This guide is based on the personal story and experiences of Scotia in her transition with a start date of November 2022, she lives near Exeter in Devon. It covers the order of the necessary steps, which practitioners can be used to maximise the chances a general practitioner (GP) will be supportive, along with the fees paid as an indicative guide. Any fees are of course subject to inflation and market forces. My experience is for male to female transition. Some may have had different, better or worse experiences but I’m working here with my own experience and several of those at the Exeter TransCafe who I’ve traded notes with.

Background and scene setting

I was born in 1980, subjected to an abusive step father from aged 4 and forced to attend an all boys boarding school from ages 13 to 18. I was never very masculine growing up and I suspect that the step father knew about ‘me’ and so banished me to school to be ‘corrected’. Of course it didn’t work! As a result, I worked hard to become invisible, rather than masculine, simply to get by. This hiding my authentic self stuck with me largely through my 20s and 30s. Over this period I suffered with chronic migraine but there was no known physical cause and no medication that worked, preventative or reactionary. I put it down to stress, except there was little about my life that was stressful.

COVID-19 arrived in March 2020 but it wasn’t until May 2021 that it all started. 2 days after receiving my first vaccination, I collapsed and spent 2 days in ICU, in a coma, being discharged a further 2 days later with hyponatremia – my blood sodium level having fallen so low I shouldn’t be here now. This triggered PTSD which I was treated for with EMDR, being too ill for CBT. Over the course of the EMDR, much of my ‘self defence’ cloak that I’d built around myself as a child was lifted and what did I find underneath...?! At first it was a bit ‘well this is weird’ but as someone with a very open mind, I wanted to explore! For 18 months I experimented with androgynous fashion, informally changed my name from Scott to Scottie (ending ‘ie’ and not ‘y’ as I thought it was more feminine), started using Mx titles whenever asked and added (they/them) to my work email signature. This worked fine for 18 months but evidently it wasn’t enough and come November 2022, I made my first GP contact.

Initial Contact with NHS Services (November 2022)

To improve the chances of a likely positive outcome, it’s best that the NHS is contacted about any gender incongruence before private services. I made a telephone appointment with my actual GP (not any at the practice) by using an online booking system that allowed me to type what I thought I was feeling and what I wanted in return. I feel this is important as what I didn’t want was the practice secretary to incorrectly interpret my words or just send me away. At my first appointment, I only went so far as explaining that I was exploring gender and could they signpost me to any local services or charities etc. to help me ask the right questions of myself. After living as a man for 2 decades, I wanted to discover if this was real or just a mid-life crisis. The important part here was getting an entry on my medical record that says gender questioning or incongruence or similar.

Referral to NHS Gender Clinic (February 2023)

After a further 3 months, I made another telephone appointment with my GP, the same person as before and appointment made in the same electronic way. I thanked them for the links and explained that I’d discovered a lot more about myself however I’d like to be referred to the NHS gender clinic. As this wasn’t my first appointment about gender, they agreed and said they’d write to my local clinic, Exeter, but explained that there was a very long wait to get a first appointment. The Exeter GIDS wrote back to my GP and I saying they’d accepted me onto their waiting list and so I was now in the NHS system with gender firmly on my medical record.

I hadn’t really appreciated what ‘a very long wait’ meant in GIDS terms until I looked it up on the Exeter GIDS website. They’d seen no new patients for 8 years! So as a minimum, I’d have 8 years but likely much longer – life’s too short!

It’s worth reinforcing at this stage that the condition of gender dysphoria, as recognised by the WHO, UK law and the NHS, is a psychological condition than can be alleviated somewhat by medical transition in some individuals. As such, it’s the psychologist that holds everything together and that any other medical services engaged in transition will report back to so it’s worth choosing a psychologist who you like – you’ll see them a lot.

