to privately sell or supply this drug to patients under the age of 18 as a puberty-suppressing treatment option for gender incongruence or gender dysphoria unless that treatment had begun before 3rd June 2024.

A GP should refuse to support an unregulated provider in the prescribing or supply of alternative medications that may be used to suppress pubertal development.

Exogenous hormones

Where the prescribing recommendation is made by a healthcare professional working for, or working with, an unregulated provider, a GP should reasonably conclude that the absence of regulatory oversight and scrutiny is a cause for concern such that a request for shared care should be refused. In such cases, the young person and family should be advised against sourcing medications from the provider, and the risks explained to them.

If the GP has concerns that declining responsibility would pose a clinical risk to the child or young person, the decision to decline a shared care agreement should be weighed against the ongoing risk posed by administration of a medicine from an unregulated source. In such cases, consider a referral to appropriate local services.

If a GP decides that an existing shared care arrangement for exogenous hormones should be discontinued:

• the young person and family should be advised against continued sourcing of medications from the provider, and the risks explained to them
• the GP should inform the unregulated provider and the young person / family in writing that the shared care agreement is no longer in place
• where the young person or family decide to continue with the medication contrary to the GP’s advice, the GP should arrange for a final set of test results to be sent to the provider that is prescribing, with a written request for that provider to establish alternative means of regular monitoring and testing. This approach is consistent with the general principle that clinical responsibility for prescribing is held by the person signing the prescription, who must also ensure adequate monitoring
• the GP should consider the individual’s need for further professional support, such as a referral to children and young people’s mental health services and / or to the specialist NHS gender pathway

Irrespective of whether a formal shared care agreement is in place, a GP should always be prepared to refer their patient for an appropriate non-routine investigation under an NHS contract where there is a concern that the child or young person may come to harm as an outcome of a medication from unregulated sources (for example, monitoring bone density; or venous thromboembolism).

In all cases, safeguarding measures should be considered where the administration of a medicine from an unregulated source presents an immediate safety risk.

A GP should always be prepared to refer their patient for an appropriate non-routine investigation under an NHS contract where there is a concern that the child or young person may come to harm as an outcome of a medication from unregulated sources.

In all cases, safeguarding measures should be considered where the administration of a medicine from an unregulated source presents an immediate safety risk.

In such cases the [NHS Children and Young People’s Gender] Service will make the child or young person and their family aware of the risks, contraindications and any irreversible or partially reversible effects of the intervention; and will make the GP or local health professional (as appropriate) aware and suggest that the GP or local health professional considers what safeguarding protocols may be appropriate for the individual child or young person’s wider circumstances including the extent to which the parents / carers are able to protect or safeguard the child or young person.

Safeguarding procedures may be necessary regardless of the endeavours and best intentions of the parents / carers in reducing risk of harm.

Safeguarding protocols should be initiated immediately where the child or young person is at risk of immediate, serious harm.

It would also be important for the GP or local health professional to explore what regulatory bodies may need to be informed if healthcare professionals registered with a UK professional body are prescribing medication contrary to NHS protocols.

Adult patients over 18 years

The advice in this document supersedes previous advice set out in the NHS circular “Primary Care Responsibilities In Regard to Private Online Medical Service Providers to Prescribe Hormone Treatments for Transgender People”, 2018 in so far as it relates to children and young people under 18 years of age.

The advice in this document does not extend to adult patients over 18 years of age.

However, in recognition that unregulated healthcare services pose a potential risk to patient safety across all age ranges, NHS England will address the management of adults who source medications outside of the NHS-commissioned gender dysphoria service, including the management of those who are using atypical levels of medications, within its current work to establish a clinical commissioning policy for exogenous hormones in 2025/26.

In the meantime, the general principles described in the 2018 circular should continue to be the basis for how a GP determines how to respond to a request for shared care for management of a hormone intervention by a private provider in relation to an adult patient (extract below):

Queries about the advice offered in this document should in the first instance be submitted to: england.contactus@nhs.net

Appendix A: the interventions

Gonadotrophin releasing hormone analogues

Also known as hormone blockers; puberty blockers and puberty suppressing hormones. Taking these hormones stops the progress of puberty. The GnRH analogues act by competing with the body’s natural gonadotrophin releasing hormone. This competition blocks the release of two gonadotrophin hormones important in puberty called Follicular Stimulating Hormone (FSH) and Luteinising Hormone (LH) from the pituitary gland. GenderGP has promoted the use of raloxifene as an alternative means of puberty suppression; this drug is used to treat and prevent osteoporosis and reduce the risk of invasive breast cancer in high-risk postmenopausal women.

