*For correspondence:gc.island@ gmail.com pollybrandon@mac. com
Competing interests:The authors declare that no competing interests exist. Received:14 August 2016 Accepted:16 August 2016 Published:09 January 2017
This article is Open Access:
https:// creativecommons.org/licenses/ by/4.0/)
sBJGP Open 2017; DOI:10.3399/ bjgpopen17X100557
Primary care in the Calais Jungle
Gerry Clare,
BSc, MSc, PhD, FRCOphth1*, Polly Nyiri,
MBBChir, DTM&H, MA International Health2*
1
Consultant ophthalmologist, Western Eye Hospital, London, UK;
2GP, Health
Inclusion Clinic, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
Introduction
Last summer our small medical team visited the Calais ’Jungle’. Since that time much has changed and the camp is being demolished and by the time this article is read, it will probably be long gone. Some youngsters are finally being brought to the UK under the ’Dubs’ amendment. However, once this camp is cleared it will not solve the ongoing flight of refugees from war torn areas: other camps are already appearing.
July 2016
A young Afghan man caught his finger on a sharp point while trying to cross a barbed wire fence. The finger was partially degloved. He attended the local hospital, where they placed a few sutures, but now, 2 weeks later, the skin is necrotic and the underlying tissue looks infected. He is in danger of losing his finger.
A middle-aged Sudanese man has been having rigors and is generally unwell. He says it is similar to when he last had malaria.
A young Ukrainian woman complains of lower back pain and urinary frequency.
The paths of these three people may never have crossed; yet here they are, denizens of the Calais Jungle. They turn up to a makeshift primary care ‘clinic’ that we set up in the heart of the unofficial refugee camp one weekend in July 2016.
With only basic medical supplies, we are immediately challenged by what we see. How can we arrange secondary care for the young Afghan in danger of losing his finger? We try to persuade him to return to the original local hospital, but he is reluctant. It was not a good experience for him the first time round.
With the other two patients, it is easier. They can attend the Salam clinic run by a local association during weekdays. Later, we receive word that malaria has been confirmed in our Sudanese patient.
More people arrive, presenting with scabies, rat bites, tinea, chest infections, and wheezing from inhaling smoke from fires lit to cook and keep warm in their tents at night. We examine a severely malnourished 2-year-old boy. We meet several of the camp’s 600 unaccompanied children, at grave risk of sexual exploitation. We learn that there is inadequate safeguarding in place to protect them. A young Eritrean man comes in worried about his eye. He has sustained direct ocular trauma from a rubber bullet, and will never see normally again out of that eye. We see haematomas from police batons, and hear about children being exposed to tear gas again and again (Figure 1).
The reality
These are no ordinary patients. They have travelled far from home to escape war, poverty, and mis-ery. They have endured personal odysseys to get here, experienced untold hardships, and suffered unimaginable privations. Many have survived the loss of their families, torture, and rape. Their jour-neys over, for the moment at least, they must make their homes in the Calais Jungle. Their new shel-ters are in many cases mere tarpaulin covers, and their new beds just rugs on the ground. They own next to nothing. There is little for them to do, besides use their ingenuity to cross the English Chan-nel in search of a better life. They are vulnerable to exploitation, crime, injury, and disease. Poten-tially violent clashes with local police, with other ethnic groups resident in the Jungle, or local far
Clare G and Nyiri P. BJGP Open 2017;DOI: 10.3399/bjgpopen17X100557 1 of 5
PRACTICE & POLICY
CC BY license (
*For correspondence:c.cliffe@ imperial.ac.uk
Competing interests:The authors declare that no competing interests exist.
