Maya Dhillon takes on April’s talking points – what responsibilities do GPs have in caring for transgender patients, and are we any closer to a national prostate screening programme?
What is the role of a GP in transgender care?
One non-GP news story that was hard to avoid this month was the Supreme Court’s ruling on the legal definition of ‘woman’. Following a lengthy battle, which began in 2018 in Scotland, five judges ruled that the Equality Act 2010 does not include transgender women when it refers to ‘a woman’. It refers to biological sex only, rendering gender recognition certificates obsolete for legal protection.
Whatever side of the debate you come down on, the ruling will have a significant impact. Not just on the so-called ‘culture war’/political football aspect of it all, but on substantial issues too; the NHS has already said it will review its policy on allowing trans women to be offered beds on women-only wards.
But the ruling also offers the opportunity to look at where GPs stand professionally on providing transgender healthcare. Prior to the Supreme Court’s judgement, the RCGP released a statement to clarify the role of GPs. The college stated that GPs should work with gender identity services in the same way they would with any other specialist service.
This also included consideration of prescribing under a ‘collaborative or shared care agreement’. It added that it does not consider a GPs role (in relation to children and young people) to involve ‘prescribing gender affirming hormones to address gender incongruence in a patient under 18’ and broadly supports the Cass Review’s recommendation that the GP’s role in the first instance is to refer either to mental health or pediatric teams. If a GP has additional expertise and feels confident to do so, they can offer a bridging prescription for adult patients who are waiting for an assessment from specialists – but this would be in the minority; the GP role should not include initiating prescriptions for a transgender patient before they have been assessed by gender identity services.
A few days later, NHS England issued a warning to GPs about shared care with ‘unregulated providers’ for transgender children. It stipulated that GPs should refuse working with providers not regulated by the CQC or Health Inspectorate for all hormone medication to children with gender incongruence.
This includes both puberty blockers and exogenous hormones. Prescribing the former, both privately and on the NHS, was stopped last year following the Cass Review. NHSE reiterated this in their statement, saying that GPs must refuse the private prescribing of puberty blockers, and ‘should’ refuse supporting an unregulated provider in prescribing and/or supplying alternative medications that could suppress puberty.
Though both NHSE and the RCGP’s statements are recent, the topics they address are not. For GPs, transgender care has been a source of concern for some time, and has left many feeling confused. This has been a long-developing story with an abundance of rulings and guidance published, as well as differing stances. While the RCGP welcomed the Cass Review, the BMA adopted a ‘neutral’ stance towards it in October, following a vote which overturned its position to ‘publicly critique’ the recommendations on treatment of transgender children.
Besides the various statements from the BMA/RCGP/NHS,complications also arise in the differences between: child and adult care; NHS or private provider; and shared care or bridging when it comes to initiating prescribing. All the moving parts, and the relatively small number of people needing this care, mean that many GPs will not feel confident in being able to provide care.
There’s also a very reasonable element of fear at play too. Trans rights are a highly emotive topic; in January, Pulse reported on a GP practice in Nottinghamshire that had faced protests from a campaigning group after it served notice on providing gender dysphoria medication and monitoring as the service was not contractual. GPs may fear that getting transgender care wrong may alienate patients in an already vulnerable group which could stoke breakdowns in doctor-patient relationships, or even official complaints.
Next week, GP leaders across the UK will gather to discuss transgender patient care at the LMC UK conference. LMCs will vote on demanding ‘clear’ national guidance on how to ensure transgender patients’ records are kept up to date. Though the motion is focused primarily on record details and administration, it will no doubt provoke conversation about the wider aspects of transgender care and how GPs can best support those patients.
Are we on the road to a national prostate screening programme?
The lack of a national prostate cancer screening programme has been an ongoing conversation for a while, especially given its prevalence – around 14% of all cancer cases in the UK are prostate. So, when the health secretary said he was in favour of a national screening programme for prostate cancer, it was significant.
Speaking to the parliamentary health and social committee, Wes Streeting clarified that any decision would have to be ‘evidence-based and evidence-led’; which is where things get more complicated. As everyone reading this will no doubt know, the way that symptomless men would be ‘screened’ is through the PSA blood test. However, there are a litany of issues with the PSA test: false positives causing unnecessary anxiety, further tests and uncertainty; false negatives giving false reassurance; and confusion about which type of prostate cancer a man has if a test comes back positive.
That final point is particularly relevant in the decision to not have a national screening programme. There is the aggressive form of prostate cancer which does kill people. But the more common one is harmless and slow-growing; those who have it die with it, rather than of it. A PSA test cannot discriminate between the two, so if they receive a positive there is no way of immediately knowing what type of prostate cancer they have.
This has been part of the National Screening Committee’s (NSC) argument against a national screening programme that operates as cervical or bowel cancer screening does. With prostate screening, the significant harms brought on by the psychological effect of unnecessary further tests and treatment may outweigh the small benefit.
But, while the NSC does not currently recommend a screening programme for prostate cancer, men over 50 can request a PSA test from their GP. It is a strange case, particular to prostate, that overrides policy. One could surmise that allowing this may be a political move from the Government to show that they are taking men’s health seriously. Indeed, last week the Government launched a call for evidence to support its new Men’s Health Strategy. The strategy is the first of its kind and has been developed to tackle ‘the stark inequalities’ in men’s health as well as the ‘unique challenges’ that men face throughout their lives – and prostate cancer is labelled as part of this.
There’s also the impetus of Sir Chris Hoy’s revelation last autumn that he has terminal prostate cancer. The NSC said, in the minutes of committee meeting in November, that it had ‘received increased calls to look at prostate cancer screening’ since he made his diagnosis public. This is not unprecedented – whenever a public figure announces a diagnosis, a national campaign to raise awareness for whatever the condition is tends to follow. Sir Chris has suggested that the eligibility should be expanded to 45 years, which could have caught his cancer earlier.
To his credit, Wes Streeting has recognised the pull of campaigns led by emotion. When speaking to the parliamentary health and social care committee, he said: ‘As politicians we have such a responsibility to sometimes resist the temptation to sign every petition or to sign up to every campaign. We’ve got to make sure that decisions we make are evidence led and evidence based.’
But there’s the rub – if you want to be led by evidence, then wait for the evidence to arrive. Professing a stance beforehand can do one (or both) of two things: put pressure on reaching a certain conclusion; and result in widespread public upset if the NSC does not recommend prostate screening. The NSC was already looking into it, but all of this – the health secretary’s view, Sir Chris’ diagnosis, and the Men’s Health Strategy – will pull it into closer observation.
If the health secretary believes in an evidence-based screening programme, then he will wait for the NSC to see if there is a good and viable way of delivering it. That might include looking specifically at risk groups (afro-caribbean men, or men with a family history of prostate cancer) or lowering the age down from 50. It might even consider doing away with the PSA test altogether. A recent study suggested that an at-home saliva test could be more accurate at assessing genetic risk of prostate cancer.
But even if the NSC were to recommend a national screening programme, implementation would not be immediate. Nothing would change in the meantime for GPs – the steady flow of men requesting PSA will continue, with notable increases when the media picks up on particular cases. A national screening programme would be popular, but it is vital that pandering to public/political pressure is weighed up with evidence and consideration for GP resource too.