NHS clinical policy (March 2024) prevents prescribing to children and young people under 18 for gender dysphoria outside of clinical trial. Government legislation prevents private sale or supply to children and young people for puberty suppression in connection with gender incongruence and/or gender dysphoria under 18 years of age subject to narrow exceptions.

Feminising and masculinising hormones

Also known as cross-sex hormones; and gender affirming hormones. These are sex hormones given as part of a medical transition for gender dysphoric individuals (testosterone for transgender males and oestrogen for transgender females).

Following a review of evidence, NHS England is pausing its existing NHS clinical policy (March 2024) on the commissioning of exogenous hormones through the NHS Children and Young People’s (CYP) Gender Service. This prevents new prescriptions for exogenous hormones through the NHS from 9 March 2026 at least until the point a final policy is determined following full consideration of consultation feedback. The evidence review found very limited and weak evidence to support the continued access to exogenous hormones by children and young people under the age of 18 years.

Appendix B: the Cass Review and recent Government legislation

In April 2024 the independent Cass Review delivered its final report on how the NHS should care for children and young people with gender dysphoria or gender incongruence. The Review represents the most comprehensive analysis of the available evidence.

The Review found that children and young people with gender incongruence present with higher levels of neurodiversity, co-occurring mental health issues and adverse childhood experiences.

The Review proposes a new and fundamentally different model of care that is less reliant on medical intervention and focused more on psychosocial and psychological support, within an integrated, multi-disciplinary pathway.

NHS England and the Government have committed to implementing the Review’s recommendations.

In March 2024 the former children’s Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust was brought to a managed close by NHS England; and new NHS Children and Young People’s Gender Services began to be operational from 1 April 2024, working to a new clinical model.

The new clinical model, as defined by NHS England clinical commissioning policy, prohibits the routine prescribing of GnRH analogues (commonly known as Puberty Blockers or Puberty Suppressing Hormones).

The Cass Review recommended a clinical trial to determine the effectiveness of puberty suppression and the safety of prolonged treatment. The trial framework was developed in close collaboration with the National Institute for Health and Care Research and NHS England. In February 2026, work to establish the trial was paused to allow the Medicines and Healthcare products Regulatory Agency to address concerns related to the trial.

An independent review was commissioned by NHS England to review the evidence on exogenous hormones (also known as cross sex hormones, gender affirming hormones, or masculinising / feminising hormones) as a treatment option for gender incongruence / gender dysphoria. The review found very limited and weak evidence to support the continued access to exogenous hormones by children and young people under the age of 18 years. On 9 March 2026, NHS England paused its clinical policy ‘Prescribing of Gender Affirming Hormones as part of the Children and Young People’s (CYP) Gender Service’ (March 2024), pending full public consultation on the evidence base as part of the process for forming a final clinical policy. The pause, which will continue until at least the point that NHS England publishes a final policy following analysis of all consultation responses, prevents children and young people aged under 18 from being initiated on exogenous hormones within the NHS for the purpose of gender incongruence or gender dysphoria.

The Cass Review concluded that it “understands and shares the concerns about the use of unregulated medications and of providers that are not regulated within the UK. Any clinician who ascertains that a young person is being given drugs from an unregulated source should make the young person and their family aware of the risks of such treatment”. The Review recommended that the Department of Health and Social Care should define the dispensing responsibilities of pharmacists of private prescriptions and consider other statutory solutions that would prevent inappropriate overseas prescribing.

In December 2024, following advice from the Commission on Human Medicines, the Government made permanent legislation that restricts the sale and supply of GnRH analogues through private prescription to young people under 18 years; these restrictions prevent, subject to certain narrow exceptions, a UK pharmacist from dispensing a private prescription for GnRH analogues and a GP from engaging in their sale or supply where the purpose of the prescription is puberty suppression in relation to gender incongruence and/or gender dysphoria. The legislation does not extend to exogenous hormones.