The Gender dysphoria service: a guide for GPs and other healthcare staff sets out five key points for GPs to consider when treating gender incongruence:
- Refer early and swiftly to a reputable gender service
- Support the treatment recommended by the gender service
- Get pronouns right; if in doubt, (discreetly) ask
- Be particularly mindful of medical confidentiality
- Avoid misattributing commonplace health problems to gender
Initial GP consultation, referral and further treatment
Patients often find it difficult to confide their feelings of gender incongruence to their GP – either through fear of ridicule, or through guilt or shame, and this may prevent them from seeking treatment. Such patients are in genuine distress and are seeking help, so GPs should be mindful of the sensitivity of their condition and how difficult it might have been for the patient to have approached a health care professional in the first place. GPs should be aware that a person’s outward appearance may not correspond to their gender identity, particularly at early stages of the person’s journey, and will need to deal with this situation with understanding.
NHS England’s 2018 guidance on Responsibility for prescribing between primary and secondary/tertiary care expresses clearly that in order to provide the most appropriate level of care to the patient, it is of the utmost importance that the GP is clinically competent to prescribe the necessary medicines, and that any transfers involving medicines with which GPs would not normally be familiar should not take place without full local agreement, and dissemination of sufficient, up-to-date information to individual GPs.
The Royal College of Psychiatrists’ document Good practice guidelines for the assessment and treatment of adults with gender dysphoria outlines what GPs should do following diagnosis:
- Take full history, including mental health assessment.
- After diagnosis, discuss with patient if they have a preference for a particular way forward.
- A routine general and sexual health screening should be offered.*
- A full physical examination should be offered either by the hormone-prescribing clinic, or by GP in collaboration with specialist team.
- When referring patients, the GP should consider whether there are any co-existing conditions, mental or physical health issues, which need to be taken into account.**
Some difficulties arise over offering disease prevention activities or NHS screening procedures to patients who have completed gender reassignment. These can be overcome by remembering that disease prevention and screening should be organ-specific and not gender-specific, and patients need to understand what screening procedures they should continue to have.
* The GPC does not believe there is robust evidence to support this statement, and screening activities are not covered by Essential or Additional Services within the GMS contract.
** The GPC believes this is a responsibility of the doctor recommending the treatment.
Prescribing, monitoring and follow-up after gender reassignment treatment
The GPC is aware that GPs being asked to prescribe hormones for patients with gender incongruence both before and after specialist involvement. NHS England's Specialised Services Circular SSC 1620 states that GPs are encouraged to collaborate with GICs in the initiation and on-going prescribing of hormone therapy and that there is extensive clinical experience of the use of these products in the treatment of gender dysphoria.
The GMC has published advice on treating transgender patients which includes sections on prescribing “bridging prescriptions” and ongoing prescribing following the recommendation of a specialist. We are aware that there exist concerns that the guidance places further obligations on GPs with regard to prescribing and education which may have broader implications beyond the scope of transgender healthcare.
In April 2016 the BMA wrote to the GMC to seek clarification about the guidance and raised its concerns. The response, in part, informs the information here, although discussions are ongoing. The two circumstances in which GPs may be asked to prescribe for patients with gender incongruence, “bridging prescriptions” and ongoing care following consultation at a GIC, raise different issues and are therefore addressed separately below.
As a harm-reduction measure, the Royal College of Psychiatrists (RCPsych) has suggested that GPs may prescribe a bridging prescription to cover the patient’s care until they are able to access specialist services. The report and its recommendations have been endorsed by a range of Royal Colleges, including the Royal College of General Practitioners. The GMC advise that GPs should only consider a bridging prescription for an individual patient when they meet all the following criteria:
- the patient is already self-prescribing with hormones obtained from an unregulated source (over the internet or otherwise on the black market)
- the bridging prescription is intended to mitigate a risk of self-harm or suicide
- the doctor has sought the advice of a gender specialist, and prescribes the lowest acceptable dose in the circumstances.
In the GPC’s view, although the advice sets out the conditions under which the RCPsych suggestion for harm reduction in a specific subsection of vulnerable patients fits within the GMC’s existing guidance on prescribing, it fails to address the resulting significant medicolegal implications for GPs, and neglects the non-pharmacological needs of these patients.
It must be remembered that prescribers take individual ethical, clinical and legal responsibility for their actions, and when deciding on appropriate management GPs should keep accurate records of their reasoning and decisions. While awaiting specialist assessment, GPs should attend to their patients general mental and physical health needs in the same way as they would for other patients, but are not obliged to prescribe bridging prescriptions.
Patients should not have to resort to self-medicating due to a failure to commission a timely specialist service, and this problem must be solved by NHSE making proper commissioning arrangements rather than by GP-prescribing before initial assessment and diagnosis. If the delay for specialist assessment is excessive GPs do have a role as their patient’s advocate in making representation to the commissioning organisation to help ensure timely provision.
Collaboration with a specialist and ongoing prescribing
The GMC advice states that “GPs must co-operate with GICs and gender specialists in the same way as they would other specialists, collaborating with them to provide effective and timely treatment for trans and non-binary people. This includes prescribing medicines recommended by a gender specialist, following recommendations for safety and treatment monitoring, and making referrals to NHS Services as recommended by a specialist.
NHS England’s 2018 guidance Responsibility for prescribing between primary and secondary/tertiary care reiterates that when clinical responsibility for prescribing is transferred to general practice, it is important that the GP or other primary care prescriber is confident to prescribe the necessary medicines. NHS England recommends that these shared care agreements are agreed locally and reflect the following principles:
- The care is in the best interest of the patient
- The care reflects individual, patient-by-patient arrangements
- It is considered in a reasonably predictable clinical situation
- The care is agreed to be shared between a consultant/specialist and the patient’s GP
- The patient is always involved in shared care arrangements
- All parties provide willing and informed consent
- There is a clear definition of responsibility
- Clinical responsibility for prescribing is held by the person signing the prescription
- The arrangement is supported by a secure communication network for those responsible
- The provision of appropriate training and resources to support the arrangement
- All appropriate monitoring requirements should be fulfilled
This helps to ensure that care arrangements are both in the best interest of the patient and supportive of the GPs and other clinicians involved with providing timely and appropriate care.
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. The advice should therefore be read in conjunction with the principles which underpin shared care as set out by the GMC in Good practice in prescribing and managing medicines and devices.
Participating in a shared care agreement is voluntary, subject to a self-assessment of personal competence, and requires the agreement of all parties, including the patient. This will necessitate NHS England arranging additional local services to meet the prescribing and related needs for the patients of those GPs not commissioned to provide these services.
A full list of monitoring tests and medication required is available in Appendix 4 Hormonal treatment: a suggested collaborative care protocol in the RCPsych guidance document.