The role of the GP in caring for gender-questioning and transgender patients

The National LGB&T Partnership welcomes that the RCGP have established a position on the role of the GP in caring for gender-questioning and transgender patients and recommendations for ensuring these patients receive equal access to the highest standard of care. We particularly welcome the assertion that “GPs are expected to approach the holistic care of gender-questioning and transgender patients as they do with every patient – openly, respectfully, sensitively and without bias” and the recognition that “The gaps in education, guidance and training for GPs around treating gender dysphoria for both adults and children, and managing broader trans health issues, also needs to be urgently addressed”, particularly the recommendation that “if GPs feel a lack of knowledge or experience about the healthcare needs of trans people, they…address their training needs as part of continuing professional development.” 

However, our support of the position statement is not without its hesitations.

We of course welcome further research which will support the development and extension of positive support for trans people, however we are concerned that there is yet again call for further research when we know that this is used as a stalling mechanism in policy change and that national and international evidence is increasingly widely available, as is community-developed intelligence. The possibility of future innovations should not be used as a reason to ignore or undermine current good practice.

We welcome the progressive position that “people who are uncomfortable or distressed by their biological sex or gender roles and behaviours assigned to them by society, but do not wish to alter their sexual characteristics” deserve appropriate support. We call on NHSE to describe how this support will be provided through a model which restricts provision of care through the NHS England commissioned services (GICs) to those who receive a diagnosis of gender dysphoria.

We contest that GPs are “being pressured into prescribing”, particularly given the numbers of service users who state their GP is refusing to prescribe, even after instruction from a GIC, and also argue that prescribing should not be seen to “fall outside the limits of one’s competence” when detailed clinical guidance on hormone therapy has been available to GPs in the NHS publication Guidance for GPs, other clinicians and health professionals on the care of gender variant people since May 2008.

We have some concern that the statement made in section 28 ii may prevent those GPs who might feel competent prescribing from the point of a patient’s presentation to them from doing so, as they are instructed to “refer patients to a GIC or equivalent if they exhibit signs of gender dysphoria and request treatment”. This is compounded by the fact that the position statement also refers to the GP “taking on the ongoing prescribing of medication for patients and the monitoring of any side effects…after a patient has been discharged from a GIC”. The statement also acknowledges the lack of capacity of GICs, long waits between appointments, and long distances that many patients are required to travel to attend. Many trans people will not be discharged from the GIC until after they have received surgical interventions, which, between the requirements of the service specifications and the capacity-affected long waiting times between appointments is often a number of years after starting hormone treatments. Requiring patients to travel to GICs to obtain prescription, administration and monitoring of their hormone regimens during this time is clearly unreasonable.

We encourage the RCGP and the NHS to further investigate the opportunities and detailed complexities of altering NHS data collection systems with regards to sex, gender and trans status, so as to find a solution which serves patients, practitioners and researchers, as the suggestions outlined in UK Wide Policy Recommendation iii (page 10) do not appear to sufficiently consider the appropriateness of the changes recommended.

We are pleased to see that the statement suggests it is “vital that frontline GPs, patients and the broader trans community are involved in the design and implementation of changes to the current system”, and welcome the RCGP to call on the National LGB&T Partnership, it’s members and colleagues to support them in this work.

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