Gender identity healthcare: evaluation of the impact of Scottish Government funding

Annex C: Review of the Literature

Context in the UK

In recent years, Scotland, and the UK more broadly, has seen an increase in the number of people identifying as trans and non-binary. While it remains difficult to pinpoint precise figures, in 2000-01, there was an estimated “5,000 transsexual people in the UK,” which amounted to less than 0.01% of the population.^[128] This data was based upon the number of people who had their passports changed. In 2001, a Scottish Needs Assessment Survey indicated that the trans population of Scotland was at half that number, 0.005%, which amounted to roughly 250 people.^[129] In 2018, the Scottish Public Health Network (SPHN) found that roughly 0.5% of the population - just under 24,000 adults - identified as trans and non-binary in Scotland.^[130] The most up-to-date figure comes from Scotland’s Census 2022, which asked a question about trans status or history for the first time. It found that there are 19,990 people in Scotland that were trans or had a trans history, equating to 0.44% of people aged 16 and over.^[131]

There is likely no simple explanation for the growth in the number of trans people, however, research has suggested contributing factors such as a positive shift in societal attitudes, coupled with growing sense of allyship across communities providing a safer environment for people to come out; an increase in information about trans and LGBTQIA+ issues in the public domain; the development of a language and vocabulary that enables members of this community to confidently speak about their identity; greater networking and community-building through social media; and a growth of service provisions that enable trans and non-binary people to live authentically.^[132]

While there has been an increase in the trans and non-binary population, current gender identity service provisions across the UK are becoming overextended to accommodate growing numbers of people seeking medical intervention. In England, GICs across the country have witnessed a steep increase in referrals in the last ten years. At the Charing Cross GIC in London for example, figures increased from 498 in 2006-07 to 1892 in 2016. Similarly, numbers increased from 30 in 2008 to 850 in 2015 at the GIC in Nottingham; from 31 in 2005 to 636 in 2016 at Exeter’s GIC; and in the space of a year at Northampton’s GIC, referral numbers increased from 8 in 2014-15 to 466 in 2015-16.^[133] Scotland’s four GICs in NHS Highland, NHS Lothian, NHS Grampian and NHSGGC have experienced a similar increase in demand.

In addition to increasing demand for gender identity services, resulting in long wait times, research has indicated that trans and non-binary patients face specific barriers when accessing services. Research published in the British Journal of General Practice found that trans and non-binary people face four major barriers when accessing care, including (1) structural barriers, related to lack of guidelines and shortage of specialist staff and centres; (2) educational barriers, related to the lack of training within the healthcare profession on trans health; (3) cultural and social barriers, reflecting negative attitudes towards trans and non-binary people, and (4) technical barriers, relating to issues with IT systems (i.e. recording changes in gender identity, and being linked up with other health data systems).^[134] The study found that primary care practitioners ‘often lack training in, and understanding of, trans identities and healthcare options.’^[135] Such barriers to care are confirmed in other research, including literature reviews and interview studies that have found that trans and non-binary people often experience ignorance and hostility when seeking to access services.^[136]

Research has revealed that barriers to accessing care - including long waiting lists, prejudicial staff attitudes, intrusive questioning, and untreated gender dysphoria - contribute to stress and adverse mental health outcomes for patients.^[137]

In 2017, the UK Government Equalities Office ran a national survey in light of the research and evidence underscoring the widespread discrimination, hate crimes, and health inequalities faced by members of the LGBTQIA+ community.^[138] This survey asked for views on public services, as well as the broader experiences of being part of this community in the UK. Of the 108,100 valid responses from those aged 16 and up, 13.3% of the survey sample identified as transgender, with 6.9% of this population identifying as non-binary, 3.5% identifying as trans women, and 2.9% identifying as trans men/masculine. Although the survey was self-selecting and therefore not representative of the whole LGBTQIA+ population in the UK, the responses and lived experiences gathered through the survey has helped to generate an image of some of the problems faced by GICs - and those accessing them - across the UK.

Of those who responded to the survey, 50% of trans men/masculine and 43% of trans women/feminine had accessed gender identity services across the UK in the previous year. Meanwhile, 16% of trans men/masculine and 15% of trans women/feminine respondents had tried to access services but were unsuccessful. Out of all respondents - both successful and not - 80% suggested access to gender identity services was not easy; citing lengthy waitlists as one of the main barriers.^[139] Similarly, for those identifying as non-binary, 7% had accessed services, with a further 6% trying to.