19 February 2017 Accepted:03 March 2017
12 July 2017
Author Keywords:transgender, gender identity, gender variance, bridging prescriptions
Copyrights2017, BJGP Open; DOI:10.3399/
bjgpopen17X101001
The transgender patient in primary care:
practical advice for a 10-minute
consultation
Charlotte Cliffe,
BSc, MBChB, FHEA1*, Miriam Hillyard,
MA, BM BCh2,
Albert Joseph,
BSc, MRes, BM BCh3, Azeem Majeed,
MD, FRCP, FRCGP, FFPH41
Honorary Clinical Research Fellow, Department of Primary Care and Public Health,
Imperial College London, London, UK;
2Foundation Doctor, North West Thames
Foundation School, Imperial College Healthcare NHS Trust, London, UK;
3Honorary
Clinical Research Fellow, Department of Primary Care and Public Health, Imperial
College London, London, UK;
4Professor of Primary Care, Department of Primary
Care and Public Health, Imperial College London, London, UK
With referrals to gender identity clinics rising rapidly, GPs are more likely to meet patients who are transgender (whose gender identity, or internal sense of gender, does not match their gender assigned at birth) or diagnosed with gender dysphoria (the severe psychological distress that is experienced by an individual as a result of the conflict between their gender identity and gender assigned at birth).1 Teaching on transgender medicine is lacking in both undergraduate and post-graduate curricula, leading to a perceived lack of expertise in this area. Furthermore, General Medi-cal Council (GMC) guidelines on the GP’s role in prescribing are vague, resulting in some controversy. As wait times for appointments at specialist clinics are often at least 18 months, primary care physicians will increasingly be involved in the initiation of the transition process: this is the pro-cess by which an individual changes their phenotypic appearance of gender to match their gender identity through medications and/or surgery.
Example case
A 36-year-old patient, who was male at birth, has been living as a woman for the last 9 months. Her birth name still appears on GP records. She would like legal recognition as a woman and a referral to specialist gender services.
What needs to be ascertained?
Preferred pronoun and name
The patient’s preferred name and pronoun should be updated on the electronic patient record sys-tem; this will help prevent any potential mistakes from being made by calling the patient by the wrong name or gender.2
Level of support
Gather an understanding of the individual’s relationship with family, friends, or a wider social net-work (including transgender communities) to determine their level of support. Social isolation, nega-tive reactions of family and friends, or limited ‘social transition’ can be risk factors for developing mental illness or gender dysphoria, both of which may require extra support from mental health teams.2
Mental health symptoms
Elicit information regarding any distress, anxiety, self-harm, or suicidal thoughts. Around 34% of transgender individuals have attempted suicide at least once; screening in this initial consultation is
PRACTICE & POLICY
*For correspondence:c.cliffe@ imperial.ac.uk
Competing interests:The authors declare that no competing interests exist.
19 February 2017 Accepted:03 March 2017
12 July 2017 Author Keywords:transgender, gender identity, gender variance, bridging prescriptions
Copyrights2017, BJGP Open; DOI:10.3399/
bjgpopen17X101001
The transgender patient in primary care:
practical advice for a 10-minute
consultation
Charlotte Cliffe,
BSc, MBChB, FHEA1*, Miriam Hillyard,
MA, BM BCh2,
Albert Joseph,
BSc, MRes, BM BCh3, Azeem Majeed,
MD, FRCP, FRCGP, FFPH41
Honorary Clinical Research Fellow, Department of Primary Care and Public Health,
Imperial College London, London, UK;
2Foundation Doctor, North West Thames
Foundation School, Imperial College Healthcare NHS Trust, London, UK;
3Honorary
Clinical Research Fellow, Department of Primary Care and Public Health, Imperial
College London, London, UK;
4Professor of Primary Care, Department of Primary
Care and Public Health, Imperial College London, London, UK
With referrals to gender identity clinics rising rapidly, GPs are more likely to meet patients who are transgender (whose gender identity, or internal sense of gender, does not match their gender assigned at birth) or diagnosed with gender dysphoria (the severe psychological distress that is experienced by an individual as a result of the conflict between their gender identity and gender assigned at birth).1 Teaching on transgender medicine is lacking in both undergraduate and post-graduate curricula, leading to a perceived lack of expertise in this area. Furthermore, General Medi-cal Council (GMC) guidelines on the GP’s role in prescribing are vague, resulting in some controversy. As wait times for appointments at specialist clinics are often at least 18 months, primary care physicians will increasingly be involved in the initiation of the transition process: this is the pro-cess by which an individual changes their phenotypic appearance of gender to match their gender identity through medications and/or surgery.
