We were all outraged at the recent shootings in Orlando, shocked and staggered that discrimination against minority groups should still go on. The LGBT group have suffered their share over the years, but what I am shocked about is the ongoing discrimination they face in the health profession.
Patients with gender variance have faced enormous battles of bigotry, prejudice, humiliation and have even been denied access to even basic care from their GPs. Following significant concerns raised about doctors’ lack of awareness and consideration in treating transgender patients, http://www.publications.parliament.uk/pa/cm201516/cmselect/cmwomeq/390/390.pdf I was delighted to see the GMC publish guidelines on managing transgender patients. http://www.gmc-uk.org/guidance/ethical_guidance/28851.asp
Of course this was to be met with a variety of concerns from NHS GPs, and I have yet to see many embrace this welcome news that we can now do more to help our trans patients.
Dr Chaand Nagpaul CBE Chair, BMA General Practitioners Committee penned his concerns to the GMC, http://www.gmc-uk.org/Dr_Chaand_Nagpaul_BMA_GP_Committee_to_Professor_Terence_Stephenson.pdf_66389523.pdf raising the emotive points that this would make GPs undertake specialist prescribing, placing them in a difficult position and forcing them to prescribe outside the limits of their competence.
Susan Goldsmith, acting chief executive of the GMC, replied http://www.gmc-uk.org/Susan_Goldsmith_to_Chaand_Nagpaul_BMA_GP_committee.pdf_66389596.pdf with reassurances including that they expect GPs to ‘acquire the knowledge and skills to be able to deliver a good service to their patient population’, which may mean undertaking training and that they don’t believe care for patients with gender dysphoria is a highly specialised treatment area requiring specific expertise.
She goes on to endorse a firm view of mine, that these patients actually require very simple care and well-known medication.
The medication for transgender care includes well-known oestrogen therapy used for treating female menopause (estradiol), injections that are given for women with endometriosis or men with prostate cancer (GNRH analogues), a diuretic used for heart failure (spironolactone), anti-androgens used in contraceptives (cyproterone acetate), medication for benign prostate hyperplasia (finasteride) and testosterone replacement therapy used for the management of the male menopause.
These are medications that are well known to GPs, and we are well-used to the side effects and monitoring.
So why is it that GPs are reluctant to take this on? There have, of course been some well-publicised legal cases of doctors trying to help transgender patients. Dr Russell Reid was criticised for ‘lack of caution in initiating hormonal and surgical gender reassignment treatment in these patients without more careful and through investigation and assessment’ and his successor Dr Richard Curtis was also subjected to a lengthy investigation.
Fear of litigation is high on any doctors’ mind but should this impair our duty to help our patients in the best way we can? GPs prescribe hormone patches for menopausal symptoms regularly, but if a ‘man’ asks you to do the same, he is met with horror. The thing is, you see, he is not a man. He is a woman, it’s just that she was born with the XY chromosomes rather than the XX – a simple yet life-changing birth defect. Had it the defect of Type 1 diabetes, she would have been given the hormone insulin, for life. But this was a different hormonal problem, and if we look at the suicide rates, just as potentially deadly as Type 1 Diabetes, but the resistance to treatment is huge.
Not all trans people want to go through lengthy assessments, procedures, hoops, surgery – they just want the right hormones to suit their gender.
These are actually very safe treatments and delays in receiving care from the GP and from the NHS gender clinics mean that people are turning to illegal and unsafe forms of medication, and in some cases, they turn to the hang-man’s noose.
The other essential aspect of transgender care is listening, hearing, caring, educating, protecting – bread and butter to GPs, but are these every day skills for an endocrinologist? These are often the key healthcare providers for transgender patients but often don’t have specific expertise in caring for them.
So many of my patients tell me of the build up and bravery that it took to finally admit to their GP that they were suffering from gender variance, to be shunned, turned away or told that they would grow out of it……
So, I have simple advice for GPs, and this may just help their patients who are transgender and may be suffering from a basic lack of medical care:
- If you don’t know – then look it up, there are many training resources and literature sources on gender care. elearning.rcgp.org.uk/gendervariance
- Listen to your patients, they are not mentally ill, they are gender incongruent.
- Their medical needs are often very simple – some hormone replacement therapy and a listening ear.
- The treatments are those that we use every day, put amy prejudices aside and get your prescription pad out.
- The cost of treating these patients is far less than the loss of life and distress caused by refusing them very simple, basic care.