GPs are being asked to conduct ‘extensive reviews’ for patients referred to gender identity clinics (GICs) due to long waits to access services, the BMA has said.
In new guidance, it said that while GPs should ‘understand gender incongruence and the issues involved’, there is a need to ‘balance what can be expected of GPs and the expertise which should rightly remain with specialist services’.
The BMA has called for better commissioning of specialist services to avoid ‘significant’ extra workload for ‘already crumbling’ practices.
It also warned of GPs being asked to prescribe hormones for patients with gender incongruence ‘both before and after specialist involvement’.
GPs can refer patients directly to gender identity clinics (GICs), which provide patients with access to a multidisciplinary team, without an assessment by mental health services prior to referral.
However, a new BMA document on the ‘Role of GPs in managing adult patients with gender incongruence’ said that the BMA has ‘concerns about the lack of specialist service provision, the impact this has on patients and the pressure it can have on practices’.
The document said: ‘There have been reports of some GICs asking GPs to review patients who had already been referred to the GIC, due to long waiting times.
‘It is the responsibility of GICs to manage their waiting lists – not practices – and they should be approaching patients directly to explore whether they still want access to their services.’
It added: ‘Practices have been asked to do extensive review including a mental health assessment confirming if the patient still needs their services and the GIC has also written to the patient to confirm the ongoing need and to discuss any issues with the GP.
‘This work is not part of GMS services and is adding a significant workload for each patient for practices already crumbling under pressure.’
Verifying waiting lists ‘has never been the role of GPs’ and the initiative should be funded ‘similarly to local pathways for support and funding to introduce local measures on other waiting lists’, the BMA said.
It added: ‘This is another example of the urgent need for commissioning of GIC services as well as a commissioning framework of mental health services both in children and adults, so that they work in unison.’
Meanwhile, the BMA also said it is ‘aware that GPs are sometimes asked to prescribe hormones for patients with gender incongruence both before and after specialist involvement’.
The guidance said that the RCGP has backed a Royal College of Psychiatrists suggestion that GPs prescribe a ‘bridging prescription’ until the patient is able to access specialist services, as a ‘harm-reduction measure’.
But the BMA argued that GPs are ‘not obliged to prescribe bridging prescriptions’ although they should attend to their patient’s ‘general mental and physical needs’ while they await specialist assessment, as with any other patient.
BMA guidance on gender dysphoria
The prevalence of gender dysphoria (or incongruence) is difficult to determine and still being underestimated. The Gender Identity Research and Education Society suggests that about 1% of the population may experience some degree of gender incongruence.
Gender dysphoria is not itself classified as a mental illness, but it can lead to mental ill health and can severely affect individuals’ quality of life. It is important that assessment and, where necessary, treatment is available.
But doctors should be aware that not all transgender patients will experience dysphoria or distress due to their gender identity and should avoid automatically attributing particular health concerns or conditions to a patient’s gender identity.
The terminology used in this area is complex, changing, and can cause distress if not used appropriately:
- transgender (or trans) is an umbrella term to describe people whose gender identity is not the same as, or does not sit comfortably with, the sex they were assigned at birth
- gender incongruence is defined in ICD-11 (International Statistical Classification of Diseases and Related Health Problems) as being characterised by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex
- gender dysphoria refers to the psychological and physiological discomfort or distress caused by a discrepancy between a person’s gender identity, their sex assigned at birth, and their primary/secondary sex characteristics.
Tips for GPs on managing patients with gender incongruence:
- Be mindful of the sensitivity of their condition and of how difficult it might have been for your patient to seek treatment.
- Be particularly mindful of medical confidentiality, when addressing your patient in person and in written correspondence.
- Avoid misattributing commonplace health problems to gender.
- Assist those patients who wish to change their personal details on their practice medical record.
- Inform your patient of any gender-specific disease prevention and organ screening programmes, including offering information on how to opt out.
- Discuss any future family plans and fertility treatments options.
- Refer early to a reputable NHS GIC (gender identity clinic).
- Get informed about prescribing medicines that you are not normally familiar with.
Source: BMA
The BMA said: ‘Patients should not have to resort to self-medicating due to a failure to commission a timely specialist service and we continue to advocate for NHS England and NHS Improvement (NHSE/I) to make proper commissioning arrangements.
‘If the delay for specialist assessment is excessive, GPs do have a role as their patient’s advocate in making representation to the commissioning organisation to help ensure timely provision.’
In a statement issued last month, it added: ‘Access to these specialist services should be rapid in order to ensure patients receive safe care – and if timely access at a GIC (Gender Identity Clinic) is not possible – additional intermediate capacity has to be commissioned locally to ensure safe and effective care pending specialist involvement.’
It also said that NHS England has ‘neglected to commission comprehensive, local, quality-controlled specialist services for the ongoing care of patients once they have been discharged from the GIC’.
The BMA will continue to call for NHS England to develop ‘national guidelines and properly commissioned services for this particular group’.
It has also issued updated guidance on inclusive care of trans and non-binary patients.
Brighton GP partner Dr Samuel Hall, who has a specialist interest in transgender health, told Pulse that GICs are ‘underfunded, poorly resourced and mostly hosted by hostile mental health trusts’.
He said: ‘Since the de-pathologisation of gender incongruence, there hasn’t been any move by NHS England – whose responsibility it is to commission this work – to try and facilitate a push down into primary care or general practice for treatment.’
Dr Hall, whose practice has around 450 trans and non-binary patients, added that transgender healthcare and in particular prescribing hormones is ‘not specialist care’ and that GP practices are the ‘right place’ to deliver it, but need more training and support.
He said: ‘[Providing] hormones to trans people is within the remit of any GP because we provide hormones to lots of people for lots of reasons all the time.
