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.

The Gender Recognition Act 2004^[1] is the legal framework by which a transgender person can have their preferred gender legally recognised. The Act also safeguards the privacy of transgender people by defining information in relation to their gender as ‘protected information’.

The Act sets out requirements for those acting ‘in an official capacity’ (which includes a GP acting in that role), and provides that it is unlawful to disclose ‘protected information’ without the person’s consent. While this legal protection covers those who have made an application for a gender recognition certificate, it is good practice to apply this principle to the records of all transgender patients, regardless of whether or not they have taken any formal legal steps to have their preferred gender legally recognised. The GMC advises that you should treat the gender status or history with the same confidentiality as any other sensitive information.

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

The Equality Act 2010 ^[2] clearly established gender reassignment as a ‘protected characteristic’, meaning that the law provides protection from discrimination for transgender people. This means that healthcare professionals cannot refuse to see or treat a patient because of their transgender status and also requires them to ensure that they do not discriminate against these patients in the course of providing treatment. The legal protection extends not just to those who are undergoing or have already undergone a process to reassign their sex by changing physiological or other attributes of sex, but includes anyone who is proposing to do so. Importantly, one does not require to have made an application for a gender recognition certificate under the 2004 Act in order to benefit from the protections provided in the 2010 Act.

To assist doctors in navigating the relevant legal and ethical frameworks, the GMC has collated helpful advice and resources in the Trans Healthcare page on its ethical hub. This sets out doctors’ responsibilities to ensure GP practices are inclusive and understand appropriate pathways for referral, as well as maintaining confidentiality, screening, prescribing and monitoring for adult transgender patients.^[3]

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 local 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.

Change of pronouns

Requests to change pronouns and gender-markers on communications should be respected. Written medical correspondence should be discreet, including the appearance of the patient’s name in the address window, and should 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, for example, as part of a consultation, so that this can be managed appropriately.

Change of gender

Patients also have the right to request a 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 not require, or need to present, a Gender Recognition Certificate or updated birth certificate for this change to be made. If a patient wishes to make a legal change to their gender, a Gender Recognition Certificate would be required.

A change of gender has implications for screening recall which is explained below.

Practices should familiarise themselves with the relevant NHS guidance which sets out the current process for changing a patient’s 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.  

Once gender is changed on the patient’s CHI number, a new CHI record is started which is linked to the previous one, then known as the ‘historic’ record. The GP records should be updated and moved to the new CHI number. Gender markers and any information related to the patient’s previous identity should be removed from all previous records by the practice.

In England and Wales: The GP practice will notify their local Primary Care Services 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). [4]

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.

Because a new NHS number is created and a new patient record is generated, it is important to discuss with the patient what this implies and that they understand which information from their previous records is not included in their new record. 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 have a new NHS number and record. Once this is made clear, the old patient records should be filed with Primary Care Support England (PCSE) or the Business Services Centre (BSC) in Wales.

Alternatively, the patient may choose to retain their current record provided the practice changes their ‘administrative’ details.

In Northern Ireland: The GP practice should contact Business Services Organisation (BSO) to request a new medical record and Health and Care Number for the patient. The practice must ensure that no reference to the patient’s previous identity or gender is contained within the new records. 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 with the patient, 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 to their new notes provided their record ‘administratively’ reflects their new personal 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 treatment for gender dysphoria or gender incongruence should be referred to an appropriate specialist gender identity service.

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 and it may be an offence to disclose it without consent.

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.

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.

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 programmes[5].

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 ensure both that the patient understands the limitations of any national screening service and that the patient’s screening results are managed locally with appropriate confidentiality and consent.

Prescribing

The GMC acknowledges that trans patients are at an increased risk of self-harm or suicide and GPs should discuss access to mental health support services where appropriate. Their guidance also acknowledges the long waiting times to access specialist services.

Good medical practice and the GMC’s prescribing guidance state that while doctors must recognise and work within the limits of their competence, they must work in partnership with patients and consider what treatment is likely to meet their needs, and must work with colleagues in the ways that best serve patients’ interests.

‘Bridging prescriptions’

GMC guidance states that “one way in which you might consider providing support to your patient is by issuing a ‘bridging prescription’”, which is “a temporary prescription of endocrine treatment that can be issued by a GP”.

However, GPs must consider local policy requirements and obtain the advice of a specialist service provider or an experienced colleague before issuing a bridging prescription.

The GMC seek to reassure doctors who wish to prescribe for their transgender and gender diverse patients that it would not be against their guidance to so issue a bridging prescription. Equally, they are clear that their guidance does not oblige doctors to do so if they do not feel that prescribing would be of overall benefit to a patient.

Prescribing medicines outside their licence

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

• GPs can prescribe unlicensed medicines following the steps set out in its Prescribing 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.

Prescribing on the recommendation of a specialist

The GMC states that GPs must collaborate with a gender specialist service, and this may include prescribing medicines on their recommendation and/or following their recommendations for safety and treatment monitoring (taking into account local arrangements, such as Shared Care Agreements or Enhanced schemes).

However, the GMC continue that it is reasonable for a GP to expect the specialist service provider to remain available to provide advice and support where necessary.

The GMC confirms that doctors are not obliged to follow the recommendations of those working for a specialist service provider who are unable to demonstrate they are suitably qualified. However, in these circumstances, it is not acceptable simply to refuse to treat a patient, and doctors must communicate with the patient and more experienced colleagues or service leads to ensure they make the care of the patient their first concern and provide a good standard of practice and care.

The future

There are ongoing legal processes by the Scottish government to reform the Gender Recognition Act.

1. Gender Recognition Act (2004)

   http://www.legislation.gov.uk/ukpga/2004/7/pdfs/ukpga_20040007_en.pdf

2. Equality Act (2010)

   https://www.gov.uk/guidance/equality-act-2010-guidance

3. GMC transgender healthcare guidance

   https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare

4. NHS England registrations guidance

   https://pcse.england.nhs.uk/help/registrations/adoption-and-gender-re-assignment-processes/

   https://pcse.england.nhs.uk/media/1291/process-for-registering-a-patient-gender-re-assignment.pdf

5. Screening guidance for transgender patients for England, Scotland, Wales and Northern Ireland.