RC for GPs scraps GIRES developed course

[CallingDannyBoy]

Does anyone have a share token for this?
www.thetimes.co.uk/edition/news/training-guide-pushed-gps-to-endorse-gender-swaps-0v28x07v8

The Royal College for GPS has scrapped an online course developed by GIRES and available on the RC website. It cites GPs with no or limited experience of transgender patients wishing to transition being reluctant to prescribe drugs because they do not have sufficient training and experience. The RC removed a reference to Mermaids as a defence or resource point in the training and GIRES objected to this.

This is a good step forward - growing unease with Mermaids and GPs ding uneasy with being asked to prescribe treatment they are not comfortable with. GIRES are painting it as denying treatment to transgender patients.

Yes. Which is why it's annoying that it seems the NHS has the infrastructure to record sex and gender identity, but has deliberately chosen not to.

More likely the NHS was lobbied by politicians and single interest groups to do this.

see Anne Harper Wright's work:
www.mumsnet.com/Talk/womens_rights/3396859-Weve-been-lied-to-about-Single-SEX-wards-since-2010

There are older people who have continued to use drugs though since the 1960's!

Yes understood, and this is why the question is there. Health issues amongst the elderly are very influenced by lifestyle. But the sort of old lady who giggles when asked if she is asked about pot, may be completely convulsed when asked if she is really a man. Apparently also some people react quite agressively to the questions as they stand. But all the same problem. People having their records sealed, and perhaps not revealing in A&E that they have been on heavy doses of cross-sex hormones, are taking the same sort of risks as someone who fails to reveal they are a heavy drinker. Doctors cannot see into people's souls.

And why training needs a medical focus, ideally using current knowledge about things like possible side effects from long term hormone use (check bone density, perhaps), and how to phrase any question about natal sex to help ensure you get an accurate answer. Training should not simply be a nice little earner for those on the "trans" speaker circuit. Nor an occasion for lobbying for "acceptabnce" or changes in NHS policy.

Did anyone look at the GIRES training course that was supposed to give GPs enough knowledge for them to treat and/or prescribe to gender variant children and adolescents? This course, which looks more suited to an 8/9 year old, carried points for CPD and successful completion (correctly answering 8/10 multi-choice questions) was recognised by a certificate.

Good grief, I do hope other GP training is not of this caliber!

cs1.e-learningforhealthcare.org.uk/public/GEV/GEV_01_001/story.html

And the test questions for that certificate

Yes understood, and this is why the question is there. Health issues amongst the elderly are very influenced by lifestyle. But the sort of old lady who giggles when asked if she is asked about pot, may be completely convulsed when asked if she is really a man

Which is why medical records must include sex M/F and this fact remain unchanged. It protects both patient and HCP.

There will also be older people who are male transpeople and may present as 'giggly old ladies'

Yes, and transpeople who refuse to accept/acknowledge their birth sex.

Not dissimilar presumably, when trying to diagnose, to the way alcoholics may deny they drink. Which is why good apolitical and fact based training is important for health professionals.

More likely the NHS was lobbied by politicians and single interest groups to do this.

I completely agree, and I feel this is very much a top-down policy. I was sarcastic when I asked whether transactivists have written the official policies .

But I keep going back to the second Anne Harper-Wright essay about "your medical record and your ladybrain," and I feel that it is clear the NHS foresaw this confusion and took steps to mitigate it by creating two categories to capture accurate data. But nobody seems to actually be using that architecture properly?

I think the NHS should probably urgently consider that whilst their sex and gender design guidance was exemplary, their execution of it has failed, horribly, and that failure is now exposing patients to actual, physical risk.
The NHS have monumentally screwed up here. There are very real risks to having patient medical records that do not capture sex, but which instead log only purported masculine or feminine feelings, changeable at will, or at the careless keystroke of an administrative assistant or busy healthcare professional. And a field which can be altered and edited easily is a field which exposes a patient to risk. Should sex be easily editable? No, it should be cast-iron locked down, and it should be the field used for every significant clinical application. And it should be sex, not gender that is the measure used to analyse patient outcomes for diseases, treatments. And it should be sex, not gender, that is the characteristic used to segregate wards for privacy.

medium.com/@anneharperwright/sex-gender-the-nhs-bb86b0c3ebb

And then you have the GMC guidance which says:
A patient’s request to change the sex indicated on their medical records should be respected; they do not have to have been granted a Gender Recognition Certificate or have acquired an updated birth certificate for this to be changed.
and
If your patient is to be issued with a new NHS number which has no reference to their sex at birth, you should explain to them that they will not automatically be contacted regarding current or future screening programmes associated with their sex at birth, and discuss the implications of this. Decisions about screening should be made with patients in the same way as any other decisions about their health.

www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare---advice-based-on-gmc-guidance#confidentiality-and-equality

I appreciate this is transactivist-led, but I still don't understand how you can apparently have an information system designed to capture both gender identity and sex, because people anticipated this problem, yet the GMC (tasked with keeping the public safe) says you can change "sex" on demand and that your actual biology can be permanently erased from your medical record....

