Transgender Patients / Gender Reassignment
A number of queries have been raised with GPC regarding the management of patients who present at their general practice with gender identity problems; including questions relating to patient records and confidentiality and, in particular, regarding prescribing and monitoring responsibilities in relation to the gender reassignment process.
In response, we have produced new guidance, which:
- Aims to explain what should be provided in primary care
- Signposts to further sources of guidance
- Highlights some of the underpinning ethical and legal considerations.
CQC have also published Nigel's surgery 101: The Adult Trans Care Pathway
On 4th Feb 2021, the RCN published the following - Fair Care for Trans Patients
Legal recognition will only follow after the issue of a full Gender Recognition Certificate by a Gender Recognition Panel. The panel must be satisfied that the applicant:
- has, or has had, gender dysphoria
- lived in the acquired gender throughout the preceding two years.
- intends to continue to live in the acquired gender until death.
In this case, the patient must be supplied with a new identity and the old identity revoked, including transferring all medical records.
Generally, patients will have lived as the alternative administrative gender prior to clinical reassignment.
A patient may request to be known by a different administrative gender without a full Gender Recognition Certificate.
This may be as a result of a clinical intervention or simply a desire to be known by a different gender.
In such cases the patient must be cautioned about the consequences of changing administrative gender, for example, in connection with cancer screening programmes. Both types of request are currently treated identically.
GPs and staff should also be careful that whatever stage of transition the person is at, this information should only be passed on when it is relevent to patient care. With the use of IT systems to help produce referral letters etc it is easy for irrelevent personal information to be included in, for example, an ENT referral, where there can be no clinical reason for sharing those details.
This information is for transgender and non-binary people in England and provides information about the adult NHS screening programmes that are available in England. - https://www.gov.uk/government/publications/nhs-population-screening-information-for-transgender-people/nhs-population-screening-information-for-trans-people#cervical-screening
What happens now?
When a patient requests a gender reassignment of either type, the patient's GP or Primary Care Trust must write to the Personal Demographics Service (PDS) National Back Office. The case will then be managed by them.
The National Back Office creates a new identity with a new NHS Number and requests the records held by the patient's GP. These records are then transferred to the new identity and forwarded to the new GP.
The old NHS Number is withdrawn so that it can no longer be used. Questions on the process should be referred to the patient's Primary Care Trust.
The Department for Constitutional Affairs (DCA), which has overall responsibility for the Gender Recognition Act, is working with NHS Connecting for Health to incorporate the new legislation into the NHS Care Records Service.
The advent of the NHS Care Records Service means that there is greater opportunity to extend the policy to the patient's entire clinical record, rather than that just held by their GP.
Please refer to Chapter 7 of the procedures guide for further guidance and information
Some Practical Advice
The LMC is frequently asked questions about the complex issues that practices face when looking after patients who are transitioning or have changed gender.
Here are some common situations and some suggestions on how to deal with them.
Scenario 1 - Patient has requested to change name and gender. How do I manage this?
Here is the current advice from PCSE about how to do this
How should I advise PCSE of a patient gender re-assignment?
Gender re-assignment process
It is important that practices are aware of the steps that need to be taken when a patient changes gender. Following the process will ensure continued patient care and ensure there isn’t an impact on your practice payments.
Please note: Patients may request to change gender on their patient record at any time and do not need to have undergone any form of gender reassignment treatment in order to do so.
When a patient changes gender, they are given a new NHS number and must be registered as a new patient at your practice. All previous medical information relating to the patient needs to be transferred into a newly created medical record. When the patient informs the practice that they wish to change gender, the practice must inform the patient that this will involve a new NHS number being issued for the them, which is not reversible. To revert back to their original gender, they would receive a third NHS number. The practice should confirm this has been discussed with the patient when notifying PCSE.
The process is as follows:
- GP practice notifies PCSE that a patient wishes to change gender via the enquiries form. The practice should include the patient’s name and NHS number in the notification to PCSE, plus confirmation that they have discussed with the patient that this will involve the creation of a new NHS number
- PCSE sends the GP practice a deduction notification for the patient and emails the main contact we hold for the practice (if available) the new details for the patient
- GP practice accepts the deduction and registers the patient using the new details provided by PCSE. Important: Do not update the patient’s original record with their new NHS number. If this happens they will not be registered and will miss out on continuity of care
- PCSE sends a new patient medical record envelope with the patient’s updated details to the GP practice
- GP practice creates new patient record using new details, and transfers all previous medical information from the original medical record. Any information relating to the patient’s previous identity should not be included in the new record.
- If the gender is being re-assigned from male to female, the screening team will contact the practice for no cervix confirmation
- If the gender is being re-assigned from female to male, screening will become the responsibility of the practice.
It is important that practices complete the new registration for the patient within five working days to ensure no interruption to patient care.
Please note: When registering new patients please do not use Select ‘I’ (Indeterminate) as the sex category. Please only select either ‘M’ for Male or ‘F’ for Female. This ensures that the appropriate screening invitations go correctly to individuals.
