GPs 'not obliged' to begin hormone treatment in transgender patients

GPs 'are not obliged' to prescribe bridging hormone treatments to transgender patients as per GMC recommendations, according to BMA guidance.

The BMA has released its own guidance to help GPs treat patients with gender incongruence, following concerns that GMC advice could leave GPs open to medico-legal risk.

GMC guidance released earlier this year advised GPs to initiate bridging hormone therapy before patients see a specialist if it appeared they were turning to self-medication with drugs from an unregulated source.

The GPC argued that that this could push GPs to prescribe beyond their competence, although the GMC stood by the recommendation.

Guidance from the BMA stresses that GPs should not feel obliged to initiate this specialist treatment before the patient has seen a gender specialist.

It says GMC advice ‘fails to address the resulting significant medico-legal implications for GPs’ as well as ‘neglecting the non-pharmacological needs of these patients’.

Transgender treatment

‘It must be remembered that prescribers take individual ethical, clinical and legal responsibility for their actions, and when deciding on appropriate management GPs should keep accurate records of their reasoning and decisions,' it says.

‘While awaiting specialist assessment, GPs should attend to their patients general mental and physical health needs in the same way as they would for other patients, but are not obliged to prescribe bridging prescriptions.

‘Patients should not have to resort to self-medicating due to a failure to commission a timely specialist service, and this problem must be solved by NHS England making proper commissioning arrangements rather than by GP-prescribing before initial assessment and diagnosis.

‘If the delay for specialist assessment is excessive GPs do have a role as their patient’s advocate in making representation to the commissioning organisation to help ensure timely provision.’

Hormone therapy

It is thought that around 1% of the population may experience some degree of gender incongruence, although this is considered to be an underestimate. If left untreated, it can lead to mental health problems and severely affect a person’s quality of life.

The BMA added: ‘Our ultimate aim is to ensure high quality service provision is made for this particular group of patients.

‘It is likely that all GPs will be providing primary medical services to this group of patients at some stage. An understanding of the issues involved is therefore necessary to ensure quality care is provided and appropriate referrals are made to specialist services.

‘In our view, there is however a need for a balance between what can justifiably be expected of GPs in providing primary medical services to patients with gender incongruence, those enhanced services which can be provided in primary care, and the knowledge and expertise which should rightly remain within the remit of specialist services.’

The BMA guidance lists five key points for GPs in treating gender incongruence:

  • Refer early and swiftly to a reputable gender service
  • Support the treatment recommended by the gender service
  • Get pronouns right; if in doubt, (discreetly) ask
  • Be particularly mindful of medical confidentiality
  • Avoid misattributing commonplace health problems to gender

The GMC has defended its guidance. Deputy chief executive Susan Goldsmith said earlier this year that the GMC ‘would not want’ GPs to feel they are being forced to prescribe beyond their competence'.

She added: ‘While [Good Medical Practice (GMP) guidance] states "you must recognise and work within the limits of your competence", this principle cannot be a bar to doctors taking on new responsibilities or treating unfamiliar conditions.

‘We would expect GPs to acquire the knowledge and skills to be able to deliver a good service to their patient population. For some unfamiliar conditions or medicines, this may mean undertaking training or working with support or supervision for a period, in order to ensure that patients receive safe, effective care while a GP is extending or updating their knowledge and skills.’

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