In April, 2016, NHSE issued guidance on the collaboration between GPs in the UK and private gender specialist services. Here we analyse the document and pull out the key points.
NHSE Specialised Services Circular 1826: Primary Care Responsibilities in Regard to Requests by Private On-Line Medical Service Providers to Prescribe Hormone Treatments for Transgender People:
Regulatory guidance and NHS England’s current commissioning protocol supports a decision by a GP to accept a request made by a private on-line medical service to assume responsibility for prescribing, and for monitoring and testing, in cases where the GP is assured that the recommendation is made by an expert gender specialist working for a provider that offers a safe and effective service.
GP collaboration with Gender Specialists
The NHS constitution gives patients the rights to access certain services by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer a range of suitable alternative providers if this is not possible.
The Women and Equalities report found significant concerns raised about doctors’ lack of awareness and consideration in treating transgender patients, and we are very happy to help GPs and patients alike.
The Specialised Services Circular 1620: ‘Guidance for GPs, other clinicians and health professionals on the care of gender variant people’ states that, ‘GPs are usually at the centre of treatment for trans people, often in a shared care arrangement with other clinicians. GPs may prescribe hormones and make referrals to other clinicians or services, depending on the needs of the particular service user. Sometimes a GP has, or may develop, a special interest in gender treatment and may be able to initiate treatment, making such local referrals as necessary. Otherwise referrals may be made to a specialist Gender Identity Clinic (GIC) where there are multidisciplinary teams of professionals. Private treatment with a gender specialist may be preferred by the service user.’
Benefits of GP / Specialist Collaboration
Collaboration between gender specialists and the patient’s GP has many benefits:
- The patient will be able to access timely and safe healthcare for their gender identity while waiting for access to NHS services which have very long waiting lists.
- The patient will be able to reduce their own personal risks by eliminating the need to purchase medication from unregulated sources without proper monitoring.
- It supports their GP in prescribing and performing and analysing blood tests until treatment that should ordinarily be available to them on the NHS becomes available, but under specialist supervision.
- There is a two-way sharing of the patient’s medical history which leads to safer and more comprehensive care and better outcomes.
- Once a diagnosis has been established the GP will be advised on which blood tests are necessary to safely monitor the treatment and medication, and at what intervals they need to be performed.
The NHS Specialised Services Circular 1620 dated 22 April 2016 confirms that there is extensive clinical experience of the use of the medications used in the treatment of gender dysphoria, which provides evidence of tolerability and safety comparable with their use for approved indications.
Managing the Interface between NHS and Private Care
Many patients worry that if they access private services while waiting for the specialised gender clinics, they may be penalised. As emphasis on patient choice within the NHS grows, it is increasingly recognised that patients are entitled to choose freely between NHS and private treatment, whether provided as a private service by an NHS body or by the independent sector, at different points in their overall care.
According to Guidance from the BMA Medical Ethics Department:
- Patients who are entitled to NHS-funded treatment may opt into or out of NHS care at any stage.
- Patients may pay for additional private health care while continuing to receive care from the NHS.
- Patients who have had a private consultation for investigations and diagnosis may transfer to the NHS for any subsequent treatment. They should be placed directly onto the NHS waiting list at the same position as if their original consultation had been within the NHS.
- All doctors have a duty to share information with others providing care and treatment for their patients. This includes NHS doctors providing information to private practitioners.
This is backed up by the NHS Guidance for Patients who wish to Pay for Additional Private Care:
- NHS organisations should not withdraw NHS care simply because a patient chooses to buy additional private care.
- The NHS should continue to provide free of charge all care that the patient would have been entitled to had he or she not chosen to have additional private care.
GMC Guidance on Treating Transgender Patients
The GMC Advice for doctors treating trans patients aims to help doctors see how the principles of Good medical practice apply in relation to trans patients and also to explain doctors’ duties under the Equality Act 2010 and other legislation.
The GMC’s advice was initially met with a variety of concerns from NHS GPs, and Dr Chaand Nagpaul CBE Chair, BMA General Practitioners Committee 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.’
Susan Goldsmith, acting chief executive of the GMC, 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.’
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 who are well-used to their side effects and monitoring needs. Although it is recognised that some of these medications are not currently licensed for use in these conditions, there is sufficient evidence of their efficacy and safety in the management of gender dysphoria.
What constitutes a Gender Specialist?
There is no specific training or qualification or specialist register for gender specialists in the UK.
Gender specialists can come from any medical specialty. In the NHS Document “clinical models operated by England’s gender identity clinics” it states that, Gender specialists may be from many different clinical backgrounds, some specialising in mental health: psychologists, psychiatrists, counselors or therapists, but they may also be GPs, endocrinologists, nurses etc
In the WPATH Standards of Care Version 7: “With appropriate training, feminizing/masculinizing hormone therapy can be managed by a variety of providers, including nurse practitioners, physician assistants, and primary care physicians (Dahl et al., 2006).”
