Saturday 21 April 2012

The GMC needs to explain why it is forcing doctors to provide sex change operations

The Mail on Sunday has today quoted my blog in a story titled ‘Doctors “forced to carry out sex-change ops” under rules meant to “marginalise Christian medics”’.

The article picks up on comments I made last week about new draft guidance issued by the General Medical Council which says that doctors who refuse to provide sex-change operations risk being struck off the medical register.

The new draft guidance, ‘Personal beliefs and medical practice’, was issued on Thursday and is subject to consultation. It warns that ‘serious or persistent failure’ to follow it ‘will put your registration at risk’.

The guidance recognises that ‘in some areas the law specifically entitles doctors to exercise a conscientious objection’ and opt out of ‘particular treatments or procedures’. It cites participating in abortion as a specific example.

It also allows doctors to opt out of providing other procedures or treatments provided that they ‘make sure that the patient has enough information to arrange to see another doctor who does not hold the same objection as you’.

However, the GMC makes a clear exception to this rule, with regard to sex-change operations.

Section 5 reads as follows:

‘You may choose to opt out of providing a particular procedure because of your personal beliefs and values.*’

But the asterisk refers to a footnote which states:

‘*The exception to this is gender reassignment since this procedure is only sought by a particular group of patients (and cannot therefore be subject to a conscientious objection – see paragraph 5). This position is supported by the Equality Act 2010 which prohibits discrimination on the grounds of gender reassignment.’

It then goes on to add the following:

‘But you must not refuse to treat a particular patient, or group of patients because of your personal beliefs or views about them†

Another appended footnote reads:

‘†The Equality Act 2010 prohibits discrimination on the grounds of nine protected characteristics: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation. ‘

The Daily Mail quotes an unnamed GMC spokeswoman saying that the new guidelines only reflected the ‘law of the land’. She said the Equality Act 2010 already prohibited doctors from discriminating against people who are undergoing gender reassignment treatment.

But do you see the problem here? She has not actually addressed the real question.

On the one hand the guidance says that doctors should not refuse to treat people because of their personal beliefs or views about them.

Absolutely right! If I have a patient who needs treating for pneumonia and or diabetes then I must treat them without any partiality or discrimination regardless of their ‘age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation’. It would be profoundly negligent to do otherwise.

But the guidance also says that doctors have no right to opt out of ‘providing’ the ‘procedure’ of ‘gender reassignment’ (ie. A sex change operation). Furthermore it claims that the Equality Act 2010 upholds this duty.

Gender identity disorder (GID) is the formal diagnosis used by psychologists and physicians to describe persons who experience significant gender dysphoria (discontent with their biological sex and/or the gender they were assigned at birth). It is classified as a medical disorder by both the ICD-10 CM and the DSM-IV TR and that is how many doctors still regard it.

On the other hand many transgender people and researchers support the declassification of GID as a mental disorder for a variety of reasons.

In other words there is a major debate going on currently between leading professionals about what Gender Identity disorder actually is. But the GMC has disregarded this and instead chosen to take one controversial view held by some people on the subject as the only acceptable view.

Gender reassignment surgery is legal in this country but remains very controversial. Many doctors in this country, for a variety of reasons, do not wish to be part of providing this procedure, either as surgeons or anaesthetists or as part of the referral pathway or pre-operative assessment.

But the GMC is now saying that they have a duty to provide it and have no right to opt out of doing so. It is also threatening them with being struck off if they do not comply.

That is a bridge too far.

This draft guidance not only imposes a duty on doctors which violates their professional freedom. But I suspect it also significantly over-interprets the law.

The GMC has some serious explaining to do. And quickly.

(A much fuller treatment of Gender Identity Disorder is available on the CMF website)


  1. I'd keep quite about the Daily Mail quoting your blog, if I were you. Having your thoughts quoted by a right wing, reactionary, hate-filled rag is not exactly a recommendation.

  2. It seems you know very little of the procedure and the hoops required to get GRS. You do not simply refer for surgery. It takes a very long time with psychiatric assessments, real life experience, hormone therapy and surgery which is undertaken by maybe 5 - 10% of patients. A surgeon working in this field is one who understands their patients and their condition.

    1. Yes of course I am aware of the psychiatric assessments, real life experience, hormone therapy etc involved in gender reassignment and have had quite a few post GRS people as patients myself but if you look at the GMC guidance (which is the actual subject of this blog) you will see that it is specifically talking about a 'particular procedure' and not 'treatment'.

