Transgender Meds: A Call for Reports

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July 8, 2019 | 16 Comments

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  1. According to multiple news outlets in the USA, “answers” to thorny questions about youth gender transition and long-term health are on the way. The National Institutes of Health has given $5.7 million to four academic medical centers to study the question.

    But somehow, this news doesn’t reassure me. And it makes me think independent efforts to get a grip on the facts – like RxISK – are sorely needed. The reason? Well for starters, all four clinic directors (in San Francisco, LA, Chicago and Boston) are already major public advocates for medical gender transition for kids at ever younger ages. They’ve already announced that their study will “examine the impact” of drug treatments on kids’ overall well-being … but will also “document the safety” of these drugs. It sounds like they have their minds made up, and may be building their careers accordingly.

    This article on one young patient at the Chicago clinic really blew my mind:

    “Born as David, Diana is male-to-female transgender and one of about 200 patients Dr. Garofalo sees at the Lake View clinic … In Diana’s case, for much of her childhood, she didn’t even realize she was transgender. She had identified as gay. It wasn’t until she was 12 and saw an episode of Oprah about transgender women that she realized her situation was more complicated.”

    “She asked her mom to make an appointment with Garofalo. The doctor immediately put her on Lupron … ”

    Whoa. Mind you, I wouldn’t try and tell kids like this who they really are, or what they should do with their lives. And I wish them well no matter what path they take. But whatever is going on with Diana, it does not exactly sound “biologically hard-wired in the brain” to me. And whatever the doctor thinks he’s doing, it sounds very reckless and one-size-fits-all. If Diana does run into trouble on this journey, I doubt we’ll hear about it from Dr. Garofalo.

    https://www.chicagomag.com/Chicago-Magazine/June-2015/Doctor-Rob-Garofalo/

  2. Difficult territory; online transgender clinic …

    Why do GPs have to prescribe for gender dysphoria?

    29 June 2016

    GPC warns the regulator’s demands could force GPs to treat outside their competence, Jaimie Kaffash finds

    http://www.pulsetoday.co.uk/your-practice/regulation/why-do-gps-have-to-prescribe-for-gender-dysphoria/20032145.article

    GPs should initiate hormones in patients with gender dysphoria in specific circumstances, the GMC has advised.

    The regulator said GPs should be capable of initiating treatment to mitigate a risk of self-harm or suicide where a patient is already self-prescribing with black market drugs and continue to prescribe as part of shared-care arrangements. 

    Ongoing row

    It is the latest in the ongoing row over GPs’ role in treating transgender patients, which has been brought to the fore after NHS England refused to designate the treatment of people undergoing gender reassignment as non-GMS work in service specifications drawn up for commissioners in June 2015.

    The service specifications said GPs would be expected to provide ‘bridging prescriptions’ for hormone therapy and carry out safety monitoring procedures, interpreting blood test results and hormone levels – which NHS England said was the ‘non-specialised’ element of the pathway. This has now been endorsed by the GMC.

    But the GPC has raised concerns about this with the regulator, pointing out that GPs should not be initiating prescribing outside their competence, and that the shared-care arrangements stipulation ‘places a worrying expectation on any GP’ to continue prescribing specialist medication.

    In response, a letter from GMC chief executive Niall Dickson detailed the ‘exceptional circumstances’ when GPs are expected to initiate medication:

    The patient is self-prescribing with hormones from an unregulated source.
    The bridging prescriptions are intended to mitigate risk of self-harm or suicide.
    The GP has sought the advice of a gender specialist and prescribed the lowest acceptable dose.

    ‘Not specialist’

    Mr Dickson added: ‘We don’t believe providing care for patients with gender dysphoria is a highly specialist area requiring specific expertise.
    ‘Our understanding is that the same, or similar, hormone medications are commonly used in general practice for treating patients with prostate cancer or endometriosis.’
    But GPC chair Dr Chaand Nagpaul told Pulse that GPs should not be undertaking this care.

