Treating transgender patients

TRANSGENDER people and those with gender incongruence could make up to 1 per cent of patients. It is well understood that these patients have complex healthcare needs, including a greater incidence of depression and risk of suicide. Access to appropriate healthcare is compounded by long waiting times to see specialists for gender reassignment treatment.

In March of this year, the GMC published new advice to help doctors support transgender patients. It is based on core guidance from Good Medical Practice and is also informed by relevant legislation including the Equality Act 2010. The advice followed publication of a report on transgender equality by the House of Commons Women and Equalities Committee. The report said doctors and other health professionals often lacked an understanding of how to provide effective care for transgender patients, including referring pathways and their own roles in prescribing treatment.

MDDUS has certainly seen an increase in calls from members seeking advice and guidance when treating people with gender dysphoria, and they are often concerned about delays in accessing appropriate specialist help.

Many doctors have and will have transgender persons as patients but few doctors are well equipped to deal with the issues that arise. Currently medical training does not produce doctors skilled in transgender health.

There are specific risks associated with meeting the healthcare needs of transgender persons and two areas where increased risk is clear are:

• Patients who self-medicate from unregulated sources.
• The risk of self-harm due to the inherent increased risk in this group, along with the added effect of delays in accessing appropriate care.

In relation to the first point, patients may seek bridging prescriptions until such time they are seen by a specialist. In these circumstances, GPs may feel out of their depth and worry that they risk acting outside their level of competence and expertise. Regarding the second point, any patient with significant mental health issues may need referral to appropriate mental health services.

It is helpful that the GMC has entered the discussion, when many doctors who are not specialists in this field have questions about their roles and responsibilities. The GMC reminds all doctors that they must provide a good standard of care for their patients and in relation to transgender patients:

"Do your best to understand your patient’s views and preferences and the adverse outcomes they are most concerned about. It may well be that the risk to your patient of continuing to self-medicate with hormones is greater than the risk to them if you initiate hormone therapy before they’re assessed by a specialist."

In relation to bridging prescriptions, a matter which generates a significant proportion of calls to MDDUS, the GMC issues specific guidance:

"A GP should only consider issuing a bridging prescription in cases where all the following criteria are met:

a. the patient is already self-prescribing with hormones obtained from an unregulated source (over the internet or otherwise on the black market)

b. the bridging prescription is intended to mitigate a risk of self-harm or suicide

c. the doctor has sought the advice of a gender specialist, and prescribes the lowest acceptable dose in the circumstances.”

It is important that all doctors dealing with the health issues of patients with gender dysphoria understand and follow the regulator’s advice. Specific GMC guidance on treatment pathways can be accessed via the link below (which also has further links to useful sites including an e-learning module about gender variance produced by the Royal College of General Practitioners and the Gender Identity Research and Education Society (GIRES).

ACTION: Check that you are up to date with the latest guidance about treating transgender patients and test your knowledge. If necessary, undertake the RCGP learning module or equivalent.

Link: Advice for doctors treating transgender patients