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Re: The struggle for GPs to get the right care for patients with gender dysphoria

 

Last week (22.01.20) an article was published in the British Medical Journal (BMJ) about the challenges faced by doctors in primary care when asked to treat a patient with gender dysphoria.

Dr Helen Webberley drafted the following response:

Dear Editor,

Once again we read about the difficulties faced by doctors who are asked to provide care for their trans patients. Yes, gender dysphoria can be a ‘difficult terrain for primary care doctors’, but it is also a difficult terrain for trans patients.

Sally Howard has carefully balanced the plight of patients stuck on long waiting lists to see specialists, with the difficulties presented by the lack of education available for doctors. She mentions that gender identity and gender dysphoria are not part of the GP curriculum, but startlingly, they are not part of any Royal College curriculum. If we examine the core competencies of the current GMC approved curricula for all of the specialties, in particular the curricula for the core competencies of General Practice, Paediatrics, Paediatric Endocrinology, Child and Adolescent Psychiatry, then the needs and care of transgender patients only exist in the GP curriculum.

There is no specific GMC speciality or sub-speciality for doctors providing treatment to transgender patients. In the section of their website on education, the GMC states: ‘We set the standards for providers of medical education and training, and we regularly check to make sure those standards are met. Here you’ll find the standards, guidance and curricula we publish along with supporting materials.’

How can standards be set, if the core competencies of a doctor’s knowledge do not include care for this patient group?

In the current absence of UK educational materials, doctors have a duty to seek out international guidance to help their patients. There are excellent published guidelines for GPs which have been written to ‘equip primary care providers and health systems with the tools and knowledge to meet the health care needs of their transgender and gender nonconforming patients.’ How is it still so acceptable for doctors not to undertake personal learning to address their lack of knowledge?

Sally Howard quotes The Royal College of GPs advising their GPs to not feel ‘expected to fill gaps in commissioned gender identity specialists and clinics.’ However, this leaves their patients unsupported and them open to litigation battles. Is this really the best advice for their members?

Articles such as this continue to reinforce the narrative that this is a ‘difficult’ and ‘complex’ issue that needs specialist training. Few publications that write about the difficulty faced by doctors in their lack of knowledge and skills, actually pin down what the patients are asking their doctor to provide.

In her letter to the BMA back in 2016 regarding their response to the GMC Guidance for doctors treating transgender patients, Susan Goldsmith, acting Chief Executive for the GMC, wrote, ‘While GMP [Good Medical Practice] states “you must recognise and work within the limits of your competence”, this principle cannot be a bar to doctors taking on new responsibilities or treating unfamiliar conditions.’ She went on to say that ‘…we don’t believe that providing care for patients with gender dysphoria is a highly specialised treatment area requiring specific expertise.’

Patients need belief, support and medication. They are not asking to be ‘diagnosed’; they are asking to be believed when they explain how their gender feels different to the one they were assigned at birth. They are not asking for medications that are addictive, dangerous or that require extensive monitoring. They are asking for medications in common use in every day practice. Medicines such as estradiol, testosterone and GnRH agonists. Commonly used medications when treating menopause, androgen insufficiency and prostate cancer. They are not asking for deep psychotherapy, they are asking for support to help them navigate their lives.

And who is better placed to provide this than their GP?

This response was published in full on the BMJ website: https://www.bmj.com/content/368/bmj.m215/rr

Photo by Hush Naidoo on Unsplash