Inclusive care of trans and non-binary patients

This guidance aims to explain first steps and best practice in providing a supportive service to transgender, trans and non-binary patients, including patients who present with gender incongruence and/or dysphoria.
Location: UK
Audience: All doctors
Updated: Thursday 31 March 2022
Discrimination crossed out circle illustration

Introduction

It is important that all groups within the patient population have access to appropriate, timely, high quality healthcare. We acknowledge that many trans and non-binary patients have had negative experiences of accessing healthcare in the past and continue to do so.

The National LGBT survey 2018 captured data about people’s experiences of healthcare.

  • 40% of trans respondents who had accessed or tried to access public healthcare services reported having experienced at least one of a range of negative experiences because of their gender identity in the 12 months preceding the survey.
  • 21% of trans respondents reported that their specific needs had been ignored or not taken into account, and
  • 18% had avoided treatment for fear of a negative reaction.

Addressing these concerns is critical to providing high quality care and reducing health inequalities, as well as to ensure an inclusive healthcare system free from discrimination.

Outside of trans-related care such as gender clinics, trans and non-binary patients have the same healthcare needs as other patients. It is therefore likely that all doctors will provide care to someone in this group of patients at some stage. An understanding of the issues involved is necessary to ensure high quality general medical care is provided and, where necessary, appropriate referrals are made to specialist services. We also urge all doctors to take advantage of opportunities for continued professional development to advance their understanding of best practice in working with trans and non-binary patients.

The advice contained here is not intended to be exhaustive. There are a number of complex issues relating to care provision that need to be resolved. The BMA will continue to press for adequately resourced services to support patients seeking treatment for gender dysphoria.

We would encourage doctors and patients to refer to the sources of additional information and guidance that are referenced throughout the full guidance document.

 

Terminology

The terminology used in this area is complex, changing, and can cause distress if not used appropriately. Doctors and medical students are encouraged to respect and reflect the language choices that an individual patient uses to describe their own identity.

Transgender (trans)

Transgender and trans are umbrella terms to describe people whose gender identity is not the same as, or does not sit comfortably with, the sex they were assigned at birth. Trans people may describe themselves using one or more of a wide variety of terms.

Transsexual

The term ‘transsexual’ was used in the past as a diagnostic term and in legislation; it is still used by some people to describe themselves, although many people prefer other terms such as trans or transgender.

Non-Binary

The spectrum of gender identities or expressions that fall outside the historically typical gender binary (masculine and feminine). This includes those who do not identify as either a man or a woman and those who are gender-fluid (gender identity/expression changes over time or in different contexts) or agender (do not define themselves as having any particular gender identity).

Gender identity

Every individual’s personal, internal sense of their own gender.

Gender expression/presentation

The way in which a person expresses their gender identity, typically through appearance, clothing, and behaviour.

Gender incongruence

Discrepancy between a person’s gender identity, their sex assigned at birth, and their primary/secondary sex characteristics. Gender incongruence is now a specific diagnostic term in ICD-11. Further information is available here.

Gender dysphoria

Psychological and physiological discomfort or distress that is caused by a discrepancy between a person’s gender identity, their sex assigned at birth, and their primary/secondary sex characteristics. Gender dysphoria is not in and of itself classified as a mental illness. Untreated, gender dysphoria can severely affect the individual’s quality of life and potentially lead to mental ill health such as depression or anxiety.

Transition

Many trans people change their gender expression to bring it into alignment with their gender identity (which may include non-binary identities). This process is known as “transition”. Transitioning is a process and may include physical, psychological, social, and emotional changes. It may also (but does not necessarily) involve various types of medical treatment, to bring a person’s physical characteristics more into conformity with their gender identity and expression. Some transgender and non-binary people have little or no desire to undergo surgery to change their body but will transition in other ways.

Retransitioning/detransitioning

In a small number of cases, people may decide not to continue transition. Detransitioning (or retransitioning, which is increasingly the preferred team) is a process of stopping or reversing the decision to transition. While this may be associated with regret, a person’s individual reasons for retransitioning are likely to be more be complex and nuanced.

  • They may no longer identify as trans or they no longer identify with a gender they previously identified with.
  • People may also have found the process of transitioning too difficult, or experienced a lack of support or rejection from people close to them.
  • Some people may have concerns about the long-term impacts of medical interventions that supported their transition.
  • Some people may choose to pause, rather than reverse, the transition process, and some people who retransition may decide to transition again at a later point.
  • Some older trans people may retransition because they are concerned that they may not receive appropriate support in care settings or for end of life care.