Perhaps I am just angry and disappointed.

was sarcastic when I asked whether transactivists have written the official policies wink.

No you’re right. TRAs ARE writing medical guidelines. It’s unprecedented.

Nowhere else does this happen. You don’t get cardiac patients writing drug guidelines- anynother patient group is consulted on things like ‘how can we design this insulin pump to fit your lifestyle better’ - not ‘formulate the insulin prep for us and design the studies to test it.’

Thingy

That has given me the rage.
Doesn't anyone do any quality assessment of these training courses?
I find it hard to imagine any of the doctors I know taking that shit lying down but perhaps by the time they have signed on and sat down to do it they roll their eyes, tick the boxes and add another hour or so to their cpd log.

Tbh we get questions of that calibre for a range of annual cpd stuff. Fire training "What should you do if you see a patient smoking?"
A Leave them to it
B light up and join them
C throw a bucket of water over them

No you’re right. TRAs ARE writing medical guidelines. It’s unprecedented.

You wonderful women on FWR taught me (many months ago), that these policies have been introduced by trans lobby groups. What I meant to say is that I shouldn't have framed my initial statement as a rhetorical question, because the answer to me is/was clear: YES transactivists are the ones writing their own guidance.

And I agree, it's unprecedented. I think it's also quite scary.

Thingybob
Is that the actual course that is referred to in the article in the Times? As you say, it looks like something designed for children in primary school.

Just girls in coveralls building awesome robots or boys in tutus dancing, being cool and accepted

One of the key things that made DS feel accepted and at home in his body was his 50:50 male/female drama group and his entirely male school choir. Maybe 20 boys out of a whole school - but it was enough.

Yes Old Crone

There is a more detailed response from GIRES here listing the RCGP deletions they objected to

www.gires.org.uk/comments-regarding-the-gender-variance-elearning-course/

GIRES objected to deletions of the following references and proposed their reinstatement:

^(reinstate) the elearning for professionals working with Gender Variant Children and Trans Adolescents, which is on the Health Education England website, badged by NHS and carries CPD points: bit.ly/GIRESelearn^

^(reinstate) the biological correlations paper, which is on the GIRES website: www.gires.org.uk/wp-content/uploads/2014/09/biological-correlations-atypical-gender-development.pdf^

(reinstate) Mermaids, the charity that supports gender diverse children and adolescents and their families

Iused2BanOptimist

Yes I've done lots of box ticking training too but at least in other training the dumbed down message could be evidenced by reams and reams of research if necessary. e.g. water puts out fire or falling from a height is likely to hurt.

In contrast, the simplistic GIRES training is being dressed up as a universal truth without any supporting evidence.

Full text of GIRES statement from Thingybob's link

Comments regarding the Gender Variance eLearning Course
2019-02-02

The Gender Variance eLearning course was previously hosted on the Royal College of GPs website.
A more detailed account

The Gender Identity Research and Education Society (GIRES) developed, entirely at its own expense, the material used in the above course, with the support of an expert working group. GIRES owns the copyright of all that material. The coursewas based on clinical evidence, the intercollegiate good practice guidelines, NHS England’s specification for gender identity services, GMC guidance, the International Classification of Diseases, the Standards of Care published by the World Professional Association for Transgender Health and the Endocrine Society’s Clinical Practice Guideline. The course was peer reviewed by the RCGP.

The course helped GPs to fulfil their responsibility, as stated by NHS England and the General Medical Council, to prescribe and monitor the medication recommended by the specialist clinicians in the gender identity clinics.

GIRES paid the RCGP £7,837 for the course to be hosted on the RCGP website, free to all users, for a period of two years, commencing in July 2015. In January 2018, the RCGP made a number of changes to the course without informing GIRES, which has not given its consent to any of those changes. GIRES discovered those changes in June 2018. Some of the changes made by the RCGP were acceptable to GIRES but, as shown below, others were inappropriate. GIRES immediately protested to the RCGP.

