This information applies to the management of adult patients. Please contact MDDUS if your query relates to children.
Introduction
GP practices must keep up-to-date with the relevant laws, professional guidance and contractual requirements in relation to the care and treatment of transgender patients.
The Equality Act 2010 [1] established gender reassignment as a ‘protected characteristic’, and therefore the law provides protection from discrimination for transgender people. This means that healthcare professionals cannot refuse to see or treat a patient because of their transgender status. They must also ensure that they do not discriminate against transgender patients in the course of providing treatment. The legal protection applies to those who are undergoing or have already undergone a process to reassign their sex by changing physiological or other attributes of sex, and anyone who is proposing to do so.
The Gender Recognition Act 2004 [2] is the legal framework by which a transgender person can have their preferred gender legally recognised. The Act also safeguards the privacy of transgender people by defining information in relation to their gender as ‘protected information’.
The Act sets out requirements for those acting ‘in an official capacity’ (which includes a GP acting in that role), and provides that it is unlawful to disclose ‘protected information’ without the person’s consent. While this legal protection covers those who have made an application for a Gender Recognition Certificate, it is good practice to apply this principle to the records of all transgender patients, regardless of whether or not they have taken any formal legal steps to have their preferred gender legally recognised. The GMC states that you should treat the gender status or history with the same confidentiality as any other sensitive information.
Importantly, a patient doesn’t have to apply for a Gender Recognition Certificate under the 2004 Act in order to benefit from the protections provided in the 2010 Act.
The need to obtain consent before disclosing a patient’s gender history is reinforced in GMC guidance applicable to all patients which states that doing so “shows respect and is part of good communication between doctors and patients”.
To assist doctors in navigating the relevant legal and ethical frameworks, the GMC has collated advice and resources in the Trans Healthcare section of its ethical hub. The GMC confirms that this hub does not set new professional standards and is not intended to replace the formal guidance. It sets out doctors’ responsibilities to ensure GP practices are inclusive and understand appropriate pathways for referral, as well as maintaining confidentiality, screening, prescribing and monitoring for adult transgender patients. [3]
GPs also have a responsibility to ensure they are aware of the practical aspects of making changes to transgender patient records, the process set out by local NHS registrations teams and how screening is to be managed if a new record is created.
This information is not exhaustive but is designed to assist GP practices in understanding how these various requirements can be applied in practice.
Training
All practice staff should receive training in trans-awareness as part of their wider equality and diversity education. It must be made clear that any information relating to a patient’s existing or previous gender status is bound by a specific legal duty of confidence.
Administrative staff must be prepared to deal sensitively with approaches from patients requesting changes to their name and title within their medical records.
Change of pronouns
Requests to change pronouns and gender-markers on communications should be respected. Written medical correspondence should be discreet, including the appearance of the patient’s name in the address window, and the practice should not assume that others in the household are aware of the individual’s gender circumstances.
It is advisable to have an early discussion with the patient about their preferences, for example, as part of a consultation, so that this can be managed appropriately.
Patients also have the right to request a change of gender, a move that may require the creation of a new medical record with a new NHS or CHI number. The patient does not require, or need to present, a Gender Recognition Certificate or updated birth certificate for this change to be made. If a patient wishes to make a legal change to their gender, a Gender Recognition Certificate would be required.
A change of gender has implications for screening recall which is explained in the ‘Screening’ section of this document.
Practices should familiarise themselves with the relevant NHS guidance which sets out the current process for changing a patient’s registered gender (for example, Practitioner Services Division in Scotland or Primary Care Support England). This includes requirements in relation to screening advice and managing the patient’s medical records.
Medical Record Management
There are different processes across the four UK jurisdictions for creating new records for transgender patients. Please be directed by your relevant primary care administration/business services to ensure you are using the most up-to-date process.
When discussing the transfer of information from the old medical record to the new one with the patient, GPs should make it clear which information is to be copied over to ensure continuity of care and avoid clinical risk. If necessary, additional reassurances should be given to the patient that any notes relating to gender transition will be treated confidentially.
Patients may agree to previous notes being transferred to their new notes provided their record ‘administratively’ reflects their new personal information.
If a patient expresses concern about the practice team having access to their record, a practice could offer to limit this to clinicians only. Any restrictions should be realistic and not detrimental to patient care.
Finally, the patient should be made aware that if they register at another practice these restrictions will no longer apply and the patient would be advised to discuss reinstating them with the new GP.
Note-taking and referral
Patients requesting treatment for gender dysphoria or gender incongruence should be referred to an appropriate specialist gender identity service.
When writing records or making referrals regarding transgender patients, reference to their transgender status should only be made if clinically relevant. Express consent should also be obtained in order to share this information and it may be an offence to disclose it without consent.
Any referral to other healthcare services made by a GP must not include reference to the patient’s gender transition/previous gender, unless:
- this has been discussed with the patient
- they have given consent to the disclosure, and
- the information provided is necessary for medical purposes.
