The role of the GP in caring for people with gender dysphoria

A GP writes about the approach GPs take to assessing patients and emphasises how important it is that the Conversion Practices Ban bill does not limit or restrict the exploratory conversations that we have with our patients.

I am a GP Partner in an inner London practice. I want to say a bit about the approach GPs take to assessing patients and emphasise how important it is that the CP Ban bill does not limit or restrict the exploratory conversations that we have with our patients.

GPs are the first port of call for the full range of human distress: from a sore throat, to a new cancer diagnosis, to acute suicidality, to gender dysphoria. The assessment of that distress is our core professional task and our core skill.

We generally conduct our assessment with the benefit of continuity of care. We know the patient, their history, their family, their social context. We are usually aware when there is a background of adverse childhood experiences, such as family breakdown, domestic violence, parental mental illness, substance misuse or incarceration. We are likely to have been consulted about pre-existing behavioural problems or suspected autistic spectrum traits.

Our job is to take a whole person view. That means the professional freedom to explore the presenting distress in a neutral non-judgemental manner, to ask open questions, to demonstrate curiosity, to show empathy. It also means exercising professional judgement about when to hold a patient’s distress: to arrange to see them again, perhaps with different family members, to continue the conversation, to watch and wait.

A gender dysphoric young person often has a complex history of childhood trauma. They often manifest comorbidities such as depression, anxiety, self-harm or symptoms of eating disorders. They may have autistic traits.

In such cases, to unquestioningly affirm their transgender identity, without wider exploration of their distress, would be an abrogation of professional responsibility and an approach at odds with the way we approach all other presentations of distress. Equally, to refer immediately to a specialist gender service would in many cases be inappropriate, creating an unhelpful focus on one dimension of the young person’s unhappiness, with the risk of allowing that to become the overarching explanatory framework for a complex range of difficulties.

We know that for the majority of gender distressed adolescents, their dysphoria is one transient feature of wider difficulties with mental health and with adolescent identity formation. GPs, located as we are in local communities and generally trusted by the families who consult us, are well placed to approach such presentations in a sensitive patient-centred manner. We can liaise with other involved professionals such as teachers and social workers. We can refer when appropriate to accessible local services such as youth counselling, primary care psychology or CAMHS.

Any attempt to characterise a neutral curious empathic therapeutic approach to a gender-distressed patient as ‘conversion therapy’ on the grounds that it is not ‘affirmative’, would be to fundamentally misunderstand and misrepresent the hallmarks of good General Practice.

The interim report from the Cass Review advocates increased GP involvement in the management of gender-distressed individuals. The CP Ban bill must ensure that clinicians in Primary Care are free to continue looking after this vulnerable group of patients, in a manner consistent with our professional ethics and training, without facing the charge of ‘conversion therapy’ when we avoid a gender-affirmative approach.