Dilemma: A valid objection?

A GP's faith dictates that gender is not fluid but biologically determined at birth. What are his obligations and personal rights in regard to treating a transgender patient?

I AM a GP in a suburban practice and recently a 22-year-old patient – Joe – attended the surgery complaining of anxiety. Closer questioning revealed that Joe has long felt that he was “born in the wrong body”. He has been researching gender dysphoria on the internet and has now decided that he wants to transition from male to female. I have been Joe’s doctor since his childhood and we have a trusting doctor-patient relationship. The difficulty is that my faith dictates that gender is not fluid but biologically determined at birth. What are my obligations and personal rights in regard to treating this patient?

This is not an unusual scenario and the fact that Joe is able to address his concerns with his GP speaks well of their relationship. Although the GP may now experience some personal difficulty with Joe’s presentation, legally and professionally he must offer the support and care required. This means putting aside personal beliefs, which may be a significant challenge, but it is not a situation where a doctor can exercise conscientious objection. The law and professional ethical guidance are clear.

If we first consider conscientious objection: there is no legal basis upon which a doctor can conscientiously object to providing care to a patient with gender dysphoria. Indeed, the law is very clear that transgender persons must not be discriminated against.

Specifically, the Equality Act 2010 protects trans patients from direct and indirect discrimination and harassment and, therefore, it is not open to a doctor to refuse to treat such a patient, even in circumstances where their personal view differs. This law places a clear obligation on the doctor to meet the patient’s healthcare needs; there is no provision to object on the basis of religious or other personal beliefs.

Professionally, a doctor’s overriding obligation is to their patient. Doctors have a duty to provide appropriate care and treatment in line with legal obligations and professional ethics. Once the doctor-patient relationship is established, there is a legal duty of care, which determines the standard of care a patient is entitled to in law.

If we consider the professional position, General Medical Council guidance in Good Medical Practice applies in all situations. Perhaps of particular relevance is paragraph 2 which states:

Good doctors work in partnership with patients and respect their rights to privacy and dignity. They treat each patient as an individual. They do their best to make sure all patients receive good care and treatment that will support them to live as well as possible, whatever their illness or disability.

Also, it is essential that doctors are aware of their professional and legal obligations and paragraph 8 makes it clear that:

You must keep your professional knowledge and skills up to date.

To address the specific questions raised, both ethically and legally, as the patient’s GP you are obliged to offer them appropriate healthcare, whatever your personal beliefs.

This is further reinforced in paragraphs 54, 57 and 59 of Good Medical Practice:

You must not express your personal beliefs (including political, religious and moral beliefs) to patients in ways that exploit their vulnerability or are likely to cause them distress.

You must not refuse or delay treatment because you believe that a patient’s actions or lifestyle have contributed to their condition.

You must not unfairly discriminate against patients or colleagues by allowing your personal views to affect your professional relationships or the treatment you provide or arrange.

In addition, the GMC offers specific guidance in its online ethical hub on Trans Healthcare, part of which states:

If you feel you lack knowledge and experience about the healthcare needs of trans people you should ask for advice from an experienced gender specialist and address your training need.

One of the first statements in Good Medical Practice regarding the duties of a doctor is: "Make the care of your patient your first concern". This must prevail in all cases and this particular case is also supported by explicit legislation which means that conscientious objection is not permitted.

It is understood that doctors come from a variety of backgrounds and are entitled to their personal beliefs but these cannot be placed above legal and ethical obligations which apply to the medical profession. In the situation described, Joe’s medical needs should be met with respect and understanding. His GP’s personal beliefs should not interfere with this and the provision of the healthcare required.

Dr Gail Gilmartin is a risk and medical adviser at MDDUS