The care of transgender patients by GPs

Introduction

It is important that GP practices keep up-to-date with the relevant laws, professional guidance and contractual requirements in relation to the care and treatment of transgender patients.

Both the UK and Scottish governments are in the process of reviewing the Gender Recognition Act (2004)1. This sets out requirements for those acting in an official capacity, including that it is unlawful to disclosure ‘protected information’ without consent.

The need to secure consent before disclosing a patient’s gender history is reinforced in GMC guidance which states that doing so “shows respect, and is part of good communication between doctors and patients”.

The 2010 Equality Act2 clearly established a person’s transgender status as a ‘protected characteristic’, meaning healthcare professionals cannot refuse to see or treat a patient because of their transgender status.

A 2016 report3 by the House of Commons Women and Equalities Committee raised serious concerns about NHS care of transgender patients. As a result, the GMC set out additional responsibilities for doctors to ensure GP practices are inclusive and understand appropriate pathways for referral, as well as maintaining confidentiality, screening, prescribing and monitoring4.

GPs also have a responsibility to ensure they are aware of the practical aspects of making changes to transgender patient records, the process set out by NHS registrations teams and how screening is to be managed if a new record is created.

This guidance is not exhaustive but is designed to assist GP practices in understanding how these various requirements can be applied in practice.

Training

All practice staff should receive training in trans-awareness as part of their wider equality and diversity education. It must be made clear that any information relating to a patient’s existing or previous gender status is bound by a specific legal duty of confidence.

Administrative staff must be prepared to deal sensitively with approaches from patients requesting changes to their name and title within their medical records.

Requests to change pronouns and gender-markers on communications should be respected. Written medical correspondence should be discreet and not assume that others in the household are aware of the individual’s gender circumstances.

It is advisable to have an early discussion with the patient about their preferences, as part of a consultation, so that this can be managed appropriately.

Formal change of gender

Patients also have the right to request a formal change of gender, a move that would require the creation of a new medical record with a new NHS or CHI number. The patient does require, or need to present, a Gender Recognition Certificate or updated birth certificate for this change to be made.

A formal change of gender has implications for screening recall (see below) but does help to clarify their gender status should they ever move practice.

Practices should familiarise themselves with the relevant NHS guidance which sets out the current process for changing a patients registered gender (e.g. PSD in Scotland / PCSE in England). This includes requirements in relation to screening advice and managing the patient’s medical records.

Medical record management

In Scotland: Once medical records have been updated to reflect the patient’s changed gender, Practitioner Services Division (PSD) Registrations will write to the patient confirming the changes and asking them to speak to the GP practice about the implications for their future care. The content of the notes will remain unaltered and anything documented before the transition will not be removed.

In England: The GP practice will notify Primary Care Services England (PCSE) Registrations (via an enquiries form) who will issue a new NHS number and deduct the old patient record. The patient must then be registered as a new patient at the practice. It is the practice’s responsibility to inform the patient that this process is ‘irreversible’ and that if they wish to revert back in future this will result in the creation of a third NHS number (and record).

Unlike in Scotland, NHS GP practices in England need to manually transfer the patient’s previous medical information into the newly created record. Any information relating to the patient’s previous identity (name/title/gender) should not be included without the patient’s consent. This process should be completed within five working days of receiving the new NHS number.

To clarify this, NHS Digital states: “At this time a new NHS number can be issued and a new record can be created, if it is the wish of the patient. It is important to discuss with the patient which records are moved into the new record and to discuss how to link any records held in any other institutions with the new record” 5. There should be a clear, documented discussion about the patient’s request to ensure they fully understand the consequences of the change, including the fact that they will get a new NHS number and record. Once this is made clear, the patient may choose to retain their current record provided the practice changes their ‘administrative’ details.

At the present time, unless a patient has a formal Gender Recognition Certificate the final decision as to what is clinically relevant rests with the clinician.

When discussing the transfer of information from the old medical record to the new one, GPs should make it clear which information should be copied over to ensure continuity of care and avoid clinical risk. If need be, additional reassurances should be given to the patient that any notes relating to gender transition will be treated confidentially.