Example case
A 36-year-old patient, who was male at birth, has been living as a woman for the last 9 months. Her birth name still appears on GP records. She would like legal recognition as a woman and a referral to specialist gender services.
What needs to be ascertained?
Preferred pronoun and name
The patient’s preferred name and pronoun should be updated on the electronic patient record sys-tem; this will help prevent any potential mistakes from being made by calling the patient by the wrong name or gender.2
Level of support
Gather an understanding of the individual’s relationship with family, friends, or a wider social net-work (including transgender communities) to determine their level of support. Social isolation, nega-tive reactions of family and friends, or limited ‘social transition’ can be risk factors for developing mental illness or gender dysphoria, both of which may require extra support from mental health teams.2
Mental health symptoms
Elicit information regarding any distress, anxiety, self-harm, or suicidal thoughts. Around 34% of transgender individuals have attempted suicide at least once; screening in this initial consultation is
PRACTICE & POLICY
*For correspondence:c.cliffe@ imperial.ac.uk
Competing interests:The authors declare that no competing interests exist.
19 February 2017 Accepted:03 March 2017
: 12 July 2017 Author Keywords:transgender, gender identity, gender variance, bridging prescriptions
DOI:10.3399/ bjgpopen17X101001
The transgender patient in primary care:
practical advice for a 10-minute
consultation
Charlotte Cliffe,
BSc, MBChB, FHEA1*, Miriam Hillyard,
MA, BM BCh2,
Albert Joseph,
BSc, MRes, BM BCh3, Azeem Majeed,
MD, FRCP, FRCGP, FFPH41
Honorary Clinical Research Fellow, Department of Primary Care and Public Health,
Imperial College London, London, UK;
2Foundation Doctor, North West Thames
Foundation School, Imperial College Healthcare NHS Trust, London, UK;
3Honorary
Clinical Research Fellow, Department of Primary Care and Public Health, Imperial
College London, London, UK;
4Professor of Primary Care, Department of Primary
Care and Public Health, Imperial College London, London, UK
With referrals to gender identity clinics rising rapidly, GPs are more likely to meet patients who are transgender (whose gender identity, or internal sense of gender, does not match their gender assigned at birth) or diagnosed with gender dysphoria (the severe psychological distress that is experienced by an individual as a result of the conflict between their gender identity and gender assigned at birth).1 Teaching on transgender medicine is lacking in both undergraduate and post-graduate curricula, leading to a perceived lack of expertise in this area. Furthermore, General Medi-cal Council (GMC) guidelines on the GP’s role in prescribing are vague, resulting in some controversy. As wait times for appointments at specialist clinics are often at least 18 months, primary care physicians will increasingly be involved in the initiation of the transition process: this is the pro-cess by which an individual changes their phenotypic appearance of gender to match their gender identity through medications and/or surgery.
Example case
A 36-year-old patient, who was male at birth, has been living as a woman for the last 9 months. Her birth name still appears on GP records. She would like legal recognition as a woman and a referral to specialist gender services.
What needs to be ascertained?
Preferred pronoun and name
The patient’s preferred name and pronoun should be updated on the electronic patient record sys-tem; this will help prevent any potential mistakes from being made by calling the patient by the wrong name or gender.2
Level of support
Gather an understanding of the individual’s relationship with family, friends, or a wider social net-work (including transgender communities) to determine their level of support. Social isolation, nega-tive reactions of family and friends, or limited ‘social transition’ can be risk factors for developing mental illness or gender dysphoria, both of which may require extra support from mental health teams.2
Mental health symptoms
Elicit information regarding any distress, anxiety, self-harm, or suicidal thoughts. Around 34% of transgender individuals have attempted suicide at least once; screening in this initial consultation is
PRACTICE & POLICY
*For correspondence:c.cliffe@ imperial.ac.uk
Competing interests:The authors declare that no competing interests exist.
