On the 23rd of September 2016, the Welsh Government issued a Health Circular which updates General Practitioners and other primary care professionals on their roles and responsibilities in prescribing hormone therapy for trans adults.
This comes in the wake of the Welsh Government's Transgender Action Plan to advance equality for transgender people and ahead of the impending public consultation to discuss the future provision of Specialist Gender Identity Services (SGIS) in Wales.
The message to GPs is clear: "Most of the medications used for the treatment of gender dysphoria are not licensed for this specific indication, although GPs will be familiar with their use in primary care for other purposes. Our guidance clearly allows for prescribing outside the terms of the licence ('off-licence') where this is necessary to meet the specific needs of the patient, and where there is no suitably licensed medicine that will meet the patient's needs."
This welcome update has been driven by two main factors: the difficulties experienced by transgender patients when attempting to access appropriate help from the NHS, and the increasing number of trans people who are self-medicating using unregulated hormones and hormone blockers sourced via the Internet.
The Gender Identity Clinics to which trans patients are referred, spend a relatively short time looking after people with gender health issues and their role is really one of assessment, diagnosis and developing a treatment plan.
In line with this, the circular goes on to say that: "Once the patient has been discharged by a GIC or gender specialist, the prescribing and monitoring of hormone therapy can be carried out successfully in primary care without further specialist input. From the patient's perspective, management in primary care is far easier, and there is no specific expertise necessary to prescribe for and monitor patients on hormone therapy."
Although, of course, the gender clinics are expected to provide support and advice when it is needed.
The GMC's guidance for doctors treating transgender patients states that GPs must co-operate with Gender Clinics and Gender Specialists in the same way that they would with any other specialist, and this includes prescribing medication and following recommendations for safety, treatment, monitoring and, crucially, referring for gender specialist treatment in the first place.
Once the patient has been discharged and recommendations have been made by the GIC then the care should be taken over by the patient's GP.
Some GP's have expressed concerns over a lack of specialist knowledge in this area and in response the GMC has issued the following advice: "If you feel you lack knowledge about the healthcare needs of trans people, you should, in the short term, ask for advice from a gender specialist. In the longer term, you should address your learning need as a part of your continuing professional development which will enable you to provide treatment to meet your patients' needs."
Ironically, the medication used in hormone manipulation for the care of transgender patients is actually very safe and already used in the management of the male and female menopause. However, many patients still find that their GP is unhappy or unwilling to help with gender referrals, prescription and monitoring. I am hoping that this circular to Welsh GP's, in addition to the circular already issued by NHS England (link below), will be a welcome resource for patients to persuade their doctor to help them in the best way they can.
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