Background information
On 6th February 2018 The Ionising Radiation (Medical Exposure) Regulations 2017(IR(ME)R) (IR(ME)R NI 2018) came into effect in the UK. This superseded IR(ME)R 2000. The purpose of IR(ME)R is to protect individuals from the harmful effects of ionising radiation. It places obligations on employers and anyone working as an entitled duty holder. A change of wording was made in the requirements for employers written procedures from ‘making enquiries of females of childbearing capacity’ to ‘individuals of childbearing potential’. This caused healthcare professionals to reflect on existing practice. It was recognised that assuming a person’s sex registered at birth from their appearance or relying on a single sex marker in their NHS record, introduced risks of accidental irradiation of a fetus which the profession felt should be addressed. SoR published early guidelines for the workforce listing the considerations for revised written procedures.
In the 2019/20 annual IR(ME)R report, The Care Quality Commission highlighted a case where a pregnant trans man had been irradiated during a CT scan because he was not asked about possibility of pregnancy. They made an action for employers to ‘make sure that procedures in imaging and radiotherapy departments are inclusive of transgender and non-binary patients, including the procedure for making pregnancy enquiries’.
At around the same time The Society of Radiographers presented its early guidelines at the International Trans Pregnancy Conference in Leeds. We heard powerful stories from trans parents demonstrating how much more needs to be done to address the needs of trans and non-binary people, including providing better information to enable them to provide valid informed consent and not putting the burden on patients to understand when they might be at risk.
In 2021 a working group consisting of highly skilled therapeutic and diagnostic radiographers and lay experts by experience spent the year working through the sometimes-conflicting requirements of The Gender Recognition Act (GRA) 2004 and IR(ME)R and considering requirements of The Equality Act 2010. Due to the lack of a known legal precent establishing a hierarchy of the legislation, SoR recognised the need to set the guidelines in the context of all three pieces of legislation and importantly to frame them in the safe and effective delivery of equitable care.
Pilot studies were run which documented both negative and positive patient feedback and highlighted a need for considerable education around the use of inclusive language.
An extensive consultation process was conducted as part of SoR publication process.
In November 2021 we published Inclusive pregnancy status guidelines for ionising radiation: Diagnostic and therapeutic exposures alongside a patient information poster, two patient questionnaires, two patient information leaflets, and a practitioner ‘paused and checked’ poster for quick reference. All these resources are freely available for public access. We ran a live webinar which attracted over 800 registrants and over 500 people attended live on the night. It was recorded and is available to members as a teaching resource and to non-members who registered for the webinar. It was stressed in the guidelines and during the webinar that any change to practice should be preceded by an analysis of staff educational requirements on inclusive language and that adequate training should be provided before using the Inclusive Pregnancy Status (IPS) resources. There was hugely encouraging engagement and positive discussion from radiographers, nurses, doctors, and students all trying to implement the guidelines and many who had already done so. Any questions not addressed due to time constraints at the webinar, were covered in a subsequent Q&A resource which is published on our website.
Response to Press reports 29.03.2022
The guidelines help the workforce to:
- deliver on the requirements of IR(ME)R, GRA, Equality Act
- work in line with the expectations of their registration with HCPC and membership of their professional body to practice patient centred care
- deliver on The NHS Patient Safety Strategy to develop safer culture and safer systems
- facilitate trans status disclosure and share the responsibility for safe care
Employers do not need to follow the IPS guidelines, but they must comply with the legislation. It is their choice how they do this. The guidelines and resources intend to assist consistency in practice across the UK and reduce inequality of care. The Society of Radiographers is aware that not all Medical Physics Experts have advised their employers to follow the guidelines and instead have chosen to manage the risk of unintended exposures. The Society of Radiographers does not feel this is an accurate interpretation of IR(ME)R. It does not deliver equitable care and it does little to promote cultures of psychological safety for Trans, Non-Binary and Intersex (TNBI) people. It would be of value to the workforce if The Department of Health could clarify what is meant by the requirement in IR(ME)R Schedule 2 (c) for making enquiries of individuals of childbearing potential to establish whether the individual is or may be pregnant or breastfeeding.
The guidelines do not require all men to be asked if they are pregnant. They recommend that local risk groups are established with the MPEs advice. This has been normal practice for many years. Typically, this will be for an age group of 12-55 and for higher radiation dose procedures where the pelvis is irradiated. Everyone in the risk group is given a questionnaire which asks them which sex they were registered at birth. They do not have to answer this, but if they respond male they are NOT then asked if they are pregnant.
The guidelines do not recommend removing ‘woman’, ‘female’ or ‘breast’ or any other term commonly used in our language. They do recommend all healthcare professional are aware of and acknowledge the preferred language of TNBI people and deliver appropriate, non-judgmental care with respect and dignity.
The patient questionnaire forms were piloted following extensive staff training, and feedback was very positive from staff and patients. Cis gender males did not respond negatively in large numbers as had been presumed they would. Most appreciated the need to be asked about sex registered at birth because they were informed why this was being recorded. In fact, we have done this generically for many years with other questionnaires, so this has not really changed.
The media has challenged the need to address the healthcare needs of a small minority group. SoR believes the argument for treating someone differently, due to a low perceived risk, or the ‘turning a blind eye approach’ is no longer acceptable to society. SoR believes that knowingly providing substandard care to a population protected by the Equality Act is in breach of The Act. Elsewhere in healthcare we do not refuse to treat a person with a condition because it is not familiar to us. We are expected to educate ourselves appropriately.
There is a sense portrayed that the workforce is not able to manage sensitive conversations that arise in the endeavour to deliver safe and equitable care. SoR challenges this as radiographers are well trained in communication skills, and specifically in the communication or benefit and risk information related to radiation dose. They are best placed to have these conversations.
In response to the comment Campaigners warned yesterday that it was the beginning of a ‘clinically dangerous’ move to record only gender, and not sex, on medical records – this is an inaccurate interpretation or lack of familiarity of the guidelines. The guidelines address the risks associated with the recording of a single sex marker and seek to prevent patients coming to harm because of this. The suggestion that only gender be recorded is misguided and inaccurate. The use of a single sex marker for sex assigned at birth and gender identity is the current standard in the NHS and where there is risk to trans patients and an unidentified fetus. This is why our guidelines advocate for improved data collection to protect patient safety.
Summary
The Society of Radiographers is disappointed that extensively considered professional body guidance is mis represented in the public arena. While we support all views, healthcare professionals have a responsibility to act in the best interests of the patient and to ensure patients are treated with dignity and respect at every interaction. Irresponsible and inaccurate media reporting increases the pressure on the workforce to deliver very sensitive information in already challenging circumstances. We hope that a clear public message will help to mitigate any damage that may have been caused by today’s news. We are very happy to be contacted to discuss this further.
The Society of Radiographers contacted the CQC on 29.03.2022 and they reiterated their position as regulators, stating that employers must comply with the requirements of IR(ME)R. While they cannot endorse professional body guidance, they recommend the use of the inclusive language in employers written procedures.
Lynda Johnson, Professional Officer Clinical Imaging, The Society of Radiographers [email protected] Charlotte Beardmore, Executive Director of Professional Policy, The Society of Radiographers [email protected]