It’s easy to help patients with gender variance – here’s what you can do
17 June 2016
Letter from Dr Helen Webberley, a GP in South Wales with a special interest in sexual health and gender care
- GPs should initiate gender dysphoria hormones in ‘exceptional circumstances’
01 June 2016
- Guidance for GPs on supporting transgender patients
19 May 2016
- GPC complains about GMC gender dysphoria prescribing guidance
17 May 2016
Patients with gender variance have faced enormous battles of bigotry, prejudice, humiliation and have even been denied access to basic care from their GPs. Following significant concerns raised about doctors’ lack of awareness and consideration in treating transgender patients, I was delighted to see the GMC publish guidelines on managing transgender patients.
These are medications that are well known to GPs
Of course this was to be met with a variety of concerns from NHS GPs, and I have yet to see many embrace this welcome news that we can now do more to help our trans patients.
GPC chair, Dr Chaand Nagpaul, 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.
Acting chief executive of the GMC, Susan Goldsmith, 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.
She goes on to endorse a firm view of mine, that these patients actually require very simple care and well-known medication.
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, and we are well-used to the side effects and monitoring.
The other essential aspect of transgender care is listening, hearing, caring, educating, protecting – bread and butter to GPs.
So, I have simple advice for GPs, and this may just help your patients who are transgender and may be suffering from a basic lack of medical care:
- If you don’t know then look it up, there are many training resources and literature sources on gender care.
- Listen to your patients, they are not mentally ill, they are gender incongruent.
- Their medical needs are often very simple – some hormone replacement therapy and a listening ear.
- The treatments are those that we use every day, put any prejudices aside and get your prescription pad out.
- The cost of treating these patients is far less than the loss of life and distress caused by refusing them very simple, basic care.
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READERS’ COMMENTS (17)
- Anonymous | Sessional/Locum GP17 Jun 2016 7:29am
I’m puzzled here. You imply that it’s a simple matter of getting out the prescription pad and prescribing hormones, yet as far as I can judge from their correspondence, our local gender clinic carries out multiple lengthy psycho-medical assessments over a period of several months before they will contemplate prescribing.
If the decision to prescribe hormones is so straightforward, why do I see these multi-page letters relating to prolonged assessment periods?
- Anonymous | GP Partner17 Jun 2016 8:58am
Generalists should be up to date on:
1. Common medical problems and long term management
2. Presentation of uncommon problems that are potentially serious if not identified and treated early.
3. Treatment of acute conditions that do not need hospital review.
4. Awareness of when acute or routine secondary care is appropriate.
Transgender prescribing falls into the uncommon, not acute category so is the lowest priority for GP to ‘find out’. Spending a few hours ensuring I’m prescribing properly AND more time setting up a disease register and recall system for one or two patients only is BY DEFINITION prone to medical error and substandard care when applied across a population of practices.
Why does the author support a policy that will lead to substandard care when surely a service that sees this problem regularly will be ‘best placed’ to prescribe and monitor these medications?
- Anonymous | GP Partner17 Jun 2016 9:01am
Re ‘it’s easy’ there are many things I could learn to do as a GP. I am a faster typist than my secretary but it isn’t the best use of my time doing this.
This applies to GPs spending hours learning about how to treat 1 or 2 patients on their list – surely a regional nurse specialist could help?
I would rather see my children at night occassionally than work out how to safely prescribe for non acute, rare conditions.
- Anonymous | GP Partner17 Jun 2016 9:10am
‘The medication for transgender care includes:’
‘well-known oestrogen therapy used for treating female menopause (estradiol)’ – we probably don’t spend enough time doing this common thing well enough in primary care!
‘injections that are given for women with endometriosis’ – this would be under direction of secondary care
‘anti-androgens used in contraceptives (cyproterone acetate)’ – not first line COC
‘testosterone replacement therapy used for the management of the male menopause.’ – contraversial and poorly understood +- managed condition which I would get secondary care advice on.
