‘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.

GenderCare: London private clinic with a winning business model

by SunMum

The author is a UK academic and mother of a son who experienced sudden onset gender dysphoria. She has attended the Gendered Intelligence parents support group, and her son consulted Stuart Lorimer at GenderCare.  She can be found on Twitter as SunMum@Mum3Sun


The business model of a private gender clinic in the UK looks a dead cert. To start with, you need demand, and the rising demand for gender reassignment services offers that in abundance. The NHS offers a gender reassignment pathway, but demand in recent years has outstripped the resources of a publicly funded health service. Waiting lists at the main adult provider, the Charing Cross Gender Identity Clinic, the UK’s ‘oldest and largest adult clinic’ founded in 1966, are currently about 12 months from the first referral. Referrals have ‘almost quadrupled in 10 years, from 498 in 2006-07 to 1,892 in 2015-16’ according to the Guardian in July 2016.

At the Tavistock and Portman, the only NHS service for children and adolescents with gender dysphoria, referrals have increased ‘about 50% a year since 2010-11.’ In the year leading up to this Guardian report, the rate of change in child referrals showed ‘an unexpected and unprecedented increase of 100%, up from 697 to 1,398 referrals’.

In the same 2016 Guardian article, Charing Cross GIC lead clinician James Barrett comments jocularly on this sudden increase in demand:

‘It obviously can’t continue like that forever because we’d be treating everyone in the country, but there isn’t any sign of that levelling off.’

Now this is a rather strange comment, given that only five years before, in 2011, Barrett stated that rates of gender dysphoria were stable and unchanging. Citing a 1996 study, he presented the condition as vanishingly rare: ‘It seems that the incidence of transsexualism is very roughly 1 in 60000 males and 1 in 100000 females, and it seems to have remained constant’. Given that ‘treatment is drastic and irreversible’, Barrett insisted that diagnosis must be entrusted to the experts of the gender identity clinic:

The least certain diagnosis is that made by the patient, made as it is without any training or objectivity. This uncertainty is not lessened by the patient’s frequently high degree of conviction. Neither does the support of others with gender dysphoria help, since conviction leads people to associate with the like­minded and to discount or fail to seek out disharmonious views. [ James Barrett, Advances in psychiatric treatment (2011), vol. 17, 381–388 doi: 10.1192/apt.bp.109.007484)

 

Pitching the service: Respect and Authority

GenderCare, headed by Stuart Lorimer, is a private London gender clinic mostly staffed by clinicians employed at Charing Cross GIC: endocrinologist Leighton Seal, psychologist Christina Richards and speech therapist Christella Antoni. These are professionals who have reputations at stake.

gendercare-home

And while GenderCare does offer some Skype and email consultations, prospective patients or parents of gender confused young adults can be reassured that this is not an online clinic like that run by Helen Webberley, a Welsh GP whose Online Transgender Medical Clinic displays no more relevant qualifications than a one hour e-course in ‘Gender Variance’ designed by a transactivist organisation for GPs.

Twitter contains some negative reports of Webberley’s outfit: ‘A guy I know was rushed into hospital with liver failure because of Dr W’s incompetence, not having his bloods reviewed meant he was on too high a dosage of testosterone & literally nearly died.’ According to one young person, Webberley ‘has this weird online ‘grooming’ thing going on, contacting young people via social media’. Of course, Twitter testimonials do not constitute actual evidence and should be viewed with caution. Yet it’s clear to anyone who spends time investigating that young people are discerning as they sift through their choices and look for medical help they trust.

weird-online-grooming

The GenderCare website by contrast is reassuringly respectable: these are ‘Specialists in Gender Care’, genuinely experts in their field. The site and FAQ frequently remind us that patients will be seen by a team of medical experts  The FAQ emphasises hormonal treatment,  with assurances that the letter needed for medical transition will be prepared as quickly as possible.

What would be the hurry? It appears that, since 2011 when Lorimer’s Charing Cross colleague James Barrett insisted on the ‘drastic and irreversible’ nature of medical transition and the caution that the ‘least certain diagnosis is that made by the patient’, there has been a sea change in the field. Now Barrett presents gender dysphoria as a condition with no parallel. It simply is what it is, and gender specialists are sui generis: neither psychiatrists, nor endocrinologists, but what it says on the can: ‘gender specialists’. Barrett compares gender dysphoria in a 2016 blog post for the BMJ, to ‘the Australasian Platypus’[full article behind paywall]:

The first specimens were dismissed as a joke of some sort.

But then more came, and alive and kicking at that. There followed a mighty taxonomological struggle. They were reptiles or perhaps some sort of bird, surely, as they were warm blooded, laid eggs and were venomous. On the other hand, the fur argued for mammals, but they didn’t have proper breasts, the defining feature of the mammals, and that business of being venomous is more of a reptile-like thing, is it not? And they do lay eggs…but warm blooded…perhaps a bird of some sort…?

In the end, it was all solved by everyone admitting that the Platypus was real, important, couldn’t be dismissed and didn’t fit any existing category very well. It got its own, special category where it has paddled, very happily, ever since, albeit joined by echidnas and some long-extinct fossilised forebears.

