Gender Construction Kit Logo

What does ''reasonably well controlled'' mean?

A phrase you might find often comes up in requirements is that other medical conditions should be “reasonably well-controlled”. For example:

If significant medical or mental health concerns are present, they must be reasonably well controlled

This wording appears in the WPATH Standards of Care 1, the NHS England Service Specifications 2;3, the NHS Wales Service Specification 4, and the NHS Scotland gender reassignment protocol and its explanatory notes 5;6.

What does this mean?


The information given in this section is based on our best understanding of current medical guidance. Your doctors may interpret the guidance differently.

The phrase “reasonably well-controlled” does not have a set meaning in medicine, and the meaning is not clearly set out in any of the NHS documents that use it.

However, these documents are largely quoting the WPATH Standards of Care 1, which does provide some more clarity.

  • For hormone treatment

    The Standards of Care state (p45) that:

    Other medical conditions … can be exacerbated by estrogen or androgen blockade, and therefore should be evaluated and reasonably well controlled prior to starting hormone therapy

    for oestrogen treatment, and

    Co-morbid conditions likely to be exacerbated by testosterone use should be evaluated and treated, ideally prior to starting hormone therapy

    for testosterone treatment.

    In other words, there are some medical conditions that might be made worse by hormone therapy, and if you have one of these conditions, this might be taken as a reason to delay your hormone treatment until your condition is better controlled.

    If your other medical conditions are unlikely to be impacted by hormone therapy, your doctor should not withhold hormone treatment from you, and if they do you can complain.

    If you have conditions that might be impacted by hormone therapy, you might be required to undergo some treatment before you can receive hormones.

  • For surgical treatment

    The Standards of Care state (p61) that:

    When patients with gender dysphoria are also diagnosed with severe psychiatric disorders and impaired reality testing … an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated. Reevaluation by a mental health professional qualified to assess and manage psychotic conditions should be conducted prior to surgery, describing the patient’s mental status and readiness for surgery. … No surgery should be performed while a patient is actively psychotic.

    In other words, if you have a diagnosis of a “severe psychiatric disorder”, your doctors will want to make an effort to treat this before considering surgery. They will also be unwilling to give you surgery if they believe you’re currently having trouble working out what is real.

    If you have not been diagnosed with a “severe psychiatric disorder”, and do not believe you are likely to receive that kind of diagnosis, this is unlikely to impact you.

    If you do have such a diagnosis, or think you might receive one, this could mean that your doctor will require you to undergo psychotherapy or psychiatric treatment before referring you for surgery.

What can I do if I’m worried about this?

If you’re worried that your health conditions might be used to deny you gender-affirming treatment, or that you might be required to undergo treatment that you don’t want, you could consider bringing an advocate to medical appointments. This could be a friend or relative, or someone experienced in medical advocacy.

If you have been denied gender-affirming treatment due to one of your health conditions, or are being required to undergo treatment that you don’t want, you can make a complaint:

  • For NHS England, you can complain to PALS
  • For NHS Scotland, you can complain to PASS
  • For NHS Wales, you can find details of your local health board’s process here
  • For HSC Northern Ireland, you can find out how to make a complaint here
  • Private clinics will have their own complaints process


  1. 1.
    World Professional Association for Transgender Health (2011) Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th Version, WPATH. Link
  2. 2.
    NHS England (2019) Service specification: Gender Identity Services for Adults (Non-Surgical Interventions), NHS England. Link
  3. 3.
    NHS England (2019) Service specification: Gender Identity Services for Adults (Surgical Interventions), NHS England. Link
  4. 4.
    NHS Wales (2019) Service Specification CP182b Gender Identity Service for Adults (non-surgical), NHS Wales. Link
  5. 5.
    Scottish Government Health and Social Care Directorate (2012) Gender Reassignment Protocol, NHS Scotland. Link
  6. 6.
    National Gender Identity Clinic Network Scotland (2012) Explanatory Notes v1.0: To be read in conjunction with the Gender Reassignment Protocol CEL 26 (2012), NHS Scotland. Link

Errors and omissions

Is there something missing from this page? Have you spotted something that isn't correct? Please tweet us or message us on Facebook to let us know.