Gender incongruence in children, adolescents and adults

More individuals are requesting medical assistance for gender uncertainty or dysphoria and provision of adult NHS gender identity services (GIS) is changing. Despite minimal medical input to polarised debates, several issues are potentially concerning: reports of poor care; rapid rises in referrals of children and young people to GIS; public conflation of biological sex with socially influenced gender roles; and extensive uncertainty in the evidence base to guide practice. Medical practice should happen within robust human rights frameworks where individual patients always have their concerns heard. Generalists, with expertise in whole-person care, handling uncertainty and complexity, have a key role when consulted by identity-questioning and transgender individuals for routine care, gender identity concerns, treatments recommended by private or NHS services, or for referral. Presentations with prior emotional trauma, co-existing mental or neurodevelopmental issues, or ‘bridging hormones’ requests may make primary care professionals uneasy. Without a considered approach to practice, high-quality evidence and guidance, a policy of active ‘affirmation’ and ‘treat or refer’ may lead to more people receiving medical interventions with uncertain outcomes.