GPs are most often the first point of contact in the healthcare system for individuals questioning their gender. In some cases, GPs can be the first people they confide in about their gender identity, or uncertainties about their gender identity. General practice plays a vital role in ensuring these patients receive the care they need. GPs are expected to approach the holistic care of gender-questioning and transgender patients as they do with every patient. In other words: openly, respectfully, sensitively and without bias.
The Royal College of GPs recognises that GPs are not experienced in treating and managing patients with gender dysphoria and trans health issues. Gender dysphoria and gender identity issues are not part of the GP curriculum or GP specialty training. GPs are currently required to refer patients experiencing gender dysphoria to gender identity specialists for further assessment and treatment advice. GPs face difficulties in accessing gender identity specialists in a timely way. This often has severe implications for the mental and physical health of their patients. GPs are subsequently under increasing pressure to provide services which are usually provided in specialist clinics. This is because they lie outside the remit of generalist expertise, with limited access to specialist support.
There is an urgent need to increase the capacity of gender identity specialists and clinics. There is also urgent need to expand the understanding of gender variance issues across the entire health system. These include more definitive knowledge about the causes of rapidly increasing referrals, and the outcomes of interventions or 'wait and see' policies. There are gaps in education, guidance and training for GPs around treating gender dysphoria for both adults and children, and managing broader trans health issues. These also need to be urgently addressed.
This paper provides an overview of the key issues facing gender-questioning and transgender patients, general practice, and the broader health system. It establishes the RCGP’s position on the role of a GP in providing care to patients experiencing gender dysphoria. It also covers the policy principles underpinning this position. Recommendations for ensuring these patients receive equal access to the highest standard of care are also laid out.
The following are common definitions of terms in this document that are provided for clarification. They are provided for explanation and their use is not necessarily endorsed by the RCGP.
Gender identity: A person’s self-identification and expression as male, female or other gender (e.g. gender neutral, non-binary, gender fluid, gender queer).
Gender dysphoria: Distress or discomfort experienced due to a discrepancy between a person’s gender identity and their biological sex observed at birth.
Gender-questioning: A person who may be processing, questioning, or exploring how they want to express their gender identity.
Gender Identity Disorder (GID): The International Classification of Diseases (ICD) 101 states that gender identity disorder is a disorder characterized by a strong and persistent cross-gender identification (such as stating a desire to be the other sex or frequently passing as the other sex) coupled with persistent discomfort with his or her sex, manifested in adults, for example, as a preoccupation with altering primary and secondary sex characteristics through hormonal manipulation or surgery.
Transgender/Trans: An umbrella term for people whose gender identity and/or gender expression differs from their biological sex observed at birth. Trans people may or may not decide to alter their bodies hormonally and/or surgically.
Transsexualism: The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to have treatment to make a person’s physical appearance. More consistent with their gender identity.
- The General Medical Council (GMC) advises that doctors promptly refer patients requesting treatment for gender dysphoria to GICs or an experienced gender specialist (who has evidence of relevant training and at least two years’ experience working in a specialised gender dysphoria practice such as an NHS GIC).2
- Current service provision in England is network-based, shaped around seven NHS Gender Identity Clinics (GICs) for adults, three providers of adult genital reconstruction surgery and only one designated provider of gender identity development services for children, adolescents and young people, the Tavistock and Portman NHS Foundation Trust, which also offers services to adults and to patients from Scotland and Wales.
- There are currently four GICs in Scotland, most of which accept regional referrals with one accepting referrals from across Scotland as well as self-referrals.
- Welsh GPs will soon be able to directly refer patients over the age of 17 to the Wales Gender Identity Clinic. The clinic will assess patients and establish treatment plans where appropriate, before discharging the patient back to the GP practice. Patients under the age of 17 are referred to the Child & Adolescent Mental Health Service (CAMHS). There is currently no gender identity service in Wales for people under the age of 17.
- In Northern Ireland, there is a paediatric gender identity service which accepts referrals from the CAMHS. There is also the Brackenburn Clinic in Belfast which provides a Regional Gender Identity Service.
A changing landscape, increasing demand and insufficient system capacity
- In England, GICs have seen a 240% overall increase in referrals over five years.3 The Tavistock & Portman clinic alone received 283 referrals in March 2019, an 8.43% increase from March 2018.4 In Scotland referrals to GICs have also increased markedly with the largest increase between 2014 and 2015. 5 In August 2017, the Welsh Health Secretary Vaughan Gething spoke publicly about the increasing demand for transgender health services in Wales, which led to the recent opening of the Wales Gender Identity Clinic.6 There is currently no official data available on the increase in referrals to the Brackenburn Clinic in Northern Ireland.
