Waiting lists are up to five years for gender identity clinics. What could GPs do?
Brighton GP Samuel Hall, who has a specialist interest and 450 trans and nonbinary patients, said that prescribing hormones and other trans healthcare is “not specialist care” and that GP practices should deliver it, though they need more training and support.
Well. Trans people want hormones. They help us transition, they help us appear of our true gender. They inhibit fertility, perhaps permanently, and medical ethics says “Do no harm”, but we would say the benefits outweigh the risks. A GP should be able to understand those risks- if there is an increased risk of embolism, monitor for that.
The British Medical Association guidance says GPs should understand gender incongruence. The Royal College of General Practitioners position statement from 2019 notes that trans patients seeking gender affirming care will first contact their GP, and the GP may be the first person they tell about their gender, but GPs are not trained in gender identity issues and are instructed to refer on. They want more research on outcomes of treatment, including “wait and see” (do nothing), and more expert services.
The BMA recognises that patients will self-medicate if we cannot get NHS prescriptions. The BMA and GPs advocate for timely treatment. The Royal College of Psychiatrists suggests GPs could prescribe hormones and hormone-blockers, but the General Medical Council advises GPs should only consider this if the patient fits all of three criteria:
they are already self-prescribing or likely to, from an unregulated source- so a GP would not take over a private prescription
The patient’s risk of self-harm or suicide would reduce, and
The GP has sought the advice of a specialist and prescribes the lowest acceptable dose.
Even though they say “untreated, gender dysphoria can severely affect the individual’s quality of life and potentially lead to mental ill-health”, they don’t seem to recognise particular benefits from hormones in themselves. Hormones do have particular risks, which they take into account as reasons not to prescribe, especially pre-op. I may have a look round to see what is established about the benefits of hormones in gender diverse adults.
So you may be able to get hormones from your GP, but it is difficult. Once the gender clinic recommends hormones, the GP should prescribe them, but that may be in five years’ time.
GPs should use the forms of address and pronouns we prefer. They should recognise our distress and the difficulty of confiding in someone. They can refer to specialists directly, and should do so.
Simon Gilbert writes that gender dysphoria is uncommon but not urgent, so GPs should be able to identify it and refer on. GPs treating risk unknown unknowns. Another GP writes he has had three trans patients in twenty years. GPs should not have to deal with trans patients “because another part of the NHS is crap”. GPs feel overworked and underqualified on trans care, and we should recognise their difficulties too. For too many GPs, managing patients means saying the right things so we use as little of their time as possible. Patrufini Duffy writes that GPs are overloaded with social problems on top of having no time to deal with their lists of patients, so cannot take on gender prescribing.
The BMA says GPs should work with us on fertility care, including sperm or egg storage.
The BMA recommends an intermediate service to provide care up to but not including surgery. There is such a service in Wales. Such a service could refer “complex” cases on to a more specialist service, but the definition of “complex” would change as its skills, experience and competency develop. The BMA pressing for more gender clinics might be a way of absolving itself of responsibility for prescribing now. It says GICs, not GPs, should manage the GIC waiting list and should not ask GPs to reassess patients in an attempt to delete some patients from the waiting lists.
Pulse, a magazine for “health professionals only”, reported on the gender clinics asking GPs to review patients on the waiting lists, and sought quotes and allowed comments from GPs.
Seven years post-op, my new GP explained that the risk of thrombosis indicated I should come off hormones. It was a disaster. I went back on; but one risk named to justify the prescription was osteoporosis. We need to be able to justify hormone prescriptions.
Picture from the Wellcome Collection shows how seriously doctors take themselves.