The survey revealed that 33% of respondents felt that GICs were not close enough to where they lived. The survey also highlighted the ‘serious consequences of having to wait’, including adverse impacts on the mental health of service users, which is confirmed in other research on trans people’s experiences of services.^[140] Due to lengthy wait times, combined with geographically inaccessible services, trans people on waitlists cited how they were turning to sex work to raise funds for international or private treatments; purchasing hormones on the internet to begin self-medicating; or attempting to access private medical treatment. 16% of trans respondents had gone abroad to pay for medical treatment, with another 50% suggesting they were considering it, citing long wait times as the reason for this.^[141] While this UK Government survey focuses on issues in the UK more broadly, it also helps draw attention to potential difficulties experienced at the GICs in Scotland around inconsistency of gender identity service provision, inequality of access across different geographical regions, lack of information regarding likely wait times, and ‘misgendering’ or ‘deadnaming’ in correspondence, and mental health implications for patients.^[142]

Context in Scotland and issues faced by patients

In 2014, the Scottish Transgender Alliance (STA), now Scottish Trans, released their “Gender Reassignment Protocol Audit, Community Engagement Focus Groups” report, which aimed to explore patient experiences of barriers to accessing gender reassignment services since 2012. These services were broken down into: GICs, counselling/psychotherapy services, hormone treatment services, speech therapy services, hair removal services, and surgical services. The report found that GICs were not, according to participants, providing patients with sufficient clarification of treatments, procedures, access criteria, risks, and expectations. The report also found significant accessibility issues due to long distance travel, a lack of co-production opportunities given to patients to discuss and agree on clear treatment plans, and significant wait times from referral to initial consultation.^[143] A report by Scottish Trans in July 2024 found that trans and non-binary people also faced barriers when accessing primary care, largely due to the lack of knowledge around trans healthcare.^[144] Trans and non-binary people also experienced problems in being referred incorrectly to a GIC when the issue was not related to gender identity, or they were referred to mental health services but not to gender identity services when this was what they needed.

According to the SPHN, between 2014 and 2017, roughly 1800 adults and 600 children were accessing GICs in Scotland, with the number of referrals markedly increasing each year.^[145] NHSGGC, NHS Lothian, and Public Health Scotland (PHS) commissioned a Health Needs Assessment between 2019-2022 that aimed to fill gaps in knowledge about the health and wellbeing of LGBT+ groups in Scotland.^[146] A supplemental report was also carried out, published by NHSGGC, that focussed specifically on the health needs of trans and non-binary people.^[147] The supplementary report detailed how the 271 trans and non-binary respondents had been referred, or referred themselves, to a GIC in Scotland. Of those respondents, 46% were on the waiting list at the time of publication, 33% were attending GICs, 17% were no longer using the services, and 4% had appointments cancelled due to COVID. Of those currently on the waiting list following a referral, 28% were referred over 5 years ago. 51% were referred within the last 5 years, and 21% were referred within the last year.^[148]

Official statistics in development published by Public Health Scotland found that, as of 31 March 2024, there were 5640 people waiting to be seen by a GIC, comprising: 4209 people waiting for up to 3 years; 618 people waiting between 3-4 years; 629 people waiting between 4-5 years; and 184 people waiting more than 5 years for a first outpatient consultation.^[149] The NHSGGC supplementary report suggested that the decision to seek gender identity care usually marked a period of improvement in mental health for trans people. However, the report also found that mental health issues could be “significantly exacerbated by the lengthy waiting period to access the services at Gender Identity Clinics which itself caused both depression and anxiety as trans people felt in limbo and unable to proceed with their medical transition.”^[150]

The SPHN’s report in 2018 outlined the general process for those seeking gender identity healthcare at that time. While we acknowledge that there may have been variation across different clinics at that time, and that processes have evolved since 2018, it is helpful to include an overview of this process here:

• Wait for referral from GP if accessing the Sandyford Clinic (in 2018, self-referrals to Sandyford were an option, but these were closed in August 2024).
• If there is no provisional diagnosis of ‘gender dysphoria’, the patient is discharged and referred for further support.
• If a provisional diagnosis of ‘gender dysphoria’ is in place and the patient wishes to undergo genital surgery, they need 12-24 months of experience living as their identity-congruent gender.
• Patients will be required to provide their clinic with verification that real-life experience in the preferred gender has been fulfilled prior to referral for genital surgery, e.g. through collateral interviews, official documentation from employers and educational institutions.
• Treatments that require one clinical assessment opinion for referral should be provided prior to, and concurrently with, the aforementioned preoperative identity experience. E.g. hormone therapy, facial hair removal, speech therapy, psychotherapy, mastectomy and chest reconstruction.
• Following the period of real-life identity-congruent experience, a second assessment and further treatment plans need to be agreed. The assessment, diagnosis, and confirmation of gender dysphoria should be made by a specialist mental health professional with general clinical competence in diagnosis and treatment of mental and emotional disorders. At this stage, it will be determined if the patient can be referred for complex surgical intervention.
• For patients wanting genital surgeries, they will be referred for 12 continuous months of hormone therapy appropriate to their gender goals. They also require two separate diagnoses of gender dysphoria from qualified professionals.
• Following any gender reassignment surgery, there will be a follow up with a GIC within 6 months, and any further treatments will be identified.
• Patients will then be discharged to their GP.^[151]