    He said: ‘We don’t believe GPs should be prescribing even in exceptional circumstances, because that is clearly outside of their competence and the guidance, which says patients should be first seen by the specialist.

    ‘It is unlikely that indemnity bodies will see “exceptional circumstances” to be a mitigating factor should a problem arise from the GP’s prescription.’
    He added that the shared-care arrangements mean GPs will be expected to prescribe hormones that ‘are not licensed in patients in this situation’.

    Dr Nagpaul said: ‘The more important thing is that the GMC is being highly reductionist in the management of patients with gender dysphoria. It isn’t about prescribing, it is about managing patients who need ongoing comprehensive care.’
    The GMC has acknowledged there are commissioning deficiencies, he added, ‘and that is what needs to be tackled’.

    How to comply with the GMC guidance

    Unfamiliar conditions can seem daunting and imposing, but meeting the new transgender guidance from NHS England and the GMC should be fairly simple for GPs – and, hopefully, rewarding. This is set to become part of routine general practice, with GPs supporting the rising numbers of people seeking help.

    Here are five tips on how GPs can manage this group of patients.

    1 Gender care is a recognised medical condition with clear treatment pathways recommended by the NHS. The charity GIRES has helped create an online learning resource with the RCGP that can help if you are unsure: elearning.rcgp.org.uk/gendervariance
    2 There are high rates of self-harm and suicide among these patients, so refer for specialist care. At the very least, the patient should be referred to their local gender identity clinic (check the NHS website). Waiting times can be as long as four years though.
    3 Don’t be afraid to diagnose. Many patients will tell you they have always felt they were assigned the wrong gender. They may be living in their preferred gender role publicly or in private and may be taking hormones they have acquired out of desperation.
    4 Don’t forget the drugs used are common prescriptions. The medication for transgender care includes well-known oestrogen therapy used for treating female menopause and finasteride, which is given to men with benign prostatic hyperplasia.
    5 Use the everyday skills GPs are good at. This condition causes great upset at home, at work and in public. Patients need a caring and kind approach, and a safe source of prescription medication, and blood tests to monitor hormone levels.
    Dr Helen Webberley is a GP in Monmouthshire and runs an online transgender clinic

    could force GPs to treat outside their competence – that’s nothing unusual …

  3. Interesting to find Finasteride there, in point number 4, described as a ‘common prescription’ – not a word about possible side effects!

  4. Heads up that the language used in the description above is offensive and may be very unwelcoming to the trans people you are hoping to reach. Calling trans men “women” and trans women “boys” or “men” is super non-affirming. Saying that trans men are on testosterone is much more appropriate than calling them women.

    Just hoping to educate about a potential barrier to being of service to the community that you intend 🙂

    • Thanks for saying this, Jessica. I came to say the same thing.

      It’s really hard to stomach that kind of language. It’s really inappropriate to misgender trans people. If you want to talk to us you’re going to have to respect our gender and who we are. The way this article is written sounds to me like you don’t believe and respect us. It makes me wary of participating.

      • These issues are tremendously tricky. For example, there are notable interactions between common meds like SSRIs and sex hormones (still called sex hormones). One of the biggest nightmares at the moment it getting women over the age of 50 off an SSRI – it can be impossible. See RxISK posts on Efexor withdrawal. Until we have data on biological females perhaps taking testosterone or biological males taking estrogens anyone trying to tackle these issues is left in a very difficult position in that it seems likely that these difficulties will hinge on the sex or origin rather a current gender. There may be additional complication stemming from taking exogenous hormones. Everyone regardless of their sex or gender needs data on issues like this if they are to make an informed choice

        DH

  5. BBC2 News : Health 22nd July 2019 :- Trangender Treatment : Puberty Blockers Study Under Investigation.

    Mostly concentrated on the Tavistock which is being investigated by the Health Research Authority . A snipet – ‘after a year on puberty blockers there was a significant increase in youngsters who had tried to harm or kill themselves.:
    The Tavistock had ignored warnings from a study and it seems practiced almost as a law unto themselves – old habits die hard.

