en English

We have been hearing disturbing reports that young trans people and their families are being subjected to enquiries and investigations carried out by social services for facilitating gender-affirming care options for their child.

We feel that this is in breach of the Equality Act, and would like to take steps to provide robust answers to parents and professionals who have been exposed to enquiries on this basis.

GenderGP is a specialist provider delivering Health and Wellbeing Services to transgender and non-binary individuals across the world.

The care of gender variant people is an emotive and politically heated subject. GenderGP operates in line with the law and based on the available evidence, to ensure safe, equitable, non-discriminatory care for all that require it. Research shows that withholding care leads to poor mental health outcomes and increased risk of suicidality within this patient population.

In January 2018, the NHS published a Specialised Services Circular, SSC 1826 which outlines the ‘Primary Care Responsibilities In Regard To Requests by Private On-Line Medical Service Providers to Prescribe Hormone Treatments for Transgender People.’

This document lays out recommendations for Primary Care services to carry out due diligence for their patients seeking collaborative care.

Trans people are protected under the Equality Act, ‘The Equality Act 2010 says that you must not be discriminated against because you are transsexual, when your gender identity is different from the gender assigned to you when you were born. For example: a person who was born female decides to spend the rest of his life as a man’

All trans people, regardless of gender, sex, age, ability, race or religion should be able to access gender-affirming care within a legal timeframe.

Gender-affirming care can include advice, support, counselling, psychotherapy, voice therapy, natal hormone suppression, cross-sex hormones and surgery. Trans people may require any type of care at any time of their life, there is no one set pattern or approach to how someone’s gender is best affirmed for them.

Young people may socially transition, and change their names, pronouns, clothes etc. They may also seek medical care, puberty suppression, hormones or surgery. Each individual must be treated on a case by case basis, there is no one correct path or journey that caters for the needs of trans people as a whole. Some individuals may socially transition alone, some may only request surgical procedures, while some may request hormones and or blockers. Individualised care is at the heart of Good Medical Practice.

 

Here we outline GenderGP’s approach to each of the criteria in turn, according to which GPs are required to measure the service providing gender specialist care, according to the Specialised Services Circular, SSC 1826.

 

(i) the request is from a reputable company that provides a safe and effective service

GenderGP has been providing gender-affirming care to trans and non binary individuals since 2015. The organisation currently supports more than 4,000 individuals, of all ages, in 42 countries worldwide.

GenderGP is owned and operated by Harland International Ltd, a global organisation, registered in Hong Kong, which provides advocacy services for LGBTQI individuals around the world.

Patients in the UK have the right to access private healthcare as outlined by the British Medical Association.

GenderGP provides healthcare services to people in the UK, Europe and worldwide, these include: gender-affirming support, medication and monitoring. GenderGP’s expertise comes from a multidisciplinary team of gender specialists including doctors, counsellors and psychotherapists from various countries.

All of GenderGP’s medical specialists are regulated in their own country, by their individual regulators. GenderGP operates entirely within the law and follows UK and international guidance on the care of transgender patients of all ages.

In order to make healthcare as affordable as possible, and to provide the widest range of options to its users, GenderGP works both as an independent service and collaboratively with the patient’s doctor.

Patients can choose whether to have blood tests privately or through their doctor. Medication can also be prescribed by their family doctor, under a shared care agreement, or via a private prescription.

Prescriptions for service users can be dispensed by their local pharmacy or using an online pharmacy, all pharmacies recommended by GenderGP are operating entirely within the required regulations of their country.

 

(ii) the circumstances of the request for the particular individual meets the general principles of the General Medical Council’s “Good Practice in Prescribing and Managing Medicines and Devices”

GenderGP follows the International Guidance of The Endocrine Society, The Endocrine Treatment of Gender Incongruent Persons. All clinical and prescribing decisions follow and adhere to guidance laid out by the General Medical Council and the General Pharmaceutical Society, ensuring best practice in management and prescribing. In addition, any provider working with GenderGP will follow any additional guidance as required by their regulatory bodies.

 

(iii) that the health professional making the request is an appropriate “gender specialist” (the term that is used in the General Medical Council guidance). A GP may decline to accept responsibility for prescribing, monitoring and testing if the GP is not assured that the provider offers a safe service, or is not assured that the request has been made by an appropriate gender specialist

Gender specialists can come from a broad range of medical specialties, such as mental health: psychologists, psychiatrists, counselors or therapists, and also GPs, endocrinologists, nurses etc. GenderGP uses the knowledge and skills of the practitioner with the relevant skills to manage the presenting issue.

In the WPATH Standards of Care Version 7 it states that: ‘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).’

In a letter from Susan Goldsmith of the GMC written to the BMA in 2016, she wrote: ‘we do not believe that providing care for patients with gender dysphoria is a highly specialised treatment area requiring specific expertise.’

All of GenderGP’s medical specialists are regulated in their own country, by their individual regulators. GenderGP operates entirely within the law and follows international published guidance on the care of transgender patients of all ages.

