The struggle for GPs to get the right care for patients with gender dysphoria

“Perverse incentives”

General Medical Council guidance recommends that GPs consider prescribing hormone treatment to adult transgender patients who try to medicate themselves while awaiting specialist care.5 Preece says that waits can create “perverse incentives” for patients to buy hormones on the internet or elsewhere. Without training, and given the media controversies about trans care, Preece adds, many GPs “actively choose not to prescribe [hormone treatments]—which protects us, but is unhelpful to the patient.”

Last year the Royal College of General Practitioners published a statement on caring for gender questioning and transgender patients.1 This says that long waits for patients to see a specialist are putting pressure on GPs to provide services beyond their remit and with limited access to specialist support if they do so. The college adds, “GPs should not be expected to fill the gaps in commissioned gender identity specialists and clinics.”

This month the Royal College of General Practitioners launched an e-learning course on gender variance this year.6

Direct discrimination

A recent study by Anna Carlile, a sociologist at Goldsmiths University of London, investigated the experience of trans children and their parents in English healthcare.7 She told The BMJ that participants reported experiencing direct discrimination and being referred to by a previous name in GP surgeries and other clinical settings and believed that GPs “lack clinical and therapeutic knowledge,” particularly concerning the prescribing of drugs to delay puberty.

GPs are wary of prescribing without robust research into the outcomes and side effects of puberty blockers and cross sex hormones, and the co-occurrence of gender dysphoria and autism can complicate diagnosis and treatment.8 The UK has no nationally recognised training programme for gender identity healthcare, although there are apprenticeship training models in specialist clinics and guidelines from international professional bodies.910

Nearly two in five adult trans respondents to a large government survey reported dissatisfaction with NHS services related to their gender identity.11 Jane Fae of the charity Trans Media Watch, which campaigns for better media coverage of trans issues, says that many trans people now view GPs as “an obstruction to overcome.” Some trans groups, including Non Binary London and Trans Forum UK, circulate lists of GPs they deem to be sympathetic or unsympathetic to requests for referrals to gender identity clinics or to prescribe treatments that patients have asked for.

Some areas in in the UK are showing signs of service reconfiguration. Cardiff’s new gender identity clinic has GPs on site.12 A model is being trialled in Manchester in which GPs work with gender identity clinics to improve their diagnostic skills.13 And the Royal College of Physicians intends to introduce a professional development programme for GPs about gender identity this year.14

Decentralised service

NHS England, meanwhile, is considering a decentralised service for adults in which GPs can prescribe cross sex hormones without specialist involvement if they have sufficient expertise.

The royal college recommends that the GP curriculum should cover gender dysphoria and trans issues, that expanding specialist gender services be a priority, and that NHS IT systems be updated to record patients’ gender identity and trans status.1

Preece would welcome such changes. “The hardest thing about being a GP is when you know that the service being offered to patients falls short of what you believe they need and deserve,” he says. “That chasm is at its greatest when dealing with patients with gender dysphoria.”