General Medical Council meeting on Trans issues

On Friday, myself and a number of other Trans activists had a productive meeting with the General Medical Council (GMC) in London, on professional standards and continuing professional development. The GMC are running a consultation which nominally finished Friday, although we were told that responses sent after then may still be read so there is still time to get your views in.

Staff we spoke with certainly seem receptive and switched on to the extent that once Sarah started quoting the Equality Act at them from her written copy, one staff member was able to join in and finish the quote from memory. The difficulty for us and the GMC is taking the discussions and situations we were having, working within the remit of the GMC to turning them in to more generic guidelines for doctors. (The GMC can only regulate individual doctors, so has no influence on NHS funding decisions for example.)

Much of the meeting was taken up with Trans folk telling their “War Stories” and I think the GMC staff were surprised at how cynical we were as a community as well as the widespread nature of problems and their general severity. One particular story had a GMC staff member put her head in her hands and exclaim “Jesus!”

Some scenarios had been prepared as discussion points of which two recounted fairly typical NHS experiences that will be familiar to any Trans activist: GPs refusing to have anything to do with Trans patients due to moral objections; NHS Gender Identity Clinics (GICs) refusing to prescribe hormones due to lack of what they perceive as adequate documentation; Doctors (And GICs!) old-naming patients. The GMC were keen to point out that these were most definitely not what they would regard as good medical practice!

Of the first of those examples, a GP refusing to even refer a patient based on the doctor’s religious belief, there was much discussion. The GMC guidance on this is unclear, but suggests a doctor can refuse to treat in certain circumstances but instead refer the patient to another GP who can help, which is pretty routine in the case of contraception. However, that guidance is from 2008 and pre-dates the Equality Act 2010 and it was pointed out that the GMC would expect the doctor to refer. However, an activist quoted a doctor working at a Gender Identity Clinic who had never seen a GP refuse treatment on ethical/religious grounds and transfer a patient to another doctor to handle. Instead, they just prevaricate and find other excuses not to handle the issue.

It was also pointed out that you can’t completely divorce medical care from moral judgements, because things can get very fraught when you’re talking about end of life care and abortion – it’s simply not realistic to expect all doctors to react in exactly the same way in these cases – but Gender Identity is one area it seems clear that the GMC do not expect doctors to be exercising any sort of ethical or religious opt out when it comes to simple referrals.

This one case is a pretty good example of the troubles of activism. Whilst it would nice to rush in and say we should prosecute a doctor that refuses to treat on religious grounds and says so, if they’re transferring you to another doctor then they are in doing better than many GPs currently do. Thus, any guidelines the GMC produce as well as needing to be generic should make sure that they don’t push GPs more towards prevarication without explicitly saying why, which is not in the best interests of the patient even if it defends the doctor from a possible legal challenge.

Another interesting point, and this is something I do tend to run up against reasonably frequently, was that our experiences in some areas are not that much different from other marginalised groups who require access to medical treatment. Several examples were cited by attendees of people being forced to see a psychiatrist or gender specialist for clearly routine gynaecological or similar treatment and the GMC has had heard similar stories from the disabled community. (E.g. In the case of someone with Down Syndrome who presents with a broken limb, the doctor will see the Down Syndrome as something to worry about, even if it’s entirely irrelevant)

Sometimes, it feels as if we have more in common with the disabled community than we do with the rest of the LGB community.

The other major area for discussion was how to handle Continuous Professional Development, (CPD) which is quite a new area for the GMC as only being a recent and still developing requirement for doctors. At the moment, a doctor can practice for 40 or 50 years after finishing their training with no further updates required, so the GMC are looking to require regular recertification of some sort for doctors. (As an IT professional I have to do this every 2 years!) However, there is some difficulty in identifying what the nature of any other activity should be as the GMC is limited in how much specific direction can be given. Peer discussions and conferences are clearly a good idea, but how do you ensure that it is appropriate content? For example, the recent and controversial Royal College of Psychiatrists conference that was cancelled would have counted for that organisation’s CPD, but is not something most people would have regarded as promoting best practice. Outside of the Trans arena and more generic, how do you stop doctors attending conferences on “talking cures” or homoeopathy as part of their CPD.

Mainly, it seems we simply need to be making doctors aware that GID exists and is something that the NHS handles because many GPs don’t know about this. If they know that and have some vague idea where to start searching for details on how to refer, things should improve. Doctors also need to not diagnose things they’re not competent in, as I have seen letters to patients from non-GIC psychiatrists saying “I don’t think you have GID” or “you might have it, but it’s not serious enough that I’m going to refer you”. All they should be doing is checking the patient isn’t in need of other mental health services (GICs do not have the resources to handle routine psychiatric issues or suicidal patents, for example) before referring, not blocking referrals based on their own untrained diagnosis.

In terms of all the above, the ball is now in the GMC’s court with respect to producing the next set of GMC guidelines. It won’t contain anything Trans-specific (It’s too small a document for that) but now they’re aware of the kind of problems we face, they can hopefully find some appropriate wording to push doctors in the right direction.

Finally, there was some discussion on Fitness-to-Practice and complaints in general, even though that was not the topic of the meeting. It seems that PALS and other NHS complaint routes have different standards than the GMC and it may, in some cases, be more appropriate to complain to the GMC directly in the first instance rather than PALS when it is an issue of transphobic actions by doctors or general clinical care. This is something we (as a community) can hopefully produce some how-and-who-to-complain-to advice on in future, but it also does not necessarily need to be a patient or fellow doctor that raises issues with the GMC for investigation, which raises some interesting possibilities for the community to act rather than having to rely on patients early in transition – who will fear reprisals from doctors.