Sarah Pickering, advisory case manager at Medical Protection, considers a recent member query in relation to this complex and sensitive area.
“An adult patient at our practice is transitioning from female to male. The patient has been referred to the local NHS Gender Identity Clinic but there is a current waiting time of 20 months to be seen. He was initially seen by a private gender clinic that started him on testosterone but I am unsure to what extent he was assessed by the clinic.
“I have very minimal information from this clinic and the patient then self-discharged from their service. He is keen for me to continue prescribing testosterone gel whilst awaiting specialist input from the NHS specialist clinic. I have informed the patient that this is not within my competence and that I would only be comfortable in becoming involved once he has been seen by the NHS clinic. The patient has complained about my stance. Was I right to have taken this approach? I am concerned about where I would stand medicolegally if I were to prescribe for this patient.”
GMC transgender guidance – the starting point
The most relevant guidance to consider here is the GMC’s guidance, Trans healthcare.1 The GMC’s guidance is split into the following categories:
- trans health
- confidentiality and equality
- mental health.
In relation to prescribing, the GMC’s main points to consider are:
- You can prescribe unlicensed medicines following the steps set out in their guidance.
- You must take care to discuss the risks and benefits of treatment with the patient.
- You will need to collaborate with experienced colleagues to provide care that best services your patient’s needs.
The GMC makes a distinction in its guidance between prescribing for patients who are yet to be seen by a gender specialist (‘bridging prescriptions’) and prescribing for patients who have been seen by a specialist. In relation to bridging prescriptions, the GMC states the following:
“A GP should only consider issuing a bridging prescription in cases where all the following criteria are met:
- the patient is already self-prescribing 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, and
- the doctor has sought the advice of an experienced gender specialist, and prescribes the lowest acceptable dose in the circumstances.”
Bridging prescriptions are therefore a harm-reduction measure and an approach advocated by the Royal College of Psychiatrists, and affirmed by the GMC in the specific scenario outlined above.2
In light of the above guidance, it would not be advisable for the GP in this case to have a blanket rule that they can only prescribe once the patient has been seen by the NHS Gender Identity Clinic, as this would go against the GMC’s guidance, where there are great risks posed to the particular individual.
It would therefore be advisable for the GP to have a discussion with the patient and assess whether they are already self-prescribing from an unregulated source – or if there is a risk that they will – and whether a prescription is necessary as a harm-reduction measure.
The GP should weigh up the risks of stopping the testosterone that was previously prescribed by the private clinic against the risks of prescribing.
Seeking specialist advice
In paragraph 14 of the GMC’s Good Medical Practice, the GMC states that doctors must work within the limits of their competence.3 However, the GMC also expects clinicians to seek further advice from specialists where needed and to expand their knowledge in certain areas.
In my experience, some clinicians have been successful in obtaining a written information leaflet from certain NHS Gender Identity Clinics (in cases where the patient has already been referred to them), which would be classed as “advice of an experienced gender specialist”. These information leaflets are not specific to the particular patient but do contain advice on how to prescribe and to help monitor hormones. Alternatively, advice could be sought from a private gender specialist; an increasing number of patients are self-referring to such private clinics. Delaying providing support and treatment to a patient until after they have been seen at a NHS Gender Identity Clinic may not be appropriate if other avenues to seek specialist advice have not been explored.
If you are taking advice from a private clinic or entering into a shared care agreement with a private clinic you must first be satisfied that the specialist is what the GMC would refer to as an “experienced gender specialist”. This would be an individual with evidence of relevant training and at least two years’ experience working in a specialised gender dysphoria practice such as an NHS Gender Identity Clinic. If you are unsure of the nature and extent of the experience of those within the private clinics it would be advisable to write to them for clarification first.
The GMC states in its trans healthcare guidance:
“If you are unsure whether a specialist working outside the NHS is suitably qualified, you are not obliged to follow their recommendations. As Good Medical Practice says ‘you must only prescribe drugs if you are satisfied they serve the patient’s needs.’
“It would not, however, be acceptable to simply refuse to treat the patient. Discuss your concerns with your patient, carefully assess their needs, seek to understand their concerns and preferences; consult more experienced colleagues and provide care in line with the guidance in Good Medical Practice.”
Good practice in prescribing
In addition to the GMC’s guidance on treating transgender patients, it would also be advisable for the GP to consider the GMC’s guidance Good practice in prescribing and managing medicines and devices.4 Paragraph 3 of this guidance outlines that doctors are responsible for any prescriptions they sign and that a clinician must be able to justify any prescribing decisions made.
If a GP were to prescribe based on guidance from an ‘experienced gender specialist’, then paragraphs 35-43 of the GMC’s prescribing guidance should be considered since they relate to shared care and prescribing at the recommendation of a professional colleague.
Paragraph 37 states:
“If you prescribe at the recommendation of another doctor, nurse or other healthcare professional, you must satisfy yourself that the prescription is needed, appropriate for the patient and within the limits of your competence.”
Any decision to prescribe or withhold treatment should be made in accordance with the GMC’s guidance above. It would not be advisable for GPs to have a blanket rule that prescribing for every transgender patient is outside the limits of their competence, nor would it be advisable to adopt a policy only to treat transgender patients once they have been seen by an NHS Gender Identity Clinic.
GPs should always focus on what would be in the best interests of the patient. If there is a real risk that the patient will self-prescribe from an unregulated source then the GP could prescribe to mitigate this risk, so long as the GP is comfortable in taking responsibility for that prescription and feels that it is within their limits of competence. Specialist input could be sought to achieve this position, even if this were simply specialist advice in writing.
This is ultimately a clinical decision for the GP to make in deciding whether to continue with the testosterone prescriptions, and whether the GP has received sufficient specialist input or advice to feel competent to continue prescribing this. The risks of stopping the medication previously prescribed by the private specialist should be weighed against the risks of prescribing.
1 GMC, Trans healthcare 2019.
2 Wylie K, Barrett J, Besser M, Bouman W P, Bridgman M, Clayton A, Ward D (2014). Good practice guidelines for the assessment and treatment of adults with gender dysphoria. Sexual and Relationship Therapy, 29(2), 154-214.
3 GMC, Good medical practice. 2019.
4 GMC, Good practice in prescribing and managing medicines and devices. 2019.
Published as Ask the expert: Treating transgender patients in our print publication, Practice Matters.