Much has been made in the media of my work with transgender patients and subsequent investigation by the GMC. I am regularly asked by patients how much truth there is to the press coverage and I would like to take this opportunity to provide some context to the situation and to invite anyone who is interested to draw their own conclusions.
In 2016, the Women and Equalities Committee report on Transgender Equality concluded that the transgender community is being let down by the NHS. The report states that: ‘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. The NHS is failing to ensure zero tolerance of transphobic behaviour. GPs too often lack understanding and in some cases this leads to appropriate care not being provided. A root-and-branch review must be conducted, completed and published by the NHS.’
Since this report was published, it seems that barely a day goes by when transgender issues are not being discussed in the media. Sadly, it tends to be against a backdrop of hysteria and sensationalism in which accusations of school yard sex changes are thrown around and parents supporting their gender-questioning children are accused of child abuse.
With delays to treatment as long as four years, the wait for help – in ANY form, we are not even talking about intervention at this stage – is excruciating for those questioning their gender, whatever age they happen to be.
So, based on my belief that this does not need to be a super-specialist, tertiary referral area of medicine, but something that all well-intentioned GPs can and should help with, I made a decision to use my skills to provide support to this group of people (while leaving the specialist clinics available for the more complex cases). It is worth noting at this stage that I am not alone in this belief, and in fact NHS England report that gender specialists can come from many different clinical backgrounds, some specialising in mental health: psychologists, psychiatrists, counsellors or therapists, but they may also be GPs, endocrinologists, nurses, etc.
I set up GenderGP initially as an advice service but this very quickly snowballed and requests for treatment were quick to follow. Patients came to me with desperate tales of their situation and their struggles to get any information, let alone support. They spoke about their situation in terms of life and death and my instincts kicked in. After all, as a GP I have been working with male and female hormones for 25 years, and it was clear that these adults knew who they were and what they needed.
Then came the children and things began to get even more emotive. Desperate parents with stories of children threatening and attempting suicide and harming themselves because no one would help them. Waiting lists so long that puberty came and went while appointments failed to materialise. So naturally, I did what I was trained to do. I assessed each individual case and, together with my multidisciplinary team including gender-specialist psychotherapists, counsellors and a highly qualified hospital consultant, made collaborative decisions about the current and future needs of the patient. Together with the patient and their support network, we agreed on the most appropriate treatment pathway to keep them safe and well until such time that they were able to be seen by the relevant experts at the Tavistock and Portman Clinic, the only specialised service for treating gender-questioning children in the UK.
Very quickly, however, complaints began to land on my doormat from the most unlikely of places. It would seem that the doctors in the NHS Gender Identity Clinics did not take kindly to my intervention and I found myself subject to investigation by the General Medical Council (GMC), the UK doctors’ regulatory body.
Puberty blockers can provide some relief by pressing pause on puberty to allow the patient to think about who they are and what they want without the pressure of time. Much has been written about the concerns of prescribing puberty blockers, but research shows that they do not have heavy side effects when used in young people. In fact, the evidence we have is that transgender children feel physically and mentally much better after starting puberty blockers that allay the fears of the wrong pubertal changes.
Having said that, little attention is paid to the side effects of NOT prescribing puberty blockers for a child suffering with gender dysphoria. These include anxiety, depression, stress and self harm along with the progressive body changes which come as the child develops in the puberty of the gender they do not identify with. If we accept that trans issues are real (which is the widely accepted view of the modern world, and of the NHS) then this means that boys will develop hips, breasts and start periods, and girls will find that their voices break and muscles and beards start to grow.
Carefully evaluated children who are recognised as transgender, request, want and need puberty blockers. It stands to reason that these children will go on to gender-affirming hormone treatment, based on the premise that they are indeed transgender. Why would a child request frequent needles that give injections to stop them developing into teenagers if there wasn’t a real need?
