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Nigel's surgery 101: The Adult Trans Care Pathway

Categories:
  • Organisations we regulate,
  • GP and GP out-of-hours services

What is transgender healthcare, gender variance and non binary?

Transgender

Transgender is usually shortened to ‘trans’. It describes people whose felt sense of gender (gender identity) is not the same as the gender assigned at birth on the basis of genital appearance.

Gender variance

Gender variance is an umbrella term used to describes gender identity, expression, or behaviour that falls outside culturally defined norms associated with a specific assigned gender.

Non-binary

Non-binary is an umbrella term to describes gender identities that are not only masculine or feminine. They are outside the ‘gender binary’ of male and female. Not all non-binary people identify as trans.

Trans health care

The General Medical Council (GMC) have produced guidance on trans care. It states that trans and non-binary people experience the same health problems as everyone else. The guidance advises that if a health problem is unrelated to gender dysphoria or its treatment, GPs must assess, provide treatment for and refer trans and non-binary patients the same as other patients.

The adult trans care pathway focuses on the care of people with:

  • Variations of Sex Characteristics (VSC)
  • Trans people aged 17 years and older and transitioning their gender
  • Non-binary people aged 17 years and older and transitioning their gender.

The trans care pathway refers mainly to patients transitioning gender medically, rather than socially or legally. The current model relies on access through primary care. It also relies on the principle of multidisciplinary teams and networks who collaborate to provide care.

Gender affirmation is the process undertaken by a transgender person to change their physical sexual characteristics to match their gender identity. This typically involves a combination of surgical procedures and hormone treatment.

Gender reassignment (wording of the Act to mean trans status) is one of the nine protected characteristics under the Equality Act 2010. It recognises prejudice and discrimination that trans and non-binary people may face in receiving both services and employment. People with VSC, trans and non-binary people may be particularly vulnerable to receiving poor care. This can be due to a number of factors. For example, lack of training, inefficient monitoring of trans status, potential transphobia.

The Royal College of GPs (RCGP) have produced a policy and position statement on transgender care. This states:

  • GPs are most often the first point of health care contact for people questioning their gender. General practice plays a vital role in making sure these patients receive the care they need.
  • GPs are expected to approach the holistic care of gender-questioning and trans patients as they do with every patient. This means openly, respectfully, sensitively and without bias.

The Royal College of Nursing (RCN) recognise that trans and non-binary people often experience prejudice and discrimination. RCN have published a resource for staff to respond to their needs.

What do we look at when we inspect practices?

We may look at the care of non-binary and trans patients in GP practices when we inspect. Practices should show how they have considered:

  • Prescription and monitoring of hormone therapies for trans and non-binary people, with the support of specialist services. Where hormones are prescribed, they should follow national guidance and specialist care recommendations. Prescribing needs to be particularly cautious where full access to a patient’s medical records is unavailable. For example, online and where treatment was not initiated by specialist services.
  • Health issues for trans and non-binary people. For example:
    • trans women are still at risk of prostate cancer
    • long-term hormone therapy issues for older trans people.
  • Whenever gender requires differences in medical care, this will be relevant to the care of trans patients. If a GP takes gender into account when making a diagnosis, due to differences in risk profile (for example breast cancer risk), they may also need to consider trans status. They may also need to consider any health interventions a trans or non-binary person has had in relation to gender.
  • Access to appropriate screening for someone’s gender assigned at birth, even after someone’s legal gender has changed. There is a Gov.uk guide on population screening for transgender people.
  • How to communicate with trans and non-binary patients about complex issues. The adult trans care pathway can be difficult to navigate. Patients should be given a large role in determining the kinds of treatments that are appropriate for them. A flexible approach to care, meeting an individual’s needs, is recommended.
  • Establishing links with and/or providing information about local trans and non-binary care support groups. Posters in waiting rooms should be inclusive of trans and non-binary issues. Peer support can reduce social isolation and distress. Peers can play an important support role and encourage the use of organisations and resources.
  • Zero-tolerance to discrimination, bullying and harassment based on gender identity, gender expression and sexual orientation. Staff should receive training. They should fully understand when a trans or non-binary person’s identity is relevant to their healthcare. Staff should understand their role in the trans care pathway. They should be aware that it may be unlawful to disclose a patient’s trans identity without consent under the Gender Recognition Act 2004.
  • How to ensure a positive environment. This includes understanding from staff to give people with VSC, trans and non-binary people confidence in using the service. GP practices should recognise there is no reliable way to know whether a patient is trans or non-binary, unless the patient tells them. It is important to be mindful of language use and avoid assuming gender. People should be addressed by their preferred name, title and pronoun. When in doubt; ask. Reception staff should be made aware that the person’s voice on the phone may not match their preconceptions about the person’s gender.
  • Patient records should be updated to show the person’s new title and gender. A trans or non-binary patient does not need to seek or have accessed medical transition for their name to be changed on their patient record. If a patient asks for their name and gender to be changed in their medical records, a signed and dated request is all that is needed. A Gender Recognition Certificate (GRC) is no longer needed for the patient to ask for change to these details.
  • Patient appointment screens should not give a title. For example, ‘Mr’ for trans women.
  • Patient self-log-in systems should ideally not ask the person their sex as an identifier. We recognise practices may not have full control over this.
  • Ability to see the same GP consistently. This is particularly important for trans people, non-binary people and people with VSC.
  • Provision of gender-neutral toilets. How to support people to use the toilet that best matches their gender identity.
  • Disabled patients who attend with a carer should have opportunity to discuss their gender identity for themselves.
  • Trans status monitoring should be included on patient questionnaires.

Further information

Last updated:
19 January 2021