Gender identity: pharmaceutical care for children and young people

“Clinical staff are governed by professional, legal and ethical guidance which demands that certain standards are met before a treatment can be provided. Clinicians carry responsibility for their assessment and recommendations, and any harm that might be caused to a patient under their care. This can create a tension between the aspirations of the young person and the responsibilities of the clinician.”
Dr Hilary Cass

NHS England has commissioned an independent review, led by Dr Hilary Cass, on how children and young people presenting with gender identity issues, are assessed, diagnosed, and provided with care. The review is still ongoing, but an interim report has been published which sets out initial findings and recommendations. The review was set up to advise on the future of services in England, but the issues discussed in this article will be of use to pharmacy professionals working across Great Britain.

Pharmacy teams providing pharmacy services to children and young people with gender incongruence or dysphoria, need to adhere to the standard process of clinical assessment and care provision they have been trained to take as healthcare professionals. The starting point is that pharmacy professionals must provide person-centred care, within the current relevant legal and regulatory context.

There are several key points to consider when providing pharmacy services to children and young people with gender incongruence or dysphoria. They include:

Professional behaviour

All interactions should be non-judgemental, inclusive, compassionate, and free from discrimination or bias.

Personal values and beliefs

Pharmacy professionals need to take responsibility for ensuring that person-centred care is not compromised because of religion, personal values, or beliefs, including their own. For more information see, our guidance document In practice: Guidance on religion, personal values and beliefs.

Professional judgement

Many of the children and young people presenting have complex needs. Pharmacy professionals need to be aware that once a child or young person has been identified as having gender-related distress, other significant healthcare issues can sometimes be overlooked, for example, mental health or neurodevelopmental assessments, and these need to be addressed.

If a pharmacy professional is unaware of the range of support and treatment options that best address the needs of the child or young person, they should consider signposting to the patient’s GP and/or other services.

Supporting vulnerable or at-risk patients

Most children and young people experiencing gender incongruence or dysphoria have waited for lengthy periods to be assessed. By the time they are seen, their distress may have worsened, and their mental health may have deteriorated.

It is important to be able to identify and appropriately refer children, young people and families who may be vulnerable, or at risk.

Clinical appropriateness of prescribed medicines

Pharmacy professionals may be concerned about dispensing prescriptions or emergency supplies to children and young people, which they do not feel able to supply in line with appropriate professional standards.

It is not enough for a prescription to be legally valid; that is just one consideration alongside others, including judgement as to whether a prescription is clinically appropriate. In some cases, prescriptions may have been issued by overseas gender clinics and prescribers who are not under the jurisdiction of UK regulators, which creates additional risk.

We expect pharmacies to have taken active steps to assure themselves that all prescribers, including those from overseas, comply with relevant UK regulatory and professional guidance.

Reasonable precautions should be taken by pharmacies to assure themselves that the prescriber has sufficient specialist expertise to assess and diagnose gender dysphoria, and to recommend prescriptions for the person concerned; for example, by following the guidance given in Specialised Services Circular (SSC) 1826.

Pharmacy professionals need to use their professional judgement when considering the risks to the patient of supplying - or not supplying - against a legally valid prescription. There may be no easy answers and no risk-free options. It is important to document the process and reasons for the decision reached, particularly in complex cases.

It may be the right thing in some cases to refuse to supply medication and instead signpost the patient to their GP. Consideration must be given to any risks that might be associated with declining to make a supply, or abruptly discontinuing to make further supplies where the patient has previously been taking particular medicines. Person-centred and compassionate communication is particularly important in these challenging scenarios.

The interim report from the Cass review makes it clear that currently it is not possible to provide definitive advice on the use of puberty blockers and feminising/masculinising hormones, due to gaps in the evidence base.

Pharmacy professionals must use their professional judgement to make sure they deliver safe and effective care; wherever they are practising, the interim report and recommendations are a useful resource.

When the final report from the Cass review is published, we will consider whether we can usefully provide additional information for pharmacy professionals.

Consent, confidentiality, and effective communication

The issues of consent (which includes capacity to consent) and confidentiality can be complicated, in the case of children and young people. Pharmacy professionals must be aware of the applicable legal framework, and work within it, mindful also of the role and legal responsibilities of parents, where relevant. 

With the patient’s consent, the pharmacy professional should work with the patient’s GP, and encourage patients to discuss their treatment with the GP.

Further information about these issues can be found in our guidance documents In practice: Guidance on consent and In practice: Guidance on confidentiality.  Pharmacy professionals should also seek legal advice if necessary, relevant to the jurisdiction where they are practising.

Partnership working

Any child or young person being appropriately considered for hormone treatment will have had a formal diagnosis and formulation, which addresses the full range of factors affecting their physical, mental, developmental, and psychosocial wellbeing. This formulation should then inform what options for support and intervention might be helpful for that child or young person.

The child or young person should provide the contact details of their regular prescriber, such as their GP, and their consent to contact them about the prescription. The GP will be able to confirm that the prescription is appropriate for the person and that appropriate monitoring is in place.

If there is no consent to share information, the pharmacy professional must think about the person’s best interests and make a risk-based assessment about whether to supply the prescribed medicines and indeed whether any further action is needed. A clear record setting out their justification for providing/not providing, should be made. For more information, see our guidance documents Guidance for registered pharmacies providing pharmacy services at a distance, including on the internet and In practice: Guidance for pharmacist prescribers.