GPs are failing transgender patients with a lack of compassion and understanding that must change, according to Dr Helen Webberley
The recent massacre in Orlando served as a grim reminder that discrimination against minority groups continues to play a very real part in our so-called ‘modern society’.
Of course, these episodes are extreme, but while this degree of hatred is mercifully rare, members of the LGBT community have come to accept prejudice as an everyday occurrence. Nowhere is that more true than if you are a trans man or a trans woman.
Every day I hear stories through my online clinic – GenderGP – from members of the trans community, about the battles of bigotry, prejudice and humiliation they face. But what shocks me most, is when that sentiment comes from members of the health profession.
Following significant concerns raised by the House of Commons Women and Equalities Committee in their recent report on Transgender Equality – specifically in relation to the lack of awareness and consideration shown by a great many doctors in treating transgender patients – I was delighted to see the General Medical Council (GMC) publish guidelines on managing transgender patients.
The guidelines state that GPs can prescribe hormones to patients suffering with gender identity disorder, under the following ‘exceptional circumstances’:
- The patient is self-prescribing with hormones from an unregulated source
- The bridging prescriptions are intended to mitigate risk of self-harm or suicide
- The GP has sought the advice of a gender specialist and prescribed the lowest acceptable dose
This was met with a variety of concerns from NHS GPs, and I am disappointed at the reluctance to openly embrace the news that we can now do more to help our trans patients.
Dr Chaand Nagpaul, CBE Chair of the BMA General Practitioners Committee, penned his concerns to the GMC, raising a number of emotive points. His main uneasiness being that specialist prescribing would place GPs in a difficult position, forcing them to prescribe outside the limits of their competence.
In response, Susan Goldsmith, acting chief executive of the GMC, provided reassurances, which included the point that GPs would be expected to ‘acquire the knowledge and skills to be able to deliver a good service to their patient population’. This, she explained, may mean undertaking training. It was clear that the GMC does not consider care for patients with gender dysphoria as a highly specialised treatment area requiring specific expertise.
Goldsmith goes on to endorse a firm view of mine: that these patients actually require very simple care and well-known medication.
The medication for transgender care includes oestrogen therapy used for treating female menopause (estradiol), injections that are typically given to women with endometriosis or men with prostate cancer (GNRH analogues) and a diuretic used for heart failure (spironolactone). Furthermore, anti-androgens used in contraceptives (cyproterone acetate), medication for benign prostate hyperplasia (finasteride) and testosterone replacement therapy, generally used for the management of the male menopause, can also be prescribed.
These are medications that are well known to GPs, and we are well versed in their potential side effects and effective monitoring.
So why is it that GPs are reluctant to take this on? There have been some well-publicised legal cases of doctors trying to help transgender patients – Dr Russell Reid was criticised for a lack of caution in initiating hormonal and surgical gender reassignment treatment, without more careful and thorough investigation and assessment. Meanwhile, his successor, Dr Richard Curtis, was also subjected to a lengthy investigation.
Fear of litigation is at the forefront of any doctors’ mind, but should this impair our duty to help our patients in the best way we can? GPs prescribe hormone patches for menopausal symptoms regularly, but if a trans man asks you to do the same, the response he experiences is often one of horror.
Not all trans people want to go through lengthy assessments, procedures, hoops and surgery – they just want the right hormones to suit their true gender.
These are actually very safe treatments, and delays in receiving care from GPs and NHS gender clinics mean that people are turning to illegal sources and unsafe forms of medication. In the very worst cases, death appears to be the only answer.
The other essential aspect of transgender care is listening, hearing, caring, educating, protecting – bread and butter to GPs. Often the key healthcare provider for the transgender patient, however, is an endocrinologist. Experts in their field yes, but have they honed their patient skills to the same extent as a GP? I would argue not.
So many of my patients tell me about the long journey they have to take, before even feeling brave enough to confide with their GP that they are suffering from gender variance, only to have their feelings dismissed or told that they will ‘grow out of it.’
Carry On Doctor
I have the following simple advice for GPs, which might just help any transgender patients they may come into contact with.
- If you don’t know, look it up. There are many training resources and literature sources on gender care. Go to elearning.rcgp.org.uk/gendervariance
- Listen to your patients, they are not mentally ill, they are gender incongruent
- Their medical needs are often very simple – some hormone replacement therapy and a listening ear
- The treatments are those that we use every day – put any prejudice aside and, if you think your patient is suffering from gender variance, get your prescription pad out
- The cost of treating these patients is far less than the loss of life and distress caused by refusing them very simple, basic care
Dr Helen Webberley MBChB MRCGP MFSRH is a GP specialising in the treatment of transgender patients on the NHS and via her private online clinic. Go to gendergp.co.uk