‘It’s just a matter of a small amount of additional learning for a GP, which happens all the time in general practice when new things crop up, to manage the hormone treatment of transgender people. It’s not very difficult basically, it’s not rocket science.’
He added that the ‘key to this is to educate GPs’ who feel ‘a little bit underskilled’ and ‘at risk of being persecuted’.
He told Pulse: ‘From my perspective, what you’re looking at here is discrimination – it’s targeted, deliberate, obstructing trans healthcare so that people can’t get what they need and it’s a way of punishing an oppressed minority group of people by depriving them of adequate healthcare.’
In 2019, the RCGP called for a whole-system approach to improving NHS care for trans patients, including more training to support GPs and for waiting times for GICs to be addressed.
It came months after the RCGP dropped an online course on gender dysphoria following GP concerns about ‘unrealistic expectations’ that they prescribe outside of their clinical competence.
GP prescribing for gender dysphoria
NHS England guidance:
- One guideline encourages GPs to ‘collaborate’ with GICs in the ‘initiation and ongoing prescribing of hormone therapy’.
- But another guideline says GPs must be ‘clinically competent to prescribe the necessary medicines and that any transfers involving medicines with which GPs would not normally be familiar should not take place without full local agreement and dissemination of sufficient, up-to-date information to individual GPs’.
The GMC has advised:
- GPs should ‘collaborate’ with GICs and/or an experienced gender specialist to provide ‘effective and timely treatment’ for trans and non-binary patients, which ‘may include prescribing medicines on the recommendation of an experienced gender specialist for the treatment of gender dysphoria and following recommendations for safety and treatment monitoring’
- GPs should only consider a ‘bridging prescription’ when the patient is already ‘self-prescribing’ or seems ‘highly likely’ to do so with hormones obtained from an unregulated source; it is intended to mitigate the risk of self-harm or suicide; or the doctor has ‘sought the advice of a gender specialist and prescribes the lowest acceptable dose in the circumstances’.
The BMA said it ‘continues to engage with the GMC on issues relating to prescribing and ongoing care arrangements to seek clarification on its guidance’.
In 2016, a row broke out between the BMA’s GP Committee and GMC over GP concerns that they were being forced to prescribe to gender dysphoria patients, without the necessary expertise. The GPC’s response was to advise GPs to ignore GMC guidance on the matter.
The following year, NHS England published a consultation on gender identity services asking for views on GPs’ involvement in prescribing hormone therapy.
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READERS' COMMENTS [9]
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You need to know your own identity, before you meddle with others.
40mins max per patient per year to deal with those that are ill or think they are ill. Managing complex issues such as gender identity is hugely specialised and I am not nor will I ever build up the expertise to consider it. 3 patients in 20 years. To have some GP with a personal hobby of gender identity telling me I should do it well sod off. Not my job and funding it is the responsibility of the centre and I am not and never will be responsible for those funding decisions. I am interested in minor surgery but I am not ding apendicectomies and breast enlargements. Just ridiculous and insidious mission creep for GP’s because another part of the NHS is crap.
General practice priorities should be:
Conditions can be urgent/time sensitive or long term.
They can be common or uncommon.
1. Common long term conditions: GPs, their staff and recall systems should be able to learn how to manage and recall their patients, stay up to date and have a good grasp of the condition to be aware of pitfalls and reduce the risk of unknown unknowns. E.g. type 2 diabetes care.
2. Common urgent conditions; GPs, their staff and their systems should be able to respond to, identify and treat in an appropriate timeframe, or arrange appropriately urgent specialist care. E.g. patient with a respiratory tract infection.
3. Uncommon urgent conditions: GPs, their staff and practice systems should know when to suspect these conditions and refer onwards for appropriate management. E.g. suspected pulmonary embolism.
4. Uncommon non urgent conditions: GPs, their staff and practice systems should be able to identify or suspect these specialist conditions and refer onwards for appropriate long term management. Trying to ‘learn’ about these conditions when the volume is small risks ‘unknown unknowns’ and failures of call/recall processes. E.g. gender dysphoria.
Like ADHD, radicalisation, safeguarding, workplace bullying, social loneliness, domestic violence, housing and obesity…the list goes on and on – ***they rope you in once again with no decent pathway out, fuelling the gender issue (there is much money to be made here you know), and you become the scapegoat and a beleaguered point of repetitive contact for free. Their hands are brushed clean, and you’re chucked in it. Next you will be consulting food poverty, climate issues and energy crises.
Not even on a fine day.
Sorry.
Too busy checking boilers.
I would respectfully disagree with Dr Hall. Numbers of such patients in any one practice will be too low to be able to provide a full and proper specialist service. It might be possible to take on prescribing under a mutually-agreed Shared Care Prescribing agreement, once the patient has been stabilised on the appropriate medication or dose, but our engagement with the very specialist aspects of care should end there. We should, of course, continue to offer the usual core services.
Dr Hall’s clinic is of such a size as to enable him to develop a special interest, and that is probably the model we should follow if we wish (and have capacity) to offer community-based care; but it should be properly resourced by the commissioner, and should not be used as an excuse to avoid funding capacity in secondary-care based gender services, which is the real problem here.
This is a vulnerable group of (often young) patients, and they deserve and need proper medical and psychological care. It is not safe or appropriate for us to step in to try to offer an unsafe and inadequate service, and it will only allow commissioners to ignore the real problem of commissioning a proper service and will perpetuate the current status quo.
Wel, if you have 450 patients the of corse your view would be ‘it’s easy, come on, what are you worried about!?’ Sigh.
Let’s do more of this…. Fine… But what will we be doing less of?