19 February 2017 Accepted:03 March 2017
12 July 2017 Author Keywords:transgender, gender identity, gender variance, bridging prescriptions
Copyrights2017, BJGP Open; DOI:10.3399/
bjgpopen17X101001
The transgender patient in primary care:
practical advice for a 10-minute
consultation
Charlotte Cliffe,
BSc, MBChB, FHEA1*, Miriam Hillyard,
MA, BM BCh2,
Albert Joseph,
BSc, MRes, BM BCh3, Azeem Majeed,
MD, FRCP, FRCGP, FFPH41
Honorary Clinical Research Fellow, Department of Primary Care and Public Health,
Imperial College London, London, UK;
2Foundation Doctor, North West Thames
Foundation School, Imperial College Healthcare NHS Trust, London, UK;
3Honorary
Clinical Research Fellow, Department of Primary Care and Public Health, Imperial
College London, London, UK;
4Professor of Primary Care, Department of Primary
Care and Public Health, Imperial College London, London, UK
With referrals to gender identity clinics rising rapidly, GPs are more likely to meet patients who are transgender (whose gender identity, or internal sense of gender, does not match their gender assigned at birth) or diagnosed with gender dysphoria (the severe psychological distress that is experienced by an individual as a result of the conflict between their gender identity and gender assigned at birth).1 Teaching on transgender medicine is lacking in both undergraduate and post-graduate curricula, leading to a perceived lack of expertise in this area. Furthermore, General Medi-cal Council (GMC) guidelines on the GP’s role in prescribing are vague, resulting in some controversy. As wait times for appointments at specialist clinics are often at least 18 months, primary care physicians will increasingly be involved in the initiation of the transition process: this is the pro-cess by which an individual changes their phenotypic appearance of gender to match their gender identity through medications and/or surgery.
Example case
A 36-year-old patient, who was male at birth, has been living as a woman for the last 9 months. Her birth name still appears on GP records. She would like legal recognition as a woman and a referral to specialist gender services.
What needs to be ascertained?
Preferred pronoun and name
The patient’s preferred name and pronoun should be updated on the electronic patient record sys-tem; this will help prevent any potential mistakes from being made by calling the patient by the wrong name or gender.2
Level of support
Gather an understanding of the individual’s relationship with family, friends, or a wider social net-work (including transgender communities) to determine their level of support. Social isolation, nega-tive reactions of family and friends, or limited ‘social transition’ can be risk factors for developing mental illness or gender dysphoria, both of which may require extra support from mental health teams.2
Mental health symptoms
Elicit information regarding any distress, anxiety, self-harm, or suicidal thoughts. Around 34% of transgender individuals have attempted suicide at least once; screening in this initial consultation is
PRACTICE & POLICY
*For correspondence:c.cliffe@ imperial.ac.uk
Competing interests:The authors declare that no competing interests exist. Received:19 February 2017 Accepted:03 March 2017 Published:12 July 2017 Author Keywords:
bridging prescriptions
Copyrights2017, BJGP Open; DOI:10.3399/
bjgpopen17X101001
The transgender patient in primary care:
practical advice for a 10-minute
consultation
Charlotte Cliffe,
BSc, MBChB, FHEA1*, Miriam Hillyard,
MA, BM BCh2,
Albert Joseph,
BSc, MRes, BM BCh3, Azeem Majeed,
MD, FRCP, FRCGP, FFPH41
Honorary Clinical Research Fellow, Department of Primary Care and Public Health,
Imperial College London, London, UK;
2Foundation Doctor, North West Thames
Foundation School, Imperial College Healthcare NHS Trust, London, UK;
3Honorary
Clinical Research Fellow, Department of Primary Care and Public Health, Imperial
College London, London, UK;
4Professor of Primary Care, Department of Primary
Care and Public Health, Imperial College London, London, UK
With referrals to gender identity clinics rising rapidly, GPs are more likely to meet patients who are transgender (whose gender identity, or internal sense of gender, does not match their gender assigned at birth) or diagnosed with gender dysphoria (the severe psychological distress that is experienced by an individual as a result of the conflict between their gender identity and gender assigned at birth).1 Teaching on transgender medicine is lacking in both undergraduate and post-graduate curricula, leading to a perceived lack of expertise in this area. Furthermore, General Medi-cal Council (GMC) guidelines on the GP’s role in prescribing are vague, resulting in some controversy. As wait times for appointments at specialist clinics are often at least 18 months, primary care physicians will increasingly be involved in the initiation of the transition process: this is the pro-cess by which an individual changes their phenotypic appearance of gender to match their gender identity through medications and/or surgery.
