Many GPs believe that prescribing hormones for trans patients is not their responsibility. Inconsistency between the planned remits of Gender Identity Clinics and GP contracts in NHS England has created ambiguity around final responsibility for patient care, which has allowed the Royal College of General Practitioners and the British Medical Association to frame refusal of care to trans patients as a labour rights issue.
On 26th February 2024, the Daily Mail ran a hit piece on Charlie Craggs, a trans woman who had spoken out on social media about being denied a hormone prescription by her GP after moving to a new area. Stories like this are common, as doctors who have long refused to provide bridging prescriptions increasingly also resist entering into shared care agreements with private clinicians, or honouring recommendations from NHS Gender Identity Clinics.
Charlie Craggs’ story quickly gained traction on X (formerly twitter). Amidst the predictable chorus of transmisogynistic hate, and the appeals for empathy from trans people and allies, a third group emerged: GPs, desperate to explain that their refusal to prescribe wasn’t transphobic, it was a labour dispute.
I respect right not to prescribe of based in resource allocation to GP rather than LGBTQ-phobia. Still crap innit?
— Seb (@SebPillon) February 29, 2024
It's clear that the likely GP strike simply needs to be us doing the GMS contract and no more... Secondary care cannot function without us!
Some medics commented expressing sympathy, or caution about cutting off prescriptions. They were not the majority. Instead, doctor after doctor chimed in to explain that prescribing hormones for trans patients was not a contractual obligation for GPs, that the GICs had “no excuse” for not prescribing themselves, and that any suggestion of wrongdoing or comparison to conversion therapy was a shocking and offensive smear. Several commenters also misrepresented the scope of GIC funding, suggesting that they were funded to prescribe but were choosing not to.
The Service Specification for NHS England’s National Programme for Gender Services makes it clear that hormone prescriptions are expected to be administered by GPs, not by clinicians at the GIC. This is also true in Wales. Hormone prescription is usually expected to be handled by GPs in Scotland, although service specifications allow for the possibility that GPs may refuse to enter into a shared care agreement. In Northern Ireland, where access to transition-related healthcare through the NHS is even more limited, a 2019 review of the Gender Identity Service recommended that “the role of the GP needs to be clarified and supported”. Although the details differ, this issue goes well beyond NHS England. Trans adults who get to the top of the GIC waiting lists (no mean feat) and make it through the psychiatric gatekeeping inflicted on us are usually told to approach our GPs for hormone prescriptions – so why do so many GPs think it’s not their job to prescribe?
One answer can be found in the Royal College of General Practitioners (RCGP) policy statement on Transgender Care. The RCGP is a professional body representing GPs in the UK. It’s not a governmental organisation, nor is it a union – it provides recommendations to the General Medical Council (GMC), the public body that regulates doctors in the UK, while remaining independent from it. As well as providing resources for professional development, it represents the interests of GPs via public statements. On issues of trans healthcare, the RCGP sets itself against the GMC’s recommendations.
There is a lot to be concerned about in the RCGP policy statement. Citations are shockingly limited, and while ‘trans people’ get a mention, there is no similar reference to trans children – only ‘young people with gender dysphoria’. The RCGP statement challenges the GMC’s advice to practitioners regarding issuing bridging prescriptions as failing to address “the ethical and safety issues around prescribing outside the limits of one’s competence”, while tacitly suggesting that GPs’ competence may include finding alternate explanations for ‘gender dysphoria’:
“However, GPs can contextualise a person’s presentation of gender dysphoria with other conditions, particularly autism, and within their broader environment. GPs may also be able to contextualise the distress felt by the individual against that person’s medical history and possibly relate it to the distress and discomfort often experienced by many young people during puberty and adolescence.”
— ‘Transgender Care’, Royal College of General Practitioners, June 2019
Regarding prescription, though, the RCGP is much cagier. They appear at first glance to support GP prescribing, arguing that the responsibility of a primary care team includes:
“Considering taking on the ongoing prescribing of medication for patients and the monitoring of any side effects, with the appropriate funding, after a patient has been discharged from a GIC.”
— ‘Transgender Care’, Royal College of General Practitioners, June 2019, 28 iii.
But the key word is ‘considering’. What the RCGP statement actually does is refuse responsibility for prescribing. The reference to ‘appropriate funding’ highlights a mostly unspoken dispute: prescribing hormones for transgender patients is not part of the service specification of the General Medical Services contract that binds GPs in England, and this looks likely to continue in its next iteration. Furthermore, many trans patients who need care from their GPs have not been discharged and so are not covered by this guidance. As good as this sounds, it’s actually a near-universal opt-out. The statement goes on to make this explicit in another closely-related context:
“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.”
— ‘Transgender Care’, Royal College of General Practitioners, June 2019, 28 iii.
NHS England have noted, in their guidance documents, a list of situations in which it may be appropriate for a GP to refuse to enter into a Shared Care Agreement. One such situation, which is often cited as part of refusal to prescribe hormones for trans patients, is when “the GP does not feel competent in taking on clinical responsibility for the prescribing of a specialist medicine.” The British Medical Association (BMA), a trade union representing doctors in the UK, emphasises the implications of this for the provision of hormone prescriptions in their own 2022 guidance on the role of GPs in ‘managing adult patients with gender incongruence’. The BMA set the GMC’s advice (“that GPs should collaborate with a Gender Identity Clinic (GIC) and/or an experienced gender specialists to provide effective and timely treatment for trans and non-binary patients”) against NHS England’s shared care guidance, and conclude that:
“Participating in a formal shared care agreement is voluntary, subject to a self-assessment of personal competence, and requires the agreement of all parties, including the patient.”
— ‘Role of GPs in managing adult patients with gender incongruence’, British Medical Association, 2022
Both the RCGP and the BMA have produced guidance that appears to support the provision of appropriate care for (adult) trans patients, but actually allows GPs to take trans patients off hormones with minimal justification or recourse. When a doctor refuses a shared care agreement (or ends an existing one) on the grounds of not assessing themselves as competent to prescribe, patients are often left stranded. Even a well-meaning and supportive GP is under pressure to prioritise their contractual workload, and ‘personal competence’ is broad and ill-defined enough to launder any amount of practitioner transphobia or headline-induced anxiety. Although GICs are sometimes able to prescribe under these circumstances, they are not resourced to do so – and patient safeguards are focused on initial refusal of care. Self-assessment of competence in this context ends up functioning similarly to conscientious objection in abortion access.
NHS England's shared care guidance says that “good professional practice requires care for patients to be seamless; patients should never be placed in a position where they are unable to obtain the medicines they need, when they need them”. Trans people are routinely placed in this position when we move to a new area, change GP surgery, or when headlines affect our doctors’ personal comfort level with prescribing for us. As with other issues of bodily autonomy, like abortion access, management of opiate dependency, and access to ADHD medication, the violence is built into the bureaucracy: the NHS prioritises continuity of control over continuity of care.
If your GP tries to take you off hormones, you can challenge this. The GMC is the ultimate regulator of doctors practicing in the UK, and their guidance conflicts with the BMA and RCGP opt-outs. This thread is a useful starting point.