There will be circumstances where it is appropriate to disclose gender information – with your patient’s consent – so that the service you are referring to is aware they may have specific needs. This allows the service to respond appropriately to the patient and care for them in a manner that supports their dignity.
GPs using referral software must ensure that any referrals are checked before sending to avoid an inadvertent breach of confidential information.
GPs should continue to ensure that they follow GMC guidance in relation to recording their work clearly, accurately and legibly. Clinical records should include:
- relevant clinical findings
- the decisions made and actions agreed, and who is making the decisions and agreeing the actions
- the information given to patients
- any drugs prescribed or other investigation or treatment
- who is making the record and when.
As doctors may be involved in arranging blood tests and prescribing hormonal medications as part of the transitioning process, it is important to document all care and treatment provided.
If the patient is to be issued with a new NHS or CHI number which has no reference to their sex at birth, the GP should explain that they may not automatically be contacted regarding current or future screening programmes associated with their sex at birth, and discuss the implications of this. Decisions about screening should be made with patients in the same way as any other decisions about their health.
The GP should discuss implications with the patient and, if they consent, contact the relevant NHS/HSC screening programmes to ensure they are invited for/referred to appropriate screening. The national health services have information available for transgender patients about screening programmes. [4]
For smear testing, which is usually undertaken in the practice, the practice may be responsible for managing recalls, taking specimens and providing results. In this event, the practice should notify the laboratory that the results are to be forwarded to the practice and not the national call/recall service.
It is the practice’s responsibility to ensure both that the patient understands the limitations of any national screening service and that the patient’s screening results are managed locally with appropriate confidentiality and consent.
The GMC acknowledges that transgender patients are at an increased risk of self-harm or suicide and GPs should discuss access to mental health support services where appropriate. Their ethical hub also acknowledges the long waiting times to access specialist services.
Good medical practice and the GMC’s prescribing guidance state that while doctors must recognise and work within the limits of their competence, they must work in partnership with patients and consider what treatment is likely to meet their needs, and must work with colleagues in the ways that best serve patients’ interests. Doctors should seek information or advice from the clinician who is sharing care responsibilities for the patient or from another experienced colleague if in doubt about their own competence to take responsibility for a patient’s ongoing care.
GMC guidance states that “one way in which you might consider providing support to your patient is by issuing a "bridging prescription’”, which is “a temporary prescription of endocrine treatment that can be issued by a GP”.
However, GPs must consider local policy requirements and obtain the advice of a specialist service provider or an experienced colleague before issuing a bridging prescription.
The GMC seeks to reassure doctors who wish to prescribe for their transgender and gender diverse patients that it would not be against their guidance to issue a bridging prescription. Equally, they are clear that their guidance does not oblige doctors to do so if they do not feel that prescribing would be of overall benefit to a patient.
Prescribing medicines outside their licenceIn relation to medicines unlicensed for this use, the GMC states that:
- GPs can prescribe unlicensed medicines following the steps set out in its prescribing guidance
- GPs must take care to discuss the risks and benefits of treatment with the patient
- GPs should collaborate with experienced colleagues to provide care that best serves patient needs.
Doctors must make the care of their patients their first concern and always provide a good standard of practice and care. The GMC states that GPs must collaborate with a gender specialist service, and this may include prescribing medicines on their recommendation and/or following their recommendations for safety and treatment monitoring (taking into account local arrangements, such as Shared Care Agreements or Enhanced schemes).
However, the GMC continues that it is reasonable for a GP to expect the specialist service provider to remain available to provide advice and support where necessary.
Doctors are required to explain and justify their decisions and actions. They must therefore consider the needs of each of their patients on an individual basis, mindful of the relevant professional guidance and clinical support available.
The GMC confirms that doctors are not obliged to follow the recommendations of those working for a specialist service provider who are unable to demonstrate they are suitably qualified.
Where a GP has doubts about the course of action proposed by a specialist service, whether because of the experience of the specialist concerned or wider patient welfare concerns, they should seek to resolve those matters with the service concerned and draw on the wider advice of more experienced colleagues with the aim of reaching a consensus as rapidly as possible
If that cannot be achieved, GPs should reflect whether substituting their own views for those of a suitably qualified specialist service goes against their professional obligations as set out above. In such circumstances therefore, the GP should consider whether they can remain responsible for the ongoing management of the patient concerned.
The GMC states that it is not acceptable simply to refuse to treat a patient, and doctors must communicate with the patient and more experienced colleagues or service leads to ensure they make the care of the patient their first concern and provide a good standard of care.
The future
This is an area of medical care that is rapidly changing and up-to-date information should always be obtained in order to ensure that appropriate care is provided.
1. Equality Act (2010)
2. Gender Recognition Act (2004)
3. GMC transgender healthcare guidance
4. Screening guidance for transgender patients for England, Scotland, Wales and Northern Ireland.
This page was correct at the time of publication. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.