Irish College of GPs removes newly published transgender guidelines from website

The Irish College of General Practitioners (ICGP) has removed a recently published guide to transgender healthcare from its website following questioning of the report by Gript. The report “Guide for Providing Care for Transgender Patients in Primary Care – Quick Reference Guide” had been written in conjunction with the Transgender Equality Network Ireland (TENI).

Following publication of the document Gript reached out to ICGP’s press office and, when no response was received, directly to Dr Des Crowley, one of the studies authors, and the Quality and Safety in Practice Committee of the ICGP, with questions regarding TENI’s involvement in the publication – Vanessa Lacey, health and education manager at TENI, was one of the authors of the document. We also asked for clarification of the relevant qualifications possessed by the second study author, Dr Des Crowley, given that his area of expertise seems to lie primarily in addiction management.

To date we have received no formal response from the ICGP to our questions, but the report has now been removed from their website.

Sections of the ICGP document were taken directly from material TENI had previously been involved in the creation of, with some parts being word for word copies of TENI material. Gript asked the ICGP to clarify the level of involvement that they and TENI had had in the production of the document, and to what extent the document was written by TENI.

One section described puberty blockers as “reversible interventions” whilst making no note about the research limitations in this area or the growing concerns regarding this claim. The NHS, for instances, had previously claimed that puberty blockers were fully reversible but has now moved to say that “little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria”, that “it is not known what the psychological effects may be”, and that “it’s also not known whether hormone blockers affect the development of the teenage brain or children’s bones.”

This claim was also discussed during the recent Bell v Tavistock case, with judges ultimately deciding against the view that the medical evidence supported the view that such interventions were reversible. The Court found that puberty blockers “prevent the child going through puberty in the normal biological process. As a minimum it seems to us that this means that the child is not undergoing the physical and consequential psychological changes which would contribute to the understanding of a person’s identity.”

Moving from that the Court found that, even if it were the case that puberty blockers were completely reversible, the available evidence suggests that 98.1% of adolescents who take puberty blockers will move on to use sex change hormones, and so puberty blockers should be considered “stepping stones” which lead, in almost all cases, to unarguably irreversible medical interventions.

Gript asked the ICGP if they had considered these facts when creating the document.

The document repeatedly directs GPs to consult with TENI resources in order to decide how best to work with transgender patients, despite the fact that TENI is not a medical organisation, but rather an advocacy group. One portion of the document, which deals with “Pubertal children/adolescents” says that “GPs can also discuss with TENI updates and difficulties with treatment pathways”. Elsewhere, under the “Suggestions for Working with Transgender Patients” the documents says that GPs should attend conferences and consult with “transgender experts e.g. TENI (www.teni.ie)” and that “further information sources are available from www.teni.ie.” Neither of these sections direct GPs to consult with medical organisations to keep themselves informed of how best to treat transgender patients.

We asked the ICGP if it were usual for them to recommend an advocacy group as a point of contact for GPs to discuss patient treatment pathways, what safeguards they had put in place to ensure that information given to GPs by TENI was correct; and if the ICGP would accept any liability if a GP, acting on the documents advice to consult with TENI, did so and subsequently implemented a treatment pathway which led to a suboptimal patient outcome.

Interestingly there are nearly 30 references to TENI spread throughout the document but, once you get past the introduction page, there is only a single reference reference to ICGP in the body of the text – a line in Appendix 3 saying that ICGP and TENI worked together to make a GP Checklist for Transgender Patients.

We’ve asked the ICGP to comment on the current status of the document, and if has been formally withdrawn, but have, at time of print, received no response. We will update this article should a response be received.

Below are the questions we sent to the ICGP and to Dr Des Crowley.

Questions for Dr Des Crowley

To start with I was curious about your professional and academic background. Do you have any qualifications, certifications, work experience, etc, that directly related to the area of transgender health?

Page 11 of the newly released document contains this line “Reversible interventions: these involve the use of GnRH analogues to suppress oestrogen or testosterone production (puberty blockers) and as a result delay the physical changes of puberty.” What was the exact evidence base for the claim that puberty blockers, as used in this instance as opposed to treating precocious puberty, are reversible? Did the recent change in NHS advice on this issue, a screenshot of which I’ve attached for your convenience, and the judgement in the recent Bell v Tavistock case, in which the judges directly discussed the evidence base for this particular claim, come into consideration when this point was being formulated?

Was there any concern that working with TENI to create these guidelines might bias the direction of the work, given that TENI are not a medical organisation but rather one dedicated to advocacy?

The report repeatedly directs GPs to contact TENI for information, training, and other purposes; as an example “GPs can also discuss with TENI updates and difficulties with treatment pathways”. How did the ICGP come to the decision that an advocacy organisation should be given as the point of contact for GPs to discuss treatment pathways?

Parts of the document are directly, word for word, taken from previous TENI material, how much of the document was directly written by yourself or the ICGP?

Does the ICGP accept any responsibility if a GP, acting on the advice given in the document, reaches out to TENI, implements their suggestion, and it leads to a suboptimal outcome for the patient, perhaps akin to what we saw in the recent Bell case but not limited to such cases?

Given the authority which the ICGP has given to TENI what ongoing safeguards have been implemented to ensure that the advice and medical recommendations TENI gives to GPs remain evidence based?

Questions for the ICGP Quality and Safety in Practice Committee

Was there any concern that working with TENI to create these guidelines might bias the direction of the work, given that TENI are not a medical organisation but rather one dedicated to advocacy?

Whilst noting Dr Crowley’s obvious expertise in the area of addiction I was unable to locate records of any professional qualification, certification, or work experience that Dr Crowley has that would position him as an expert in the area of transgender health. Assuming that is a correct and full view of his expertise in this area why was Dr Crowley selected as an author on this document? If this is a correct and full view of Dr Crowley’s expertise in this area, were there any concerns that selecting an author who does not have expertise or qualification in this area might lead to a suboptimal outcome?

The second author of the study, who has worked directly for TENI for the last decade, does not appear to have any medical qualification, bar a BA in psychology. When this individual was selected as an author was there any discussion of the potential impact of such a decision on the end document?

Is it normal for the ICGP to allow clinical guidelines to be authored by respectively, an author who appears to have no medical qualifications and is actively working in an advocacy position, and an author who, despite significant medical qualifications, does not appear to have expertise in the issue at hand?

The report repeatedly directs GPs to contact TENI for information, training, and other purposes; as an example “GPs can also discuss with TENI updates and difficulties with treatment pathways”. Is it the belief of the committee that advising GPs to consult with an advocacy group, rather than a group with relevant medical expertise, is the recommendation most likely to lead to positive patient outcomes?

Parts of the document are directly, word for word, taken from previous TENI material, how much of the document was directly written by the ICGP? What systems were put in place to ensure material taken from TENI documents was accurate and unbiased? Is it common for the ICGP to allow advocacy organisations to directly write guidelines?

Does the ICGP accept any responsibility if a GP, acting on the advice given in the document, reaches out to TENI, implements their suggestion, and it leads to a suboptimal outcome for the patient, perhaps akin to what we saw in the recent Bell case but not limited to such cases?

Given the authority which the ICGP has given to TENI what ongoing safeguards have been implemented to ensure that the advice and medical recommendations TENI gives to GPs remain evidence based?

Share mdi-share-variant mdi-twitter mdi-facebook mdi-whatsapp mdi-telegram mdi-linkedin mdi-email mdi-printer mdi-chevron-left Prev Next mdi-chevron-right Related
Comments are open

The biggest problem Ireland faces right now is:

View Results

Loading ... Loading ...