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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)

  • I'm puzzled here. You imply that it's a simple matter of getting out the prescription pad and prescribing hormones, yet as far as I can judge from their correspondence, our local gender clinic carries out multiple lengthy psycho-medical assessments over a period of several months before they will contemplate prescribing.

    If the decision to prescribe hormones is so straightforward, why do I see these multi-page letters relating to prolonged assessment periods?

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  • Generalists should be up to date on:
    1. Common medical problems and long term management
    2. Presentation of uncommon problems that are potentially serious if not identified and treated early.
    3. Treatment of acute conditions that do not need hospital review.
    4. Awareness of when acute or routine secondary care is appropriate.

    Transgender prescribing falls into the uncommon, not acute category so is the lowest priority for GP to 'find out'. Spending a few hours ensuring I'm prescribing properly AND more time setting up a disease register and recall system for one or two patients only is BY DEFINITION prone to medical error and substandard care when applied across a population of practices.

    Why does the author support a policy that will lead to substandard care when surely a service that sees this problem regularly will be 'best placed' to prescribe and monitor these medications?

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  • Re 'it's easy' there are many things I could learn to do as a GP. I am a faster typist than my secretary but it isn't the best use of my time doing this.
    This applies to GPs spending hours learning about how to treat 1 or 2 patients on their list - surely a regional nurse specialist could help?

    I would rather see my children at night occassionally than work out how to safely prescribe for non acute, rare conditions.

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  • 'The medication for transgender care includes:'

    'well-known oestrogen therapy used for treating female menopause (estradiol)' - we probably don't spend enough time doing this common thing well enough in primary care!

    'injections that are given for women with endometriosis' - this would be under direction of secondary care

    'anti-androgens used in contraceptives (cyproterone acetate)' - not first line COC

    'testosterone replacement therapy used for the management of the male menopause.' - contraversial and poorly understood +- managed condition which I would get secondary care advice on.

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  • On the other hand...

    The "well-known medication" is not designed or licensed for the purpose the author is advocating.

    GNRH analogues for delaying puberty when medically indicated and for endometriosis are administered through specialist clinics. GPs may choose to administer them for prostate cancer under specialist advice but that is for a clear medical indication within the licence and is not by any means comparable.

    Familiarity with the drugs used as intended is quite different from familiarity with the use of male hormones on female bodies and vice versa.

    Patients in this situation are best served by seeing someone with an interest and relevant experience - or is that the problem? Are the ethical dilemmas, prescribing risks and long term responsibility for prescribing outside one's field being handed to GPs because this is mental health led and the psychiatrists are unfamiliar with the drugs they are expecting someone else to use or because not enough doctors with an interest can be found to operate a dedicated service?

    I would think those with an interest in this area should be arguing for more specialist involvement, not suggesting that anyone could and should do it.

    I am quite happy to offer basic medical care in my capacity as a GP but I do not agree that what the author is suggesting comprises basic medical care.

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  • Helen Webberley

    The issue that we have is that gender care is on a true spectrum, and some of the cases are really very simple. Imagine a person, born male, who has felt female since birth. Secretly always cross-dressed and now, out of desperation, started taking estradiol bought off the Internet to try and make the body match the mind.

    All we need to do is listen, care, replace the potentially dangerous drugs with prescription meds and check some blood tests.

    The waiting times for the gender identity clinics in some areas are currently approaching 4 years, and with referrals rising rapidly, we should leave the specialist clinics to deal with the complex cases - because many are in fact very simple - and our GP skills are perfect for these desperate patients.

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  • Gender dysmorphia is a very hot topic at the moment with some high profile cases in the media of late.

    At present the Tavistock clinic is the main assessment and treatment centre I am aware of. Dr Webberley may have an interest in this area, but is she aware she is often being seen by parents who are trying to undercut the waiting time of the big clinics.

    Really, Dr Webberley should be starting these medications herself, getting patients stabilised and asking to hand over responsibility to GPs. If we as GPs refuse to accept responsibility, then private scripts should be issued and parents should be aware that going private will incur high costs.

    We as GPs don't have the experience with prescribing drugs off license in gender dysmorphia and until proper guidance comes out, I will continue to refuse to prescribe such drugs.

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  • If you can't get on train because of a lack of drivers you don't ask a lorry driver to have a go instead.

    Dr Webbereley should campaign for more specialist services for these patients.

    Of course in a wonderful centrally funded NHS these decisions are political, rather than market driven i.e. the punter uses money to buy expertise rather than uses politics to force the unwilling to develop an interest.

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  • Dear Dr Webberly
    You state you have a special interest in this topic. You have not stated that you run a private clinic for transgender patients.
    It would be useful for all concerned if you could state which bits of your advice is for your private patients and which for NHS ones.
    It would also be useful if you could point out where the resources are for NHS GPs. Locally agreed shared care agreements, monitoring via the near patient testing arrangements and administration costs of any injections.
    Without these minimum resources then all management should stay with the gender identity clinics which are part of specialised commissioning. not even secondary care and certainly not primary care

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  • Helen Webberley

    Hi, the trouble is that the specialist clinics are bursting and a lot of very simple cases could actually be managed in Primary Care.

    Many GPs are currently even refusing to monitor or prescribe under supervision of the gender clinics, for reasons that they 'don't approve' or 'don't agree' with this as a condition. So that could be a very simple step to take - just to agree to shared care.

    Some patients are do desperate that they are self-medicating and looking for safe and reliable sources of medication. I am hoping that more GPs would feel able (as the GMC recommends) to offer a bridging prescription while they wait for the GIC.

    And then maybe some other GPs would like to do a little more training to take this speciality on a bit further, and offer simple hormone regimes for cross-sex therapy. Many cases are barn-door, simple presentations, and the family GP could be by far the best person to help.

    We don't all have to take this on full steam ahead, but if we all did a little bit more than we may do now, then this very rewarding condition could be helped better, and maybe the shocking self-harm and suicide statistics may improve.

    We don't have to all become gender specialists, but actually if you read around the subject we can make little steps to make the lives of these gender variant people much happier and healthier.

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