‘Bridging hormones’: Increasing number of UK GPs leery of prescribing treatment

by SunMum

SunMum is a UK parent with kids who have been affected by gender ideology. She can be found on Twitter @Mum3Sun

 If you are a medical care provider and you have concerns about the safety and appropriateness of prescribing hormones and surgery to young people who are uncomfortable with their bodies, you are not alone. Trans activists frequently cite the non-existent ‘consensus of the medical community’ to argue that the only effective way of treating gender dysphoria is social and medical transition. However, in this carefully researched piece, SunMum reveals that a growing number of general practitioners (GPs) in the UK appear to feel uncomfortable providing transgender health services.

 Special note to UK readers: If you are concerned about proposed changes regarding transgender health services in this country, please complete the NHS survey by October 16. A helpful guide can be found here.

The recent sudden increase in young people identifying as trans presents a quandary for the UK’s National Health Service. Trans activists demand access to ‘life saving’ health care but there are simply not enough gender specialists to deal with all the new patients. Currently NHS England is holding a twelveweek public consultation on specialised gender identity services for adults who, worryingly, they define as ‘17 and above’. But it seems that not all GPs are happy with the role they are being asked to play. The current arrangement is that the patient’s own GP is responsible for ‘prescribing, on the recommendation of the specialist team’. But according to the Guide to Consultation ‘a small but significant and increasing proportion of GPs do not feel able to accept responsibility for prescribing’.

Why are GPs increasingly unhappy to prescribe gender medicine? Surely the profile of transgender has never been higher as trans charities work to ‘Embrace. Empower. Educate’?

Zara Aziz, a GP partner in Bristol writing in the Guardian newspaper in August 2017 in response to the consultation, is concerned about the demands placed on GPs by what she describes as ‘a niche field’ of medicine. GPs are asked to monitor gender treatment through blood and hormone levels. And since 2016, new British Medical Association guidelines ask them in some circumstances – where patients are self-medicating with hormones or where there is self-harm or risk of suicide – to provide “bridging prescriptions” for emergency hormones. This new demand has met with resistance from the General Practitioners Committee which states that GPs ‘should not be obliged to prescribe “bridging prescriptions’’’. So the BMA and the GPs own organisation are in conflict. According to the GPC, the British Medical Association’s report ‘fails to address the resulting significant medicolegal implications for GPs, and neglects the non-pharmacological needs of [gender dysphoric] patients.’ It almost sounds as if GPs would prefer psychotherapy to medication for these patients. As Dr Aziz put it, GPs are worried about ‘the risk of complaints and litigation against family doctors’.

GPs have clearly noticed the sudden increase in demand for gender medicine. Zara Aziz reports that ‘this year I have seen three gender dysphoria patients (although I have not prescribed any treatment for them yet), but before that it was that many in nine years.’ Like many of us, these reluctant GPs seem to be waking up to the realisation that something strange is going on. Just 10 years ago the number of adolescents who wanted to transition to the opposite gender was vanishingly small; today they seem to be in every school.

If a GP does go ahead and offer a ‘bridging prescription’ for hormones, she will be doing so off-label; these drugs are tested and licensed for other uses. As the NHS consultation document points out: ‘This arrangement differs from prescribing practice in many other secondary and tertiary care services, particularly when prescribing for ‘off label’ indications.’

Gender medicine asks GPs to behave in ways for which they have not been trained.  Perhaps the protocols of gender specialists are increasingly diverging from those of other medical specialties, and this gives the doctors pause?

2015 miller enquiry sunmum

From left: Susie Green, CEO Mermaids, and Anna Lee, first “queer trans disabled lesbian woman” to run for women’s officer at the National Union of Students, listen to Bernadette Wren (on right), consultant clinical psychologist at Tavistock clinic.