Example case
A 36-year-old patient, who was male at birth, has been living as a woman for the last 9 months. Her birth name still appears on GP records. She would like legal recognition as a woman and a referral to specialist gender services.
What needs to be ascertained?
Preferred pronoun and name
The patient’s preferred name and pronoun should be updated on the electronic patient record sys-tem; this will help prevent any potential mistakes from being made by calling the patient by the wrong name or gender.2
Level of support
Gather an understanding of the individual’s relationship with family, friends, or a wider social net-work (including transgender communities) to determine their level of support. Social isolation, nega-tive reactions of family and friends, or limited ‘social transition’ can be risk factors for developing mental illness or gender dysphoria, both of which may require extra support from mental health teams.2
Mental health symptoms
Elicit information regarding any distress, anxiety, self-harm, or suicidal thoughts. Around 34% of transgender individuals have attempted suicide at least once; screening in this initial consultation is
Cliffe Cet al. BJGP Open 2017;DOI: 10.3399/bjgpopen17X101001 1 of 5
important as it helps to determine whether a referral to the community mental health team is required.3
Self-medication
Patients may obtain unregulated and unverified hormonal medications; these are usually procured online.4These could:
. contain contaminants;
. have doses different from those stated; or . be inactive.
GPs should determine whether there are any absolute contraindications to hormonal prepara-tions; such as, past history of thrombosis, breast cancer, or current pregnancy. There are also relative contraindications that should be considered and for which specialist advice should be sought; for example, regarding renal or liver impairment, heart disease, and family history of thrombosis or can-cer. GPs should be aware that suddenly stopping oestrogens may result in withdrawal, leading to menopausal-type symptoms; this may worsen any distress experienced.2
Patient’s hopes for the future
It is important to ask the patient how they see the future, and whether this involves undergoing cross-sex hormonal therapy or surgery; not all patients will want these. The procedures can be dis-cussed in more detail at a later stage if necessary.
Surgeons prefer the patient to stop smoking before, and for several months after, any procedures so it is worth discussing smoking cessation early. Other modifiable risk factors for surgi-cal fitness (for example, obesity or hypertension) should be also addressed.2
Actions advised
. Ensure the patient’s electronic record is updated with the correct pronoun and patient’s desired name.
. Outline potential treatment options to include psychological therapy, speech and language therapy, hormones, and surgery.
. Discuss with the patient a direct referral to a specialist gender identity clinic (the locations of UK clinics are given inFigure 1), advising that wait times are often lengthy.
. Explain that initiating medications is usually done by the specialist gender identity team or under their advice, then discuss medication side-effects and risks (Boxes 1 and 2).
. If the individual is distressed or experiencing mental ill health, discuss a referral to the commu-nity mental health team.
. If the patient is self-medicating, consider specialist advice from an endocrinologist.
. Discuss smoking cessation if the patient is a smoker, or weight loss if they are overweight. . Provide the individual with advice on websites or support groups for transgender people.2,5
GMC guidance on prescribing cross-sex hormones
GMC guidance advises that there are three scenarios when it may be appropriate for GPs to ‘bridge a prescription’6of cross-sex hormonal therapy until patients are seen by specialists:
. The individual is self-medicating with unverified hormonal preparations.
. Without medications, the patient experiences severe distress that may cause them to self-harm or attempt suicide. In both scenarios the GMC argues that the patient is likely to come to more harm without, rather than with, the medications. However, specialist advice is still rec-ommended before starting hormones, leaving some ambiguity about their guidance.7
. Medications are recommended and under guidance of a specialist service, and the lowest pos-sible dose is prescribed.
Figure 1.UK locations of specialist gender identity clinics.