    2. Actually, you're not 100% correct here. Only surgeons can carry out "gender reassignment" surgeries. They're the only doctors who are capable and have the knowledge to do so, and there are only 3 or 4 of these doctors in the NHS in the entire country. The way you're talking, it sounds as though you believe General Practitioners have the ability to do these procedures. Not true in the slightest.

      The only part of "gender reassignment" that GPs are able to do is administer/prescribe hormones. This is something that they should do - regardless of their religious beliefs.

      Nowhere in the Christian New Testament does it say "Thou shalt not give hormones to transgender patients." In fact, the New Testament (which contains all the "laws" Christians should be following - Christ fullfilled the Old Testament laws, remember) doesn't mention transgender people AT ALL. Therefore there shouldn't be any christian beliefs that go against any form of "gender reassignment", whether the "procedure" is the administering of hormones or surgery.

    3. It is true that GPs can only administer hormones. But why should they if it against their convictions? Just because you wish to have gender re-assignment does not mean I should be forced to give it to you. You can find some other GP to do it for you, without forcing me to do it. You are talking complete nonsense.

    4. And by the way, it has nothing to do with christian beliefs. I am a hindu, and anyway even atheists can have objections to these things. I don't like the way a minority of people are forcing their idealogies on the rest of us.

    5. Muir,

      I am fully aware that this is a very specialised field where only a few surgeons who are already committed to the procedure have the necessary skills (I am a surgeon myself and worked with a guy who did them) but the point is that under this guidance the duty to 'provide gender reassignment' will in practice affect everybody on the referral/treatment pathway and not just the surgeons - GPs, juniors, pre-op assessment etc and also those involved in caring for the large number who get reassigned hormonally but not surgically as Raghu implies.

      The key question is why there should be an absolute duty to comply and be involved with no opportunity of an opt-out from the process. This is what the GMC guidance is calling for and it is totally and utterly barking mad.

    6. I was using Christianity as an example because that was the "spin" used by the Daily Mail in their article. As for the Hindu religion, does it not consider those who are transgender to be tritiya-prakriti and thus an outward manifestation of the unlimited diversity of the universal creation? Several Hindu sects regard tritiya-prakriti to be semi-divine or at least touched/blessed by the divine.

      As for being "forced to give it", all the GP does is prescribe the hormones. It's a nurse who actually administers it. Would a GP have a problem prescribing HRT to a woman who had a hysterectomy or a man whose body didn't make enough testosterone? What about prescribing progesterone to a woman who needed it for either birth control or other medical reasons? Would a nurse refuse to administer the injections in these cases? If they can opt out of treating transgender patients who often need these treatments for both their physical and mental health, why not allow them to opt out of treating those who are not transgender who need the same treatments? Taking it even further down, would a medical centre receptionist be able to "opt out" of signing in a transgender patient - even if they were the only receptionist at the desk?

      Do you see how allowing GPs and others to opt out of treating transgender patients can quickly turn into something "totally and utterly barking mad"? Not to mention it would cause patients to have to change GPs, which for a lot of people is impossible to do.

  3. "On the other hand many transgender people and researchers support the declassification of GID as a mental disorder for a variety of reasons."

    So where do you stand on this, Dr Saunders? Do you believe that GID is a mental disorder? Would you opt to refuse to perform sex reassignment surgery on a patient if you were given the choice to do so?

    1. Yes I believe the DSM IV is correct in classifying GID as a mental disorder and I would refuse to carry out gender reassignment surgery if asked to do so.

    2. "Yes I believe the DSM IV is correct in classifying GID as a mental disorder"

      You're not a qualified psychiatrist, Peter, and your opinion is misinformed. I have gender dysphoria, something I have been aware of since adolescence, but it is most certainly not a mental illness. Standard psychological tests systematically confirm that my brain's gender does not correspond to my physical gender.

      "I would refuse to carry out gender reassignment surgery if asked to do so."
      I should hope so. It's very specialised surgery, and you haven't practised for over 10 years. In fact, since you're no longer a registered medic, it would be illegal for you to perform any surgery.

  4. Tell me Dr S - is the GMC really - and I use your own words - "forcing doctors to provide sex change operations"?

    Or is that a terminological inexactitude? What some would say is "bearing false witness" in order to push a particular religious viewpoint?

    Many doctors in this country, for a variety of reasons, do not wish to be part of providing this procedure, either as surgeons or anaesthetists or as part of the referral pathway or pre-operative assessment.

    That much is true. In fact, not just many, but most, an overwhelming majority according to the last reliable survey I'm aware of. In excess of 70%.

    They would rather see them die, though I think very, very few realise that that is the alternative in many cases. It is a specialised area, and very few have studied it in depth.