The 2022 Health Needs Assessment asked trans and non-binary survey respondents who had been on a waiting list for longer than 6 months to detail the implications of long wait times. Describing a sense of limbo, respondents highlighted increased rates of anxiety, depression, anguish, suicidal thoughts and self-harm caused by a prolonged wait and continued gender dysphoria.^[152] Of those who took part in the survey, 40% of trans and non-binary respondents cited long-term and limiting mental and emotional health problems in comparison to 16% of cis gender gay/lesbian men and women.^[153] A survey of young people by LGBT Youth Scotland in 2023 similarly found that while 63% of trans respondents who had accessed a GIC felt supported and respected by the service in terms of their sexual orientation and/or gender identity, the experience of long waiting lists and a lack of communication during the waiting period was a theme that ‘strongly resonated’ with respondents who were waiting to attend GICs.^[154]

These findings align with the outcomes of the SPHN 2018 Health Needs Assessment, which sought to understand how gender identity services across Scotland “relate to the needs of service users, and how they might be improved to respond to current and future demand.”^[155] The SPHN survey highlighted issues around waiting times, much like previous and subsequent research. Long wait times were found to pose a serious risk to those waiting to receive gender identity healthcare. For example, 67% of the survey respondents cited poorer mental health because of extended wait periods, 62% cited lower self-esteem, and 58% reported feeling more isolated or excluded. Of this group citing lower mental health, 29% of respondents said they had self-harmed, and 13% had attempted suicide or engaged with drug and alcohol abuse. An important theme to emerge from this data centred around patients withholding information from clinic staff, or feeling they had to behave in certain ways, for fear that they would not be able to access treatment. 30% of respondents reported withholding information or lying to clinicians (i.e. saying their mental health was okay), and 30% also felt pressured to do something they did not want to, in order to receive treatment.^[156]

Issues of trans and non-binary patients withholding information from clinic staff was also a key theme reported in the 2022 Health Needs Assessment supplementary report commissioned by NHSGGC. This report detailed how “trans people frequently… avoided seeking help for mental health problems for fear that this would be used as a reason for refusing or delaying access to medical transition.”^[157] In a survey of GIC service users, the following percentages of respondents withheld information from staff about their wellbeing due to fear that it would act as a barrier to hormone therapy and/or surgery: self-harm (22%), mental health issues (21%), suicide attempts (18%), sexual orientation (10%), and preferred gender identity (8%, nearly all of whom were trans men/masculine or non-binary).^[158] The survey revealed that, not only did patients hide mental health issues from staff at GICs, but they also felt deterred from seeking external help for their mental health for fear the information would be shared with the GICs, leaving patients in a mental health crisis for the duration of the waiting period.

A report by 2024 Scottish Trans in 2024 also found that people had a fear of disclosing being trans or non-binary, as they were concerned it would affect their care.^[159]

Extended wait times were also forcing those seeking gender affirming healthcare to look outside of NHS Scotland. Many trans and non-binary people opted to seek private treatment, or to buy hormones online to start self-medicating until they could be seen at GICs, with the supplementary report finding that 15% of respondents were accessing non-prescribed cross-sex hormones online, and 18% were accessing cross-sex hormones by private prescription from a health professional.^[160] The NHSGGC supplementary report also flagged geographical constraints as an accessibility issue for individuals living in rural areas and the Highlands and Islands, as well as the lack of Gender Reassignment Surgery (GRS) offered in Scotland. This meant that patients seeking surgical transitioning were required to travel to England, not only for the surgery itself, but also for the pre- and post-operative consultations.

