Our second presentation to MPs and Lords in Parliament

Why I do not prescribe cross-sex hormones as a GP

I am the GP who wrote the Anonymous blog for Nick Wallis A message to you, GPs – Gender Blog Some of the content from my talk will be found there. I have witnessed the irreversible harms caused by cross sex hormones and the distress it causes to patients.

Effects of Oestrogen in males

• Weight gain

• Infertility

• Ischaemic Heart Disease

• Pulmonary embolism

• Ischaemic stroke

• Early mortality

• Increased risk of Breast Cancer

• Reduced libido

• Erectile dysfunction

• Mood changes e.g. anxiety, depression.

• Reduced bone density

Effects of Testosterone in females

• Virilising (wanted side effect but irreversible)

• Weight gain

• Endometrial hyperplasia (risk factor for Endometrial Cancer)

• Urogenital atrophy (can occur within 6 months of treatment)

• Stress incontinence (pelvic floor dysfunction)

• Sexual dysfunction

• Infertility

• Mood changes: irritability, aggression. Depression, psychosis

• Unexplained persistent pelvic pain

• Ischaemic Heart Disease (raised BP, Polycythaemia and atherogenic changes in lipid profile)

• Strokes

• Possibly breast cancer and ovarian cancer

• Increased mortality

Patients are not being fully informed of the irreversible harms by Gender Identity Clinics as evidenced by my experience in general practice.

Patients cannot give fully informed consent. GPs need to know the long-term harms of exogenous hormones to enable patients to give fully informed consent. The GMC states that you must give patients the information they need or want to make a decision, which includes potential risks and benefits. ‘You must’ is used in GMC guidance for a legal or ethical duty you’re expected to meet (or be able to justify why you didn’t). Due to a lack of robust long term data fully informed consent is not possible.

Medicines are used off licence. GMC prescribing standards state that if proposing, prescribing or providing an unlicensed medication you must be satisfied that there is sufficient evidence or experience of using the medicine to demonstrate safety and efficacy. Can this be said in child and adult medical transition? We have not demonstrated safety but we know enough about the irreversible harms to not prescribe.

GPs are not competent. The GMC Good medical practice guidelines state that to be competent you must keep up to date with guidelines. GP guidelines are inconsistent and based on weak evidence such as WPATH. They do not incorporate the Cass Review.

Lack of clinical governance. Most Gender Identity Clinics discharge patients into primary care with no long-term follow up. This is unsafe and will lead to more long-term harms.

Litigation. GMC prescribing guidelines require GPs to be responsible for the prescriptions they sign so liability for harms will lie with prescribing GPs.

The US Health and Human Services report describes in detail the harms of puberty blockers and exogenous hormones. It also goes into detail as to why WPATH should be discredited as an evidence base for patient care.

Considering all of the above, I do not believe clinicians within Gender Identity Clinics are competent to prescribe. The RCGP position statement on The role of the GP in transgender care states that the UK lacks a nationally recognised training programme for ‘gender identity healthcare’. How can they be competent if there is no consistent evidence-based training? Would this be allowed to happen in any other speciality in medicine?

Conclusion. The current approach to care in gender questioning patients is flawed and harmful. The Cass Review need to be implemented and I question whether any doctor is truly competent to prescribe considering what I have mentioned, including those within Gender Identity Clinics.

As someone replied on our twitter timeline, ‘I expect this to be a scandal in the future. We really don’t act like this in other areas of medicine’. What if cardiologists ran their departments like this? The trusts would not allow this as there would no doubt be litigation due to patient harm and increased mortality, but data points to this already happening in medical transition.