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Why do GPs have to prescribe for gender dysphoria?

GPC warns the regulator’s demands could force GPs to treat outside their competence, Jaimie Kaffash finds

finasteride pills spl suo

finasteride pills spl suo

GPs should initiate hormones in patients with gender dysphoria in specific circumstances, the GMC has advised.

The regulator said GPs should be capable of initiating treatment to mitigate a risk of self-harm or suicide where a patient is already self-prescribing with black market drugs and continue to prescribe as part of shared-care arrangements. 

Ongoing row

It is the latest in the ongoing row over GPs’ role in treating transgender patients, which has been brought to the fore after NHS England refused to designate the treatment of people undergoing gender reassignment as non-GMS work in service specifications drawn up for commissioners in June 2015.

The service specifications said GPs would be expected to provide ‘bridging prescriptions’ for hormone therapy and carry out safety monitoring procedures, interpreting blood test results and hormone levels – which NHS England said was the ‘non-specialised’ element of the pathway. This has now been endorsed by the GMC.

But the GPC has raised concerns about this with the regulator, pointing out that GPs should not be initiating prescribing outside their competence, and that the shared-care arrangements stipulation ‘places a worrying expectation on any GP’ to continue prescribing specialist medication.

In response, a letter from GMC chief executive Niall Dickson detailed the ‘exceptional circumstances’ when GPs are expected to initiate medication:

  • The patient is self-prescribing with hormones from an unregulated source.
  • The bridging prescriptions are intended to mitigate risk of self-harm or suicide.
  • The GP has sought the advice of a gender specialist and prescribed the lowest acceptable dose.

‘Not specialist’

Mr Dickson added: ‘We don’t believe providing care for patients with gender dysphoria is a highly specialist area requiring specific expertise.

‘Our understanding is that the same, or similar, hormone medications are commonly used in general practice for treating patients with prostate cancer or endometriosis.’

But GPC chair Dr Chaand Nagpaul told Pulse that GPs should not be undertaking this care.

He said: ‘We don’t believe GPs should be prescribing even in exceptional circumstances, because that is clearly outside of their competence and the guidance, which says patients should be first seen by the specialist.

‘It is unlikely that indemnity bodies will see “exceptional circumstances” to be a mitigating factor should a problem arise from the GP’s prescription.’

He added that the shared-care arrangements mean GPs will be expected to prescribe hormones that ‘are not licensed in patients in this situation’.

Dr Nagpaul said: ‘The more important thing is that the GMC is being highly reductionist in the management of patients with gender dysphoria. It isn’t about prescribing, it is about managing patients who need ongoing comprehensive care.’

The GMC has acknowledged there are commissioning deficiencies, he added, ‘and that is what needs to be tackled’.

How to comply with the GMC guidance

dr helen webberley 3x2

dr helen webberley 3x2

Unfamiliar conditions can seem daunting and imposing, but meeting the new transgender guidance from NHS England and the GMC should be fairly simple for GPs – and, hopefully, rewarding. This is set to become part of routine general practice, with GPs supporting the rising numbers of people seeking help.

Here are five tips on how GPs can manage this group of patients.

1 Gender care is a recognised medical condition with clear treatment pathways recommended by the NHS. The charity GIRES has helped create an online learning resource with the RCGP that can help if you are unsure:

2 There are high rates of self-harm and suicide among these patients, so refer for specialist care. At the very least, the patient should be referred to their local gender identity clinic (check the NHS website). Waiting times can be as long as four years though.

3 Don’t be afraid to diagnose. Many patients will tell you they have always felt they were assigned the wrong gender. They may be living in their preferred gender role publicly or in private and may be taking hormones they have acquired out of desperation.

4 Don’t forget the drugs used are common prescriptions. The medication for transgender care includes well-known oestrogen therapy used for treating female menopause and finasteride, which is given to men with benign prostatic hyperplasia.

5 Use the everyday skills GPs are good at. This condition causes great upset at home, at work and in public. Patients need a caring and kind approach, and a safe source of prescription medication, and blood tests to monitor hormone levels.

Dr Helen Webberley is a GP in Monmouthshire and runs an online transgender clinic

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Readers' comments (14)

  • Comments above seem to have totally ignored "...where a patient is ALREADY self-prescribing with black market drugs..."

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  • I don't think it makes a difference; it's still a specialist field. Why can't clinics issue "bridging" scripts while patient on waiting list if it's so simple? Alternatively, address the long waiting time.

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  • |Anonymous | Sessional/Locum GP|04 Jul 2016 5:25pm
    "...where a patient is ALREADY self-prescribing with black market drugs..."

    So if a patient told you they were buying 'yellow valiums' or methadone you would happily give them a prescription?

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  • It is high time the GMC reviewed the requirement for a GP to issue a 'prescription on the statutory form for any treatment that the patient may require', alongside the directive that 'a doctor must not practice outside their areas of experience and expertise', and come up with something a lot clearer, fairer, less risk to doctors and their MDOs, and more patient-friendly.
    The current situation should be totally unacceptable to patients, where they are forced to accept sub-standard care from a GP who is forced to prescribe items with which they are unfamiliar, and is unable to provide the associated support and after-care simply because specialists are unwilling to accept responsibility for their own prescribing decisions, and LHBs/commisioners for their failure to provide adequate resources and services to patients.
    The GMC needs to insist that NHS immediately implements a system whereby specialists and consultants have access to the UHR and repeat prescription systems and can accept responsibility for their own prescription funding AND MONITORING direct to repeatable item lists - but with the same interaction warnings and safety measures as GPs have in theri prescribing systems.
    Is this 21st century medicine or what?

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