Gender Identity Clinics requesting practices sign an MOU
We are receiving increasing queries from practices who are being asked to sign an MOU with a Gender Identity Clinic.
Our stance is that this is an inappropriate request as it includes monitoring and prescribing responsibilities being passed to general practice. An MOU is also not an appropriate form of agreement between the provider and general practice.
We are aware the commissioned service is insufficient as it does not currently include a prescribing and we have requested NHSE change the contract to include this. It is not the responsibility of general practice to pick up the prescribing by default and instead the service and NHSE should be looking at other solutions.
In the menu above please see our letter to the GIC clinic.
It depends on the request and your comfort and confidence in providing the care requested.
You should not be considering any form of shared care with a private provider UNLESS they are CQC registered and the request is coming from a UK registered individual healthcare professional.
Please see recent NHSE guidance regarding unregulated providers for children and young people.
Please refer to the RCGP and BMA guidance above.
From NHSE guidance
“GPs must cooperate with Gender Identity Clinics and other gender specialists by prescribing medications, providing follow up and making referrals as recommended by those specialists
It may be appropriate for a GP to issue a prescription where an individual is already self-prescribing via an unregulated source, and where the prescription is intended to mitigate a risk of self-harm and is supported by appropriate specialist advice”
‘GPs are therefore advised to consider each request on a case-by-case basis to satisfy themselves that
- the request is from a reputable company that provides a safe and effective service; and
- the circumstances of the request for the particular individual meets the general principles of the General Medical Council’s “Good Practice in Prescribing and Managing Medicines and Devices”; and
- that the health professional making the request is an appropriate “gender specialist”.’
Exceptions are where
- The GP is not sufficiently confident to prescribe unfamiliar meds.
- If ‘the GP is not assured that the provider offers a safe service or is not assured that the request has been made by an appropriate gender specialist.’ (this would include the provider not being willing to provide the details of who the clinician is, see guidance page 3 for more details) Even here though there’s a caveat that the GP could only decline on those grounds ‘as long as the GP is also satisfied that declining responsibility would not pose a significant clinical risk to the individual’.
If your patient is under 18 please refer to the information below regarding legislation on puberty blockers.
Please note the recent legislation regarding prescribing to under 18's.
Regulations have been introduced to restrict the prescribing and supply of puberty suppressing hormones / gonadotrophin releasing hormone (GnRH) analogues to children and young people under 18 for the purposes of gender dysphoria / gender incongruence.
The ban means that no new patients under 18 will be allowed to begin use of these medicines for the purposes of puberty suppression in those experiencing gender dysphoria/incongruence, outside of designated specialist NHS services.
gov.uk page - Extension to the temporary ban on puberty blockers
NHSE guidance and the Legislation
From 26th June 2024 no new under 18's should start on GnRH treatment.
Guidance on shared care agreements with unregulated providers for children and young people with gender incongruence
NHS England has cascaded new guidance that advises general practitioners against shared care agreements with unregulated providers in relation to hormone medication to children and young people under 18 as a response to gender incongruence / gender dysphoria.
The guidance outlines that:
- A GP must refuse to support the private prescribing or supply of GnRH analogues.
- A GP should refuse to support an unregulated provider in the prescribing or supply of alternative medications that may be used to suppress pubertal development.
- A GP should refuse to support an unregulated provider in the prescribing of exogenous hormones.
The cascaded letter states an unregulated provider is one that is not registered with, or regulated by, a UK health regulator such as the Care Quality Commission or Health Inspectorate Wales. More information is available in the letter (available on Connect NoW).
In all cases, safeguarding measures should be considered where the administration of a medicine from an unregulated source presents an immediate safety risk.
we have a template letter available to push back on requests for monitoring
The process for when a patient wishes to change their gender/title/name on their medical record is a national one carried out by PSCE. It is very similar to the current adoption process.
These processes are under review by NHSE nationally, however until this review is concluded the current process on PCSE should be followed.
Please note this process is for over 18's only.
Following the Sullivan review there should be no re-assigning of gender and sex identity in medical records for children and young people.
Following the review there is likely to be a change in the process for adults as well but this will need some working through with the various related pieces of legislation. The recommendation of the review is "The NHS should cease the practice of issuing new NHS numbers and changed ‘gender’ markers to individuals, as this means that data on sex is lost, thereby putting individuals at risk regarding clinical care, screening, and safeguarding, as well as making vital research following up individuals who have been through a gender transition across the life course impossible. In the case of children, this practice poses a particularly serious safeguarding risk, and should be suspended as a matter of urgency."
Current Process 1/4/25
Links to PCSE Guidance are available here:
It is a patient’s choice to change their gender on their medical record. This can be done at any stage and should be honoured. Changing gender on the medical record from an administrative point of view has no legal standing, patients can choose to do this without following the legal process to change gender.
Patients are also able to request they be referred to as their chosen gender(pronoun) and use a different name/title without having their gender changed on their medical record (even if they have fully transitioned).
However, if a patient follows the legal process of getting a ‘Gender Recognition Certificate’ by a ‘Gender Recognition Panel’ then they have legally changed gender and at this stage they must change their gender on their medical records. Once their certificate is issued they cannot choose to only change their name/title, they have to change their gender as well, and get a new record with new NHS number.
Changing a patient’s gender cannot be done through their current record. Instead, the patient will be given a new record and NHS number with their new gender.
The practice then needs to copy across all previous medical information and any significant codes will also need to be recorded within the new record to support on-going care. The standard process is that this is done without references to their previous name/identity/gender in the new record. Before redacting their record, practices should have a discussion with the patient regarding their preferences around redacting their previous name and pronoun from their medical history.
To provide safe and appropriate care the full medical record should ideally be transferred. It is likely to be clear from the content of previous consultations/letters/results that the patient has transitioned. As such the benefit of redacting name/pronoun is limited. If the patient consents practices can attach their entire unredacted former record to the new record, with the appropriate consent recorded.
If there are any elements of the patient’s previous medical record they do not consent to being transferred then they should be made aware of the potential impact of not having a full medical history when providing ongoing care.
Before changing a patient’s gender it is advisable to have a detailed conversation with the patient regarding their medical history and the implication of all previous medical information not being transferred to their new record could have on their on-going care, so they can make an informed choice. The process is not reversible and if at any point they wish to revert back to their previous gender this requires a third NHS number and third medical record.
The NHSE guide on Screening for trans and non-binary people also contains information the patient needs to bear in mind when making their decision.
Currently national screening recalls are based on gender, not the presence of organs. If gender is re-assigned in the medical record, recall for screening linked to their previous gender becomes the responsibility of the practice. A new process to manually add patients to the national recall is now available for cervical screening but not the other screening programmes. Patients should be made aware that if they change GP practice, they need to ask to be recalled for these screening tests.
The new opt-in process for transgender and non-binary people to receive automatic routine invitations is now live. GP practice managers and screening providers, including sexual health clinics and transgender services, should now begin to identify and invite eligible participants for a consultation to discuss the opt-in.
A guide outlining the process to be followed, and a recording of the recent NHS England webinar which describes the opt-in can be accessed on FutureNHS (login required).
The NHSE guide on Screening for trans and non-binary people also contains information the patient needs to bear in mind when making their decision.
Currently national screening recalls are based on gender, not the presence of organs. If gender is re-assigned in the medical record, recall for screening linked to their previous gender becomes the responsibility of the practice.
As per above information PCSE piloted a way to manually add patients to the national recall for cervical screening which is now avaialble nationally. But this only covers cervical screening currently.
Patients should be made aware that if they change GP practice, they need to ask to be recalled for these screening tests.