In our experience, most patients agree to previous notes being transferred provided their record ‘administratively’ reflects their new information.

GPs are also advised to seek consent to share the patient’s transgender status with the practice team, who may need to access their medical record in order to provide care.

The patient should be reassured that no information about their gender history will be disclosed without their specific consent.

If the patient expresses concern about access to their record, a practice could offer to limit this to clinicians only.

Any restrictions should be realistic and should not be detrimental to patient care.

Finally, the patient should be made aware that, if they register at another practice, these restrictions will no longer apply and the patient would be advised to discuss reinstating them with the new GP.

Note-taking and referral

Patients requesting a gender change should be referred to an appropriate specialist UK gender identity clinic. In the meantime, if criteria set out by the GMC are met, the GP should consider whether it is appropriate to provide a bridging prescription (see ‘Prescribing’ below).

When writing records or making referrals regarding transgender patients, reference to their transgender status should only be made if clinically relevant. Express consent should also be obtained in order to share this information.

GPs should continue to ensure that they follow GMC guidance in relation to recording their work clearly, accurately and legibly. Clinical records should include:

  • relevant clinical findings
  • the decisions made and actions agreed, and who is making the decisions and agreeing the actions
  • the information given to patients
  • any drugs prescribed or other investigation or treatment
  • who is making the record and when.

As doctors may be involved in arranging blood tests and prescribing hormonal medications as part of the transitioning process, it is important to document all care and treatment provided.

Any referral to other healthcare services made by a GP must not include reference to the patient’s gender transition/previous gender, unless:

  • this has been discussed with the patient
  • they have given consent to the disclosure, and
  • the information provided is necessary for medical purposes.

There will be circumstances where it is appropriate to disclose gender information – with your patient’s consent – so that the service you are referring to is aware they may have specific needs. This allows the service to respond appropriately to the patient and care for them in a manner that supports their dignity.

GPs using referral software must ensure that any referrals are checked before sending to avoid an inadvertent breach.

Screening

If the patient is to be issued with a new NHS or CHI number which has no reference to their sex at birth, the GP should explain that they may not automatically be contacted regarding current or future screening programmes associated with their sex at birth, and discuss the implications of this. Decisions about screening should be made with patients in the same way as any other decisions about their health.

The GP should discuss implications with the patient and, if they consent, contact the relevant NHS screening programmes to ensure they are invited for/referred to appropriate screening. The NHS has information available to help patients understand the implications across all screening programmes6. For smear testing, which is usually undertaken in the practice, the practice may be responsible for managing recalls, taking specimens and providing results. In this event, the practice should notify the laboratory that the results are to be forwarded to the practice and not the national call/recall service.

It is the practice’s responsibility to manage the patient’s lifelong care and to this end, they should ensure they understand the limitations of any national screening service and ensure the patient is managed locally with appropriate confidentiality and consent safeguards.

Prescribing

The GMC advises GPs of the increased risk of self-harm or suicide amongst trans patients, and to discuss access to mental health support services where appropriate.

GPs should only consider providing a bridging prescription for an individual patient awaiting specialist review when they meet all the following criteria:

  • the patient is already self-prescribing with hormones obtained from an unregulated source (e.g. the internet/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.

In relation to medicines unlicensed for this use, the GMC states that:

  • GPs can prescribe unlicensed medicines following the steps set out in its guidance.
  • GPs must take care to discuss the risks and benefits of treatment with the patient.
  • GPs should collaborate with experienced colleagues to provide care that best serves patient needs.

The GMC adds: “GPs must co-operate with gender identity clinics (GICs) and gender specialists in the same way as they would other specialists, collaborating with them to provide effective and timely treatment for trans and non-binary people. This includes prescribing medicines recommended by a gender specialist, following recommendations for safety and treatment monitoring, and making referrals to NHS services as recommended by a specialist”.

The future

The UK and Scottish governments have both completed stakeholder consultations to reform the Gender Recognition Act.

  1. Gender Recognition Act (2004)
  2. Equality Act (2010)
  3. House of Commons Women and Equalities Committee Report
  4. GMC transgender healthcare guidance
  5. NHS England registrations guidance
  6. Screening guidance for transgender patients

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