- Under the NHS Constitution for England, the maximum waiting time for an initial specialist appointment following referral is 18 weeks. As of 2018, the average waiting time for an initial appointment at a GIC in England following a GP referral was 18 months, with around 7,500 adults waiting for a first appointment as of August 2018.7 In 2016, NHS England pledged to reduce waiting times to below 18 weeks by 2018.8
- In Scotland, under the Referral to Treatment Standard there is a maximum waiting time of 18 weeks for diagnostic tests, assessments and treatment if required.9 Scotland’s main GIC, the Sandyford clinic, has an average waiting time of 12 months for an initial appointment.10
- If a person is registered with a Welsh GP, they are subject to the NHS Wales waiting times and referral criteria which includes a waiting time target of 26 weeks or less from referral to treatment.11
- As of March 2018, the waiting time target for an initial specialist appointment in Northern Ireland is no longer than 9 weeks for at least 50% of patients, with no patient waiting longer than 52 weeks.12 The Brackenburn Clinic in Northern Ireland has a current waiting time of approximately 2 years for an initial appointment with the Regional Gender Service following referral.13
- A report on transgender equality published by the House of Commons Women and Equalities Committee in January 2016 found “serious deficiencies in the quality and capacity of NHS gender identity services” and expressed concern about “the apparent lack of any concrete plans to address the lack of specialist clinicians in this field.”14 The Committee reports the uneven geographical distribution of GICs, meaning people need to travel long distances to access treatment.
- Whilst the current GP curriculum broadly references the need for GPs to adapt their clinical approach for gay, lesbian, and transgender people, it is unsurprising that the House of Commons Committee report also found that GPs often lack a deeper understanding of trans identities, gender dysphoria, referral pathways into gender identity services, and their own role in prescribing hormone treatment. It was asserted that in some cases this leads to appropriate care not being provided.
- The UK lacks a nationally recognised training programme for gender identity healthcare. Although there are apprenticeship training models in several specialist GICs and guidelines are available from various organisations such as the British Association of Gender Identity Specialists (BAGIS), the European Professional Association for Transgender Health (EPATH) and the World Professional Association for Transgender Health (WPATH), the GIHP workforce needs to expand rapidly to meet service need therefore a comprehensive national training programme is needed.
- Whilst in the past, many transgender patients sought a gender transition treatment, increasingly many people identify with a range of gender types (such as trans, fluid, non-binary, and genderqueer). Not all these people seek interventions for their gender dysphoria. Gender identity services are also needed for people who are uncomfortable or distressed by their biological sex or gender roles and behaviours assigned to them by society, but do not wish to alter their sexual characteristics.
- The significant lack of evidence for treatments and interventions which may be offered to people with dysphoria is a major issue facing this area of healthcare. There are also differences in the types and stages of treatment for patients with gender dysphoria depending on their age or stage of life. Gonadorelin (GnRH) analogues are one of the main types of treatment for young people with gender dysphoria. These have long been used to treat young children who start puberty too early, however, less is known about their long-term safety in transgender adolescents. Children who have been on GnRH for a certain period of time and are roughly 16 years of age can be offered cross-sex hormones by the NHS, the effects of which can be irreversible.15 There is a significant lack of robust, comprehensive evidence around the outcomes, side effects and unintended consequences of such treatments for people with gender dysphoria, particularly children and young people, which prevents GPs from helping patients and their families in making an informed decision.
Transgender patient and family experiences
- Of the 108,100 respondents to the Government Equalities Office (GEO) National LGBT Survey, 13% of respondents were transgender. Of these respondents, 38% accessing general healthcare services reported a negative experience due to their gender identity. Some of the respondents specifically called for healthcare professionals to be trained in not making assumptions about their patients’ gender identity.
- Of the 2,900 respondents who elaborated on their experiences of gender transition and gender identity services, the emerging overall view was of hard-to-access services, and a lack of knowledge among GPs about what services are available and how to access them. Of all the trans respondents who had tried accessing gender identity services, 80% said that access had not been easy, with the majority of these (68%) reporting that waiting times had been too long. The survey also found that 16% of trans respondents had gone outside the UK to pay for healthcare or medical treatment, and a further 50% were considering it.
- Informal feedback is that some new university students may not register with a new GP practice near to their campus due to fear of dropping off the waiting list for a GIC appointment, which is linked to referral from a GP in the surgery they were originally registered at.
