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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: elearning.rcgp.org.uk/gendervariance

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)

  • I am saddened that pulse uses a piece from Dr Webberly pretending to be from a fellow GP.
    She has provided a private, online prescribing service for many years for people with transgender problems. This is clearly not core General Practice.
    She has retired from General Practice and seems to be in the process of setting up a specialist service for people with transgender problems. Again this is not core General Practice. I am unable to tell if it is an NHS service that is intended or a private one taking NHS contracts. Perhaps she would care to enlighten us.
    Most of what she says about the core values of General Practice are perfectly reasonable,apart from
    'This is set to become part of routine general practice, with GPs supporting the rising numbers of people seeking help.'

    I would disagree, unless adequate resources are provided.

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  • Daunting and imposing and 90% of the workload already. We CANNOT do anymore. Just CANNOT.

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  • What is the evidence base and incidence for self harm due to waiting times for these clinics? Surely risk of self harm is a prompt for a rapid response from the clinic, in the same way risk of Stroke from TIA or risk of cancer from PV bleed post menopause has an urgent pathway to specialist care?

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  • Paul Attwood

    No

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  • GPs' ideally placed for

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  • @Anonymous | GP Partner30 Jun 2016 6:12pm "Surely risk of self harm is a prompt for a rapid response from the clinic, in the same way risk of Stroke from TIA or risk of cancer from PV bleed post menopause has an urgent pathway to specialist care?"

    It's good that you recognise it is ridiculous that there isn't an urgent pathway for at risk patients.

    http://www.gires.org.uk/assets/Medpro-Assets/trans_mh_study.pdf

    "Nearly 60% of them reported being seen within a year (N=293), with around 32% waiting one to three years and under 10% waiting for more than three years. 58% of the participants (N=295) felt that this wait had led to their mental health or emotional wellbeing worsening during this time" pg 27

    "...of significant concern, was the finding that just under 20% of respondents
    had wanted to harm themselves in relation to, or because of involvement with a GIC
    or health service (N=461)." pg56

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  • It is utterly reprehensible to see the abject failure of NHS England Specialised commissioning of transgender services being covered up by collusion with the General Medical Council professional regulator with a " GMC say do it or else" threat circulated by NHS England.
    The GMC have done themselves no favours.
    The General Practitioners Committee should be credited for backing the regulator down from " on demand for everyone or else" to a specific set of guidance -( those acting criminally and suicidal" as a harm minimisation activity AND ONLY UNDER SPECIALIST GUIDANCE.)
    The Initial purported "guidance" breached clear and longstanding standards of personal practice espoused by the GMC.
    Please don't forget that there is a vulnerable group of patients with complex AND SPECIALISED care needs that have been badly let down by NHS England specialist commissioning arrangements.
    Heads should roll at the GMC and NHS England for this provable malfeasance in public office.

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  • No. Not general practice and we should not be landed with specialist prescribing and responsibility just because there is a wait to see a specialist.

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  • No No No

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  • Sadly, there is no evidence that treating gender dysphoria reduces the risk of self-harm and suicide. Rates remain the same, whether or not people are treated. GPs should therefore not feel railroaded into prescribing potentially harmful drugs outside their area of competence in a misguided belief that this will reduce the risk of self-harm.

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