Summary

Doctors checked the records of all 68 trans and gender-minority patients at one Cornish family doctor practice to see how their care compared with guidelines. There was no family doctor guideline to check against, and UK gender clinics and international guidelines gave conflicting advice on doses and check-ups. Judged against a US specialist guideline, up to two-thirds had missed some recommended check-ups. Patients waited an average of 26 months for an NHS gender clinic and had high rates of recorded anxiety, depression and self-harm. Of 41 who had started hormones, eight chose to stop, and five of them had notes recording detransition or regret. The authors call for proper family doctor guidance and larger checks like this. With so few patients, one practice and no talking to patients, the figures are a starting point for questions, not national rates.

Key findings

• 登録患者20,136人のうち68人（10万人あたり337人）がトランスジェンダーまたはジェンダー・マイノリティでした。内訳はトランス男性42人（62%）、トランス女性22人、ノンバイナリー4人で、年齢の中央値は22歳でした。
• 記録上、メンタルヘルスの問題は一般的でした。不安またはうつ病が76%、自傷が54%、パーソナリティ障害が10%、自閉症が15%でした。19%には子ども時代の虐待、ネグレクト、暴力の記録がありました。
• NHSのジェンダークリニックを待っている患者の待ち時間は平均26か月でした。クリニックの診察を受けた48人のうち15人（31%）は民間でのみ診察を受けており、自分で紹介を申し込んだ16人は全員が民間クリニックに行きました。
• かかりつけ医が照らし合わせられるガイドラインがなく、英国のジェンダークリニックからGPへの指示は、互いに、また国際的なガイドラインとも、用量、目標とするホルモン値、検査の内容で食い違っていました。
• 米国の専門家によるホルモンのガイドラインと照らすと、最大で3分の2の患者が推奨される検査をすべては受けておらず、その大半はこうした食い違いが原因でした。
• ホルモンを開始した41人のうち8人（20%）が、平均約5年後に自分でやめることを選びました。トランス男性4人にはデトランジションを記述したメモがあり、トランス女性1人には精巣摘出後の後悔が記録されていました。
• 調査されたガイドラインはいずれも、デトランジション、後悔、治療をやめた患者のケアについての助言を示していませんでした。

Abstract

Primary care must ensure high quality lifelong care is offered to trans and gender minority patients who are known to have poor health and adverse healthcare experiences. This quality improvement project aimed to interrogate and audit the data of trans and gender minority patients in one primary care population in England. A new data collection instrument was created examining pathways of care, assessments and interventions undertaken, monitoring, and complications. General practitioners identified a sample from the patient population and then performed an audit to examine against an established standard of care. No appropriate primary care audit standard was found. There was inconsistency between multiple UK gender identity clinics' (GIC) individual recommended schedules of care and between specialty guidelines. Using an international, secondary care, evidence- informed guideline, it appeared that up to two-thirds of patients did not receive all recommended monitoring standards, largely due to inconsistencies between GIC and international guidance. It is imperative that an evidence-based primary care guideline is devised alongside measurable standards. Given the findings of long waits, high rates of medical complexity, and some undesired treatment outcomes (including a fifth of patients stopping hormones of whom more than half cited regret or detransition experiences), this small but population-based quality improvement approach should be replicated and expanded upon at scale.

Conclusion

These findings complement secondary care-generated knowledge and suggest room for improvement. Gender minority/trans people will be better served by evidence-based primary care guidance, including monitoring and communication standards. Existing guidance is contradictory. Given the findings of long waits for GIC assessment, and some unwanted outcomes and complications (including detransition), this small but hypothesis-generating primary care-focused, population-based, quality improvement approach should be replicated and expanded upon at scale.