The comparison is witty and memorable, but leaves us no wiser. Lorimer also subscribes to what we might call the Platypus model of gender theory (‘a variety of clinical specialisms might lay reasonable claim to ownership of gender care but, like the platypus, it’s its own creature, distinct and different’. Although trained as a ‘Liaison psych’ he believes that ‘ultimately, it’s about pragmatism – who has the appropriate skill-set to do the work.’

For gender identity, there is no well-founded theoretical model, no objective test: we simply have to believe in the authority of the expert. Believe me because I say so. For the young people who visit GenderCare, diagnosis by a gender specialist offers confirmation and validation of their internal sense of self. YouTube videos about ‘my first visit’ to GenderCare form a genre of their own, revealing the overwhelming power of this validation. One young person reports

‘It were a really positive experience. He were very validating and he shouldn’t have been because I obviously know that someone validating your experience isn’t necessary. But hearing him saying the words saying he’s diagnosed me, he’s signing me off…It’s like all my Christmases come at once.’

There are many transition YouTubes made by young clients of Dr. Lorimer; they are moving videos, in which these young people freely admit they suffer with self harm and sometimes suicidality. A single visit to GenderCare can apparently provide a rapid remedy. The process is quick and simple: when blood tests are in and the letter comes through, a young woman who desires to transition FTM can start testosterone. One has already got ‘syringes through the post’, the ‘sharps bin’ and the needles:

‘I don’t know if you’ll be able to see this. Look at the fucking size of that needle. Look at it compared to the size of my finger. Well clearly I’m not needle-phobic. But fuck, it’s huge. I’d hit myself in the face with a brick if it meant starting on testosterone.’

Pushing at the boundaries

In taking on private work, Lorimer would need to protect his professional reputation and adhere to legal and medical regulations.  This may at times present complications. In 2014, according to a post on ‘The Angels’ (a trans support forum), the UK’s Care Quality Commission (CQC) raised questions about the ‘grey area’ of his private practice, prompting Dr Lorimer to temporarily stop seeing clients.

Lorimer Care quality commission 4.jpg

lorimer-care-quality-commission-3

Leaving aside the question of what may or may not have happened in 2014, the key regulatory boundaries with gender reassignment are to do with time (how quickly hormones are dispensed) and age (those under 18 are treated in a different way from adults). For much of 2016, the GenderCare website warned that hormones are not normally prescribed on a first visit. That is certainly not the belief expressed on Twitter today:

sweetie-one-visit

The burgeoning youth market

GenderCare’s FAQ tells us they primarily treat over-18s, although some exceptions are made. Lorimer confirms this on Twitter:

dr-p-edit

Earlier in this post, we saw that some young people on Twitter were freaked out by what one calls ‘this weird online grooming thing going on’ by Helen Webberley’s outfit. The respectable GenderCare would surely do no such thing. But Lorimer too has a social media presence through which he touts for business, a Twitter voice seemingly designed to speak to the young – especially trans men. Here we find him mythologizing the joys of testosterone:

lorimer-horsemen

Parents know that when young people want something, they want it Now! And for some young women the thing that is needed, and needed quickly, is testosterone, seen by dysphoric adolescent females as a panacea for all ills.

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About ‘two thirds’ of his patients, Lorimer explains are ‘trans men’:

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Like the proverbial high court judge, I need to make my way over to the Urban Dictionary . But Lorimer is the doc who talks to young people, who plays knowingly with the idea of ‘A girl’s body and the way she carries it.’ Looking at YouTube or at Twitter, you would think that Stuart Lorimer was an expert on adolescent gender dysphoria. But this apparently is not the case:

lorimer-limited-experience

Lorimer may have ‘extremely limited experience of children/adolescents’. But it takes a very limited dip into the sea of adolescent angst freely available on Twitter and YouTube to realise that GenderCare clients are in the throes of the kinds of relationship and body issues that many adults remember. These are not strange young people, but people suffering from a horribly familiar set of feelings. Of course, we don’t know the age of all those who tweet of vlog about their GenderCare appointments. They might simply be youthful in spirit, but young they certainly appear to be. These don’t sound like people who are approaching ‘drastic and irreversible’ bodily alterations with maturity, discretion or objectivity:

 

Perhaps most troubling is that in 2016 Lorimer arrived on Tumblr, overwhelmingly a place for young people (very popular with ages 13-18), with a GenderCare Tumblr site. Lorimer seems anxious. Why? Is it because he knows he’s rather old to be on Tumblr?

lorimer-tumblr-scare

Tumblr is full of accolades for GenderCare. And whilst one might think a need for hormones and surgery would be necessary only for those who strongly believe themselves to be the opposite sex, evidently even ‘nonbinaries’ are supported in their quest for medical intervention via GenderCare:

tumblr-nonbinary

Lest readers think this nonbinary stuff is hyperbole, Dr Lorimer (aka The MXMaster) confirmed the Tumblrite’s observation on Twitter last August.

lorimer-mxmaster

The market potential for ‘nonbinaries’ must be unlimited.  Who amongst us fully conforms to gender stereotypes? And GenderCare isn’t the only UK gender clinic cashing in on the ‘enbie’  market:

yelland-enbie

Let’s see: Can you spot the difference between ‘non-binary’ and ‘binary’ mastectomy?