Issues faced by gender identity service staff

While reports by the SPHN in 2018 and by NHSGGC, NHS Lothian and PHS in 2022 highlighted the barriers trans and non-binary people face when seeking gender affirming healthcare, they also pointed to the strain and pressures placed on GIC staff. The NHSGGC supplementary report on trans and non-binary people for the Health Needs Assessment 2022 highlighted how GIC staff felt overstretched, with patient demand far exceeding the capacity and bandwidth of the staff and clinicians available. Staff, and the provision of services in GICs in Scotland, also felt hampered by a lack of specialists in gender dysphoria, which led to significant impacts on service delivery, especially if a member of staff was on leave, or left the clinic altogether.^[161] This finding correlates with other research on barriers facing healthcare professionals working in gender identity, namely, a lack of education and professional training in trans healthcare, which has resulted in a dearth of specialists in this area.^[162]

The SPHN report also raised an important issue around staff specialism. During interviews with service providers and stakeholders, participants were asked if there were any changes needed in the way GICs in Scotland work together. This question led to a discussion around an expansion and de-specialisation of the workforce, particularly in light of categorisation changes for ‘Gender Identity Disorders’ in the World Health Organization’s (WHO) new International Classification of Diseases 11th Revision (ICD-11), which is the global standard for diagnostic health information.^[163]

The ICD-10 (the previous, 10th revision of the classification of diseases) included a category for Gender Identity Disorders - applicable to people with gender dysphoria - within a chapter on ‘Mental, Behavioural, and Neurodevelopmental Disorders.’ Recently, however, the WHO has reconceptualised this categorisation by replacing the word ‘disorder’ with ‘incongruence,’ and moving the newly termed ‘Gender Incongruence’ to a chapter on ‘Conditions Related to Sexual Health’ in the ICD-11.^[164] Given this clinical reframing, some service providers raised questions in the SPHN report around the necessity of psychiatrist-run services, offering alternative suggestions for nurse-led, sexual health- and multidisciplinary-run services instead.^[165]

This conversation adds weight to a broader UK-wide discussion around staff specialism from a 2016 report by the National Institute of Economic and Social Research. The report aimed to “identify the nature of inequality and relative disadvantage” experienced by members of the LGBT community in the UK and found that trans people were being pathologised by GPs with respect to their mental health. Trans people in the report provided examples of visiting GPs for a mental health issue and were instead directly referred to a GIC as opposed to a general psychiatric service, with GPs assuming mental health conditions must be a product of “being transgender” and not a separate issue. Those with lived experience felt this pathologisation was disempowering and presumptuous, inferring that trans people were unable to make judgements about their own treatment. The report also suggested that “the placement of treatment in the hands of psychiatrists (rather than, for example, endocrinologists) was seen by some as reinforcing the idea of transgenderism as a mental health issue.”^[166]

To help remedy widespread issues in Scotland’s GICs around wait times, staffing, and service pressures, the SPHN offered a range of recommendations based on qualitative results from service providers. Considerations of alternative care models that engaged with multidisciplinary teams, primary care workers, and those from the voluntary sector were highlighted, alongside staffing increases for clinical and nursing staff, and the implementation of short-term staffing at GICs. Further suggestions included increased education for generalists and expanded service capacity to meet demand.^[167]

The current evidence on gender identity healthcare in Scotland therefore indicates that many problems stem from significant wait times and service inaccessibility - across all stages of care pathways - which has had a pronounced effect on patient wellbeing. Not only have there been significant wait times for initial consultations, but long waits between appointments, and for referrals, transcriptions and letters, with clinical correspondence sometimes being addressed to deadnames and previous genders.^[168] The NHSGGC supplementary report concluded: “many trans and non-binary people asserted huge frustration in the waiting lists and services offered by the GIC” and that respondents used terms like ‘dehumanising’ to describe attempts to access services.^[169]

Current and future research areas

In recent years, and in light of such evidence coming to the fore, the SG has considered ways in which these issues can be remedied. In 2012, the SG introduced the Gender Reassignment Protocol (GRP), a framework to improve and standardise gender reassignment clinical pathways in Scotland. (The protocol was updated and superseded by the Gender Identity Healthcare Protocol (GIHP) in September 2024.^[170]) In 2014, the National Gender Identity Clinical Network for Scotland (NGICNS) was established to support the implementation of the GRP/GIHP.

In December 2021, the SG released their NHS Gender Identity Services: Strategic Action Framework 2022-24. The Framework outlined plans to provide £9 million over a 3-year period (which was extended to a 5-year period in July 2024) to fund new service models, address waiting times, and support those waiting to access services. This money would also be used to support staff development, and drive service improvement through enhanced data collection and reporting.