    Intersex people face the same problems. Many medics lack the competence to treat them, but even more have religious objections to their existence. They prefer to "pass by the wayside" as it were, to pretend that people whose existence contradicts a literalist reading of Genesis I, don't exist after all. Such people make them feel uncomfortable.

    Kudos to you for providing care to post-GRS people. Many with your beliefs would not. Even to stop them exsanguinating. They let Nature take its course.

    1. This is not about denying 'gender reassignment' to anyone.

      There are doctors already in this country who are willing to provide it, whether this involves hormone treatment or surgery. I believe that they are mistaken both about the nature of the condition and its treatment but they are acting within the law.

      My objection to this new draft guidance is that it makes 'providing' such treatment a duty that no doctor has any right to opt out of. Furthermore doctors who persistently refuse to be involved will be struck off the medical register.

      This I believe is correctly described as 'being forced' and is completely unacceptable.

  5. Frankly as a patient of transgender (m2f) treatment, most of what has been said here is utter utter bullshit.

    When I sought treatment I was told by the first two general practitioners that I couldn't ever qualify and that they would administer testosterone only.

    The third actually did some tests and discovered that my hormone levels were really odd (extremely high testosterone with a display of lack), then he told me that he felt that he couldn't correlate his beliefs with providing me treatment - he told me to go away.

    I actually had a legitimate hormonal condition, along with haemochromatosis (which he also tested for and indicated in notes, but didn't refer to in consultation), which he failed to treat me for either - in fact he put me down as actively homosexual (which I was not) so as I couldn't donate blood (New Zealand rules).

    The fourth actually referred me to a specialist - which is all that any general practitioner is ever asked to do.

    Only after that point was I ever diagnosed with anything, which took about another two years.

    None of this was ever any part of the decision making process for general practitioners, they don't have a say if a specialist administers treatment.

    General practitioners are not required to diagnose treatment to transgendered patients, they are required to administer treatment upon the advice of a specialist. in short, all a regular doctor is to do is to pass the patient on to a qualified individual, or alternately, yo provide treatment to the patient as recommended by the qualified individual.

    A general practitioner is no more qualified to refuse treatment to a transgendered patient then they are qualified to refuse treatment to a patient who has an urgent genetic condition which would cause a massive overload of saturated iron and subsequent multiple organ failure.

    If you don't get the reference then you shouldn't be a doctor - I nearly lost my life to an unrelated condition due to the fact that the doctor thought I was 'icky'.

    1. You don't give enough clinical details here to draw conclusions but there is a difference between the various conditions of 'intersex' where hormones already may be abnormal due to some underlying physical condition and GID.

      In practice, the GMC will see involvement in the referral/treatment pathway for 'gender reassignment' as part of 'provision' so this guidance as presently drafted will apply to GPs and all others involved in the referral/treatment pathway, for example junior doctors doing preop assessments and postop care.

      This is not about refusing treatment to transgender people. They should be treated like any other patients and given the right treatment when they are sick - obviously.

      This is about participating in a very controversial form of 'therapy' that many doctors believe is both clinically inappropriate and morally wrong. And the GMC should not be threatening doctors with being struck off if they will not comply. To do so is to undermine their professional integrity.

    2. There is a clear therapeutic pathway that is in place for the assessment and treatment for transgendered patients. This isn't something that has been made up on the spot by one person, it's a process which has been tested extensively.

      It's pretty clear with other pathways (for other conditions). If the condition is outside of the doctors experience, that the doctor can (in fact is 'morally' obliged to) admit this and to withdraw themselves from the therapeutic pathway in that case.

      What they can't (ethically) do is to overrule the present therapeutic pathway, or to fail to inform the patient as to how they should proceed. This is what happened to me the first three times I sought treatment for what I assure you is a legitimate condition.

      They also should not prescribe non-standard, or contra-indicated treatments, nor should they prescribe for conditions with which they are unfamiliar. As such the doctors who wanted to treat me hormonally with testosterone were in essence doing the equivalent to prescribing vitamin-C for bowel cancer (talking in terms of therapeutic pathways, if not potential lethality of their foolishness).

      As for my 'condition', I don't know what that means, you can only do so many tests before you have to just work with the symptomatic presentation, genetic testing is not as simple as most people make out, and is a whole lot more expensive too. My endocrinologist finally threw in the towel after testing something like fifteen genes for abnormalities, this after he was absolutely certain that something was seriously odd. I seriously doubt that you could diagnose me over the internet.

      For the effect of the 'controversial', 'inappropriate' and 'immoral' treatment on me, well it's working just fine thanks for asking. Funnily enough most of the transgendered people I know who are being treated are doing fine also, those who are not, well... not so much.

