Tavistock and Portman, the UK’s largest gender identity clinic, said refusals to prescribe HRT were a “frequent occurrence” but it was not able to provide the relevant data due to the format it was held in. The Gender Identity Service in Leeds said it had experienced an increased number of GP practices that were unable to begin or continue prescribing HRT. It also could not provide specific figures.
The picture is complicated by the fact that some trans+ people opt for private services. Different NHS practices will have their own policy on whether they collaborate with private healthcare providers. Gender Plus, a private provider, told TBIJ that 35% of the adults it had recommended HRT prescriptions for received these privately, not from their NHS GP.
Not enough funding
One reason cited – both to patients and to services – by GPs who have declined to provide care for their trans+ patients, is a lack of funding.
It was reported by the Health Service Journal in November that prescriptions, including for mental health conditions and eating disorders, were being cancelled by GP practices, potentially as a form of “collective action” in response to a lack of funding. The article cited a letter written by GPs in Dorset in which they said they would be declining “shared care” requests including those relating to gender dysphoria.
A spokesperson for the British Medical Association, told TBIJ that the “collective action” is about GPs “stopping work that is not properly paid for or resourced”, adding that it recommends alternative arrangements are put in place by NHS Commissioners so patients are not “adversely impacted by these actions”.
“Overstretched practices continue to do a considerable amount of work that is not commissioned by the NHS but should be,” they said.
“Many GPs are not trained to provide the specialist care these patients need and therefore fear risking patient safety. Because of this, some are refusing to take on new shared care agreements until there is a proper agreement that protects both patients and practice staff.”
Before 2022, the responsibility for starting and monitoring a HRT prescription rested solely with GPs. Then two years ago, some NHS gender clinics became able to prescribe directly to their patients for a limited period before transferring to GPs. But they aren’t designed to prescribe and monitor HRT for their patients on a long term basis.
Sussex is one region in England where extra money is available for GPs to provide gender-affirming care, including paid training and additional funding per patient. But, despite the extra cash, prescription refusals still occur.
The Cass Review
Multiple sources working within gender services and primary care told TBIJ that HRT prescription refusals or withdrawals have become more frequent in the last year. They believe the Cass Review, and the response of the Royal College of General Practitioners (RCGP), have contributed to the issue.
The RCGP updated its official position on transgender care in April in response to the Cass Review. It stated that GPs should “work with the gender services in the same way as with any other specialist” and called for the ongoing care of trans+ people to be adequately funded.
However, it also said that the RCGP would support GPs who felt their workload prevented them from providing such care for trans+ patients. The General Medical Council contacted the RCGP in May, warning that its statement risked introducing unfair discrimination.
Five months later the RCGP updated this statement again – removing the sentence that supported individuals from refusing care due to workload and clarifying that the statement was not meant to apply to patients who already had established HRT prescriptions.
A spokesperson for the RCGP told TBIJ: “The care of transgender and gender questioning people is a complex area of medicine and the RCGP has members with widely diverging views on the issue.”
It added that its position statement had been “rapidly” updated in response to the Cass Review. After reviewing feedback it had received following this update, it made some clarifications and “minor edits”.
“The College remains strongly committed to the improvement of services for patients with gender incongruence,” the spokesperson said.
Duncan, a GP for Sussex Gender Service, a NHS adult gender service pilot scheme said: “The Cass Review made recommendations for people up to the age of 25, even though it was a review of children’s [gender] services. I think those issues have confused the picture somewhat and I think GPs are genuinely scared that they’re being asked to do something that might potentially be breaking the law.”
Duncan told TBIJ: “[Some staff] don’t care about our community and they can get away with it because they’re emboldened by the rhetoric in society and politics. And I think part of it to be fair to them is that they are beleaguered, they are already overstretched.
*Names have been changed