GPs should understand gender incongruence and the issues involved to ensure quality care is provided. However, we also need to balance what can be expected of GPs and the expertise which should rightly remain with specialist services.
This guidance aims to explain what should be provided in primary care and to highlight some of the underpinning ethical and legal considerations.
It is not exhaustive and we encourage practices to refer to the information referenced throughout. We also recommend to read it in conjunction with our guidance on inclusive care of trans and non-binary patients.
Background and terminology
The prevalence of gender dysphoria (or incongruence) is difficult to determine and is still being underestimated. The Gender Identity Research and Education Society suggest that about 1% of the population may experience some degree of gender incongruence.
Gender dysphoria can lead to mental ill health and can severely affect individuals’ quality of life. It is important that assessment and, where necessary, treatment is available.
The terminology used in this area is complex, changing, and can cause distress if not used appropriately:
- transgender (or trans) is an umbrella term to describe people whose gender identity is not the same as, or does not sit comfortably with, the sex they were assigned at birth
- gender incongruence is defined in ICD-11 (International Statistical Classification of Diseases and Related Health Problems) as being characterised by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex
- gender dysphoria refers to the psychological and physiological discomfort or distress caused by a discrepancy between a person’s gender identity, their sex assigned at birth, and their primary/secondary sex characteristics.
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 is known as misgendering. This can make people feel invalidated or disrespected, particularly if it occurs repeatedly.
The most straightforward way to determine pronouns is to ask “what are your preferred pronouns”? If you make a mistake, apologise and carry on.
Tips on managing patients with gender incongruence
- Be mindful of the sensitivity of their condition and of how difficult it might have been for your patient to seek treatment.
- Be particularly mindful of medical confidentiality, when addressing your patient in person and in written correspondence.
- Avoid misattributing commonplace health problems to gender.
- Assist those patients who wish to change their personal details on their practice medical record.
- Inform your patient of any gender-specific disease prevention and organ screening programmes, including offering information on how to opt out.
- Discuss any future family plans and fertility treatments options.
- Refer early to a reputable NHS GIC (gender identity clinic).
- Get informed about prescribing medicines that you are not normally familiar with.
Prescribing for the treatment of gender incongruence
We are aware that GPs are sometimes asked to prescribe hormones for patients with gender incongruence both before and after specialist involvement.
NHS England guidance encourages GPs to collaborate with GICs in the initiation and on-going prescribing of hormone therapy.
The BMA continues to engage with the GMC on issues relating to prescribing and ongoing care arrangements to seek clarification on its guidance.
The Royal College of Psychiatrists suggests that GPs may prescribe a bridging prescription to cover the patient’s care until they are able to access specialist services. The GMC advises that GPs should only consider a bridging prescription when:
- the patient is already self-prescribing, or seems highly likely to self-prescribe, with hormones obtained from an unregulated source (online or otherwise on the black market)
- the bridging prescription is intended to mitigate a risk of self-harm or suicide, and
- the doctor has sought the advice of a gender specialist and prescribes the lowest acceptable dose in the circumstances.
Collaboration with gender specialists
The GMC advice states that GPs must co-operate with gender identity clinics and specialists to provide effective and timely treatment for trans and non-binary people.
NHS England’s guidance states that when clinical responsibility for prescribing is transferred to general practice, it is important that the GP is confident to prescribe the necessary medicines.
In our view, this advice reaffirms that GPs should approach shared care and collaboration with gender identity specialists in the same way as they would any other specialist.
It is important that GPs feel clinically competent to prescribe the necessary medicines in order to provide the most appropriate level of care to the patient.NHS England - guidance on responsibility of prescribing between primary and secondary/tertiary care
Commissioning of services
Disclosures of information
The Gender Recognition Act 2004 provides safeguards for the privacy of individuals with gender dysphoria and restricts the disclosure of certain information.
The Act makes it an offence to disclose ‘protected information’ (ie a person’s gender history after that person has changed gender under the Act) when that information is acquired in an official capacity.
Primary Care Support England guidance sets out the steps involved in changing the patient’s name and gender on the patient record.