 

Providing inclusive support for all trans- and non-binary patients

The BMA affirms the rights of all transgender and non-binary individuals to access healthcare and live their lives with dignity, including having their identity respected. Doctors should work collaboratively with their trans and non-binary patients as they do with any patient: in a respectful, open and sensitive way, free from discrimination or bias.

Doctors should be aware that not all transgender and non-binary patients will experience dysphoria or distress due to their gender identity, and should avoid automatically attributing particular health concerns or conditions to a patient’s gender identity. Trans and non-binary people, as a broad group, experience relatively poorer access to health services compared to other groups within the population. Inequitable access can result in trans and non-binary people receiving less care relative to their needs, or sub-optimal care, which can lead to poorer experiences and overall health outcomes.

The following sections cover topics of relevance to the management of all trans and non-binary patients regardless of whether they are seeking treatment for gender dysphoria.

 

Core principles of supportive care for transgender and non-binary patients

WPATH (The World Professional Association for Transgender Health) sets out broad principles for supportive care of transgender and non-binary patients, including:

  • exhibit respect for patients with non-conforming gender identities
  • provide care (or refer to knowledgeable colleagues) that affirms patients’ gender identities and reduces the distress of gender dysphoria
  • become knowledgeable about the possible health care needs of transgender and non-binary people in general, including the potential benefits and risks of treatment options for gender dysphoria
  • match treatment approaches to the specific needs of patients
  • facilitate access to appropriate care and offer continuity of care
  • seek patients’ informed consent before providing treatment and involve them in decision-making.

 

Demonstrating a trans-inclusive approach

Forms of address

It is important that individual preference should be respected. Doctors, medical students and other health care workers, and non-clinical staff, should address transgender and non-binary patients as they would prefer to be addressed. This is not dependent on any official name change. If in doubt, an opportunity should be found to discreetly ask the individual which form of address they prefer, and how they see their own gender identity. One way to do this would be to ask about someone what pronouns they use (see below).

Written correspondence should take into account the fact that others in the household may be unaware of the individual’s gender circumstances so preferences for written communication should also be asked about and documented. Doctors may for example wish to address written correspondence using an initial and surname, rather than using gendered titles such as Mr or Mrs.

A quick guide to pronouns

We all have pronouns. The most common ones are ‘she’, ‘her’ and ‘hers’ or ‘he’, ‘him,’ ‘his’. Some people prefer gender-neutral pronouns, like ‘they’, ‘them,’ and ‘theirs’. Some people will use different pronouns at different times. Changing pronouns can be an important part of transition.

 

Using the wrong pronoun for someone – for example, referring to someone as ‘he’ when they prefer to use ‘she’ – is known as misgendering. This can make people feel invalidated or disrespected, particularly if it occurs repeatedly or deliberately. If you make a mistake, apologise and carry on.

 

One straightforward way to determine pronouns is to ask “what pronouns do you use”? It may be helpful to share your own pronouns too if you wish.

Training and awareness

All healthcare workers should receive training in trans and non-binary awareness as part of their education and training and should seek awareness raising activities as part of their own professional development. The BMA will continue to lobby the Medical Schools Council and Royal Colleges to ensure that trans awareness is part of both undergraduate and postgraduate training.

In addition, all healthcare organisations should ensure their staff undertake training on trans and non-binary awareness alongside other training on inclusivity and respect. All healthcare workers and staff should respect the dignity of patients with respect to pronouns and gender-markers on any communication with the patient, including face-to-face interactions.

Healthcare workers and staff should be aware that a person’s outward appearance may not correspond to their gender identity and will need to be sensitive and interact with patients in a way that demonstrates an understanding that gender identity is not based on appearance. Similarly, when using telemedicine, healthcare workers and staff should avoid making assumptions about a person’s gender identity based on their voice, for example assuming that a person with a deep voice identifies as a man.

Changing medical records

Sometimes doctors are asked by transgender patients to change their name and/or gender on the medical record. Patients have the right to change the name and gender on the medical record irrespective of whether they intend to obtain a Gender Recognition Certificate. Healthcare workers should follow the advice outlined in the GMC’s advice to ensure patients’ rights are respected in this area and that they are properly informed of what documentation, if any, is needed to make changes.