- Anonymous | GP Partner17 Jun 2016 11:48am
On the other hand…
The “well-known medication” is not designed or licensed for the purpose the author is advocating.
GNRH analogues for delaying puberty when medically indicated and for endometriosis are administered through specialist clinics. GPs may choose to administer them for prostate cancer under specialist advice but that is for a clear medical indication within the licence and is not by any means comparable.
Familiarity with the drugs used as intended is quite different from familiarity with the use of male hormones on female bodies and vice versa.
Patients in this situation are best served by seeing someone with an interest and relevant experience – or is that the problem? Are the ethical dilemmas, prescribing risks and long term responsibility for prescribing outside one’s field being handed to GPs because this is mental health led and the psychiatrists are unfamiliar with the drugs they are expecting someone else to use or because not enough doctors with an interest can be found to operate a dedicated service?
I would think those with an interest in this area should be arguing for more specialist involvement, not suggesting that anyone could and should do it.
I am quite happy to offer basic medical care in my capacity as a GP but I do not agree that what the author is suggesting comprises basic medical care.
Helen Webberley | Sessional/Locum GP17 Jun 2016 1:09pm
The issue that we have is that gender care is on a true spectrum, and some of the cases are really very simple. Imagine a person, born male, who has felt female since birth. Secretly always cross-dressed and now, out of desperation, started taking estradiol bought off the Internet to try and make the body match the mind.
All we need to do is listen, care, replace the potentially dangerous drugs with prescription meds and check some blood tests.
The waiting times for the gender identity clinics in some areas are currently approaching 4 years, and with referrals rising rapidly, we should leave the specialist clinics to deal with the complex cases – because many are in fact very simple – and our GP skills are perfect for these desperate patients.
- Anonymous | Salaried GP17 Jun 2016 1:29pm
Gender dysmorphia is a very hot topic at the moment with some high profile cases in the media of late.
At present the Tavistock clinic is the main assessment and treatment centre I am aware of. Dr Webberley may have an interest in this area, but is she aware she is often being seen by parents who are trying to undercut the waiting time of the big clinics.
Really, Dr Webberley should be starting these medications herself, getting patients stabilised and asking to hand over responsibility to GPs. If we as GPs refuse to accept responsibility, then private scripts should be issued and parents should be aware that going private will incur high costs.
We as GPs don’t have the experience with prescribing drugs off license in gender dysmorphia and until proper guidance comes out, I will continue to refuse to prescribe such drugs.
- Editor’s comments
This comment has been moderated
- Anonymous | GP Partner17 Jun 2016 1:56pm
If you can’t get on train because of a lack of drivers you don’t ask a lorry driver to have a go instead.
Dr Webberley should campaign for more specialist services for these patients.
Of course in a wonderful centrally funded NHS these decisions are political, rather than market driven i.e. the punter uses money to buy expertise rather than uses politics to force the unwilling to develop an interest.
- Jeremy Luke | GP Partner17 Jun 2016 6:42pm
Dear Dr Webberley
You state you have a special interest in this topic. You have not stated that you run a private clinic for transgender patients.
It would be useful for all concerned if you could state which bits of your advice is for your private patients and which for NHS ones.
It would also be useful if you could point out where the resources are for NHS GPs. Locally agreed shared care agreements, monitoring via the near patient testing arrangements and administration costs of any injections.
Without these minimum resources then all management should stay with the gender identity clinics which are part of specialised commissioning. not even secondary care and certainly not primary care
Helen Webberley | Sessional/Locum GP18 Jun 2016 11:28am
Hi, the trouble is that the specialist clinics are bursting and a lot of very simple cases could actually be managed in Primary Care.
Many GPs are currently even refusing to monitor or prescribe under supervision of the gender clinics, for reasons that they ‘don’t approve’ or ‘don’t agree’ with this as a condition. So that could be a very simple step to take – just to agree to shared care.
Some patients are do desperate that they are self-medicating and looking for safe and reliable sources of medication. I am hoping that more GPs would feel able (as the GMC recommends) to offer a bridging prescription while they wait for the GIC.