      What I don't get from what you wrote though is the problem with a junior doctor doing a pre-op assessment. Do they normally get to choose who they get to provide care to during a surgical rotation - wee Billy the racist doesn't have to hold hands with melanin proficient people for instance?

      Surgery is surgery, it's not generally a great time for the patient, and it's not really the ideal time or place to let peoples 'moral' qualms take over from standards of care. Boycotting the treatment (I use that word deliberately) of a class of patients surely runs counter to almost every ethical expectation that the public has of doctors.

      Surely a doctor on a surgical rotation, or an anesthetist, or a similarly skilled person cannot pick and choose their patients due to standards other than those immediately relevant to the task at hand, else they'd be refusing to treat gays, lesbians, people of *insert race/religion here* origin, etc.

      If (a lamentably sizable number of) doctors are enabled to refuse any and all treatment (look to the united states for examples of emergency personnel doing exactly this) to patients for so called 'ethical' reasons then you will be facing deaths.

      Lastly, You might be surprised by this, but many trans people who actually want nothing to do with the medical community due to the fact that we have been so badly treated by those 'paragons of virtue' (see, I can do scare quotes too). Myself, despite having a graduate school degree (after transition incidentally) and being well respected in my field, I will not go to a doctor I do not know for anything short of a life threatening condition as I know I will be subject to their whims - frankly I'd rather attempt to treat myself for minor stuff than go through that sort of rubbish again.

    3. I am well aware of the 'treatment' pathways and of the discrimination against transgender people. I have had a number of post GRS patients myself and always treated them with respect and never withheld treatment that they needed. But I would not support GR or GRS for people with GID.

      There are a number of intersex conditions (usually understood to be congenital, involving chromosomal, morphologic, genital and/or gonadal anomalies, such as diversion from typical XX-female or XY-male presentations, eg. sex reversal (XY-female, XX-male), genital ambiguity, or sex developmental differences) which need very careful management however and some do require surgery if they have ambiguous genitalia. But this is a very specialised area.

      It is very important to ascertain the correct diagnosis before embarking on any treatment.

      GID, however, is not one of these conditions and I believe it is different.

      There are doctors who treat GID patients with gender reassignment. I have serious reservations about this as I have described above and I do not believe that doctors should be forced to comply as the GMC is suggesting.

      The appropriate course, if the patient is adamant about what they want, is to inform them of their right to see another doctor.

  6. I actually agree with your final statement, in the case of a general practitioner - if they feel unqualified (for whatever reason) to provide treatment to a patient for whatever reason then they should inform the patient of this and refer them on to somebody who is.

    A doctor in a recovery ward on the other hand specifically 'is' qualified to provide post operative medical care in the form of medications for infections, wound dressings and suchlike - to refuse to do so is churlish and obstructive at best.

    As you say that you have had a number of post operative gender reassignment patients you must be aware that the diagnosis process is a lengthy one - for me it was some two years to receive hormonal medication, that after I got past the doctors who obstructed the treatment as was referred to a sympathetic endocrinologist and mental health team.

    It's not a case of the patient saying they think they're trans and being told to hop up on the table.

    As for genetic, morphological, and other intersex disorders, that is a red herring, very few trans patients are ever diagnosed with those conditions, though many are tested. I didn't raise that as some sort of an example of my supposed suitability for treatment, but rather as an example of what a doctor ignored in their rush deny me treatment, The iron overload alone should have been a huge red flag (>60%), but was ignored as an inconvenient detail. As it happened, my mother, a medical receptionist, noticed it.

    Perhaps you are a reasonable and genuinely sympathetic person who will do their best for a patient within certain bounds, but I'm sure that you are quite aware that the pre-existing discrimination within the medical community towards GBLT people is a problem which needs to be addressed.

    The reality for doctors is that transgendered people aren't terribly common (Ca. 1:2500 or thereabouts, right?), and that even when a transgendered person makes contact it's not likely to be to beg for the doctor to start treatment, after all, most of us get the flu every other year, but undergo GRS only once. It's not like there's going to suddenly be 25 trans people coming in each day asking for surgery in your average practice.

    Prescribing hormonal medication to a post-op patient who is already on it and is thus dependent on it is also likewise hardly a huge ethical issue. The reality is that most trans people will go to more than one GP in their seeking treatment, if every doctor who refused to treat trans people (or even gay people) was struck off then you'd probably be able to charge one hell of a lot more for your services then you do - the estimation of +/- 70% of doctors turning trans patients away further up the pace actually sounds about right.


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