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How the decision on whether or not to support trans individuals has become more about politics and less about patients.

 

In the UK, as things currently stand, the decision by doctors on whether or not to provide care to trans individuals appears to be unduly influenced by political and societal factors. Care providers on the NHS have been accused by some of intervening too quickly, while the community itself reports that the process is unacceptably slow.

Whatever approach doctors take, it appears that they can’t win. If they treat the patient they risk a political backlash, if they simply ignore the problem and hope it goes away, the patient suffers.

But where should the doctor’s priority lie? The obvious answer is with the patient. However, as a doctor who has chosen patients over politics and has suffered the consequences of doing so, I can understand why this isn’t the approach that GPs are rushing to take.

The real question is why it is that a proactive, gender affirmative approach, such as mine, is considered worthy of investigation by the GMC, while the approach taken by so many UK doctors: that of ‘opting out’ of timely, accessible trans patient care – appears to be perfectly acceptable.

When it comes to transgender care, the UK operates a network of specialist clinics. These clinics were set up to manage a cohort of patients which has since grown exponentially, rendering the small capacity of the specialist clinics unfit for purpose. Furthermore, education and understanding of the transgender experience has developed during this time, while protocols followed by these clinics have remained largely unchanged. As a result, waiting lists have grown into years and the obligatory lengthy assessment process, geared towards the ‘validation’ of the patient’s gender, has become outmoded.

The obvious solution is to bring trans care into a primary care setting, so that it sits with the family doctor. Unfortunately this approach has proven unpopular with the large majority of GPs who claim that, despite having excellent knowledge of hormone manipulation, they are unable to support trans people with said hormones.

So, an alternative route is being trialled via the introduction of various ‘satellite clinics’ throughout the UK. One such clinic is situated in Wales (my home town and ironically the birthplace of GenderGP some five years ago). The clinic aims to assist those trans individuals who ordinarily would have had to travel to London for their care. The service will provide support, advice and prescriptions in cases where Wales-based GPs refuse to care for their trans patient.

To be clear, rather than normalise transgender care, making it possible for GPs to support their patients, the NHS is setting up yet another layer of specialist service provision.

The doctor in charge of this particular clinic, Sophie Quinney, is being hailed as a local hero and I couldn’t agree more. Any doctor who actively seeks to improve care for any underrepresented patient cohort is indeed a hero. In Sophie’s case, she has managed to bridge the gap between NHS and trans care without becoming a social pariah, in the same way that so many have before her – including myself.

So what is it that separates the two of us? Why is it that her approach has been given the NHS stamp of approval, while my approach – which started as a simple bridging service – met with roadblocks at every turn?

When I compare our situations it is abundantly clear. I see two progressive, trans-friendly GPs. Both Dr Quinney and I have taken a long hard look at the state of trans healthcare in the UK and we have said it is not good enough. We both chose to do something about it. Albeit via different routes. We have both worked incredibly hard to change the face of transgender healthcare for the better – one from within the NHS and one from outside of the NHS.

 

Therein, it would appear, lies the rub.

It seems to me that if you challenge from within but are prepared to work alongside outdated and harmful protocols, your input is welcomed.

If instead, you are brave enough to challenge the accepted ‘norm’, to push back against the establishment, to fight for better, more accessible, more timely care in line with International Best Practice and evidence-based guidelines, you are shut down.

 

The question of which approach is better for the patient appears not to matter.

Five years on, Wales is openly celebrating the nation’s “progressive” approach to transgender healthcare “thanks to Dr Quinney’s new service”. While I sit here awaiting the outcome of the investigation into my groundbreaking work. Work which resulted in the creation of an organisation which has proven itself to be transformational in the lives of so many transgender individuals.

Over the past five years, GenderGP has become a World leading resource. The service provides insight and information, access to international guidelines, research, counselling and hormones to thousands of people all in the comfort of their own homes. When I was suspended from the Medical Register, for providing care that is standard in the USA, Canada, Australia, New Zealand and parts of Europe, GenderGP employed other medical expertise and has continued to grow and flourish.

Yet, despite the incredible impact the service has had on transforming transgender healthcare, I am not the one flying the Pride flag, teaming with Pride Cymru to discuss the health services dedicated to the support of trans people in Wales. Instead I am actively shunned, silenced and hidden away.

I have offered the wealth of my experience and knowledge to Wales, and to NHS England and to the Royal College of GPs. My offers go unanswered, my gender affirming approach, upon which GenderGP is founded, is at odds with the current NHS way of working.

While it is hard to accept being ousted from my profession, I can’t help but reflect back on my initial argument that transgender healthcare has become a question of politics versus patients. I know that, whatever I have lost, I chose to put patients first. My reputation may be shot, but in GenderGP, the community has found a safe haven and I played a pivotal role in that. Even though I am unable to practice medicine, I can continue to affect change through advocacy and education.

The proof of the pudding as they say, will be in the eating. I wish the team setting up this new venture all the luck in the world. The transgender community needs as much support as it can get from as many allies and advocates as possible, but let’s make sure that amongst all the flag waving and back patting, patients continue to be the priority.

 

If you are using the service or involved in its development and implementation take time to ask the difficult questions, whether they are palatable or not.

  • How many trans people in Wales are still waiting for treatment?
  • How many people will these new dedicated health services be helping?
  • What about younger trans people, will they also get the support they need?
  • If so what will that involve?
  • How long are the waiting lists for Welsh patients to be seen?
  • What support is in place for people while they wait?
  • What criteria must trans people meet to ‘prove’ their identity?
  • Will their eligibility be determined based on how well they answer any questions asked?
  • How is it that Welsh GPs are still allowed to refuse care for their patients?

 

The answers to these questions will ultimately determine the true value of the service to the community.

We’d love to hear your thoughts, feel free to comment below. If you would like to get in touch with Dr Helen you can follow her on Twitter @MyWebDoctorUK