  6. Update – legal challenge has been made
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    NewsBBC News
    Health
    NHS use of puberty blockers legal challenge begins
    By Alison Holt
    Social affairs correspondent, BBC News
    8 January 2020
    Share this with Facebook Share this with Messenger Share this with Twitter Share this with Email Share
    Legal action is being launched against the NHS over the prescribing of drugs to delay puberty.

    Papers have been lodged at the High Court by a mother and a nurse against the Tavistock and Portman NHS Trust, which runs the UK’s only gender-identity development service (Gids).

    Lawyers will argue it is illegal to prescribe the drugs, as children cannot give informed consent to the treatment.

    The Tavistock said it had a “cautious and considered” approach to treatment.

    Papers were formally lodged on Wednesday by the lawyers for the complainants.

    The Tavistock will have three weeks to submit its response, after which a judge will consider the case and decide on the timings of any hearings.

    Referrals up
    The nurse, Sue Evans, left the Gids more than a decade ago after becoming increasingly concerned teenagers who wanted to transition to a different gender were being given the puberty blockers without adequate assessments and psychological work.

    Since then, she says, even younger children are being given the drugs, which block the hormones that lead to puberty-related changes including periods and facial hair.

    The number of young people referred to the Gids rose from 678 in 2014-15 to 2,590 in the past year.

    Of these 2,590:

    more than 1,700 wanted to transition to male
    624 wanted to transition to female
    most were in their early to mid-teens
    171 were under 10
    Ms Evans said: “I used to feel concerned it was being given to 16-year-olds.

    “But now, the age limit has been lowered – and children as young as perhaps nine or 10 are being asked to give informed consent to a completely experimental treatment for which the long-term consequences are not known.”

    ‘Too young’
    The mother, known only as Mrs A, has a 15-year-old with autism who is on the waiting list for treatment at the Gids.

    She told BBC News her child presents to the outside world as a boy but, while she is happy to allow that, she is extremely concerned about the possibility of drugs that are not fully understood being prescribed.

    “I’m worried that they will look at her age and say, ‘Well, she still says this is what she wants and therefore we will put her on to a medical pathway,'” Mrs A told BBC News.

    “And given her communication of what she feels internally is slightly different because of her autism spectrum, I worry that what she says and what she means are often two different things.”

    What are puberty blockers?

    They are drugs which can pause the development of things like breasts, periods, facial hair and voice breaking

    They can be prescribed to children with gender dysphoria who feel their sex at birth doesn’t match up with their gender.

    This is meant to give them more time to weigh up their options before they go through the physical changes of puberty.

    Although puberty blockers are described by the NHS as reversible, Gids acknowledges that their impact on brain development and psychological health is not fully known.

    Read more: What are puberty blockers?

    Mrs A said her child was too young to really assess the potential impact of puberty blockers on the rest of their life, including such things as fertility.

    “As an adolescent, what we think will make us happy is not necessarily what will make us happy,” she told BBC News.

    “It might help us in the short term – but it might not help us in the long term.”

    ‘Rated good’
    A Tavistock and Portman NHS Foundation Trust official said: “It is not appropriate for us to comment in detail in advance of any proposed legal proceedings.

    “The Gids is one of the longest-established services of its type in the world with an international reputation for being cautious and considered.

    “Our clinical interventions are laid out in nationally set service specifications.

    “NHS England monitors our service very closely.

    “The service has a high level of reported satisfaction and was rated good by the Care Quality Commission.”

  7. Update
    #BBCNews #Newsnight on IPlayer
    NHS child gender clinic: Staff welfare concerns ‘shut down’ – BBC Newsnight
    24,602 views•18 June 2020
    Newsnight has seen transcripts that show staff say they were discouraged from raising welfare concerns at England’s only NHS child gender clinic.

