GP knowledge, process and referrals

Young people we interviewed had mixed experiences with their General Practitioner (GP) and their GP surgery. People talked about their GP’s knowledge of trans healthcare and how this impacted their experiences.

They talked about GPs’ knowledge in the following ways:

  • Knowledge and understanding
  • Training
  • Referrals
  • Wrong information
  • Acting as your own practitioner

Knowledge and understanding

Young people said that a GP’s knowledge, understanding and training was important in understanding their care. Many said their GP’s knowledge of trans healthcare was often poor or inadequate. G described their GP’s knowledge as ‘non-existent’ and their general attitude as ‘apathetic’. Charke said, ‘I don’t think [my GP] really knew anything at all… his knowledge was non-existent’. Reuben described his experience of GPs knowledge of trans healthcare as ‘awful, I mean [the GP] even said that he had no idea what he was doing.’

Sally felt that ‘there’s no real understanding of just like what the process even is to begin with. Some GPs, they don’t even have that basic knowledge.’ Bailey said ‘they’re a bit like, “What? I don’t know that, I’m just gonna leave that to the professional” cause they’re not in that field’. Begam said her GP’s knowledge was ‘very limited, very poor but he does signpost me to different providers, like trans sexual health [service]…but his knowledge was very limited.’

Henry says a lot of healthcare professionals can hide behind a mask of general ignorance and unwillingness to educate themselves.

Age at interview 25

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Some young people were satisfied with their GP’s knowledge. Loges said his GP ‘has quite a good knowledge [and] she’s always quite respectful to me.’ He added, ‘she’s never really asked any questions I wouldn’t really wanna be asked’. A few people appreciated their GP’s willingness to learn. Alistair said his GP said ‘she didn’t know anything about it and [asked whether I could] come back for another appointment when she knew more.’ PJ said his GP ‘was really open [that] she had no idea what she was doing, which I found is a regular thing. But she was really open to [making a referral] she was really supportive’.

Henry said,‘My first GP that I spoke to initially about wanting to be referred to a gender clinic was not very well informed but lovely and supportive, and willing to learn I think, and was very pro-active.’ Jay said his GP admitted that her knowledge of trans healthcare ‘wasn’t great’. The GP said ‘she was gonna do her own research and everything’ before the next appointment.

Training

People discussed a number of reasons why their GP’s knowledge could be poor. For some it was a lack of experience working with trans patients. Jaz felt that ‘a lot of it just depends on the number of trans patients they’ve seen’. People often felt awareness training could be improved.

H said that when he raised healthcare needs with GP ‘[the GP] was like, “No, no,” he was like “No I can’t do it cos I’m not trained in this.”’ Jay said, ‘I think [my GP] was a bit uncomfortable with it. It seemed like she hadn’t really had any training on the topic.’ Michelle said, ‘There needs to be more training because the [GP] didn’t know what he was doing’. In her view GP training should involve ‘getting some folks in, diversity role models… from a trans organisation somewhere, for over a lunchtime talk about trans stuff, to train a lot of NHS staff’. Ezio said, ‘It would be nice if there was a [mandatory] course’.

Shash describes the racism in medical training a lot of [people of colour] learn to hide pain.

Age at interview 23

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Young trans people of colour also discussed how medical training did not address race and ethnicity. Shash felt that ‘more emphasis’ could be put on medical racism. In particular, ‘the understanding that there [are] differences in the sense of what ethnicity means, and like risk factors and stuff like that.’ She added ‘medical racism is something that needs to be taken seriously, especially… now, with not only the Black Lives Matter movement, but also Covid, it’s terrible’. N said ‘One thing I’ve always really struggled with, [with] GP’s anyway, [is] to ask for what I need, I think that’s about the intersection of class and race and that’s something that doesn’t get [talked about]’. Read more about feeling valued and heard in GP surgeries.

Referrals

For young people under the age of 17, referrals are accepted by the Gender Identity Development Service (GIDS) through a number of routes including a local Child and Adolescent Mental Health Service (CAMHS), as well as other health, social care, and education professionals, and commonly through GPs. More information can be found at GIDS. For trans people over the age of 17 referrals are accepted at Gender Identity Services (GIS) by GPs and other health professionals. For more information see GIC [London].

Some people reported experiences where their GPs didn’t understand the process of referral. Some said GPs relied outdated information. A psychiatric assessment is not required for trans patients over the age of 17 asking for a referral*.

Kat talks about her positive experience of her GP making a referral to the GIC.

Age at interview 15

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Other people talked about their GPs not following this. Noelle said her GP ‘was quite insistent [that] he wouldn’t give me the referral [to gender identity services] unless I did the psychiatrist appointment’.

Ari said, ‘Both of the GPs I’ve encountered have had wildly out of date information on referring people and how to refer.’ They said ‘considering that is essentially now the primary role a GP plays in trans healthcare, I wish they knew more about it in general and they were kept up to date.’ Bay felt ‘very fortunate’ their GP ‘has a decent awareness of [trans healthcare]’ and was ‘very understanding’ of the steps to take. They appreciated there was no ‘resistance to getting a referral… that was all very smooth.’ Bay said their GP ‘has known as much as he has needed to know’. They said the key bits of information were ‘the process of referral… a decent awareness of the potential impacts of testosterone… knowing what to look for on blood tests and what blood tests to run and stuff like that.’