The LMC view is that this is likely to prove to be very difficult in practice. Transgender patients often will have extensive medical records covering their transition, mental health and physical health. To remove all references to gender may be almost impossible and will render the notes incomplete or incomprehensible.
However, it is obviously important to preserve the medical record as much as possible for the ongoing safe care of the patient and for the handover of care to other clinicians in the future.
Our advice is as follows
- Engage with the patient and explain fully the importance of maintaining the clinical record.
- Some patients may be happy for their old records to be kept under the new identity. If this is the case then we suggest that you keep a record of the conversation with the patient and obtain their consent to keep the old records with the new identity.
- If not, then offer to redact Name and Gender but not remove clinical information that reveals a previous gender identity (e.g. prescriptions for contraceptive pill, previous breast conditions, previous gynaecological history etc.)
- If the patient insists that all references to previous gender are removed and this is practically impossible then we suggest that the important clinical information should be summarised in a way that is gender neutral.
- For example, a pulmonary embolus following breast surgery as part of gender re- assignment might be coded as “Post-operative Pulmonary Embolus” and in free text a note to ask patient for further details.
- If the entire record is not kept then the patient should be asked to consent to this and a record kept of the discussion and consent.
- Old records should not be kept in a separate file
- Always involve the patient in the decision and ensure that a full discussion takes place.
One of our Wessex practices has produced a helpful patient discussion checklist that can act as a template and record of the discussion with the patient. (appendix 1)
Scenario 2 - I have to refer my transgender patient to a hospital outpatient clinic.Can I do this and what information should I disclose in the referral letter?
The GMC advice on this is as follows:
If your patient requests treatment for gender dysphoria, referring them to a Gender Identity Clinic (GIC) or an experienced gender specialist without delay will likely be the best option. An experienced gender specialist will have evidence of relevant training and at least two years’ experience working in a specialised gender dysphoria practice such as an NHS GIC.
Every patient’s treatment journey will be different and GICs aim to provide care packages tailored to individual need. By focusing on your patient’s priorities and concerns and exploring with them the options available, you can collaborate with GICs to provide effective care and a positive experience for your patient.
All GPs in England, Northern Ireland and Scotland may refer their patients directly to a GIC and do not need to refer them to a mental health service for assessment beforehand. GPs in England don’t need to seek prior approval from their Clinical Commissioning Group (CCG).
Disclosing gender history
It is unlawful to disclose a patient's gender history without their consent.
When communicating with other health professionals, gender history doesn't need to be revealed unless it is directly relevant to the condition or its likely treatment.
The gender status or history of trans and non-binary people should be treated with the same level of confidentiality as any other sensitive personal information.
However, there will be circumstances where it is appropriate to disclose this information - with your patient's consent - so that the service you are referring to is aware that your patient may have specific needs.
For example, if you are referring a trans man for treatment to a gynaecology service, letting the clinic know in advance should allow them to make sure that clinical, administrative and support staff respond appropriately to your patient and care for them in a manner that respects their dignity.
The BMA guidance states the following:
The Gender Recognition Act 2004 provides safeguards for the privacy of individuals with gender incongruence and restricts the disclosure of certain information. The Act makes it an offence to disclose ‘protected information’ (i.e. a person’s gender history after that person has changed gender under the Act) when that information is acquired in an official capacity.
This means that the ‘protected information’ can only be disclosed when:
- it is to another health professional; and
- it is for a medical purpose; and
- there is a reasonable belief that the patient has consented to the disclosure.
The LMC advice, based on this is:
- Involve the patient in the decision on what information to disclose
- Only disclose information that is clinically relevant to the condition that the patient is being referred for and that the patient has agreed to share.
- Offer to copy the patient into the correspondence including the referral letter
Scenario 3 - A transgender male patient (changed identity to male) but has not undergone surgery remove female reproductive organs. He has asked to continue cervical screening. What do I do?
- If the gender is being re-assigned from female to male, screening will become the responsibility of the practice.
It is possible via Open Exeter to download and complete a blank cervical screening form. If this is completed in male identity with the appropriate clinical history, then the lab will process the sample with a male identity.
The responsibility for cervical screening in this situation passes from the national programme to the GP practice.
Our advice is:
- Engage with the patient and agree how call and recall will be organised and how it is recorded on the record
- Stress the importance of accurate and complete medical records and encourage the patient to have the information recorded on their medical record.
- If the patient does not want it recorded in the medical record then consider giving the patient the results and putting a non-specific recall on the notes for the appropriate time interval. The patient should be informed of when the next smear is due and advised to make arrangements with the practice at that time.
Scenario 4 - I have a patient who is transitioning. I’m not sure what pronoun to use. What should I do?
Using the correct pronoun is very important to Trans or non-binary people. The GMC advice should be followed. Be aware that a pronoun may change during the process of transition.
Use the patient’s preferred name and title.
The way you address patients who are transitioning or have transitioned is extremely important. Taking care to use the right (i.e. the patient’s preferred) name and title shows that you are treating them with respect. If you are not sure how you should address someone, ask them:
- “how do you prefer to be addressed?”
