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

• 20,136 名登記患者中有 68 人（每 10 萬人 337 人）為跨性別或性別少數：42 人（62%）為跨性別男性、22 人為跨性別女性、4 人為非二元性別，年齡中位數 22 歲。
• 病歷中常見心理健康問題：76% 有焦慮或憂鬱、54% 有自傷、10% 有人格障礙、15% 有自閉症。19% 有童年受虐、受忽視或暴力的紀錄。
• 等待 NHS 性別門診的患者平均已等了 26 個月。在 48 名已由門診看診的患者中，15 人（31%）只在私人診所看過，16 名自行轉診者全部都去了私人診所。
• 沒有可供家庭醫師對照的指引，而英國各性別門診給家庭醫師的指示彼此不一致，也與國際指引在劑量、目標荷爾蒙濃度和檢查上不一致。
• 對照美國專科荷爾蒙治療指引，多達三分之二的患者沒有完成所有建議的檢查，主要原因就是這些不一致。
• 在 41 名開始使用荷爾蒙的患者中，8 人（20%）在平均約五年後選擇停用。四名跨性別男性的紀錄描述了去過渡，一名跨性別女性在睪丸切除後有後悔的紀錄。
• 所檢視的指引都沒有提供關於去過渡、後悔，或照護停止治療患者的任何建議。

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.