“The patient’s interests must come first”: French general practitioners’ experience of initiating testosterone therapy for trans people against national regulations, a qualitative study

Background In France, it is forbidden for general practitioners (GPs) to write the initial prescription for testosterone, because it is considered a potentially doping substance. However, some GPs choose to do it for trans and gender-diverse (TGD) patients who have difficulties accessing gender-affirming hormone therapy.Aim To explore the experience of French GPs initiating testosterone therapy for TGD patients, against current regulations, and the meaning it had for them.Methods In-depth semi-structured interviews with nine French GPs of various gender identities and backgrounds were conducted and analyzed following the interpretative phenomenological analysis method.Results GPs experienced this practice as an ethical imperative and professional duty, a social commitment for justice and equity, and for some, an activist and political form of medical care. They felt responsible for helping TGD people access care, against medical gatekeeping. Therefore, they chose to transgress, in the name of their patients’ interests, regulatory restrictions that they deemed illegitimate. Despite difficulties, threats, or disciplinary sanctions, they chose to persevere, negotiating professional risks, building networks and communities with colleagues and TGD people. They experienced a more horizontal doctor/patient relationship, and recognized the value of community expertise. They wanted to exchange knowledge and share power with patients considered as partners. They focused on a patient-centered approach, and aimed to co-build the best possible care for TGD individuals. To them, this was the heart of what being a GP means.Conclusion These GPs’ experiences showed commitment to ethical, evidence-based, patient-empowering practice, despite a socio-institutional context that may be unsupportive or ambiguous. Choosing to accompany TGD patients’ self-determination sometimes put them under duress, given their medico-legal liability in the current system. National and international guidelines on the GPs’ role in transgender care are evolving. If French regulations changed to better acknowledge GPs’ testosterone prescriptions, doctors and patients could feel safer.