Comments regarding the Gender Variance eLearning Course

The Gender Variance eLearning course was previously hosted on the Royal College of GPs website.


A more detailed account

The Gender Identity Research and Education Society (GIRES) developed, entirely at its own expense, the material used in the above course, with the support of an expert working group. GIRES owns the copyright of all that material. The coursewas based on clinical evidence, the intercollegiate good practice guidelines, NHS England’s specification for gender identity services, GMC guidance, the International Classification of Diseases, the Standards of Care published by the World Professional Association for Transgender Health and the Endocrine Society’s Clinical Practice Guideline. The course was peer reviewed by the RCGP.

The course helped GPs to fulfil their responsibility, as stated by NHS England and the General Medical Council, to prescribe and monitor the medication recommended by the specialist clinicians in the gender identity clinics.

GIRES paid the RCGP £7,837 for the course to be hosted on the RCGP website, free to all users, for a period of two years, commencing in July 2015.  In January 2018, the RCGP made a number of changes to the course without informing GIRES, which has not given its consent to any of those changes. GIRES discovered those changes in June 2018. Some of the changes made by the RCGP were acceptable to GIRES but, as shown below, others were inappropriate. GIRES immediately protested to the RCGP.

Following an exchange of correspondence and a meeting in November 2018, it became clear that the RCGP was unwilling to reverse the changes that GIRES deemed were inappropriate. Both parties decided in December 2018 that the course should be removed from the RCGP website.

GIRES objected to deletions of the following references and proposed their reinstatement:

  1. (reinstate) the elearning for professionals working with Gender Variant Children and Trans Adolescents, which is on the Health Education England website, badged by NHS and carries CPD points:  bit.ly/GIRESelearn
  2. (reinstate) the biological correlations paper, which is on the GIRES website:  https://www.gires.org.uk/wp-content/uploads/2014/09/biological-correlations-atypical-gender-development.pdf
  3. (reinstate) Mermaids, the charity that supports gender diverse children and adolescents and their families

GIRES also objected to the insertion of some additional wording, recommended its removal and proposed its reinstatement or replacement, as shown in sections A to D below:

A – (remove) “Prescribing hormones is not without risk and monitoring may be necessary. This monitoring may be done in primary or secondary care, depending on shared care arrangements.”

GIRES proposed the following:

(replace with) The NHS England specialised services circular: “Primary Care Responsibilities in Prescribing and Monitoring Hormone Therapy for Transgender and Non-Binary Adults (updated)” recommends that:

“General Practitioners should co-operate with the specialist Gender Identity Clinics and prescribe hormone therapy (feminising or virilising endocrine therapy) recommended for their patients by the Gender Identity Clinic. The specialists at the Gender Identity Clinic make recommendations for the prescription and monitoring of these therapies but they do not directly prescribe them, or provide physical and laboratory monitoring procedures for patients.

General Practitioners should collaborate with Gender Identity Clinics in the initiation and on-going prescribing of hormone therapy, and for organising blood and other diagnostic tests as recommended by the Gender Identity Clinics.

General Practitioners are also expected to co-operate with Gender Identity Clinics in patient safety monitoring, by providing basic physical examinations (within the competence of General Practitioners) and blood tests and diagnostic tests recommended by the Gender Identity Clinic (and outlined in this course).”

http://shsc.nhs.uk/wp-content/uploads/2016/04/SSC1620_GD-Prescribing.pdf


B – (remove) “Monitoring of prescribed hormones may be carried out by the GP or secondary care, depending on shared care arrangements. Whilst a GP may wish to prescribe to help a patient (for whom the specialist service may not be local), it is also important that we only prescribe if we are happy that safe monitoring is in place and that prescribing is not outside our area of competence.”

Rationale for removing inserted text above: Opinion of a Fellow of RCGP: “Outside my competence” is simply an admission of a newly-identified professional learning need that has arisen when a new clinical need is first met; this should not result in the doctor saying “so I won’t do this” on every subsequent occasion the same challenge arises.

Therefore, the course should prompt them to:

(insert) Follow the General Medical Council’s guidance to:

  • Keep yourself informed about the medicines that are prescribed for the patient
  • Be able to recognise serious and frequently occurring adverse side effects
  • Make sure appropriate clinical monitoring arrangements are in place and that the patient and healthcare professionals involved understand them
  • Keep up to date with relevant guidance on the use of the medicines and on the management of the patient’s condition.

(In addition insert) General Medical Council guidance makes clear that GPs should:

  • Prescribe medicines recommended by a gender specialist for the treatment of gender dysphoria
  • Follow recommendations for safety and treatment monitoring
  • Make referrals to NHS services that have been recommended by a specialist
  • Keep yourself informed about the medicines that are prescribed for the patient

All this and more can be found at: https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare—advice-based-on-gmc-guidance#prescribing

In addition to the above, GIRES therefore proposed reinstating the text:

(reinstate) “GPs are responsible for the non-specialist aspects of treatment:  prescribing, administering and monitoring hormone treatment as set out by the specialist service.”


 C – (remove) but monitoring may be done in secondary care, in which case good communication is essential”.

 (rationale for removal) Again, this promotes secondary care which was not the intention of NHSE. This new wording should be removed. Monitoring is not beyond the competence of GPs and this course gives the necessary information.


D – (remove) “assuming that safe monitoring arrangements have been put in place following discussion between primary and secondary care.”

(replace with) Ongoing prescribing and monitoring will take place in primary care in line with the recommendations of the paediatric endocrine service of the Gender Identity Development Service, and the relevant information in this course.


Additional points proposed by GIRES:

  • Under Hormone blockers, physical effects add after: ….gamete storage must be discussed: “Hormone-blocking is reversible, but if followed directly by gender affirming hormones, this will prevent maturation of eggs and sperm so fertility may be lost. Once maturation has been achieved, possibly involving temporary withdrawal of GnRHa until maturation occurs, gametes can then be stored, and blocking may then be resumed. For some young people this will not be an acceptable option; they may prefer to forego the chance of having offspring.
  • Under Genital surgery, note that it is now available from 17 y.o
  • Provide links to the Human Rights and Equality Acts
  • Minor corrections of some of the references given in the course.

Bernard Reed OBE, MA, MBA

Trustee


Original Document: GIRES – RCGP – Sunday Times – TR3 (DOCX, 76KB)

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