Transgender patients: providing effective healthcare services
To ensure effective healthcare continues to be provided once an individual’s gender identity has been changed on their medical records, there are important considerations for medical professionals and healthcare providers.
Gender Recognition Act 2004
Under the Gender Recognition Act 2004 (GRA), it is an offence to disclose an individual’s gender identity change to any other person. There are exceptions, including disclosure with consent. There is a specific exception for healthcare settings where disclosure is made to a healthcare professional, for medical purposes, and the person making the disclosure reasonably believes that the individual has given consent or cannot give such consent.
Any individual is able to change their gender identity on their medical records simply by asking to do so, with no mention of their natal gender remaining. This is of the utmost importance to respect privacy and dignity. In the NHS, once this is requested the patient will be given a new NHS number which reflects their gender identity. NHS numbers end in an even digit for female patients and an odd digit for male patients. The medical records available to view under the NHS number must not disclose that the patient has changed their gender identity from the one assigned to them at birth as this would be in contravention of the GRA.
This can be challenging as there are times when it is necessary for healthcare professionals to know a patient’s natal gender to provide the best care. Although this information can be shared with consent or under the exception for healthcare professionals if required (as referred to above), there are two challenges:
- If a patient is not known to the clinician, that clinician will not be aware of the possibility that their gender identity has changed so will not know to ask for any information.
- How healthcare professionals can share this information with others in a discreet way which is not then obvious in the records to those who do not need to know.
These challenges come to light in certain areas of healthcare, two of these being radiology and cancer screening programmes.
The Ionising Radiation (Medical Exposure) Regulations 2017 requires clinicians to enquire whether an individual is pregnant or breastfeeding, in the case of an individual of childbearing potential.
This includes not just those who present as female but all those who have female reproductive organs.
It is not always obvious which patients this will apply to and can leave a patient vulnerable and/or cause concern for the radiographer who must enquire to ensure they comply with this duty and maintain the safety of the patient. Information will not be readily available on the patient’s records as this would contravene the GRA.
Clinicians must consider when and how to ask their patients in order to protect their privacy and dignity.
To ensure hospital trusts and private healthcare providers comply with the regulations and to keep patients safe without breaching privacy and confidentiality, solutions could include:
- Developing posters for imaging waiting areas, alongside the equality and diversity team within the hospital trust/private healthcare provider and external LGBTQ+ groups, explaining the need to disclose information and encouraging disclosure of it without concern of it being recorded or shared without consent.
- Sharing the potential healthcare risks associated with non-disclosure of gender status with clinical teams, as well as local LGBTQ+ services.
- Routinely asking every patient of childbearing age the same question to challenge any assumption based on appearance or perceived gender.
- Using patient questionnaires to facilitate effective communication, perhaps asking what reproductive organs a patient has rather than their gender history, which will not be filed on their records.
- Creating an alert on the medical records online system whereby the records disclose this information only to departments where it is vital for safety or treatment. However, this presumes a patient’s consent.
Similar challenges can be met in blood testing and prescribing the correct dose of a drug, as both depend on a patient’s physiology.
Once a patient changes gender on their records, they are automatically removed from screening programmes that do not apply to that gender. For example, someone whose identity changes from female to male would not be invited for cervical smears. These screenings remain physiologically relevant and are important for patient safety. Inversely, a patient whose identity changes from male to female would be invited for a cervical smear although they do not have a cervix.
Again, there is no simple solution to add them back to the screening programme. This requires the patient’s GP to be proactive and to have a discussion with the patient to ensure correct screenings are offered. GPs must put screening appointments through manually on each occasion. It is also important that the GP considers, with the patient’s consent, letting those providing screening know of the patient’s gender identity so that the patient is not questioned when they attend and are treated in a manner to protect their dignity.
The respect for privacy of those who change their gender identity must always be paramount. Currently however, medical professionals may not have all the information they need to treat and the onus is on the patient to understand the importance of sharing information.
There therefore needs to be support and information for patients, and more dialogue around how best to provide care that depends on this information not just within the trusts and healthcare organisations but more widely between organisations and with patients. In conjunction with that, perhaps medical records systems should be adapted to share this information (subject to patient consent having been provided) with areas of the healthcare profession where it is vital as supported by the GRA healthcare exception, with GPs playing an important role in discussing consent and the need for this with their patient at the time their identity changes.