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You can find the current article at its original source at https://www.theguardian.com/society/2017/aug/15/gender-dysphoria-patients-need-specialists-not-gps
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| Version 2 | Version 3 |
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| Gender dysphoria patients deserve better treatment than I can give them | Gender dysphoria patients deserve better treatment than I can give them |
| (about 9 hours later) | |
| GPs don’t have the time or the expertise to provide the holistic treatment that transgender patients require. Proper services are required urgently | |
| Tue 15 Aug 2017 12.00 BST | |
| Last modified on Mon 27 Nov 2017 18.29 GMT | |
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| Gender identity clinics have seen a huge demand for services in recent years. Waits can vary from 12 to 18 months in most cases, but can extend to three years in some parts of the country. It is estimated that about 1% of the population is transgender, although some believe this figure to be higher. Many have a higher incidence of mental health problems, such as depression and anxiety. | Gender identity clinics have seen a huge demand for services in recent years. Waits can vary from 12 to 18 months in most cases, but can extend to three years in some parts of the country. It is estimated that about 1% of the population is transgender, although some believe this figure to be higher. Many have a higher incidence of mental health problems, such as depression and anxiety. |
| Those waiting months for their first appointment can resort to buying unverified hormonal treatments on the black market, seeing private specialists (often online) or looking for support and prescriptions from their GP. Private specialists can reassure them that their GP will prescribe and monitor their treatments. This leads to some difficult conversations with patients. | Those waiting months for their first appointment can resort to buying unverified hormonal treatments on the black market, seeing private specialists (often online) or looking for support and prescriptions from their GP. Private specialists can reassure them that their GP will prescribe and monitor their treatments. This leads to some difficult conversations with patients. |
| We are well placed to offer patients a first point of contact and support, but the issue of prescribing and specialised support is more contentious. This year I have seen three gender dysphoria patients (although I have not prescribed any treatment for them yet), but before that it was that many in nine years. | We are well placed to offer patients a first point of contact and support, but the issue of prescribing and specialised support is more contentious. This year I have seen three gender dysphoria patients (although I have not prescribed any treatment for them yet), but before that it was that many in nine years. |
| It is true that GPs are generalists, but we are experts, too, in prescribing and monitoring in many clinical areas that we commonly encounter, or that we may have developed an interest in. At present, gender dysphoria remains a niche field. Patients need specific management with a multi-disciplinary team approach that encompasses endocrinologists, surgeons, psychiatrists, pharmacists and others: something that GPs are not able to offer in our time-poor and under-resourced primary care. | It is true that GPs are generalists, but we are experts, too, in prescribing and monitoring in many clinical areas that we commonly encounter, or that we may have developed an interest in. At present, gender dysphoria remains a niche field. Patients need specific management with a multi-disciplinary team approach that encompasses endocrinologists, surgeons, psychiatrists, pharmacists and others: something that GPs are not able to offer in our time-poor and under-resourced primary care. |
| Yet last year the General Medical Council (GMC) issued guidance on treating trans patients which left GPs worried and a little confused. It recommended that we give “bridging prescriptions” in some exceptional cases, for example if patients were already on self-medicated hormonal treatments (which many can be on) or to mitigate the risk of self-harm or suicide. But it also suggested seeking specialist advice from a gender identity clinic. However, if this criteria was not met and a GP did not feel able to prescribe with confidence, then it suggested seeking advice from a gender identity clinic and/or the local clinical commissioning group. It still remains difficult, however, to ascertain what exactly “exceptional circumstances” are. | Yet last year the General Medical Council (GMC) issued guidance on treating trans patients which left GPs worried and a little confused. It recommended that we give “bridging prescriptions” in some exceptional cases, for example if patients were already on self-medicated hormonal treatments (which many can be on) or to mitigate the risk of self-harm or suicide. But it also suggested seeking specialist advice from a gender identity clinic. However, if this criteria was not met and a GP did not feel able to prescribe with confidence, then it suggested seeking advice from a gender identity clinic and/or the local clinical commissioning group. It still remains difficult, however, to ascertain what exactly “exceptional circumstances” are. |