Or perhaps these GPs are concerned about the influence that activist groups like Mermaids and Action for Trans Health are having on transgender health care. After all, these groups are pushing for earlier and swifter intervention. In evidence to the UK Parliament Transgender Equality Inquiry in 2015, Susie Green of Mermaids spoke of the frustration of parents with NHS treatment pathways and explained that her organisation helped them to access early intervention abroad:

 ‘We have current conversations going on; I have at least six families who have children who are pubertal who are looking at that option now and are actively contacting the Hamburg centres and America to access that treatment, because they know that they are not going to get it here within the NHS.’ (Q58)

Many activist groups believe the role of the clinician is only to supply the drugs and medication requested by the transgender  patient. Perhaps GPs are concerned that activists are driving treatment decisions that rightfully belong in the hands of medical professionals.

In 2009, one of the leading British gender specialists, Dr Stuart Lorimer, a psychiatric consultant at Charing Cross Gender Identity Clinic and founder of GenderCare, a London private gender clinic, was asked what he saw as his biggest impediment in the development of gender identity services. The answer was ‘medical colleagues, GPs, other psychiatrists’. Lorimer mentioned a survey of 1,000 doctors of which 84 percent felt that gender services are ‘not legitimate, not deserved, should not be in the NHS’.

It is clear that a consensus on the protocols of transgender medicine does not exist outside the small group of specialists. A much-cited Swedish study from 2011 describes the standard treatment for gender dysphoria as ‘a unique intervention not only in psychiatry but in all of medicine’. Searching for parallels, one contributor to 4thwavenow had to go as far back as lobotomy. No other contemporary psychiatric therapy, after all, includes ‘the surgical removal of [healthy] body parts.’

Transgender medicine is not just a specialized field but something of a club. A 2003 Dutch study asked 382 Dutch psychiatrists about their experience of ‘diagnosing and treating patients with gender identity disorder’ and found that ‘[a] small number of psychiatrists’ were responsible for a large proportion of the referrals to ‘specialized sex reassignment therapy centres’. The study concludes that ‘the therapy options proposed to patients with gender identity disorder depend heavily on the personal preferences of psychiatrists’. (Am J Psychiatry 2003; 160:1332–1336) Personal preference is not a reassuring basis for medical treatment.

In the UK it seems that nothing much has changed in the 14 years since the Dutch study. Transgender medicine continues to be in the hands of a small group of clinicians and the NHS consultation guide cited above notes that ‘there is limited collaboration and sharing of best practice across the current providers’. A small number of treatment centres operate on the basis of limited evidence about outcomes.

It’s both welcome – and worrying – that the NHS is only now bidding for research into gender medicine. The commissioning brief acknowledges ‘the lack of a UK evidence base for the NHS to inform decisions about gender identity health services’. And the research bid notes that ‘the long-term iatrogenic impacts of hormonal treatments and surgeries on young people and adults are largely unknown, but some studies show some treatments increase risks of several long-term conditions including cardiovascular and renal diseases, and fracture risk, while research on user satisfaction and psychological outcomes in the UK is of small scale and duration.’ These treatment protocols, in other words, could be causing long term damage – we don’t know enough to rule this out.

When evidence is lacking, we might expect doctors to be cautious. But instead of trying to understand the reluctance of so many GPs, trans activists demand swifter interventions and ascribe medical caution to bigotry. Zara Aziz explains that ‘any reticence on our part to prescribe can be challenged and can sometimes be misinterpreted for prejudice.’ Specialists and activists work to bypass the caution of mainstream doctors. Lorimer’s private GenderCare clinic is designed specifically to get round the reservations of GPs. He explains that:

 In my GenderCare clinic, I saw those people who’d yet to reach a GIC, whose GPs had stalled, dismissed or, in one memorable case, informed them that no such service had ever existed in the UK.

Guidance for NHS clinicians who also offer private treatment issued in May 2009 recommended that ‘specialists should as a general rule make it clear to members of the public that they usually do not accept patients without a referral from a GP or other practitioner.’lorimer summer reading

GPs may not subscribe to the conventions of gender clinicians, but they do tend to know their patients and their family situations. And that, more than anything else, may explain the increasing reluctance of many GPs to provide transgender health services. Just as parents know their children, GPs know their patients. Perhaps more and more of them are seeing young patients who never expressed discomfort with their bodies as children suddenly demanding transgender health services. That would certainly be enough to make a good GP think hard before writing a prescription for cross-sex hormones.

