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Care of Transgender and Non-Binary Patients in Primary Care

Page Contents

Prescribing and collaboration with gender specialists

Waiting Lists

Changing medical records (gender and / or name)

NHS Screening

Disclosing gender history

Supporting trans patients: a guide for staff at the GP surgery

A number of queries have been raised with the LMC regarding the management of patients who present at their general practice with gender identity issues; including questions relating to patient records and confidentiality and, in particular, regarding prescribing and monitoring responsibilities in relation to the gender reassignment process.

The BMA affirms the rights of all transgender and non-binary individuals to access healthcare and live their lives with dignity, including having their identity respected. Doctors should work collaboratively with their trans and non-binary patients as they do with any patient: in a respectful, open and sensitive way, free from discrimination or bias.

GPs should understand gender incongruence and the issues involved to ensure quality care is provided. However, we also need to balance what can be expected of GPs and the expertise which should rightly remain with specialist services

The BMA has produced guidance, which:

A copy of the guidance can be found on the BMA website .

CQC have also published The Adult Trans Care Pathway and the RCN have published - Fair Care for Trans and Non-binary People .

The GMC has published Advice on Treating Transgender Patients

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Prescribing and collaboration with gender specialists

The BMA suggests that GMC advice and NHS Guidance reaffirms that GPs should approach shared care and collaboration with gender identity specialists in the same way they would with any other specialist.

When patients are seen in an NHS Gender clinic, GPs may be asked to prescribe and monitor for these patients, but this is done so under formal shared care arrangements, which are voluntary on the part of the GP

GMC ‘Good Medical Practice’ emphasises the need for doctors to ‘Recognise and work within the limits of your competence.’

You may justifiably consider prescribing and monitoring of puberty blockers/ hormones to be outside of your competence. According to the GMS contract regulations, the GMC’s Good Medical Practice, and an RCGP position statement The role of the GP in caring for gender-questioning and transgender patients

A health care professional may not perform any clinical services under the contract unless that person has such clinical experience and training as are necessary to enable the person to properly perform such services.

Doctors must provide a good standard of practice and care; recognise and work within the limits of your competence.

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.

The Royal College of GPs recognises that GPs are not experienced in treating and managing patients with gender dysphoria and trans health issues. Gender dysphoria and gender identity issues are not part of the GP curriculum or GP Specialty Training, and GPs are currently required to refer patients experiencing gender dysphoria to gender identity specialists for further assessment and treatment advice. GPs face difficulties in accessing gender identity specialists in a timely way which often has severe implications for the mental and physical health of their patients. As such, GPs are under increasing pressure to provide services which are usually provided in specialist clinics, as they lie outside the remit of a GPs generalist expertise, with limited access to specialist support.

The BMA Medical ethics department produced a useful guidance document titled ‘The Interface between NHS and private treatment : a practical guide for doctors in England, Wales and Northern Island’, May 2009

Patients who are entitled to NHS-funded treatment may opt into or out of NHS care at any stage.

When patients seek specialist treatment privately, the private consultant may prescribe any necessary medication. Often, however, consultants recommend a particular medication and patients ask their GP to issue a NHS prescription rather than paying for it privately. Even though individuals opt for private treatment or assessment, they are still entitled to NHS services.

Where the GP considers that the medication recommended is clinically necessary:

Given the long wait for NHS specialist services, it is understandable that some patients will choose to approach private providers for support.

If you do accept any shared care with a private provider, you would need to satisfy yourself that the provider is appropriately accredited and practising in line with UK best practice. We are aware of some private providers where concerns have been raised about their credibility and practices. You may wish to review the GMC registration of the provider via the GMC website.

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Waiting Lists

You have a duty to try to support the needs of the patient within the constraints of the NHS offer with appropriate referral to the NHS GIC. The fact that there is a long wait for this service on the NHS is out with your control and is very much an issue for the Commissioners and in no means obliges you as an individual GP to find/provide an alternative service.

Its is the responsibility of specialist Gender Identity clinics to manage their waiting lists-not practices-and if there is the necessity to explore whether a patient still requires access to their service after a long wait then they should be approaching the patient directly.

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Changing medical records (gender and / or name)

Sometimes doctors are asked by transgender patients to change their name and/or gender on the medical record. 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. Patients have the right to change the name and gender on the medical record irrespective of whether they intend to obtain a Gender Recognition Certificate

Read information for GP practices in England on the process for updating medical records and a summary of the process .

When a patient informs the practice that they wish to change gender, the practice should inform the patient that this will involve a new NHS number being issued for them, which is not reversible. If the patient wanted to change their gender marker back to the gender they were assigned at birth, or to a different gender, patients would receive a third NHS number.

The process is as follows:

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 in practice it is likely to prove to be very difficult to transfer all medical information to the new record. 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

Name Change on GP record.

Note the following from PCSE on name / title change -

A patient can change their name without having a new NHS number allocated to them but they have to retain their birth gender. Their ‘Title’ must match the birth gender or alternatively they can have MX as their title.

If they want to change their title to a title that does not reflect their birth gender they have to have a new NHS number allocated.

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NHS Screening

It is important that practices and patients understand the implications of gender change in relation to the NHS screening programs

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

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Screening for trans people at a glance

Trans women and non-binary people assigned male at birth who are registered with a GP as female:

Trans women and non-binary people assigned male at birth who are registered with a GP as male:

Trans men and non-binary people assigned female at birth who are registered with a GP as female:

Trans men and non-binary people assigned female at birth who are registered with a GP as male:

Trans men who are pregnant should be offered the same antenatal and newborn screening tests as all other pregnant individuals.

Advice on managing cervical screening in a transgender male who has not undergone surgery to remove female reproductive organs

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:

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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:

The LMC advice, based on this is:

 

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Updated on Friday, 9 September 2022 15766 views