With increasing understanding and awareness around gender identity issues, it is essential for GPs to treat transgender patients with utmost care and sensitivity. It is also important for GPs treating transgender patients to be aware of and understand relevant regulation, legal pitfalls and administrative complexities that could impact on their care.
This includes the recent introduction of the GMC Advice for doctors treating transgender patients.
This guidance was introduced in early 2016 in response to the first report by the House of Commons Women and Equalities Committee, which highlighted concerns around doctors’ awareness and consideration in treating transgender patients.
One particularly important issue is addressed in the new guidance under the heading 'Tackling the risk of harm: "Bridging prescriptions"'. This requires GPs to issue ‘bridging prescriptions’ as a harm reduction measure to patients who are already self-medicating and who are likely to experience lengthy delays accessing a gender specialist and/or a gender identity clinic (GIC).
The new GMC guidance specifically states that a GP may prescribe ‘bridging’ endocrine treatments as part of a holding and harm reduction strategy while the patient awaits specialised endocrinology or other gender identity assessment and treatment elsewhere. This may or may not result in a recommendation for a prescription of hormones.
This means that GPs treating transgender patients who are self-medicating with hormones are now required to assess the risk of continued self-medication or cessation of self-medication, and to balance this against the benefits of prescribing bridging hormonal therapy, if that would be safer.
Medical Protection advice
To assist GPs in confidently treating potentially vulnerable transgender patients and to ensure these patients aren’t left without anywhere to turn for treatment and monitoring, Medical Protection advises GPs to ensure that they have weighed up carefully and discussed with the patient the risks and benefits of prescribing hormones.
- 'the patient is already self-prescribing with hormones obtained 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
- the doctor has sought the advice of a gender specialist, and prescribes the lowest acceptable dose in the circumstances.'
If a GP does not feel that these criteria are met, that prescribing in the circumstance may not be in the patient’s interests, or that they do not have the requisite knowledge to do so, they should counsel the patient and take specialist advice from the CCG prescribing lead or a specialist in gender dysmorphia.
Any doctor must be able to justify their decision to prescribe or withhold hormone therapy in light of the GMC’s transgender guidance and the principles set out in its guidance on prescribing and managing medicines and devices. Rationale for decisions made and discussions with patients should clearly be documented in the patient’s medical records.
GPs may be worried about the risk of their care being subject to a claim for clinical negligence or complaint to the regulator. However, if a clinical or management decision is made in accordance with the guidance, it is unlikely that the GP will be criticised.
This means that as long as GPs carefully assess the risks that are specific to each patient and follow advice from a GIC specialist (and, I suggest, carefully document these in patient records) it is unlikely that a claim or complaint would succeed. This is because the expected standard of care will itself be based on the guidance
Of course, patient confidentiality must always be protected and consent should be sought before any discussions with third parties that identify the patient. For example, if a patient has a Gender Recognition Certificate it may be a criminal offence to disclose the patient’s previous gender without consent, under the provisions of the Gender Recognition Act 2004.
Gender dysphoric patients have the right to be treated with respect and for their concerns to be recognised and hopefully resolved.
If GPs have any questions around bridging prescriptions, it is a good idea to contact their local CCG prescribing lead in the first instance. If they would like to discuss medicolegal aspects relating to the care of transgender patients, they should contact their medical defence organisation for advice specific to their individual situation.
- Dan Kremer is medicolegal adviser at Medical Protection