I read the excellent article on Transgender issues  in the latest CMQ

I just wondered where we stand if a patient asks us for a referral for a transgender clinic? I am certainly not happy with doing so and am dreading someone coming asking for this! (Obviously I would treat them with respect and explore all the underlying psychological issues etc)

Is there any guidance on conscientious objection??  I was appalled to see recent program on BBC where children as young as around 6 were living as opposite sex - and adults approving of this!!!!! 

Thanks for any guidance

Authors  reply 

That’s very  kind of you  to  say  so. Writing it was hard work.

When the GMC revised its document of personal  beliefs they  started out with  a view that  one protected group (religion) would not be able to  impose its views on another protected group (Transgender). As a result they  suggested that  the trans group  would trump the religious viewpoint and that  to  refuse services to  them would be “defacto” discriminatory. We pointed out that  that  could not be so. If a thing is unethical  it should not be done and the fact  that  a minority  group  member which  has legal  protection is asking for it cannot be a sufficient reason to  be forced to  provide it and to  abandon ethical  considerations.   For example, if a Catholic mother insisted upon intensive care admission for an infant which had no  chance of survival, the fact  that this was a request  from  a minority  group  would not mean that  the request  could not be refused.

That  view carried the day  and it was concluded that  if we think  a procedure is unethical,  then  we can refuse to  provide it. But the right of ethical  rand conscientious objection does require that  we must  refuse to  provide it to  all  groups and not just  the minority  group.

That  stipulation does not particularly matter for transgender issues as the things that  are done are moreorless entirely specific to  that  group. Although there is a real  challenge for doctors and pharmacists who  are asked to  provide on-going prescriptions for sexual  phenotype changing hormones.

For contraception it works well  for those (Catholics) who  refuse to  provide the pill  to  all  women married or not,  though  it works less well  for those Anglicans who only want to  give the pill  to married couples.

For Viagra,  and in other circumstances,  there are some real  challenges. Many  are likely to  think  that  Viagra  to  enable continued sexual  intercourse between a husband and wife is different from  giving Viagra to  single men who  are wanting to  be able to  have a one night stand. We hope to publish  more on that  soon.

So  there is some real  complexity.  Would you  prescribe Viagra for an unmarried man who  wants a one night stand? Would the GMC  respect your refusal  to  do  so?

But with the transgender campaign there is, in fact  a more complex issue which  probably triggered the pharmacists troubles earlier this year. Some pharmacists (and some GPs are refusing to  provide the oestrogens etc to  transitioning and transitioned (to  female phenotype) men. In men  who are starting transition,  we might well  refuse to  provide the hormones as we think  that  such  treatment is mutilating. And therefore unethical. But for those who  are established on female hormones,  is continuation of those hormones a continuation of the mutilation,  or has the water passed under the bridge and is this maintaining the (new) status quo the best  remaining option. It might well  be. I  don’t think  we fully understand that  issue yet. And it needs careful  thought and discussion. The instinct  is not to  provide and not to  cooperate. But although  we should not cooperate in an unethical  act  ,  we will  support people with ethical  care once that  unethical  act  has been completed.  I am thinking of the very  different situation of a woman undergoing an abortion.

Adrian Treloar