Following an exchange of correspondence and a meeting in November 2018, it became clear that the RCGP was unwilling to reverse the changes that GIRES deemed were inappropriate. Both parties decided in December 2018 that the course should be removed from the RCGP website.

GIRES objected to deletions of the following references and proposed their reinstatement:

1. (reinstate) the elearning for professionals working with Gender Variant Children and Trans Adolescents, which is on the Health Education England website, badged by NHS and carries CPD points: bit.ly/GIRESelearn
2. (reinstate) the biological correlations paper, which is on the GIRES website : www.gires.org.uk/wp-content/uploads/2014/09/biological-correlations-atypical-gender-development.pdf
3. (reinstate) Mermaids, the charity that supports gender diverse children and adolescents and their families

GIRES also objected to the insertion of some additional wording, recommended its removal and proposed its reinstatement or replacement, as shown in sections A to D below:

A – (remove) “Prescribing hormones is not without risk and monitoring may be necessary. This monitoring may be done in primary or secondary care, depending on shared care arrangements.”

GIRES proposed the following:

(replace with) The NHS England specialised services circular: “Primary Care Responsibilities in Prescribing and Monitoring Hormone Therapy for Transgender and Non-Binary Adults (updated)” recommends that:

“General Practitioners should co-operate with the specialist Gender Identity Clinics and prescribe hormone therapy (feminising or virilising endocrine therapy) recommended for their patients by the Gender Identity Clinic. The specialists at the Gender Identity Clinic make recommendations for the prescription and monitoring of these therapies but they do not directly prescribe them, or provide physical and laboratory monitoring procedures for patients.

General Practitioners should collaborate with Gender Identity Clinics in the initiation and on-going prescribing of hormone therapy, and for organising blood and other diagnostic tests as recommended by the Gender Identity Clinics.

General Practitioners are also expected to co-operate with Gender Identity Clinics in patient safety monitoring, by providing basic physical examinations (within the competence of General Practitioners) and blood tests and diagnostic tests recommended by the Gender Identity Clinic (and outlined in this course).”

shsc.nhs.uk/wp-content/uploads/2016/04/SSC1620_GD-Prescribing.pdf

B – (remove) “Monitoring of prescribed hormones may be carried out by the GP or secondary care, depending on shared care arrangements. Whilst a GP may wish to prescribe to help a patient (for whom the specialist service may not be local), it is also important that we only prescribe if we are happy that safe monitoring is in place and that prescribing is not outside our area of competence.”

Rationale for removing inserted text above: Opinion of a Fellow of RCGP: “Outside my competence” is simply an admission of a newly-identified professional learning need that has arisen when a new clinical need is first met; this should not result in the doctor saying “so I won’t do this” on every subsequent occasion the same challenge arises.

Therefore, the course should prompt them to:

(insert) Follow the General Medical Council’s guidance to:

• Keep yourself informed about the medicines that are prescribed for the patient
• Be able to recognise serious and frequently occurring adverse side effects
• Make sure appropriate clinical monitoring arrangements are in place and that the patient and healthcare professionals involved understand them
• Keep up to date with relevant guidance on the use of the medicines and on the management of the patient’s condition.

(In addition insert) General Medical Council guidance makes clear that GPs should:

• Prescribe medicines recommended by a gender specialist for the treatment of gender dysphoria
• Follow recommendations for safety and treatment monitoring
• Make referrals to NHS services that have been recommended by a specialist
• Keep yourself informed about the medicines that are prescribed for the patient

All this and more can be found at: www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare—advice-based-on-gmc-guidance#prescribing

In addition to the above, GIRES therefore proposed reinstating the text:

(reinstate) “GPs are responsible for the non-specialist aspects of treatment: prescribing, administering and monitoring hormone treatment as set out by the specialist service.”

C – (remove) “but monitoring may be done in secondary care, in which case good communication is essential”.

(rationale for removal) Again, this promotes secondary care which was not the intention of NHSE. This new wording should be removed. Monitoring is not beyond the competence of GPs and this course gives the necessary information.

D – (remove) “assuming that safe monitoring arrangements have been put in place following discussion between primary and secondary care.”

(replace with) Ongoing prescribing and monitoring will take place in primary care in line with the recommendations of the paediatric endocrine service of the Gender Identity Development Service, and the relevant information in this course.