  8. Update
    Guardian Weekly

    Transgender
    Puberty blockers: under-16s ‘unlikely to be able to give informed consent’
    NHS says clinic has suspended new referrals after pair, including woman who took blockers, win court case
    Keira Bell
    Owen Bowcott Legal affairs correspondent
    @owenbowcott
    Tue 1 Dec 2020 17.18 GMT

    Children under the age of 16 considering gender reassignment are unlikely to be mature enough to give informed consent to be prescribed puberty-blocking drugs, the high court has ruled.

    Even in cases involving teenagers under 18 doctors may need to consult the courts for authorisation for medical intervention, three senior judges have ruled in an action brought against the Tavistock and Portman NHS trust, which runs the UK’s main gender identity development service for children.

    An NHS spokesperson welcomed the “clarity” the decision had brought, adding: “The Tavistock have immediately suspended new referrals for puberty blockers and cross-sex hormones for the under 16s, which in future will only be permitted where a court specifically authorises it. Dr Hilary Cass is conducting a wider review on the future of gender identity services.”

  9. UIntended for healthcare professionals

    BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n205 (Published 21 January 2021)
    Cite this as: BMJ 2021;372:n205

    Clare Dyer
    England’s only gender dysphoria service for young people has been rated inadequate, after inspectors found “significant concerns” following an unannounced inspection.1

    The Care Quality Commission (CQC) took enforcement action against the Tavistock and Portman NHS Foundation Trust, which runs the gender identity development service (GIDS), imposing conditions on the trust’s registration to try to reduce the service’s lengthy waiting list.

    The CQC inspected GIDS last October and November after healthcare professionals and the children’s commissioner for England, Anne Longfield, raised concerns relating to clinical practice, safeguarding procedures, and assessment of capacity and consent to treatment.

    Referrals to the service have skyrocketed from 77 in 2009-10 to more than 2700 in 2019-20. There were more than 4600 young people on the waiting list, with some waiting more …pdate

  10. Shame on David Bell knowing children were still being damaged after he made a report ,waited until he had retired before speaking out on TV including about the bullying and threats others will receive if they speak out
    Others did and left the Tavistock ages ago —-on TV All4.com Homepage
    Take me to All 4

    23 Jan 2021
    ‘Children have been very seriously damaged’ by NHS gender clinic, says former Tavistock staff governor
    Cathy Newman
    Presenter
    Consultant psychiatrist Dr David Bell, who served as a staff governor at the Tavistock Trust, wrote an internal report in 2018, raising the concerns brought to him by colleagues about the way the Gender Identity Development Service was treating patients.

    He faced disciplinary action.

    But after 24 years working with the Tavistock, Dr Bell, a former President of the British Psychoanalytic Society, has recently retired, and in his first television interview since then, he began by outlining his worries about the service.

  11. Update

    01 February 2021
    Paul James Smith
    Statistician

    Re: Gender dysphoria service rated inadequate after waiting list of 4600 raises concerns
    Re: Gender dysphoria service rated inadequate after waiting list of 4600 raises concerns Clare Dyer. 372:doi 10.1136/bmj.n205
    NOTE: Please accept the resubmission of our earlier Rapid Response letter that was published on 31.01.21. The beginning of the third paragraph was changed, to accurately represent the exact wording of the BMA motion.

    Dear Editor,

    BMA members may not be aware that their trade union has been given leave to intervene in the Tavistock’s Appeal against the High Court judgment in Bell vs Tavistock Judicial Review. (1) In this judgment – that is well worth reading in full – the Court found that under 16 year olds who present with gender dysphoria cannot meaningfully consent to being treated with puberty blockers and asked clinicians to apply for a Court order if they believed such experimental interventions (2) were necessary. This was done in order to safeguard children.