Providing assurance to GPs
All our clinical staff are highly trained in the care of gender patients. They have extensive experience of the assessment, diagnosis and treatment of gender dysphoria. All counsellors and psychotherapists involved in the MDT process are all members of BACP and undergo regular CPD and supervision related to gender identity, and attend regular CPD in this area. Some excellent links have been formed with NHS commissioning specialised GICs.
Examining the criteria for treatment
The NHS England’s current commissioning protocol relates to the treatment of adults over the age of 17:
- All of the health professionals that our patients are referred to for support and evaluation specialise in gender dysphoria and have vast and extensive experience in the assessment of management of patients who may have associated mental or emotional distress.
- All patients are evaluated by at least two gender specialists, one of which is a medically qualified doctor and only the doctor will make decisions regarding endocrine treatments.
- Our MDT meets regularly to discuss cases and management and to review and develop the service.
- Fertility preservation is a key priority and is discussed with all patients along with HFEA advice.
Considerations for treating younger patients
NHS England will, as part of the Gender Identity Development Service for Children and Adolescents, commission cross sex hormones for young people with continuing gender dysphoria from around their 16th birthday subject to individuals meeting the eligibility and readiness criteria.
All of our prescribing physicians have extensive knowledge and experience in endocrinology and are fully qualified to treat children and adults. Both NHS and private gender specialists come from many backgrounds, counselling, psychology, general practice, general medicine, psychiatry, endocrinology, paediatrics.
The WPATH criteria for mental health professionals working with children include:
- Meet the competency requirements for mental health professionals working with adults.
- Trained in childhood and adolescent developmental psychopathology.
- Competent in diagnosing and treating the ordinary problems of children and adolescents.
The Endocrine Society Guidelines 2017 advise the following ‘We advise that only MHPs who meet the following criteria should diagnose GD/gender incongruence in children and adolescents:
- Training in child and adolescent developmental psychology and psychopathology.
- Competence in using the DSM and/or the ICD for diagnostic purposes.
- The ability to make a distinction between GD/gender incongruence and conditions that have similar features (e.g., body dysmorphic disorder).
- Training in diagnosing psychiatric conditions.
- The ability to undertake or refer for appropriate treatment.
- The ability to psychosocially assess the person’s understanding and social conditions that can impact gender-affirming hormone therapy.
- A practice of regularly attending relevant professional meetings.
- Knowledge of the criteria for puberty blocking and gender-affirming hormone treatment in adolescents.
- We suggest that adolescents who meet diagnostic criteria for GD/gender incongruence, fulfill criteria for treatment, and are requesting treatment should initially undergo treatment to suppress pubertal development.
- We suggest that clinicians begin pubertal hormone suppression after girls and boys first exhibit physical changes of puberty.
- We recommend that, where indicated, GnRH analogues are used to suppress pubertal hormones.
- In adolescents who request sex hormone treatment (given this is a partly irreversible treatment), we recommend initiating treatment using a gradually increasing dose schedule after a multidisciplinary team of medical and MHPs has confirmed the persistence of GD/gender incongruence and sufficient mental capacity to give informed consent, which most adolescents have by age 16 years.
- We recognize that there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/gender incongruence, even though there are minimal published studies of gender-affirming hormone treatments administered before age 13.5 to 14 years. As with the care of adolescents > 16 years of age, we recommend that an expert multidisciplinary team of medical and MHPs manage this treatment.
The Risks of Withholding Medical Treatment for Adolescents
Women and Equalties Report:
‘We recognise that there are legitimate concerns among service-users and their families about the clinical protocols which the clinic operates regarding access to puberty-blockers and cross-sex hormones. Failing to intervene in this way, or unnecessarily delaying such intervention, clearly has the potential to lead to seriously damaging consequences for very vulnerable young people, including the risk of selfharm and attempted suicide.
There is a clear and strong case that delaying treatment risks more harm than providing it. The treatment involved is primarily reversible, and the seriously dangerous consequences of not giving this treatment, including self-harming and suicide, are clearly well attested.
Accordingly, we recommend that, in the current review of the service specification and protocol for the Gender Identity Development Service, consideration be given to reducing the amount of time required for the assessment that service-users must undergo before puberty-blockers and cross-sex hormones can be prescribed.’
WPATH: ‘Refusing timely medical interventions for adolescents might prolong gender dysphoria and contribute to an appearance that could provoke abuse and stigmatization. As the level of gender-related abuse is strongly associated with the degree of psychiatric distress during adolescence (Nuttbrock et al., 2010), withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents.’
Weighing up the pros and cons of GP supporting by prescribing and monitoring under supervision of a gender specialist
According to the House of Commons Women and Equalities Committee report 2016: ‘The NHS is letting down trans people: it is failing in its legal duty under the Equality Act. Trans people encounter significant problems in using general NHS services, due to the attitude of some clinicians and other staff who lack knowledge and understanding – and in some cases are prejudiced.’ We are very happy to advise on the safe prescription and monitoring of bridging hormones.
While the Abortion Act 1967 allows ‘conscientious objection’ which permits doctors to refuse to participate in terminations, no such clause exists for the care of transgender patients and patients are entitled to receive objective and non-judgmental medical advice and treatment. This position is supported by the Equality Act 2010.