- NHS England’s transgender communities listening exercise from 2013/14 found that most of the frustrations experienced by trans patients and their families with the NHS system related to a perceived poor cooperation between GPs and GICs.16
Gender identity clinic perspectives
- The significant increase in referrals to GICs and the lack of capacity in the system to meet this demand for specialist care, has placed immense pressure on GICs to meet the demand from both patients and other healthcare professionals including GPs.
- The Tavistock and Portman NHS Trust website states that GICs do not endorse GPs prescribing hormone therapy or bridging prescriptions for self-started, internet-sourced hormones, until a GIC has made a full assessment of the patient.
- 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's outside their area of competence to advise patients with gender dysphoria. However, GPs can contextualise a person’s presentation of gender dysphoria with other conditions, particularly autism, and within their broader environment. GPs may also be able to contextualise the distress felt by the individual against that person’s medical history and possibly relate it to the distress and discomfort often experienced by many young people during puberty and adolescence.
- The GMC guidance suggests if GPs feel a lack of knowledge or experience about the healthcare needs of trans people, they ask for advice from an experienced gender specialist and address their training needs as part of continuing professional development. However, GPs face significant challenges with accessing advice from specialists and there are limited CPD programmes available for gender identity and trans health issues. It is also important to note that GPs undertaking CPD in gender identity would not reduce the requirement for access to specialist advice and support.
- GPs are facing increasing difficulties addressing patient requests for “bridging” prescriptions, particularly for those patients who have self-started medication, including medication which they have procured over the internet.
GMC advice on ‘bridging prescriptions’ for trans and non-binary people17 recommends that GPs should only consider issuing bridging prescriptions in cases where all the following criteria are met:
- the patient is already self-prescribing from an unregulated source (over the internet or otherwise on the black market)
- the bridging prescription is intended to mitigate a risk of self-harm or suicide, and
- The doctor has sought the advice of an experienced gender specialist and prescribes the lowest acceptable dose in the circumstances.
Additionally, GMC advice references a harm reduction approach, whereby GPs or other medical practitioners may prescriber bridging endocrine treatments as part of a holding or harm reduction strategy while the patient awaits assessment and advice from a specialist, if it is judged that this approach benefits the patient overall.18 However, this advice fails to address the ethical and safety issues around prescribing outside the limits of one’s competence, the significant medicolegal implications this carries and the non-pharmacological needs of patients as they await access to a specialist.
Further, the GMC advice above conflicts with their Good Medical Practice ethical guidance which states that GPs must recognise and work within the limits of their competence. As such, GPs face conflicting messages about how to approach advising and prescribing for these patients, which poses a significant risk to GPs in their practice, and patient safety. 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 GMC advice needs review and clarification.
- GPs face even greater challenges in addressing the needs of children and young people under the age of 16 who are experiencing gender dysphoria or are in the process of transitioning to another gender. These challenges include the vulnerabilities of young people at this time and the heightened risk of self-harm and attempted suicide, the concerns of parents who may not be accepting of what is happening to their child and the lack of a robust evidence base for interventions. Parental and carer involvement in the care of these patients is crucial and adds another layer complexity to the GPs role.GPs also face difficulties with current IT systems which do not accommodate for transgender and non-binary patients in relation to referrals and screening. For example, a trans male cannot be referred for a cervical smear or to a gynaecology clinic if they are recorded as male in the practice database, despite still having female reproductive organs.
- The policy principles underpinning the RCGP’s position statement reflect the role of the GP in working with and alongside specialist colleagues, to care for any patient presenting with a relatively rare or infrequent physical and/or psychological experience, within a system of services which are adequately funded and delivered.
- GPs and their teams are required to show the same level of support, dignity, respect, sensitivity and understanding, to patients with gender dysphoria or trans patients, as they would with any other patient.
- GPs should not be expected to fill the gaps in commissioned gender identity specialists and clinics. Patients who are experiencing gender dysphoria should not have to resort to self-medication without the advice of a gender identity specialist.
- Patients with possible or diagnosed gender dysphoria, or who self-define as trans, should receive prompt and timely access to the skills of relevant healthcare professionals across the healthcare system (GPs, gender identity specialists, mental health professionals, counsellors and so forth) and appropriate treatment when they need it. These patients should have access to high quality, joined-up, person-centred healthcare based on robust evidence.
- GPs should be trained and prepared to provide high-quality, holistic care to patients who identify as suffering from or are diagnosed as has having gender dysphoria. The GP curriculum should be enhanced to develop GPs’ knowledge of gender variance and trans health issues. There should also be comprehensive resources readily available to GPs to ensure they can keep their professional knowledge about these issues up to date, and provide the appropriate support, advice and referral information to patients with various types of gender identity needs. This does not remove the need for gender identity specialists and there should no expectation for GPs to advise patients outside the remit of their role as expert generalist, even if some GPs have more training than others in gender identity and trans health.