- “what pronouns do you prefer people to use when referring to you?”
Employers have a responsibility to ensure that all staff are trained to understand trans issues. Trans women's voices can sound masculine on the phone.
Sometimes ‘misgendering’ a person is a genuine mistake. If you do misgender someone, just apologise.
Receptionists, practice nurses as well as doctors need to consider the long-term effects on mental health and wellbeing of trans people, if those they turn to for help don’t treat them with respect.
A bad experience could make patients reluctant to seek healthcare at all.
Scenario 5 - My patient has been seen in the Gender Incongruence Clinic (GIC) and I have been asked to prescribe some hormone treatments. I’m not sure I should be doing this…
Prescribing, monitoring and follow-up after gender reassignment treatment
The GPC is aware that GPs being asked to prescribe hormones for patients with gender incongruence both before and after specialist involvement. NHS England have released their Specialised Services Circular SSC1417 which states that GPs are encouraged to collaborate with GIC in the initiation and on-going prescribing of hormone therapy and that there is extensive clinical experience of the use of these products in the treatment of gender dysphoria.
The GMC has published Advice on Treating Transgender Patients which includes sections on prescribing “bridging prescriptions” and ongoing prescribing following the recommendation of a specialist. We are aware that there exist concerns that the guidance places further obligations on GPs with regard to prescribing and education which may have broader implications beyond the scope of transgender healthcare.
In April 2016 the BMA wrote to the GMC to seek clarification about the guidance and raised its concerns. The response, in part, informs the information here, although discussions are ongoing. The two circumstances in which GPs may be asked to prescribe for patients with gender incongruence namely “bridging prescriptions” and ongoing care following consultation at a GIC, raise different issues and are therefore addressed separately below.
These are prescriptions issued to patients prior to being seen in a GIC to patients who have been self-medicating with hormones, usually unregulated and bought through an illicit source.
As a harm-reduction measure, the Royal College of Psychiatrists (RCPsych) has suggested that GPs may prescribe a bridging prescription to cover the patient’s care until they are able to access specialist services. The report and its recommendations have been endorsed by a range of Royal Colleges, including the Royal College of General Practitioners. The GMC advise that GPs should only consider a bridging prescription for an individual patient when they meet all the following criteria:
- 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.
In the GPC’s view, although the advice sets out the conditions under which the RCPsych suggestion for harm reduction in a specific subsection of vulnerable patients fits within the GMC’s existing guidance on prescribing, it fails to address the resulting significant medicolegal implications for GPs, and neglects the non-pharmacological needs of these patients.
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. 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 NHSE 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 try to ensure timely provision.
Collaboration with a specialist and ongoing prescribing
The GMC advice states that “You must co-operate with GICs and gender specialists in the same way that you would co-operate with 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 as recommended by a specialist”.
In our view, this advice reaffirms that GPs should approach shared care and collaboration with gender identity specialists in the same way as they would any other specialist. The advice should therefore be read in conjunction with the principles which underpin shared care as set out by the GMC in Good practice in prescribing and managing medicines and devices.
Participating in a shared care agreement is voluntary, subject to a self-assessment of personal competence, and requires the agreement of all parties, including the patient. This will necessitate NHS England arranging additional local services to meet the prescribing and related needs for the patients of those GPs not commissioned to provide these services.
Specifically with regard to transgender patients, the RCGP published a position statement this summer. This document recognises that patients often cannot access specialist services in a timely manner and may have approached a private specialist. Some patients even seek ‘bridging prescriptions’ from a GP until they are seen by a specialist, which does not apply here. Section 28 of the statement is relevant.
28. Based on the above principles, and with consideration of current guidance from various organisations, we believe the overall role of the GP in providing care to patients with gender dysphoria is to:
- Liaise and work with GICs and gender specialists in the same way as any other specialist, to jointly provide effective and timely treatment for patients. This includes considering taking on the ongoing prescribing of medication for patients and the monitoring of any side effects, with the appropriate funding, after a patient has been discharged from a GIC.
- It is common for GPs to work under Shared Care Agreements (SCAs) set up between GICs and practices to provide joint care for patients. It is important that SCAs are agreed upon by all parties involved, ensuring the appropriate levels of resource, competence and expertise are established, as informed by the patient’s level of medical risk. NHS bodies need to ensure that local shared care arrangements are adequately funded to support the ongoing care and treatment of patients.
- When responsibility for ongoing medical monitoring and prescribing is assumed by a GP, the limitations of this need to be recognised and mitigated. This is especially important for children and young people, where there is concern regarding the outcomes of some interventions. The GIC involved in the SCA should have access to the patient’s GP records and be accessible to provide specialist consultation to GPs to ensure the patient is being monitored correctly and the appropriate dosages of medication are being prescribed based on the progress of the patient.
Therefore, this makes it clear the shared care agreements must be agreed by the GP, who must have the appropriate competence to provide the service in question. The Agreement must be clear, unambiguous and should be funded through a commissioned service.