| Patients are faced with conflicting messages. The profession, too, remains uneasy and unsupported | Patients are faced with conflicting messages. The profession, too, remains uneasy and unsupported |
| Subsequently, NHS England has also advised that GPs should undertake this work, including monitoring treatments through blood and hormone levels. Yet the British Medical Association’s general practitioner committee has issued contradictory advice. It warns GPs not to prescribe specialised treatments, as it could fail to provide holistic care to gender dysphoria patients – and increase the risk of complaints and litigation against family doctors. | Subsequently, NHS England has also advised that GPs should undertake this work, including monitoring treatments through blood and hormone levels. Yet the British Medical Association’s general practitioner committee has issued contradictory advice. It warns GPs not to prescribe specialised treatments, as it could fail to provide holistic care to gender dysphoria patients – and increase the risk of complaints and litigation against family doctors. |
| This leaves patients caught in the middle, and faced with conflicting messages. The profession, too, remains uneasy and unsupported in this work. | This leaves patients caught in the middle, and faced with conflicting messages. The profession, too, remains uneasy and unsupported in this work. |
| As clinicians we have always been taught to work within our competencies. Yet GMC advice (despite its best intentions) seems to gloss over this fact. To prescribe hormone treatment as part of a harm-reducing strategy to this group of patients makes sense – but are GPs really best placed to take this on? And if GPs do take on this role, there is a possibility that it could set a precedent for us to bridge the gap in other areas of healthcare where there are increasing gaps in the specialised commissioning (as there invariably continues to be) of treatment. Other examples where specialist work has been “handed over” to already overstretched primary care include child and adult mental health. | As clinicians we have always been taught to work within our competencies. Yet GMC advice (despite its best intentions) seems to gloss over this fact. To prescribe hormone treatment as part of a harm-reducing strategy to this group of patients makes sense – but are GPs really best placed to take this on? And if GPs do take on this role, there is a possibility that it could set a precedent for us to bridge the gap in other areas of healthcare where there are increasing gaps in the specialised commissioning (as there invariably continues to be) of treatment. Other examples where specialist work has been “handed over” to already overstretched primary care include child and adult mental health. |
| Deficiencies in the commissioning of gender dysphoria services need to be tackled urgently. GPs who aren’t gender identity specialists are not best placed to fill that role safely and effectively, yet we still carry the responsibility for our prescribing. However, any reticence on our part to prescribe can be challenged and can sometimes be misinterpreted for prejudice. | Deficiencies in the commissioning of gender dysphoria services need to be tackled urgently. GPs who aren’t gender identity specialists are not best placed to fill that role safely and effectively, yet we still carry the responsibility for our prescribing. However, any reticence on our part to prescribe can be challenged and can sometimes be misinterpreted for prejudice. |
| I therefore welcome thecurrent public consultation by NHS England on managing specialised gender identity services for adults in the community. So far ideasIdeas put forward include GPs with a special interest in gender identity running community clinics, or national clinics offering more prescribing and monitoring support to GPs. I hope that when the consultation closes at the end of next month, NHS England is able to commission a robust and accessible gender identity clinic locally that can support patients and GPs alike. Those with gender dysphoria may be a small percentage of our population, but their care and wellbeing matters. Cutting costs by expecting non-specialist, overstretched GPs to prescribe treatment at their expense cannot continue. | I therefore welcome thecurrent public consultation by NHS England on managing specialised gender identity services for adults in the community. So far ideasIdeas put forward include GPs with a special interest in gender identity running community clinics, or national clinics offering more prescribing and monitoring support to GPs. I hope that when the consultation closes at the end of next month, NHS England is able to commission a robust and accessible gender identity clinic locally that can support patients and GPs alike. Those with gender dysphoria may be a small percentage of our population, but their care and wellbeing matters. Cutting costs by expecting non-specialist, overstretched GPs to prescribe treatment at their expense cannot continue. |
| • Zara Aziz is a GP partner in north-east Bristol | • Zara Aziz is a GP partner in north-east Bristol |
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