    A main objection to these interventions, which in part informed the High Court judgment, is that there is no evidence they improve gender dysphoria. There is evidence of harm, such as worsening of psychological symptoms, bone loss, and impairment to cognitive and reproductive development, let alone the adult sexual function that pre-pubertal children cannot understand before alienating. Other irreversible medical interventions that seek to physically alter their bodies to resemble the opposite sex follow in 98% of cases (3), although children do not consent for the lifetime package at the outset.

    The BMA recently passed a motion to campaign for gender self-identification and to ensure that under 18s are able to access healthcare in line with existing principles of consent established by UK Case Law and guidelines published by the public bodies which set the standards for healthcare. The BMA is using this position to support access for gender dysphoric children to puberty blockers based on the so-called “informed consent” model. This ‘urgent’ motion was introduced at the recent, first virtual, annual conference with very short notice. With a late and inadequate briefing paper, barely 20 minutes was allotted for discussion and delegates had no more time to think or consult wider membership about these fundamental changes in medical policy. The motion passed with a small majority, with many delegates abstaining. Since then, and despite opposition, the BMA has submitted a response to a government inquiry, advocating for gender self-identification and changing women’s single-sex spaces into mixed-sex.

    In the most recent CQC inspection (4), the Tavistock clinic was given an “inadequate” rating, due to widespread failures to meet acceptable standards of care. This included failure to document information relating to informed consent, failures to investigate comorbidities and inadequate rationale for their decisions to refer patients for puberty blockers.

    The BMA is seen by politicians and the general public alike to represent mainstream medical opinion. It should be wary of assuming members’ support to intervene on behalf of one NHS organisation and its system of care, which lacks supporting evidence and is not aligned with basic medical principles such as shared decision making, first do no harm and whole person care.

    If the doctors have robust comparative evidence that children do better with development-defying and life-long interventions let us see and support it! Partisan political activism and ideological lobbying about controversial medical practice is inappropriate without the extensive debate that is necessary for such major policy change.

  12. Community Care

    Puberty blockers and consent to treatment: an analysis of the High Court’s ruling
    The experimental nature and potential lifelong consequences of puberty-suppressing medication led judges to conclude that the courts must sanction its use for children with gender dysphoria, says Michelle Janas
    December 11, 2020 in Children

    Update
    UK
    Transgender children can receive puberty blockers if parents consent, High Court judge rules
    The decision could see a reversal of rules that require a court order for transgender children to receive the treatment
    It is common practice for parents to consent to other medical treatments for which children are not deemed competent, lawyers argued
    Weekend Breaking News Editor
    March 26, 2021 6:23 pm
    (Updated 6:35 pm)
    Transgender children can get puberty-blocking drugs without the need to go to court as long as their parents agree to the treatment, a High Court judge has said.

  13. UpdateIntended for healthcare professionals
    Trust them they’re doctors – no self interests at stake here? just the lives of often very young children In uk children as young as 12 can over ride parental/guardians’ consent and decide whether of not to have vaccines.
    Doctors can decide if children are able to consent to puberty blockers, say judges
    BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n2307 (Published 20 September 2021)
    Cite this as: BMJ 2021;374:n2307

    It is for doctors to decide whether a child under 16 can give informed consent to treatment with puberty blockers, the Court of Appeal has ruled.1

    Three senior judges, headed by the Lord Chief Justice, Lord Burnett, overturned a High Court decision which cast doubt on under 16s’ ability to understand the long term effects of puberty blockers and suggested court applications might be needed.

    The Tavistock and Portman NHS Foundation Trust, which runs the UK’s only gender reassignment service for young people, appealed against the ruling.

    • Given that the System has decided that children aged 12 can decide to get the Covid Vaccines against their parents wishes, then this is consistent Maybe the Appeals Court was thinking of the wider implications. I wonder has anyone decided to ‘correct’ the rule that you can’t have your ears pierced under the age of 16 without parental consent

      D

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