20 thoughts on “‘Bridging hormones’: Increasing number of UK GPs leery of prescribing treatment

  1. Thank you for carrying out this research, SunMum. I always find it reassuring when I read that medical professionals are worried/questioning current approaches to the treatment of gender dysphoria. It’s mind-boggling that the preferences of a handful of “specialists” dominate discourse and practice when evidence of treatment efficacy and lack of harm is virtually non-existent. Unsurprising I guess when we consider the atmosphere of fear trans activists have created.

    I don’t know if I’m imagining things but it seems that more people are becoming aware of all the issues involved. It can’t come soon enough.

    Liked by 4 people

  2. Thank you for this interesting piece. Let me make sure I understand it. This sentence: “And since 2016, new British Medical Association guidelines ask them in some circumstances – where patients are self-medicating with hormones or where there is self-harm or risk of suicide – to provide “bridging prescriptions” for emergency hormones” appears to be the heart of the piece, correct? So to paraphrase, general practice physicians are now being advised by their own medical association that in some cases, these doctors should bypass the customary evaluation process, designed to insure patient safety, and prescribe hormones essentially on demand? How long does it take in Great Britain to have blood levels checked anyway? If a patient is able to get in to see a GP, why would it be that same GP couldn’t even take the time to do a physical examination, if the patient is in the GP’s office already? I feel like I must not be understanding something here.

    I can see why doctors would not like being told, especially by their own medical association, not to use their professional judgment and discretion regarding patient care. Moreover, doesn’t this create a loop-hole big enough for a Mack truck? What is to stop any person desiring immediate hormone treatment from going to a GP, telling that GP s/he was suicidal, and receiving the emergency prescription then?

    I also find this language of “bridging hormones” to be obfuscatory and to represent, at the least, a highly unusual approach to medicine. What exactly is being “bridged” here? The person in crisis + hormones = the person out of crisis? Really? If a person is imminently about to die, say from an allergic reaction, yes at that point perhaps a doctor wouldn’t worry too terribly much about administering an antidote with side effects. It really says a lot that the trans-lobby seems to have convinced doctors to equate gender dysphoria with being unable to breathe though.

    Liked by 3 people

    • The General Medical Council ethical advice on bridging prescriptions is here http://www.gmc-uk.org/guidance/ethical_guidance/28852.asp
      The rationale is that a GP, though not a specialist endocrinologist, is likely to be able to offer a less damaging option than self-medication: ‘It may well be that the risk to your patient of continuing to self-medicate with hormones is greater than the risk to them if you initiate hormone therapy before they’re assessed by a specialist.’ It’s a question of balancing risks – not of a risk-free therapy. By self-medicating, or threatening other forms of self-harm, the patient effectively puts the GP in the position of comparing relative degrees of harm. The advice is specifically designed in the context of long waits for over-subscribed gender clinics (a product of the boom in gender dysphoria). It is also, of course, designed in response to trans activism. It’s noticeable that the GMC advice is that the GP undertake the one hour online training module designed in consultation with GIRES (an activist organisation). http://elearning.rcgp.org.uk/course/info.php?popup=0&id=169
      This is all about degrees of damage.

      Liked by 2 people

      • Thank you SunMum for this interesting piece. I like the idea of having to wait a very long time for this type of medical intervention. It seems Americans have no patience in waiting for any type of medical care.

        Liked by 2 people

    • So, if you are a physician in the U.S. and say that you basically don’t believe in medicalizing girls caught up in the trans craze, will you lose your status in your medical organization–even your license?

      Liked by 2 people

      • It’s not clear, and that’s a huge problem.