When a patient informs the practice that they wish to change gender, the practice should inform the patient that this will involve a new NHS number being issued for them, which is not reversible. If the patient wanted to change their gender marker back to the gender they were assigned at birth, or to a different gender, patients would receive a third NHS number. All previous medical information relating to the patient needs to be transferred into a new created medical record and the patient registered as a new patient at the practice. How to do this varies slightly between nations in the UK where health is devolved - MDDUS provides additional information.

Propagating changes like this through the NHS records systems across multiple organisations can take a long time and the doctor and the patient will need to be aware that “the system” may still produce documents and letters with their previous name and gender on them for some time. If this happens, staff should apologise to the patient and have records and systems updated again to try to minimise recurrence.

Disclosure of information and medical records

A person’s gender history should not be divulged to anyone without their consent. Care needs to be taken around communications such as referrals to ensure that information that is relevant to the patient’s ongoing care is retained, but that information that may reveal gender history and which is not of relevance to the current medical situation is not disclosed.

A patient’s gender history can be revealed in ways other than explicitly stating that a person is trans or non-binary. For example, listing certain operations they have previously had that doesn’t match their current gender might make the patient’s gender history clear to the reader; for example, either gender confirming surgery, or sex-specific surgery such as colposcopy or prostate surgery. Care must be taken when processing documentation where computer systems can populate sections of forms with such data automatically.

The Gender Recognition Act 2004 provides safeguards for the privacy of transgender individuals and restricts the disclosure of certain information. The Act makes it an offence to disclose ‘protected information’ (i.e. a person’s gender history after that person has changed gender under the Act) when that information is acquired in an official capacity. Patients who are undergoing the transition process are also entitled to the same protection against disclosure of their gender history.

This means that the ‘protected information’ can only be disclosed in healthcare settings when:

  • it is to another health professional; and
  • it is for a medical purpose; and
  • there is a reasonable belief that the patient has consented to the disclosure.

Information obtained in the course of providing healthcare would usually be considered as acquired in an official capacity and therefore inappropriate disclosure would be an offence. Best practice would be to discuss with the patient why disclosure is considered necessary in a specific circumstance and to gain written consent from the patient to the disclosure of the information.

 

Continuity of care

Patients who have transitioned or are transitioning, or who are non-binary, may require or request access to medical services and treatments aligned with their registered sex at birth and/or former gender identity. It is important that doctors are able to provide general advice on these issues while respecting their patient’s gender identity and their autonomy to make decisions about their own healthcare.

NHS Screening calls

Trans and non-binary patients may require access to disease prevention and organ specific screening programmes (such as cervical smears, breast screening or prostate examinations) which are habitually offered only to specific groups and which may not align with the patient’s own gender identity.

Doctors should work with these patients to ensure that they understand any screening procedures they should continue to have. This may also include providing access to information on how patients may opt out of specific screening calls.

Prescribing

Doctors may be asked by trans and non-binary patients to support them in accessing hormone treatment either before they have received support from a gender specialist or with ongoing prescribing once they have been discharged from a specialist gender service:

Prescribing in this field is not part of the General Medical Services contract for GPs and prescribing in this field may be outside the competency of some GPs. Those GPs with relevant training and knowledge in this field may be able to support prescribing prior to, or in association with, specialist gender services.

Fertility care

Doctors who work with trans and non-binary patients who are considering surgery and/or endocrine treatments should work with those patients to explore whether they may wish to have biological children in the future and options to preserve this capacity, such as whether gamete storage might be considered.

The Human Fertilisation and Embryology Authority (HFEA) has useful information for trans and non-binary patients and their doctors on fertility and fertility treatment issues.

Retransitioning

Healthcare workers should avoid assuming that a decision to restransition/detransition is based on regret or that the person is no longer experiencing gender dysphoria. As with transition, patients who are retransitioning should be treated with empathy and their choices about their care should be respected.

Many of the practical processes involved in retransitioning will involve the same processes that were undertaken for transition; for example, establishing preferred pronouns or amending information on the medical record. Patients who are, or are considering, retransitioning may also benefit from specialist support, particularly if they have undertaken medical treatment as part of their original transition process.

 

Conclusion

All patients deserve respectful, supportive treatment in the healthcare system, both with their gender-related care and their medical care more generally. Doctors play a key role in demonstrating this and should be mindful of the lifelong need to provide sensitive care that recognises a patient’s gender history where medically necessary, but which broadly and consistently treats the patient according to their wishes around their gender identity and expression.