Private Psychology (July 2023)

I elected to go with Gender Identity South West(GISW) in Exeter. Being local, this gave me the option of in-person appointments which I prefer as it allows me to read body language better – I’m that kind of person. When selecting private medical services that you’d like to link up to the NHS, it’s imperative that the practitioner is General Medical Council (GMC) registered in the United Kingdom. Without this accreditation, the GP is in their right to disregard any communication or instruction from them. The psychologist will also likely state that they are following the WPATH guidance and that what they are doing is exactly as would be the case if you’d been seen at the NHS GIDS. Many private practitioners also work part time at GIDS, this was the case with all of my engagements. This also gives peace of mind. When reports were written by GISW, they stressed that they were following WPATH & NHS standard practice and also set out why the GP should accept their report and support my medical journey. GISW produced an 8 page report, allowing me to see a draft copy, and edit if required, before sending a final copy to my GP and also to my chosen endocrinologist (hormone specialist). It’s psychology that provide the referral for hormone therapy.

Initial diagnosis of gender dysphoria, 2x 1 hour sessions - £500

Baseline Blood Tests (August 2023)

Before the endocrine appointment, I’d been given instructions to acquire a base line blood test of a range of parameters. I was told that my GP should be willing to do this. I set up a telephone appointment with my GP, filing the appointment request in the usual electronic way, to discuss shared care and to ask them to support. As they had the referral from NHS GIDS and the psychology report from GISW, they were happy to support on an ongoing basis and arranged the bloods there and then. Success!

Baseline blood test – NHS – no charge

Endocrinology (November 2023)

I went with a practitioner in the Gender Care group (GISW is psychology only) who happens to work from a private hospital in Torquay, again allowing me to have an in-person appointment. This followed much the same format as psychology with the same considerations for GMC registration and again they also worked part time at a GIDS, but this one was in London. The report again stressed all the same points about WPATH and following NHS practice and with an offer to discuss hormone therapy with my GP, should it be necessary. Again a lengthy report was produced, copied to me, the GP and also GISW.

The plan going forward is also set out at this stage so the GP and I can see what’s required. Initially this is quarterly blood tests with a plan to increase the Estradiol dose every three months until the correct blood levels are achieved. Testosterone also falls naturally but in most individuals it’s not enough to be within the typical female range. If a testosterone blocker is required, this will likely be added after 6 months, timed with the second dose increase.

Assessment for hormone therapy, issuing a plan and prescribing instructions to GP. 1 hour - £250

On-Going Care (November 2023 onwards)

Estradiol trans-dermal patches – NHS HRT pre-payment certificate* - £20 annually

* NHS HRT prescription prepayment certificates are valid for any purpose, not just menopause.

Blood tests – quarterly for 12 months but becoming annually – NHS – no charge

Testosterone blocker – quarterly until gonads removed – by intramuscular injection, administered by GP practice within care plan – medication as standard NHS prescription charge ~£10 each

Endocrine review appointments, annually - £160

Facial Hair removal (November 2023 onwards)

I’m lucky enough to have a skin and hair combination that is treatable with laser as it’s faster, cheaper in the long run and less painful than electrolysis. Dark hair is required, and fair skin although mine is a kind of Mediterranean type olivey colour and it’s been fine. To date I’ve had 18 sessions and it’s almost gone. Sessions tend to be at 4-6 week intervals although with a break in the summer as sun tan is problematic with laser. The NHS will only pay for 8 sessions so private extension sessions might be likely anyway for many. Do make sure your beauty salon uses laser and not IPL, they’re not the same thing and it’s often quite confusing trying to find out who locally has the best machine. If using laser rather than electrolysis, expect single top up sessions possibly once a year or every other year once full growth is removed.

Laser hair removal - ~£600 per 6 sessions for full face & neck. £1800 spent, so far...

Voice Coaching (November 2023 onwards)

I engaged a gender affirming voice coach through GISW to help get me going and to listen to me speak back to them. I’ve had just 4 private sessions, 3 at 1 month intervals and then a 4th session in January 2025 to help me with one aspect I was still missing. YouTube is also excellent as are a number of mobile apps for analysing your voice and allowing you to hear yourself speak. I promise, it isn’t cringy for long! The in-person sessions were useful to me but I expect excellent results can be achieved with the following channels and a mobile app. Singing is also excellent for building range, stamina, power and karaoke prowess once you have the sound you like.

https://www.youtube.com/@TransVoiceLessons https://www.youtube.com/@oliviaflanigan5938

Private voice coaching - £90 per hour

New NHS Number (May 2024)

This coincided with me formally changing my name. When I informed the GP practice, I sent my Deed Poll and also asked that my gender marker be changed making reference to my medical record with the psychology report and the GPs agreement of shared care. There were no issues here at all, all completed in about 3 days! The practice did call to let me know that it meant a new NHS number and was I happy? I’d also taken the trouble to ask them to retain me on any programmes for prostate cancer and AAA screening but to remove me from automatic enrolment to cervical screening. Their comments were “You’re very well informed!”