        In general, no doctor has to provide care that is outside the area of his/her competence. And, what we have seen in the U.S., for instance with abortion, is that doctors are not compelled or required to perform procedures or give care that contradicts their own moral or religious beliefs. It can get dicey, for instance when a doctor is opposed to birth control, is functioning in certain capacities (e.g. at a public hospital or clinic), and then refuses. (We see this with pharmacists also.) But the answer is not simple and often turns out to be, “it depends.”

        As a legal matter, I am not aware that any state currently requires a doctor or nurse to provide transgender medical care. I imagine that a creative lawyer could try and leverage an anti-discrimination law in that direction, and I would be really interested to hear of any such actual cases. Again, any doctor could avoid having to provide transgender medical care by claiming (which would likely be true) that he/she did not have the necessary medical expertise to do so. We don’t require dermatologists to provide brain surgery…

        Where the difficulty comes in is with the “anti-conversion therapy” laws that states are now jumping on the bandwagon to pass. This pertains in the area of psychiatric or psychological counseling provided to minors. In the United States, there was a history of religiously-influenced therapy provided, often to minors who did not choose to be there, to “convince them” not to be gay or lesbian. This led to some fairly abusive situations, even involving physical or mental distress.

        “Anti-conversion therapy” laws, originally intended to outlaw the type of abusive therapy referred to above, have now been expanded to cover efforts to “change gender identity.” This is a problem. Arguably, initiating discussions with a client as to why he/she has come to the transgender belief, or about the negative aspects of transition, or to seek to “go behind” the transgender belief, are all “conversion therapy” and now banned. Unfortunately, most of the conversion therapy laws are modeled on one standard law, and the drafting is so unclear that a typical therapist cannot know exactly what is prohibited and what is not – and thus will feel constrained to follow only the “gender affirmation” model. In my view, this unnecessarily hamstrings and limits a therapist in the type of care that can be provided, and improperly interferes with a therapist’s professional judgment. Unfortunately, the states that have ruled on the issue (California) disagree with me.

        Liked by 4 people

    • Thank you so much for this link and your comment – I searched for ages! Am editing post to add it as a hyperlink. I think that probably means that the gloss ‘‘not legitimate, not deserved, should not be in the NHS’ is Lorimer’s reading of that survey.

      Liked by 3 people

  3. I write on behalf of my daughter, Kate Gould. This comes from her email because I don’t think I can reply if I forward this on to myself from her phone. I wanted you to know that Kate died on Monday. Her death is most likely to be a SUDEP (sudden unexplained death in epilepsy). I know that she would not want you to think that she had stopped caring and wanting to be involved in your work. She admired and valued you greatly. Best wishes Valerie Gould veegould@hotmail.co.uk

    Sent from my Sony Xperia™ smartphone

    Liked by 3 people

  4. I don’t know if anyone is aware but Lisa Littmans study on sudden onset gender dysphoria is published in the Journal of Adolescent Health. I’m a tech dummy so don’t know how to attach link but if you type in Lisa Littman study on sudden onset the link will come up. And I am so so very grateful to everyone involved on this site and to Lisa Littman as well for giving these concerns some light.

    Liked by 3 people

  5. This article from the Daily Mail (actually a very good one, raising some pertinent questions) puts much of what is worrying in the NHS and transgender treatment and research into focus.
    James Caspian, a psychologist who is closely involved with the Beaumont Trust in the UK, has been blocked from researching into trans regret and detransitioning because it is deemed to be “politically incorrect”. He is greatly concerned that the move is towards therapists exploring only issues around gender and being prevented from looking at other mental health issues.
    PS. thanks to Oak and Ash for linking to the article first over on GenderTrender

    Liked by 2 people

  6. Every time I see trans activists promoting the idea of puberty-blocking drugs (actually off-label use of medications for real medical problems like precocious puberty), they make it sound like the purpose is delaying maturation so the child will have time to decide whether or not to transition. But looking at how de-transitioners are either ignored or mistreated by the Ts, I think the delaying of maturation is only being pushed to serve the purpose of making the transition of the child take longer for the purpose of having more time to condition the skeptical parents into going along.

    Liked by 1 person

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