Care of Transgender and Non-Binary Patients in Primary Care

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:

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.

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

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:

he or she would be required under the NHS terms of service to prescribe that medication within the NHS, even if the assessment from which the need was identified was undertaken in the private sector; however
if the medication is specialised in nature and is not something GPs would generally prescribe, it is for the individual GP to decide whether to accept clinical responsibility for the prescribing decision recommended by another doctor. (The same principles apply to requests to undertake diagnostic tests or other procedures within the NHS.

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.

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.

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:

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 they 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 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

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.

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.

Process for registering a patient gender re-assignment

It's 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. Click here for further information on the process for registering a gender reassignment.

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

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:

are invited for breast screening
are invited for bowel cancer screening
do not need cervical screening as they do not have a cervix
are not routinely invited for abdominal aortic aneurysm (AAA) screening but can request screening

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

are not routinely invited for breast screening but can request screening
are invited for bowel cancer screening
do not need cervical screening as they do not have a cervix
are invited for AAA screening

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

are invited for breast screening
are invited for bowel cancer screening
are invited for cervical screening
are not invited for AAA screening

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

are not routinely invited for breast screening but can request screening
are invited for bowel cancer screening
are not routinely invited for cervical screening but can request screening
are invited for AAA screening but do not have a high risk of AAA

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

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

Coding on Patients Medical Records

We have sought further advice and the Snomed browser has the following:

1108101000000105 - Provision of information about NHS screening programmes available to transgender and non-binary people – this would suggest that the trans or non-binary patient is fully informed about the screening programmes and could be used to identify them.

Perhaps also adding one of the following screening codes:

715011000000109 - Breast screening administration – free text could be added to indicate whether screening is due or not.

512501000000109 - Breast Screening Offered

811481000000106 - Breast screening disclaimer received. – to indicate that the patient has opted out of breast screening.

1104621000000103 - Cervical cancer screening offered

112241000119107 - Cervical Cancer screening declined.

1104671000000104 - Cervical cancer screening not offered.

171169001 - No smear – no cervix

There are few codes which would apply, without adding something to indicate that the patient is either transgender or non-binary, so we would suggest that the practices search for the main code initially, then link it to one of the other codes - as any of the screening codes could be used for any patient.

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

Talking Transgender Podcast

Dr Cora Sargent, Educational Psychologist and a Senior Training Fellow at the University of Southampton, joins us to discuss the work she carries out as part of the gender research group. Cora draws on her own experiences of being transgender to explain her journey with trans services and her GP. She also highlights the societal barriers that non-binary and transgender people face.

Listen to the podcast here: Talking Transgender

This page appears in...

Guidance

Bookmark...

Add to my Learning Diary

About this page...

Updated on Tuesday, 14 March 2023 18235 views

Care of Transgender and Non-Binary Patients in Primary Care

Page Contents