 

(iii continued) CRUCIALLY as long as the GP is also satisfied that declining responsibility would not pose a significant clinical risk to the individual.

Studies show that the prevalence of suicidal thoughts and attempts among transgender adults is significantly higher than that of the U.S. general population. Using data from the 2015 U.S. Transgender Survey, this report examines key risk factors associated with suiciality among a sample of transgender people.

GenderGP’s approach is in line with that of the American Medical Association, the Endocrine Society, the Pediatric Endocrine Society, the American Academy of Pediatrics, the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry, who all agree that gender-affirmative treatments are an important option for transgender youth.

 

(iii continued) In particular the GP will need to consider whether the health professional making the request has sufficient specialist expertise to assess and diagnose gender dysphoria and to recommend prescriptions for the individual concerned. In such cases the GP may wish to request evidence of training and experience in the assessment, diagnosis and prescribing for gender dysphoria, which may include the following: formal links with NHS-commissioned specialised Gender Identity Clinics; formal links with relevant professional associations; previous time spent working in NHS commissioned specialised gender identity services; evidence of ongoing continuous professional development which may include: attending relevant meetings, workshops, or seminars; obtaining supervision from a health professional with relevant experience; or participating in credible research related to gender nonconformity and gender dysphoria. GPs may also wish to consider the criteria set out in NHS England’s current commissioning protocol and relevant clinical commissioning policies.

The GenderGP team adheres to the Standards of Care laid out by the WPATH. Many are current members and have completed Global Education Initiative (GEI) training with the Association.

There are no UK NHS published guidelines for the care of transgender people. The Gender Identity Development Service (GIDS) provides NHS care to UK trans youth according to Service Specifications. This is their own protocol which differs widely from protocols used by centres of excellence in transgender healthcare internationally.

GenderGP does not operate according to NHS policies which have been found to be lacking in many areas by the Women and Equalities Committee report on transgender equality.

 

In all cases the criteria include:

  • The assessment, diagnosis and confirmation of gender dysphoria must be by a health professional who specialises in gender dysphoria and has general clinical competence in diagnosis and treatment of mental or emotional disorders

As outlined above both NHS England and WPATH guidelines agree 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.’ ‘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).’

 

  • The decision to recommend endocrine therapy should have the documented support of two gender specialists who are directly involved in the patient’s care; at least one of whom must be medically qualified and who must make the prescribing recommendation

There is no requirement for a minimum or maximum number of specialists needed in order to manage or care for a person having gender-affirming care. All patients should be assessed, diagnosed and managed according to clinical need and utilising a multidisciplinary or interdisciplinary approach.

 

  • The provider has an effective multi-disciplinary team of gender specialists that meets regularly, either in person or through electronic communication

GenderGP has a wide and experienced multidisciplinary team of gender specialists which includes doctors, counsellors and psychotherapists from various countries. All practitioners working with GenderGP support thousands of patients in their capacity as gender specialists.

All of GenderGP’s medical specialists are regulated in their own country, by their individual regulators. GenderGP operates entirely within the law and follows international published guidance on the care of transgender patients of all ages.

The UK has a long and successful working relationship with non UK-based doctors and nurses who have provided a very welcome extra pair of hands when the UK’s own NHS services have been under-staffed.

 

  • The impact on the individual’s fertility has been discussed with them; and informed consent has been given Additionally, where the individual is a young person under 17 years of age the criteria include:

Consent is obtained from all patients, regardless of age, at multiple stages throughout the process. An informed consent model of care ensures patients are provided with all the available information about gender-affirming care and how hormones will impact them – including their fertility, so that they can weigh up the risks and benefits associated with any decision relating to their health and decide on the right path for them. This approach serves to protect individual autonomy. For younger patients (under 16) parental consent is encouraged in line with Good Medical Practice. Where safe parental consent is unavailable, the patient must demonstrate that they are Gillick competent in order to be able to consent to their own treatment.

 

  • A Consultant Endocrinologist who specialises in prescribing to gender variant children and young people is directly involved in the individual’s care agrees on the suitability of the endocrine intervention

There is no requirement for a gender specialist to be a consultant endocrinologist. Many Gender Clinics from around the world rely on the expertise specialists from a broad range of specialties. If an endocrinology input is required, it will be sought. The core competencies of an endocrinologist do not include the management of gender variant individuals.

 

  • Prescriptions for cross sex hormones are not issued to young people until they have attained the age of around 16 years

The Endocrine Society Guidelines, 2017, recognise that there may be compelling reasons to prescribe gender-affirming hormones to someone under the age of 16. International best practice recognises the requirement for a ‘Stage, not Age’ basis on which to provide care. GenderGP does not adhere to NHS protocols which are outdated and result in delays which can be harmful to trans youth. Delaying treatment is not a neutral option. In line with the Endocrine Society, GenderGP also operates according to a stage not age approach. There may be compelling reasons as to why a young person, who is completely aligned with their gender identity, might benefit from having puberty induced before the age of 16.

The UK policy and protocol of withholding gender-affirming hormones until ‘around the age of 16’, is outdated and potentially harmful.