Ari talks about the change in guidelines for referral trans people [over 17] to the gender identity services.

Age at interview 23

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Wrong Information

Some young people talked about their GPs relating gender identity distress solely to a mental health disorder*. Max said his GP ‘was gonna put me through counselling at first [which] just made me think that all of this is like a disorder thing.’ Ezio  went to his GP ‘about getting referred to the gender clinic… and [his GP] kept looking through my notes and bringing up the fact that I had depression’. Ezio said, ‘[The GP kept trying to prescribe anti-depressants and it took me a good 20 minutes [to say] I just want you to refer me to the clinic.’ People also felt GPs conflated gender identity distress with general body dissatisfaction. CJ said ‘I went to my GP and I went, “I think I’m trans.” And she said, “Oh. Are you sure you don’t just want to lose some weight?” And I said, “No, no, I’m pretty, pretty confident that my issues with my body aren’t weight related, but thanks for that.”

Some people experienced GPs relying on media coverage. Jay said  his GP refused to prescribe hormones; ‘I felt like everything was just crashing down on me’. He said his GP ‘said that the doctors had been reading articles on the BBC and places like that about detransitioners. They had then decided for me that I might change my mind and they didn’t want that. So, that was why they decided not to prescribe’. He said ‘it was just awful to hear’.

Noelle talks about her GP not allowing a referral to the gender identity services without seeing a psychiatrist.

Age at interview 23

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Young people said that being given wrong information and advice contributed to a lack of trust in GPs and healthcare professionals. Rahul described  ‘a lot of very misinformed nurses and GPs that have straight up told me that I can’t do things that I know that I can do or told me that I should do things that I know that I shouldn’t’. He said ‘you kind of have to take everything with a grain of salt’ and ‘it makes you very distrustful of the sector in general.’

Freya talks about weighing up online information about trans healthcare with information from health professionals.

Age at interview 21

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Acting as your own practitioner

Many  people felt they had to provide knowledge and information to GPs. PJ said that usually GPs ‘don’t really know what they’re doing, and you have to kind of explain it to ’em.’ Sally said that her GP asked questions such as “I hope I’m doing the right thing. Am I doing the right thing? Is this what I’m supposed to be doing?” She said ‘it’s always a bit concerning’.

People felt this was often the case when a young person was a GP’s first trans patient. Declan said, ‘I was very unfortunate to be [his GP’s] first [trans patient]’. He said ‘it showed because you had to like tell them everything. They didn’t really get it and you kind of had to come out and tell your story every single time you went in.’ Ari said ‘for both of my GPs, I was their first trans patient.’ Ari said they felt it was their responsibility ‘to bring [the GPs] up to date on treatment pathways and terminology and all that sort of stuff.’ They said it was ‘quite a lot of emotional labour.’ Noelle said she ‘did a quick search [online] before going into the GP appointment’. She said ‘I had read all the [trans healthcare] documents…and that only took me like a couple of hours…it wasn’t that hard.’

M says Information related to trans healthcare is difficult [because] you have to be your own healthcare advisor.

Age at interview 25

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Henry says its exhausting’ always having to assert your own power in order to get the support that you need.

Age at interview 25

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G talks about their wish for healthcare professionals to be experts in trans healthcare rather than relying on the patient.

Age at interview 23

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Explaining to GPs was a stressful and frustrating experience for those we interviewed. Rahul said that GPs and nurses ‘don’t really want to hear it because they don’t want to be told that they don’t know what they’re doing, but they don’t know what they’re doing. So it’s a very frustrating experience.’ He said ‘I quite often avoid just going to the GP with my actual health problems’. June said he has brought his GP ‘pages of research to look at and printed out articles and stuff’. He said ‘I really felt like I had to like educate her from the baseline, she obviously didn’t ever work with a trans person before’. He said ‘it would have been okay if she was a little bit more empathetic but she was incredibly patronising’.

Patrick found taking on this role gave him more confidence. He said, ‘Now that I’m more confident in myself and I know what I am entitled to in terms of healthcare it’s a lot easier because I go in knowing what I need and what I want’. He said if [the GPs] aren’t willing to give it to me I will challenge them on it… I go in with the knowledge which has made it easier [and] it means I can sort of stand up for myself and fight for what I’m entitled to.’

Ezio says about trans healthcare, we haven’t been told this by a medical professionalwe’ve had to go out and research ourselves.

Age at interview 23

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Patrick feels that when visiting the GP he always has to do the explaining.

Age at interview 20

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See also:

Experiences of GP surgeries

Views on improving healthcare

Race, culture, religion and healthcare

Experiences of Gender Identity Development Service (GIDS)

Experiences of Gender Identity Clinics (GIC)

* Most recent guidance explains that gender identity clinics “obviate the need for any psychiatric assessment in advance of referral. Gender dysphoria is not a mental health disorder.” (Barret, 2017).
Barrett, J., 2017. Gender dysphoria: assessment and management for non-specialists. BMJ, 357.

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