GP Guide for trans care in Ireland is an excellent start but more must be done
I was very pleased to see the Irish College of General Practitioners (ICGP) launch their quick reference guide for GPs on trans healthcare, however, it is important to note that it is a guide for social, rather than medical, care.
Ireland and the UK desperately need some clear and evidence-based guidance to inform on the healthcare provision for trans people. We are falling far behind other more progressive Western countries in our gender-affirmative approach.
By acknowledging the needs of this marginalised group, the Irish body responsible for the training and development of healthcare practitioners has certainly taken a step in the right direction, and it is one which the UK has yet failed to make. .
I was delighted to see the obvious close collaboration between this medical establishment and a key stakeholder TENI, which has provided crucial insight from the very people who are impacted by the topics raised in its pages. I absolutely applaud the ICGP for its interest and effort in drafting this document, as basic training in understanding the issues trans people face is desperately needed.
There is no doubt that the tool will be invaluable in raising awareness among healthcare professionals, including GPs, of the specific needs and challenges facing the trans community and gender questioning people. Indeed, as stated in the document: “it is hoped that this guide will create a positive change in the way transgender people are cared for within health services in Ireland.”
However, although this guide is written for GPs, it fails to provide clear medical guidance to enable them to give basic medical treatment to this patient cohort. Instead the focus is placed on referring to specialised services which is, in reality, a very small part of the duty of a doctor.
If we are truly going to care for trans patients, the focus needs to be on providing clear guidance on how to communicate effectively, take a medical history, the necessity of any examination or investigations, and then medical intervention and monitoring. Those are the fundamentals of basic medical care.
Yes, it is important to have clear guidance on the approach to trans patients but the document published by the ICGP continues to place the focus on referrals. This merely exacerbates an already dire situation, in which waiting times stretch into years and trans people are treated as ‘specialist’ cases, when in fact in most situations, their needs can be easily met in Primary Care.
There is a fear amongst doctors as to whether they are permitted to provide care, and whether a GP is able to gain the knowledge and skills to do so. We need to give GPs the tools they need to feel empowered to step up and take on the care of trans individuals, right from their first presentation.
One key question often asked in the UK is whether current British regulation, guidance and advice allows a doctor to help their patient without specialist input. GenderGP examines this question in detail in its guide for health professionals: Helping your trans patient to live their life more easily.
It is time to make our doctors accountable for their part in failing to educate themselves about the basic medical care of transgender individuals. Those with legal obligations to produce and maintain standards of medical care and service provision must step in and demand better from our professional colleges and regulators.
Five years ago, In 2016, the University of San Fransisco and California published its Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. This is a comprehensive, evidence-based guide on the care of trans people.
It includes very detailed information about what it means to be transgender, the terminology that is used, the support that may be required (for the patient and the healthcare provider), and a complete overview of how to medically manage patients, and surgical options that are available. It then goes on to include several chapters on specific considerations of healthcare matters that trans people may face. Importantly, it guides the provider from when a trans person is young, through to old age.
In 2019, the UK Royal College of General Practitioners published a Position Statement on the role of the GP in caring for gender-questioning and transgender patients. It is not a clinical guideline but a document which calls for improved education and explains why GPs do not feel able to provide care. It asks for more research, both on outcomes of treatment programmes but also of ‘wait and see policies’. It calls for more capacity in specialist service settings, but does not ask or teach its GP members how to provide care.
Now, in 2021, the ICGP has published its Quick Reference Guide for Providing Care for Transgender Patients in Primary Care. It explains and educates about what it means to be transgender, and how to refer to specialist services, but it fails to empower GPs to provide the care or to manage their patient from start to finish within their surgery or Primary Care Setting. This is particularly distressing when it is widely understood that referral services are failing to deliver the timely care that this patient cohort needs.
All around us we hear the anguish of trans patients, the lack of support and care, the poor mental health of those on long waiting lists. Yet the UK and Irish position is so far behind other comparably well-provided for countries. We know the UK and Irish trans specialist services are relying on outdated models of care that are perceived as harmful. We know that waiting times to receive this care are illegally and dangerously long. We rely on political leaders to keep our trans friends safe, yet they seem to be deafeningly quiet on the subject.
The clinical guidelines have been written, that work is done. The UCSF provides a clear and comprehensive toolkit for physicians and other providers to provide care. This approach must be endorsed to give doctors the confidence they need.
On behalf of the trans community, we call for better education for GPs.
We call for:
- All Primary Care Services to be expected to provide basic medical hormonal manipulation for trans people.
- Regulators to enforce the duty of care in this regard.
- Patients to have a real expectation that they will receive care that they need within legal timeframes.
- Action to be taken on doctors and other healthcare professionals who are not prepared to undertake self-directed learning to be able to provide this care.
- Action to be taken on regulatory bodies who are legally obliged to enforce this minimal standard of care.
- An end to the discrimination against patients and healthcare professionals who seek to access or provide patient-centred care.
- This to happen NOW.
The ICGP in its work with TENI has taken the first step. All eyes will now be on the UK to see if and how it will choose to respond.