Additional points proposed by GIRES:

• Under Hormone blockers, physical effects add after: ….gamete storage must be discussed: “Hormone-blocking is reversible, but if followed directly by gender affirming hormones, this will prevent maturation of eggs and sperm so fertility may be lost. Once maturation has been achieved, possibly involving temporary withdrawal of GnRHa until maturation occurs, gametes can then be stored, and blocking may then be resumed. For some young people this will not be an acceptable option; they may prefer to forego the chance of having offspring.
• Under Genital surgery, note that it is now available from 17 y.o
• Provide links to the Human Rights and Equality Acts
• Minor corrections of some of the references given in the course.

Bernard Reed OBE, MA, MBA

Trustee

I am not a doctor, but read this as GIRES saying GPs should be the main care providers, whereas some GPs, concerned about the implications/potential complexity of the care they are supposed to provide, are saying they don’t feel qualified and that they want to make secondary referrals.

I’m with GPs. The health implications of long term use of undertested drugs, especially on young children, is frightening. As a taxpayer I hope the NHS gives proper weighting to the likelihood of malpractice suits.

Under Hormone blockers, physical effects add after: ….gamete storage must be discussed: “Hormone-blocking is reversible, but if followed directly by gender affirming hormones, this will prevent maturation of eggs and sperm so fertility may be lost. Once maturation has been achieved, possibly involving temporary withdrawal of GnRHa until maturation occurs, gametes can then be stored, and blocking may then be resumed. For some young people this will not be an acceptable option; they may prefer to forego the chance of having offspring

Background to lobbying / threat of legal action to NHS which led to the fertility protocol for patients diagnosed with cancer being used as basis for NHS fertility treatment for people idenifying as transgender:

announced (?) on BBC New Year's Eve 2018:
www.mumsnet.com/Talk/womens_rights/3465629-the-bbc-have-just-peak-transed-the-nation

August 2018
www.mumsnet.com/Talk/womens_rights/3333708-NHS-faces-lawsuit-for-not-funding-fertility-services-for-transgenders-who-want-kids

www.mumsnet.com/Talk/womens_rights/3326933-NHS-told-give-trans-patients-equal-access-to-fertility-service

www.mumsnet.com/Talk/am_i_being_unreasonable/3373056-To-be-very-angry-the-trans-lobby-are-getting-the-NHS-sued

Two questions for Doctors:

1. When final year medical students apply for training F1 & F2 positions, quite a lot of weighting is given to performance on an ethics test. If the content of Gires training is not unchallenged, is there a danger that in order to score well and get offered a place of your chosing, a student would have to learn, and be able to repeat, the jelly bean theory of gender?

1. I assume that, say doctors with strong anti-abortion views, may choose to stay away from specialities which might result in conflict between their beliefs and NHS policy. Where would a GP stand if they felt reluctant to prescribe puberty blockers for a pre-teen child. (The custody case of the child whose mother was convinced her child was transgender and who ultimately was told to keep her distance from Mermaids suggests the sort of scenario where a GP might feel uneasy.) Would a young doctor who is Gender Critical be best advised to stay away from General Practice?

A doctor remains responsible for what they prescribe. Whether you can deem them liable for damage depends on a few things. If a doctor is following the current standard of care then it’s unlikely you’d have redress, even if the drug is off label. This is why TRAs want the guidelines rewritten, so that affirmation plus drugs becomes the default. If that happens, you’d be less likely to have a case if you wanted to sue because they could argue that they were following best practice.

That’s why it’s important to keep watchful waiting as the standard of care - because it makes people responsible for their actions and prescribing, and that’s why the GP statement is important.

Thank you. This then is really important for that 4000% increase in children and teens presenting as transgender and for their parents.

I also assume that "gametes can then be stored" implies nasty, invasive and expensive IVF type treatment for young teenagers. It really does not bear thinking about.

There are youtube accounts by young females who identify as trans and have had egg collection.

Their age and fact that they are not experiencing fertility issues (as would be the case for other women having IVF) makes it more likely a lower risk of side effects etc.

The issue will be what happens after egg collection and storeage.
If those females then embark on cross-sex hormones, they will be less likely to be able to go through the fertilisation, implant stages of IVF

See current push for change in UK surrogacy laws?

There are presumably so many reasons why doctors should be cautious about medicating healthy young people. Do no harm.

And only today new research that suggests that IVF is not problem free.

www.dailymail.co.uk/health/article-6665203/Women-birth-IVF-40-likely-experience-complications.html

There are known risks associated with IVF.

The factors which cause the infertility and so lead to the IVF treatments are also of course relevent.

There are presumably so many reasons why doctors should be cautious about medicating healthy young people. Do no harm.

This is the key reason why its important for robust evidence-based studies into co-morbid issues alongside young people questioning their gender identity, unpicking of suicide/self-harm statistics and causes.