IN 2020, BEFORE the pandemic slowed treatment further, the NHS set up three new pilot gender clinics with the aim of cutting a long backlog by moving much treatment into primary care. A fourth was added in 2021. The idea was to make it easier for GPs to prescribe hormones to trans-identifying adults and refer them for surgery. Previously, all adults who wished to pursue a medical transition would be referred to one of several specialist Gender Identity Clinics (GICs) attached to major hospitals. The GICs are a bottleneck, with 13,500 people on waiting lists in 2020 and some people having to wait three years for an appointment.
Until relatively recently, the GICs had robust assessment systems. Only the most severe cases of gender dysphoria—discomfort with one’s sexed body—were referred for medical transition, since cross-sex hormones and gender surgery can cause sterility, sexual dysfunction and other complications. But increasingly, specialist clinics follow an “affirmative” care model imported from America, which eschews most assessment and takes each person’s identity claims at face value. The GICs do, however, still employ psychologists and psychiatrists for complex cases.
The pilot clinics aim to bring this affirmative approach to GPs. The Indigo clinic in Manchester, for example, will be staffed by GPs who will train others to prescribe hormones without detailed psychological evaluation. It describes itself as “a service designed by and for trans and non-binary people” that takes a “flexible view of transition”. It will initially support people on the waiting list for GICs, but then accept referrals from GPs and directly from patients. It expects to see 900 people per year by 2026. “If you are interested in taking hormones,” says its website, the service “can help from as early as your second appointment.” It can make referrals for mastectomies and connect people with the GIC in Nottingham for genital surgery.
Currently, GPs may choose to give a short-term “bridging prescription” to a trans-identified person who is already taking sex hormones bought online or whose life appears to be in danger. Indigo is sending GPs on a part-time “credentialling programme” run by the Royal College of Physicians (RCP), which aims to give them the confidence to go beyond such interim measures. Supporters point to NHS specifications on treatment for gender-identity issues published just before the pandemic, which are being used to guide care at the pilot clinics.
But the specifications raise troubling questions. Initial consultations should be with a “regulated health professional” (ie, not necessarily a doctor). A second consultation should be with a “medical practitioner or clinical or counselling psychologist (or by a supervised trainee)”. Buried in the appendices is the statement: “Psychological interventions will not be offered routinely or considered mandatory.”
“The danger is that [this approach] will sideline mental-health expertise and thereby not address co-existing mental health problems that might be worsening the gender dysphoria,” says Lucy Griffin, a psychiatrist in Bristol. The Economist’s requests for interviews with senior NHS figures about the pilots were declined. An NHS spokesman said: “Hormone treatment is only prescribed by a GP if, following a patient’s assessment appointments at a clinic, a specialist doctor diagnoses gender dysphoria. Anyone undergoing hormone treatment must have thorough tests and checks before and during treatment.”
As for the credentialling course, four current or past members of the RCP’s ethics committee have expressed concerns to The Economist about it. They say they raised questions and were ignored, a claim denied by the head of the committee. Alasdair Coles, a professor of neurology at Cambridge University, was on the committee until 2019, when it discussed the course, and he heard a presentation from its organisers. “We did not get the sense that gender medicine was open to scrutiny or self-criticism on standard medical criteria, such as side-effects and long-term outcomes,” he says. A spokesman for the RCP says the course is about “exploring the complexities of this subject”, and “supporting health-care professionals to support their patients in making choices”.
Many doctors are already uncomfortable with the direction of travel, let alone the idea that it should speed up. The new clinics “are following an ideology-driven—not an evidence-driven—agenda,” says Julie Maxwell, a paediatrician in Hampshire. “If I refer someone to a cardiologist, and they outline a particular treatment that I haven’t heard of, I take on trust that this cardiologist is practising sound evidence-based medicine,” says Louise Irvine, a GP in south London. “We make the assumption that the gender clinics have a similar approach. But actually, they don’t.” Many of the bodies representing and regulating clinicians do not seem to recognise the concerns on these issues or give adequate guidance, says Dr Irvine. The result is “an atmosphere of ignorance and fear”.
Another GP, who declined to give her name, says that doctors are now expected to talk about gender dysphoria as a sexual-health problem, rather than a mental-health one. That, she says, “is pretty ironic since, in treating it with cross-sex hormones and surgery, you are messing up a person’s entire sexual health”. She used to refer patients to gender clinics, but stopped. A third GP tells of a patient with serious mental-health issues who self-referred to a pilot clinic. It wrote to the GP saying that gender dysphoria had been diagnosed after one meeting, in which the patient requested orchiectomy (removal of testicles). It asked the GP to refer the patient for surgery at the local hospital. The doctor declined. “I suspect there is likely to be pushback from many GPs,” he says. ■