Summary
- Hormonal treatments for gender incongruence carry a lot of potential risks, and require expert monitoring which is outside of the competence of NHS GPs.
- As NHS GPs, we would consider engaging with NHS gender identity clinics where a shared care protocol is being followed and appropriate assessments have been carried out.
- The practice will not be able to prescribe hormone treatments for gender incongruence outside of an NHS shared care protocol. This includes requests from private providers, and patient-directed requests for “bridging” prescriptions.
- Patients should be advised to avoid procuring hormone medication from online sources without qualified specialist advice.
- Patients seeking treatment from private medical providers are entitled to do so at their own judgement, but the practice would not be prepared to take over a prescribing role on behalf of a private clinic.
Background
As a GP practice we are committed to providing the best possible primary care for our patients. Patients who are transgender and experiencing gender difficulties (gender incongruence, also referred to as gender dysphoria) often have problems which GPs are best placed to help, treat, support, and signpost or refer to specialist services. At the practice we pride ourselves in being able to help many patients with multiple aspects of their mental and physical health, to support their general wellbeing.
Sadly, in the UK the gender identity services (Indigo in Manchester) are vastly under-resourced for the demand that is put upon them. Often the waiting lists are several years in length. Gender identity clinics are very important for coordinating the detailed psychological assessments that are required before making decisions such as medical (hormones) or surgical therapies to treat gender incongruence. As a result, GPs are facing increasing difficulties addressing patient requests for “bridging” prescriptions while they wait for formal assessment in the gender identity clinics, particularly for those patients who have self-started medication, including medication which they have procured over the internet.
It is easy to understand the frustration that patients can feel in this situation, but it is important to ensure we are practising medicine in a safe and fair way.
All hormone medications used to treat gender incongruence are being used outside of their UK license and are subject to complex monitoring requirements that are directed by specialist gender physicians and endocrinologists. Some of these medications have irreversible unwanted effects, and may adversely affect physical characteristics, impair future fertility, and can also pose risks such as risks of breast cancers and major blood clots.
As General Medical Council (GMC) registered doctors, we are bound to follow the rules of GMC Good Medical Practice. Article 14 of GMC GMP states “You must recognise and work within the limits of your competence”, and the GMC guidance on prescribing medications outside of their UK license states that this must only be done if the GP is able to accept personal responsibility for the medication, is competent in all areas of its use, and is able to council patients thoroughly about risks and side effects. In the GMC document “Trans healthcare: Ethical Guidance 2019” they have defined an “experienced gender specialist” as a doctor who has “evidence of relevant training and at least two years’ experience working in a specialised gender dysphoria practice such as an NHS Gender Identity Clinic”.
The Royal College of General Practitioners (RCGP) has published a statement about GP competences to prescribe hormones for gender incongruence including the topic of “bridging” prescriptions (https://www.rcgp.org.uk/policy/rcgp-policy-areas/transgender-care). This statement included the following: “GPs are expert generalists. The provision of detailed advice about gender identity issues and associated treatments does not fall within the remit of a GPs education and training, therefore GPs often feel it its outside their area of competence to advise patients with gender dysphoria. … GPs are ultimately responsible for their prescribing and should not be pressured into prescribing where they feel it is unsafe or involves unacceptable risks.” The RCGP has repeatedly recommended the UK Government and NHS England provide more funding for gender services to reduce waiting lists.
Practice approach to prescribing treatments for Gender Incongruence
As GPs, we would be pleased to discuss possible treatments and support with individual patients. There is a lot that GPs can offer patients with gender incongruence, this support may include aspects of mental and physical health, and we can help signpost or refer individuals to a lot of helpful services. If a patient is wishing to seek medical (hormones) or surgical gender treatments, we can have a preliminary discussion with them, and refer relevant NHS gender identity clinic services.
Once a patient has been seen by an NHS gender identity clinic, the GPs at the practice will be happy to discuss and engage with NHS gender identity clinics about the possibility of starting hormone treatments. Providing a satisfactory and safe “Shared Care Protocol” has been produced by the specialist clinic, we would be willing to discuss prescribing these treatments on behalf of the specialist, following the strict monitoring requirements set out by the specialist, with the safety-net of further NHS gender specialist review should side-effects occur, or abnormalities be found on monitoring.
In Greater Manchester, our local adult gender identity clinic is Indigo (https://indigogenderservice.uk/). Indigo is an NHS commissioned gender identity clinic which uses established and approved “Shared Care Protocols” agreed with the health board in Greater Manchester (the Greater Manchester Medicines Management Group, GMMMG: https://gmmmg.nhs.uk/).
However, prescribing hormones outside of a rigorous “Shared Care Protocol” would be outside of our competence as GPs. This applies to where patients may be sourcing treatment themselves from the internet, from private providers (who often do not provide a rigorous NHS-level standard of care, and frequently are not accessible by GPs for support), and requests for unsupervised “bridging” prescriptions. It is outside of our expertise and competence to prescribe hormones for gender incongruence where proper assessments and care agreements have not taken place.
Further notes on self-sourced medication or private prescription services
The practice does not recommend patients to seek prescriptions online without specialist assessment, for the safety reasons listed above.
For patients seeking assessments from private providers, any person is entitled to seek private healthcare on their own initiative, and at their own risk and cost. The practice cannot recommend private providers to patients. For the reasons listed above, we may not be prepared to take over prescribing roles on behalf of a private provider (on an individual basis). This is also reflected in NHS England advice about the NHS-Private interface, which sets out rules on the separation of private and NHS treatment. Specifically, “the NHS cannot pay for or subsidise your private hospital treatment” and “there must be as clear a separation as possible between your private treatment and your NHS treatment”. More information can be found on the NHS website: https://www.nhs.uk/common-health-questions/nhs-services-and-treatments/if-i-pay-for-private-treatment-how-will-my-nhs-care-be-affected.