Box 1. Side-effects of hormonal preparations for trans men and women.2
Trans women Trans men
.Breast development takes 2 years .Beard and body hair growth
.Decreased hair loss .Male pattern baldness .Reduced muscle bulk .Enlarged clitoris .Erection/orgasm harder to achieve .Heightened libido
.Weight gain .Acne
.Reproductive implications, such as infertility .Sleep apnoea .Weight gain
general practice — so, if GPs are unsure about the best course of action, it is advisable to seek spe-cialist advice about the lowest possible dose, before initiating hormonal therapy.5–8
Follow-up
Long-term follow-up requires ongoing monitoring of hormone medications. Measuring blood pres-sure and blood tests at least every 6 months for the first 3 years is recommended by a number of specialist sources.9,10Tests cover:
. full blood count; . electrolytes;
. liver function; . HbA1C
. lipids; . testosterone;
. oestrogen; . prolactin; and
. thyroid function.
Regular monitoring prevents any potential for peaks and troughs of hormone concentrations.11 Care must be taken to retain patients in appropriate national screening programmes following transition. For example, depending on surgical status, a trans man may still need regular cervical smears or mammograms but may not automatically be included for recall via electronic patient records. Be aware that trans women retain a risk of prostate cancer, and trans women who take oes-trogens have a higher risk of breast cancer compared with non-transgender men. Finally, risk stratifi-cation (for instance with tools such as Q-Risk 2, FRAX) should assume gender assigned at birth and include the effects of hormonal treatments when calculating risk.2,10
Provenance
Freely submitted; externally peer-reviewed.
Acknowledgements
Imperial College London is grateful for support from the NW London NIHR Collaboration for Leader-ship in Applied Health Research & Care, the Imperial NIHR Biomedical Research Centre, and the Imperial Centre for Patient Safety and Service Quality. The views expressed in this article are those of the authors.
References
1. Lyon K. Gender identity clinic services under strain as referral rates soar.Guardian, 2016; 10 July. https:// Box 2. Risks of hormonal preparations for trans men and women.2
Medications for trans women Medications for trans men Self-medication
Thrombosis Polycythaemia Non-genuine or inactive product Gallstones Hyperlipidaemia Contaminated/harmful preparation Elevated liver enzymes Cardiovascular disease May have contraindications
Hypertriglyceridemia Hypertension Inadequate monitoring, such as liver fuction tests Hyperprolactinaemia Type 2 diabetes Over- or underdosing
Type 2 diabetes
2. RCGP. E-learning for GPs on gender variance. 2016.http://elearning.rcgp.org.uk/course/info.php?popup=0 &id=169(accessed 14 Jun 2017).
3. Maguen S, Shipherd JC. Suicide risk among transgender individuals.Psychology and Sexuality2010;1(1): 34–43.doi: 10.1080/19419891003634430
4. Gender Identity Research and Education Society. NHS Gender Identity Clinics (England).https://www.gires. org.uk/health/nhs-gender-identity-clinics-england(accessed 22 Jun 2017).
5. Palmer J, Bewisk M. Primary care responsibilities in relation to the prescribing and monitoring of hormone therapy for patients undergoing or having undergone gender dysphoria treatment. NHS England 2014. http://www.wlmht.nhs.uk/wp-content/uploads/2016/04/Primary-Care-Responsibilities-Circular.pdf(accessed 14 Jun 2017).
6. Millett D. GPs could initiate hormone therapy for transgender patients, says GMC. 2016. http://www. gponline.com/gps-initiate-hormone-therapy-transgender-patients-says-gmc/article/1388228(accessed 22 Jun 2017).
7. General Medical Council. Treatment pathways: referral to a Gender Identity Clinic (‘GIC’). http://www.gmc-uk.org/guidance/ethical_guidance/28852.asp(accessed 14 Jun 2017).
8. Millet, D. GMC transgender advice could push GPs to prescribe beyond competence, warns GPC. 2016. http://www.gponline.com/gmc-transgender-advice-push-gps-prescribe-beyond-competence-warns-gpc/ article/1395279(accessed 14 Jun 2017).
9. Deutsch MB, Bhakri V, Kubicek K. Effects of cross-sex hormone treatment on transgender women and men. Obstet Gyneco2015;125(3):605–610.doi: 10.1097/AOG.0000000000000692
10. Dahl M FJ, Goldberg J, Jaberi A.Endocrine therapy for transgender adults in British Columbia: suggested guidelines. Vancouver, BC: Vancouver Coastal Health, 2006.