But returning to GenderCare, one of the more ironic aspects of all this is that Lorimer himself is certainly old enough and wise enough to see beyond the teenage rush for bodily alteration. A highly flattering image of Lorimer appears on the website of photographer James M. Barrett (not the gender clinician this time but a photographer who specialises in beautiful images of gay men). The photographer’s Facebook page comments sagely on the contemporary rush for bodily alteration:

 ‘In popular culture, there is an extraordinary urgency to take charge of our bodies and minds, and to “become the person that we were always meant to be”! It is as if we can rewrite our lives and give birth to new selves, simply through the power of positive self-belief, and some bloody good cosmetic work on our physical appearance! It is not just a practical idea that looking more attractive might increase our pulling power or lift our spirits. It is the fantasy that if we could just become achingly beautiful, then we will also be unbearably desirable, and our whole lives will be transformed from ordinary to unique. And of course, digital photography plays right into this fantasy, allowing us to perform virtual nick-and-tuck manipulations, and to airbrush a veneer of youthfulness onto our imagined selves. The images in this portrait series have also been heavily worked in post-production, but the effect is meant to suggest something very different: a harsh beauty that resonates with uncertainty, doubt, restlessness, world-weariness, perhaps mid-life crisis…but which also carries a tender intimacy, resilience, ruggedness, and a new-found robustness that comes from surviving a crisis.’

Wise words. And we know that Lorimer subscribes to this aesthetic. Not only has Barrett photographed him but under another image a ‘Stuart Lorimer’ comments: ‘Fantastic portrait!’. In his own photograph, Lorimer looks great: retouched, digitally improved, there is no necessity for cosmetic surgery, drugs, or scalpels.

For professional purposes, simpler photographic techniques suffice:

lorimer-business-cards

Now Lorimer knows, for certain, that Tumblr is for young people:

‘Tumblr, like lycra is probably not for anyone over 30 –yet here I am. Every fibre in my fortysomething being is screaming at me “GO! THIS IS FOR YOUNG PEOPLE!” but I’m resisting that because I think it may be useful for me to tout for lucrative business, as head of GenderCare, to have a presence here.’

Why? Maybe because young people use Tumblr to explore sub cultures of body hatred and body alteration. Lorimer is careful to add a disclaimer that he does not represent his ‘NHS employers or my GenderCare colleagues’.

But there is no escaping the fact that this is the official GenderCare Tumblr. There is no doubt that he is advertising transition services. In this location, Lorimer does not share his wise appreciation of the power of digital photographic enhancement to act out our fantasies. Instead he offers age-appropriate ‘links to things I find diverting that are not especially relevant (cute animals)’:

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Don’t worry, young person about your first trip to get T. You will meet a cuddly gender doc wearing a pink suit.

lorimer-pink-suit

After all, this is all a game, a joke. Fun. Isn’t it?

Well I for one don’t think it is. My son, you see, became seriously depressed in his second year at university and developed sudden onset gender dysphoria. No earlier signs, easily the most ‘boyish’ of my boys. But after a romantic rejection and drug experimentation he developed depersonalization, googled his symptoms, found they were a symptom of trans, stopped washing, seeing his friends, his handwriting changed, he made odd repetitive hand movements, he became angry and he stayed up all night. I thought he was having a breakdown. His GP thinks it is depression or maybe schizophrenia. But, urged on by a counsellor, I in my naivete paid out for an assessment at GenderCare. After all, the clinicians were the real thing, weren’t they? They all worked at Charing Cross GIC in the NHS. They couldn’t be just cynical or stupid, could they?

I was astounded when my son came back telling me that he would be starting hormones in a few weeks. I emailed GenderCare and asked whether I could supply some contextual information. Lorimer contacted my son to ask permission (since he was 22 at the time). Son said yes, so I sent off a timeline of events, including details that I thought might be relevant to a diagnosis, including a series of recent traumatic events. Lorimer duly wrote a report saying he was a bit worried and wanted a second opinion. The second opinion was with his colleague at Charing Cross GIC, James Barrett (not the photographer, who could only have beautified my beautiful son digitally acting out his fantasies). As Barrett had no access to context (this time son said No), he had an avuncular chat with son (cost £200) and advised on choosing a new name and the right to access female toilets. My son, who a family therapy team thought was ‘struggling with his decision to transition’, now repeatedly refers to the fact that he has been ‘diagnosed by two gender experts’. But in this matter, there is no diagnosis: doctors simply echo back to patients their own self-diagnosis. And the first doctor to offer him that external recognition was Stuart Lorimer.

GenderCare combines accessibility to the young through its active presence on social media, with a show of clinical expertise. The recent news that the Charing Cross GIC would be run within the Tavistock and Portman NHS trust led Lorimer to comment on ‘that potentially big plus. Possibilities for great cross-fertilisation between child and adult services.’ He wouldn’t notice the crassness of the metaphor, because what Lorimer is breeding is a business model; the fertility of confused young people is neither here nor there.

cross-sterilisation