And then maybe some other GPs would like to do a little more training to take this speciality on a bit further, and offer simple hormone regimes for cross-sex therapy. Many cases are barn-door, simple presentations, and the family GP could be by far the best person to help.
We don’t all have to take this on full steam ahead, but if we all did a little bit more than we may do now, then this very rewarding condition could be helped better, and maybe the shocking self-harm and suicide statistics may improve.
We don’t have to all become gender specialists, but actually if you read around the subject we can make little steps to make the lives of these gender variant people much happier and healthier.
- Jeremy Luke | GP Partner18 Jun 2016 9:32pm
Specialist problems need to be managed by specialists. If the clinics are over-subscribed then the commissioners need to balance the need of this group of patients against that of other groups.
Fertility patients face a terrible struggle to get timely treatment. Should we all prescribe a bit of climbed whilst we wait for the clinic. Should I start patients on methotrexate or olanzepine because the local trusts cannot meet their two week appointments for arthritis or psychosis.
We have to be there to help our patients but we must not be rash and we must not risk our registration.
Dr Webberley, I understand your crusading zeal has pushed you into leaving mainstream GP, perhaps you are not the right person to lecture us Generalists on what good general practice is
- Anonymous | GP registrar20 Jun 2016 2:52pm
Dear Dr Webberley,
I’m concerned about the long term benefits of hormonal treatment and gender reassignment – can you point me towards an evidence based review? I haven’t done detailed research, but whilst it seems that gender dysphoria can be helped by transition in the short term, does this have a lasting effect, and are the suicide rates reduced?
Of particular concern is the treatment of children, when the American College of Pediatrics highlights that “According to the DSM-V, as many as 98% of gender confused boys and 88% of gender confused girls eventually accept their biological sex after naturally passing through puberty.” https://www.acpeds.org/the-college-speaks/position-statements/gender-ideology-harms-children
Rupert Everett expressed his concern about the treatment of children here – https://www.theguardian.com/film/2016/jun/19/rupert-everett-dangers-of-child-sex-change-operations-gender.
Clearly the experience of one person isn’t grade 1 evidence but it seems to be a very dangerous thing to allow treatment to reassign gender even if it was a minority in whom the dysphoria would resolve by the end of puberty.
- Anonymous | Salaried GP20 Jun 2016 4:56pm
We as Gp’s are familiar with transfer of workload from secondary care to primary care. Fine, I will perform my first open cardiac surgery tomorrow….in the car parc…no room in waiting area in the surgery!
- Jeremy Luke | GP Partner20 Jun 2016 8:56pm
There are real risks that standard GPs could get swept along with this enthusiasm. we are specialist in general practice, not niche areas
- Editor’s comments
This comment has been moderated
Helen Webberley | Sessional/Locum GP21 Jun 2016 8:49am
The problem with talking about driving lorries, performing open heart surgery and other extreme specialist services is that it dilutes what we are actually talking about here.
Many GPs refuse to refer to GICs, a lot of GPs refuse to share care with the specialist clinics, too many GPs turn patients away because they say they don’t know anything about gender care.
It is the small steps of listening, caring, sharing care, referring appropriately that we could ALL do.
And then, for perhaps the more modern thinking GPs, bridging prescriptions or initiating therapy in very easy cases of gender dysphoria will honestly save lives.
My ‘crusading zeal’ is not trying to persuade you to perform gender reassignment surgery in the car park, but to just do what GPs do best.
- Jeremy Luke | GP Partner21 Jun 2016 9:37pm
Did I get moderated?
All I did was post Dr Webberleys online prescribing website address.
Surely GPs would like to see the market opportunities.
obviously we could not provide an NHS service for our own patients.
that still leaves loads of patients whose GPs have no access to CCG resources to manage this work dumping from tertiary care, so a good cash crop.
will I get moderated again/ anyone can use a search engine!
- Paul Evans | Sessional/Locum GP30 Jun 2016 5:40pm
Show me where it’s GMS and I’ll ‘upskill.’