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GPs buried under trusts' workload dump

It’s easy to help patients with gender variance – here’s what you can do

Letter from Dr Helen Webberley, a GP in South Wales with a special interest in sexual health and gender care

Patients with gender variance have faced enormous battles of bigotry, prejudice, humiliation and have even been denied access to basic care from their GPs. Following significant concerns raised about doctors’ lack of awareness and consideration in treating transgender patients,  I was delighted to see the GMC publish guidelines on managing transgender patients. 

These are medications that are well known to GPs

Of course this was to be met with a variety of concerns from NHS GPs, and I have yet to see many embrace this welcome news that we can now do more to help our trans patients.

GPC chair, Dr Chaand Nagpaul, penned his concerns to the GMC, raising the emotive points that this would make GPs undertake specialist prescribing, placing them in a difficult position and forcing them to prescribe outside the limits of their competence.

Acting chief executive of the GMC, Susan Goldsmith, replied with reassurances including that they expect GPs to ‘acquire the knowledge and skills to be able to deliver a good service to their patient population’, which may mean undertaking training and that they don’t believe care for patients with gender dysphoria is a highly specialised treatment area requiring specific expertise.

She goes on to endorse a firm view of mine, that these patients actually require very simple care and well-known medication.

The medication for transgender care includes well-known oestrogen therapy used for treating female menopause (estradiol), injections that are given for women with endometriosis or men with prostate cancer (GNRH analogues), a diuretic used for heart failure (spironolactone), anti-androgens used in contraceptives (cyproterone acetate), medication for benign prostate hyperplasia (finasteride) and testosterone replacement therapy used for the management of the male menopause.

These are medications that are well known to GPs, and we are well-used to the side effects and monitoring.

The other essential aspect of transgender care is listening, hearing, caring, educating, protecting – bread and butter to GPs.

So, I have simple advice for GPs, and this may just help your patients who are transgender and may be suffering from a basic lack of medical care:

  • If you don’t know then look it up, there are many training resources and literature sources on gender care. 
  • Listen to your patients, they are not mentally ill, they are gender incongruent.
  • Their medical needs are often very simple – some hormone replacement therapy and a listening ear.
  • The treatments are those that we use every day, put any prejudices aside and get your prescription pad out.
  • The cost of treating these patients is far less than the loss of life and distress caused by refusing them very simple, basic care.

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Readers' comments (17)

  • Specialist problems need to be managed by specialists. If the clinics are over-subscribed then the commissioners need to balance the need of this group of patients against that of other groups.
    Fertility patients face a terrible struggle to get timely treatment. Should we all prescribe a bit of climbed whilst we wait for the clinic. Should I start patients on methotrexate or olanzepine because the local trusts cannot meet their two week appointments for arthritis or psychosis.
    We have to be there to help our patients but we must not be rash and we must not risk our registration.
    Dr Webberley, I understand your crusading zeal has pushed you into leaving mainstream GP, perhaps you are not the right person to lecture us Generalists on what good general practice is

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  • Dear Dr Webberley,

    I'm concerned about the long term benefits of hormonal treatment and gender reassignment - can you point me towards an evidence based review? I haven't done detailed research, but whilst it seems that gender dysphoria can be helped by transition in the short term, does this have a lasting effect, and are the suicide rates reduced?

    Of particular concern is the treatment of children, when the American College of Pediatrics highlights that "According to the DSM-V, as many as 98% of gender confused boys and 88% of gender confused girls eventually accept their biological sex after naturally passing through puberty." https://www.acpeds.org/the-college-speaks/position-statements/gender-ideology-harms-children

    Rupert Everett expressed his concern about the treatment of children here - https://www.theguardian.com/film/2016/jun/19/rupert-everett-dangers-of-child-sex-change-operations-gender
    Clearly the experience of one person isn't grade 1 evidence but it seems to be a very dangerous thing to allow treatment to reassign gender even if it was a minority in whom the dysphoria would resolve by the end of puberty.

    Thanks.

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  • We as Gp's are familiar with transfer of workload from secondary care to primary care. Fine, I will perform my first open cardiac surgery tomorrow....in the car parc...no room in waiting area in the surgery!

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  • There are real risks that standard GPs could get swept along with this enthusiasm. we are specialist in general practice, not niche areas

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  • This comment has been moderated

  • Helen Webberley

    The problem with talking about driving lorries, performing open heart surgery and other extreme specialist services is that it dilutes what we are actually talking about here.

    Many GPs refuse to refer to GICs, a lot of GPs refuse to share care with the specialist clinics, too many GPs turn patients away because they say they don't know anything about gender care.

    It is the small steps of listening, caring, sharing care, referring appropriately that we could ALL do.

    And then, for perhaps the more modern thinking GPs, bridging prescriptions or initiating therapy in very easy cases of gender dysphoria will honestly save lives.

    My 'crusading zeal' is not trying to persuade you to perform gender reassignment surgery in the car park, but to just do what GPs do best.

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  • Did I get moderated?
    All I did was post Dr Webberleys online prescribing website address.
    Surely GPs would like to see the market opportunities.
    obviously we could not provide an NHS service for our own patients.
    that still leaves loads of patients whose GPs have no access to CCG resources to manage this work dumping from tertiary care, so a good cash crop.
    will I get moderated again/ anyone can use a search engine!

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  • Show me where it's GMS and I'll 'upskill.'

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