Surgery Referral by Psychology (January 2025)

This appointment again was at GISW, in person and serves as the referral for surgery. This continues the theme that gender dysphoria is a psychological condition and everything medical is held together by the psychologist. As well as ensuring I’m in a mentally fit enough state to consent to surgery, the appointment also covered the surgical details. Was I aware it was permanent (!), the possible complications, ongoing care etc… to ensure that they were things I’d considered and were happy with, but with a chance to discuss there and then. This aspect was largely dealt with at this stage and not later with the surgeon.

Pre-surgery psychology appointment & referral for surgery – 1 hour, £200 (existing customer discount)

It’s also necessary to have a second independent pre-surgery psychology referral appointment to ensure that no glaring omissions have been made by the primary referral – a kind of sanity check. For this I engaged GenderPlus on a one-off basis.

Second Pre-surgery psychology appointment by VTC & referral for surgery – 1 hour, £240

Pre-Surgery Assessment (March 2025)

There are generally only 2 hospitals in the UK that perform affirmation surgery that is aligned with the NHS, both also taking private clients. Both operated by Nuffield, Parkside (SW London) and Brighton. There are some other clinics offering services but I think on a private and part time basis only? I opted for the Brighton option as the price was significantly less (I’m a cash buyer) with the only difference I could see being in/out of London. The surgeon I’m seeing in Brighton only performs male to female reconstruction so I’m given confidence that it’s a procedure they’re very familiar with.

The assessment is 20 minutes with the surgeon, who was lovely, to very briefly discuss the permanent aspect but then said “I can see from the referral, all this is covered” before presenting me with a menu. Which bits would I like and with the pro’s and cons of each. Amazing! I’d already been considering this for about six months and discussed with GISW. I was relieved that my choice was also the surgeons preferred option, and for some good reasons too. We’d come to the same conclusion independently. We also discussed old age and ageing after surgery, something they said most overlook but little is known about, yet. The surgeon also has a brief inspection of the operation site to check there’s enough material for the chosen option and to advise if any permanent hair removal is required. Thankfully for me, no permanent hair removal required!

There is also 10 minutes with a nurse to document current medication, height, weight, blood pressure etc...

I left the Brighton Nuffield with the biggest grin ever, simply bouncing off the walls and convinced I was right to be doing this and also that I’d picked the right hospital.

Pre-surgery assessment as outpatient at hospital – in person, 30 minutes - £250

Passport (March 2025)

I’d deliberately left this as long as possible as I wanted my new passport to have a picture of me looking at worst androgynous but definitely not masculine as my face has changed shape considerably. I asked GISW to write a supporting letter, addressed to the passport office to justify the sex marker being changed. This is all that was needed, new passport returned in 10 days with no questions asked!

Letter to support change of passport sex marker from GISW, as existing customer – Free

Affirmation Surgery (September 2025)

I’m just waiting for a date now, having spoken to the gender group PA on Tuesday who assured me that my chosen dates were fine, just waiting for the surgeon to confirm theatre days. Waiting times are about 3-4 months after the pre-op appointment but I’d asked to wait until late September or early October to avoid summer holidays and the end of the work leave year to cause the minimum disruption possible. This was agreed at the pre-op so hopefully the week commencing 22nd September!

The surgery fee is a package price that essentially includes everything; it also including any surgical revisions required in the first 12 months, even for aesthetic reasons. This again gives peace of mind in case all doesn’t go quite to plan.

Gender affirmation surgery – package price £18,500

If there are any questions, please ask anything – I don’t really have a filter for this kind of thing in a space like Beaumont. Either in the forum of by private message – both are equally valid.

Scotia, xx