The concerns raised with the GMC by those who oppose my work with transgender patients stem from a belief that I am:
- not qualified enough and
- that I don’t ‘assess’ people well enough to make sure that they aren’t trying to obtain hormones for the ‘wrong reasons’
To the first point see the above findings from NHS England. To the second point, my approach starts from a position of belief in what the patient is claiming, that the patient knows what they are going through, based on a lifetime of experience, and is not required to prove themselves over a lengthy period of time. It is worth noting that this patient-led approach is one which the NHS has been promoting among patients and doctors for some time, it is known as ‘informed consent’ and is becoming the best practice approach to helping patients with gender dysphoria.
Interestingly, no complaints have been made about me by the patients themselves. Indeed, if the comments and emails we receive at GenderGP on regular basis are to be believed, for the patients, the service is seen as a bona fide lifeline.
The investigation is ongoing and is due to conclude in September 2018. In the meantime, in spite of initially restricting my treatment of transgender patients, the Medical Practitioners Tribunal Service (MPTS) which runs hearings for doctors whose fitness to practice is called into question by the GMC, has (as of 19 March 2018) lifted this restriction and I am now able to return to this essential work.
Furthermore, in recent months we have seen subtle shifts by the NHS in an attempt to address some of the concerns outlined in the report from the Women and Equalities Committee. As recently as January, NHS England issued a Specialist Services Circular outlining in no uncertain terms that GPs can and should be working with specialist private services to treat transgender patients. The aim is to help reduce the extensive waiting lists and prevent self-medicating which can lead to patient harm. As the only private service of this kind, GenderGP welcomes such clarity and support for GPs who should absolutely be managing more straightforward cases.
I am a doctor and I have been listening to, and caring for, people for more than 25 years. I am in a very privileged profession that has allowed me to be part of many lives, families and stories, as well as being party to some of their deepest secrets. Nowhere has this been more evident than in my time treating transgender patients. When I became a doctor I wanted to help people. Never did I believe I would truly save lives but this is exactly what I hear from the patients I have helped through GenderGP.
Good healthcare is about listening and understanding. Every patient is different and brings a different set of life experiences which will influence their health beliefs and their needs. When I worked as clinical tutor for the Interactive Skills Department at the University of Birmingham, our main focus was on how doctors communicate with patients; listen and hear, explain and be heard. Yet here, that vital element of communication seems to be missing. The doctors that criticise me and feel so strongly that I should not continue to provide my services to patients have done so without engaging in any form of communication with me. No email, no telephone call, not even a letter. Just straight to the online complaint form of our regulatory body to express their concerns.
The GMC understands that undergoing an investigation can be stressful for the doctor. Between 2005 and 2013 there were 28 reported cases in the GMC’s records where a doctor committed suicide or, suspected suicide, while under their investigation procedures. These are the reported cases, but we know very well that the life-changing shame and humiliation felt by doctors who find themselves in this situation often goes unreported, and many doctors’ careers never recover. The irony of the fact that I am subject to this investigation, which has led to doctors in my position taking their own lives, as a result of trying to help a marginalised group of people at high risk of suicide, has not escaped me.
However, this is a fight worth fighting. I have met some amazing people who have held their head high, despite the ignorant insults hurled at them on a daily basis. The same insults that I see replicated in the comments sections of articles written about me and on Twitter – and I will also keep my head held high.
He is famously quoted as saying, ‘I ask myself, in mercy, or in common sense, if we cannot alter the conviction to fit the body, should we not, in certain circumstances, alter the body to fit the conviction?’
He was one of the first to understand the beneficial effects of cross sex hormones and sex reassignment surgery on people suffering with gender dysphoria. In an interview in 1975 he said, ‘When I began my work, there wasn’t a reputable hospital in this country that would have dreamed of permitting transsexual surgery. Now there are at least thirty.’
I welcome the GMC investigation if it will assuage the fears of those who wrongly accuse me of substandard practice. If the investigation finds in my favour there is no doubt that it will be a mini victory for me but, more importantly, it will be a major victory for the transgender community, as more doctors with an interest in the field might be more confident about treating this group of individuals who so desperately need our help.