For some reason or other the simple act of changing a trans person's name and title on medical records seems to be a subject that puts some GP practices and hospital records clerks into an awful tizzy.
This recent example is typical of the kind of question I'm often asked. In this case a gender clinic was being asked for guidance by the patient's GP practice:
We have a patient who is presently registered and was born as female. They have undergone a legal name change of forename to something more masculine. In the letter that you have sent to the practice you refer to the patient as male. You are assessing the suitability for cross-sex hormone therapy; I assume this indicates the patient has not had surgery.
In order for our practise to have this patient registered as male the Family Health Services Authority re-register the patient with a new NHS number and disregard the previous document as archived.
Could you please tell me at what point this patient should be registered as male?
This kind of question is covered in the Department of Health's guide, "Trans: A Practical Guide for the NHS". A common problem is that officials sometimes assume that they ought not to make any changes until the patient obtains a Gender Recognition Certificate. In a footnote on page 30 it says,
"Note that the purpose of a GRC is merely to facilitate the creation of a new entry in the register of births, from which a new birth certificate can be issued. The GRC as a document has no other legal standing. It is not appropriate to operate a policy of requiring sight of a GRC in order to change an individual's name in patient or employee records. A statutory declaration or deed poll is the most that should be required for changes of name and title, just as for anyone else, and regardless of the individual's state of transition."
In case that's not enough, the guide then touches on the topic again and again. There are passages about medical records on page 43, on record keeping on page 55 and a best practice fact box on page 35.
Yet still these questions are asked. For these reasons I thought it would be worthwhile to feature the rest of my answer to the above query. Essentially it comes in two parts:
Firstly, the appropriate time for changing records is when the patient commences living permanently in the new gender role. It is not appropriate to insist that they have had any particular endocrine or surgical treatment – or to insist they have a GRC.
Changing name and title is no big deal. Tens of thousands of such changes are accommodated every year when women marry, so the mechanisms already exist.
The most important day to day change for a trans person is that the records contain the appropriate form of title (Mr, Miss, Mrs, Ms) and the name they have taken. UK law does not require any specific process for that. You and I can change our names at any time just by telling everyone that henceforth we will be known as 'x'.
It's not technically necessary to have a piece of paper (deep poll, statutory declaration or marriage certificate), but banks and other agencies prefer something to put on file, so trans people are recommended to complete a statutory declaration of their name change. As this is a legal document, NHS Trusts should take account of it. To refuse to change records on this basis would be unlawful discrimination.
The second consideration is how records work for the purposes of sex-specific screening (e.g. inviting women over 50 for breast screening or people with prostate glands for checks). The Trans Guide again explains very clearly (top of p43) that screening should be on the basis of physiological need. Thus, depending on the way their systems work, GP practices and hospitals must make appropriate arrangements.
I'm not familiar with the precise operating details of these systems, but if it's possible to make a distinction between title (Mr / Miss / Mrs etc) and sex, there is a decision to make over whether the sex indicator should be changed or not.
A balance needs to be struck between calling the patient for the right kinds of screening and fulfilling the requirements of the Gender Recognition Act when they have a GRC. (i.e. A flag that says a trans man is female could be visible to people who should not see it and the practice would break the law in terms of unauthorised disclosure of protected information).
The best way in my view is to change the flag (as it should be) to reflect the transitioned gender and simply make alternative arrangements to screen the patient. E.g. diary events could be set up on the patient's personal record.
This is preferable in any case as a trans man would need to be seen for gynaecological examinations in a setting which preserves his privacy and dignity. I.e. You wouldn't just let the computer send him along to sit in a clinic full of women.
The same goes for a trans woman needing BOTH prostate exams and breast exams but not gynaecological tests.
Issuing a new NHS number is OK – and some trans people specifically request this. I'm not clear whether there's a gender indicator buried in the number or not. Conflicting answers have been given on this.
However, issuing a new NHS number is separate to the question of whether the patient's medical record should be replaced. Clearly that would not be in the interests of the patient.
The best thing, however, is not to try and make these decisions on a blanket policy basis but to sit down with the patient and discuss the options and the implications so they can decide what's best for them in an imperfect system.
For instance, if one option would mean that doctors couldn't access their previous medical history then patients may well decide that that isn't in their interests.
Remember that all people want is an appropriate sense of privacy, protection from disclosures that could make them vulnerable in their wrong hands, and respect for their dignity.