- Based on the above principles, and with consideration of current guidance from various organisations19, we believe the overall role of the GP in providing care to patients with gender dysphoria is to:
- Holistically assess the patient’s health needs, collaborating with other healthcare professionals and services as relevant.
- GPs should be mindful that patients often find it very difficult to confide in their feelings of gender incongruence and that approaching a healthcare professional to discuss their gender identity needs can be considerably distressing for them. GPs and their practice teams should approach these patients openly, respectfully and sensitively, with an awareness and understanding that a person’s outward appearance may not necessarily correspond to their gender identity, particularly at early stages of the person’s journey to exploring their gender identity.
- Promptly refer patients to a GIC or equivalent if they exhibit signs of gender dysphoria and request treatment or wish to consult with a gender identity specialist for further advice. Liaise and work with GICs and gender specialists in the same way as any other specialist, to jointly provide effective and timely treatment for patients. This includes considering taking on the ongoing prescribing of medication for patients and the monitoring of any side effects, with the appropriate funding, after a patient has been discharged from a GIC.
- It is common for GPs to work under Shared Care Agreements (SCAs) set up between GICs and practices to provide joint care for patients. It is important that SCAs are agreed upon by all parties involved, ensuring the appropriate levels of resource, competence and expertise are established, as informed by the patient’s level of medical risk. NHS bodies need to ensure that local shared care arrangements are adequately funded to support the ongoing care and treatment of patients.
- When responsibility for ongoing medical monitoring and prescribing is assumed by a GP, the limitations of this need to be recognised and mitigated. This is especially important for children and young people, where there is concern regarding the outcomes of some interventions. The GIC involved in the SCA should have access to the patient’s GP records and be accessible to provide specialist consultation to GPs to ensure the patient is being monitored correctly and the appropriate dosages of medication are being prescribed based on the progress of the patient.
iv. Recognise that the family members of a patient experiencing gender dysphoria also face significant challenges and refer these family members to further support services where appropriate.
v. Provide appropriate treatment or signposting to patients presenting with gender dysphoria alongside other social or medical issues. This may include referring the patient to mental health services or engaging with social care, safeguarding or sexual health colleagues.
- To ensure gender-questioning and trans patients are receiving the care and advice they need, when they need it, it is crucial that GPs, primary care teams and the wider health system are equipped with the adequate knowledge, skills and resources to address these needs.
- The RCGP calls for the implementation of the following policy recommendations (outlined in the boxes below) as priority to enabling a high-quality service over the next five years. It is vital that frontline GPs, patients and the broader trans community are involved in the design and implementation of changes to the current system.
Expanding and improving services
- NHS England is taking steps to address the insufficient clinical capacity and geographical inequality of gender identity services across England. A two-year pilot was agreed in January 2019 whereby the Greater Manchester Health & Social Care Partnership is jointly working with NHS England to build a new model of healthcare for transgender and non-binary people in Greater Manchester, as there are currently no specialist clinics in the North West of England. NHS England is also developing a new model for gender identity services – we await the details around this new model and the evaluation of the Greater Manchester pilot and highlight the need to ensure there is a sufficient specialist workforce to support the expansion of clinics.
- The RCGP will work with the other Royal Colleges, the GMC, and the NHS, to collectively improve gender identity services for patients, reduce barriers to accessing these services and ensure the appropriate educational pathways and standards of accreditation are in place to enable doctors to pursue professional development in this area.
- We strongly encourage the NHS to consider the expansion of gender identity services in the Devolved Nations and for gender-questioning children as well as adults.
- The NHS should urgently address the extensive waiting lists for GICs across the country and ensure the commissioning of gender identity services is sufficient to support the level and spread demand for specialist advice from patients and GPs.
- Up-to-date IT systems and associated IT training is needed to enable GPs and other healthcare professionals to treat trans patients and patients with gender dysphoria in a safe and respectful manner (for example, documenting generalist and specialist advice in writing as part of the patient record, maintaining safe access to screening programmes such as smears after a patient’s gender has been changed on records). NHS systems should record codes for biological sex as well as gender identity, while ensuring all patients are afforded the right to express their preferences for how they wish to be named and referred to by their GP and other healthcare professionals.
Preparing GPs and their teams
- The RCGP is currently developing an e-Learning module, which aims to expand the understanding of gender variance for primary care, covering patients who are transgender and non-binary. The module will cover a wide range of issues including the risks and benefits of prescribing, the ever-changing and expanding language in this area and the need to treat patients with respect, confronting reasons why some GPs may feel uncomfortable advising patients on gender identity issues.
- The Royal College of Physicians with the support of NHS England, is developing an interprofessional postgraduate certificate and diploma (PGCert/Dip) in GIHP for GPs and other regulated healthcare professionals working within the NHS who wish to deepen their skills and expertise in gender identity and gender variance. The PGCert/Dip is planned to launch on 1 November 2019.The RCGP welcomes and support the development of this programme of study as a way of expanding the capacity of the wider system and ensuring specialist practitioners working in this field are appropriately trained and meeting threshold standards of competence.
- The GP curriculum should cover gender dysphoria and broader trans health issues to ensure GPs have an understanding of these issues for both adults and children, to inform the care and advice delivered to these patients.
- Educational and training bodies, commissioners and employers should provide training programmes and materials which help and support GPs and their teams with engaging with and advising trans patients. These materials should include comprehensive, consistently updated, evidence-based information about identifying gender dysphoria, interacting with patients in a respectful and unbiased manner, signposting patients to relevant support services, referring patients to specialist services when appropriate, and understanding their role as a GP in the prescription of various treatments. Such materials should also include information about the uncertainties in contemporary knowledge about gender dysphoria and associated interventions, and guidance for GPs when considering SCAs.
Research & regulation
- The promotion and funding of independent research into the effects of various forms of interventions (including ‘wait and see’ policies) for gender dysphoria is urgently needed, to ensure there is a robust evidence base which GPs and other healthcare professionals can rely upon when advising patients and their families. There are currently significant gaps in evidence for nearly all aspects of clinical management of gender dysphoria in youth. Urgent investment in research on the impacts of treatments for children and young people is needed.
- The fundamental standards of care and principles of oversight and regulation applied by the Care Quality Commission (CQC) in England and equivalent bodies in the Devolved Nations, should be applied to all providers of gender identity services, through regular service reviews and publication of results.
- World Health Organisation, International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10), 2016.
- General Medical Council, ‘Trans healthcare’ Ethical Guidance, 2019
- I. Torjesen, ‘Trans health needs more and better services: increasing capacity, expertise, and integration’, BMJ, vol. 362, no. 3371, 2018.
- The Tavistock and Portman NHS Foundation Trust, ‘Gender Identity Clinic Waiting Times’, 2019
- R. Thomson, J. Baker and J.Arnot, ‘Health Care Needs Assessment of Gender Identity Services’, Scottish Public Health Network, May 2017.
- ’New adult gender identity service to be established in Wales’, GOV.WALES, 25 August 2017
- H. Westcott, ‘Transgender people face two-year wait for NHS appointment’, BBC News Online, 30 January 2018, I. Torjesen, ‘Trans health needs more and better services: increasing capacity, expertise, and integration’, BMJ, vol. 362, no. 3371, 2018.
- ‘Transgender patients in England face 'long waits' for appointments’, BBC News Online, 21 February 2016.
- Parliament. House of Commons (2018) NHS maximum waiting times standards and patient choice policies. (07171).
- ‘Gender Specialists’, Scottish Trans Alliance, 2019.
- Parliament. House of Commons (2018) NHS maximum waiting times standards and patient choice policies. (07171).
- ‘Brackenburn Clinic (Regional Gender Identity & Psychosexual Services’, Belfast Health and Social Care Trust, 2019.
- Parliament. House of Commons Women and Equalities Committee (2016) Transgender Equality. (HC 390). London: The Stationery Office Limited.
- C. Heneghan, T. Jefferson, ‘Gender-affirming hormone in children and adolescents; BMJ EBM, 25 February 2019.
- NHS England Specialised Commissioning, ‘Experiences of people from, and working with, transgender communities within the NHS- A summary of findings, 2013/14’, 27 November 2015.
- General Medical Council, ‘Trans healthcare’ Ethical Guidance, 2019
- Royal College of Psychiatrists, ‘Good practice guidelines for the assessment and treatment of adults with gender dysphoria’, October 2013.
- Royal College of Psychiatrists, ‘Good practice guidelines for the assessment and treatment of adults with gender dysphoria’, October 2013; World Professional Association for Transgender Health, ‘Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People’, Version 7; General Medical Council, ‘Good Medical Practice’, 29 April 2019; General Medical Council, ‘Trans healthcare’ Ethical Guidance, 2019