Running alongside this framework from 2022-24 is the National Gender Identity Healthcare Reference Group, which was established to “progress improvement in the provision of gender identity healthcare and to oversee the implementation of the commitments set out in the Strategic Action Framework.”^[171] This group is made up of people with lived (and living experience) of using NHS gender identity services, clinicians, academics, representatives from Health Boards, and LGBTQIA+ support organisations. Under the umbrella work of the Framework, the SG seeks to:

• address geographical variations in provisions of care to ensure equitable access to specialist services and subsequent care in all regions;
• scope out the feasibility of providing gender reassignment surgeries in Scotland; reduce waiting times; improve current service provisions;
• support NHS staff by commissioning a Transgender Care Knowledge and Skills Framework, develop Equality, Diversity and Inclusion (EDI) training for all staff, and ensure improved resources and training for all staff; and
• develop national standards for the care of adult and young people’s gender identity services, conducted by Healthcare Improvement Scotland.

In December 2023, Healthcare Improvement Scotland (HIS) put out draft standards for adult and young people’s gender identity services for public consultation. The consultation lasted for 13 weeks and closed on 1 March 2024. In its report on the draft standards, HIS recognised “that services in Scotland would benefit from the development of national standards for gender identity healthcare,” and that the standards should “seek to underpin what high-quality, equitable healthcare looks like for trans and non-binary people to support current and future service provision.”^[172] The draft standards were revised following the consultation and the final standards were published on 3 September 2024. A summary of the standards is as follows:

1. Person-centred care and shared decision making: People are supported to make informed and shared decisions about their care.

2. Reducing inequalities: Organisations actively work to reduce inequalities in accessing and delivering gender identity services.

3. Collaborative leadership and governance: Organisations demonstrate effective and collaborative leadership, governance and partnership working in the planning, management and delivery of gender identity healthcare.

4. Staff training, education and support: Staff have the training and skills to deliver person-centred, high-quality care and support for people accessing gender identity healthcare.

5. Access to gender identity healthcare: People have timely, equitable, consistent and person-centred access to gender identity healthcare.

6. Assessment and care planning: People have a holistic, effective and person-centred assessment and care plan.

7. Referral to gender identity services: NHS Boards ensure referral and timely access to gender identity services.

8. Specialist gender identity healthcare: People have access to safe, high-quality specialist gender identity healthcare.

9. Mental health and wellbeing: People have timely, equitable, consistent and person-centred access to mental health and wellbeing support.

10. Gender identity services for young people: Young people have timely access to safe, high-quality and person-centred gender identity services which understand, respect and uphold their rights.^[173]

Under the Strategic Action Framework, the SG has also committed to work with the Chief Scientist’s Office “to develop research proposals and make funding available for additional research on long term health outcomes for people who are accessing gender identity healthcare.”^[174] The University of Glasgow has been awarded a grant by the Scottish Government to administer a programme of research on health outcomes.

A few months after the SG Strategic Action Framework was launched, in March 2022, the Gender Recognition Reform (Scotland) Bill was introduced (stage 1) to the Scottish Parliament.^[175] The bill sought to reform the process by which people in Scotland can legally change their gender, including removing the requirement of a medical diagnosis of gender dysphoria, extending the right to apply for a gender recognition certificate (GRC) to 16 and 17 year olds, and reducing the time required for an applicant living in their acquired gender before self-certifying from 2 years to three months. The legislation would involve amending the UK Gender Recognition Act 2004 (GRA) and changing the process of obtaining a GRC in Scotland.^[176] In January 2023, the UK Government made an order under Section 35 of the Scotland Act (1998) to block the Gender Recognition Reform (Scotland) Bill. A SG challenge to this action was rejected by the Court of Session in Edinburgh in December 2023. The court found that the UK Government had acted lawfully in blocking the bill. The SG made the decision not to challenge the court’s decision. However, the SG has since indicated that it still wishes to see the Section 35 order lifted, to allow the legislation to take effect.^[177]

Meanwhile, the research landscape around gender identity healthcare is constantly evolving and in April 2024, Dr Hilary Cass submitted her final report to NHS England after reviewing gender identity services for children and young people in England. The review sought to understand the significant increase in referrals for young people over the last 5-10 years and the change in case-mix, and to identify “the clinical approach and service model that would best serve this population.”^[178] The report, and subsequent recommendations, were commissioned by NHS England and speak only to the evidence gathered in NHS England gender identity services.

In a statement in April 2024, SG Minister for Public Health and Women’s Health Jenni Minto detailed how the Cass Review required consideration, and while “not all the recommendations may be applicable to the NHS services in Scotland … it is vitally important that these recommendations are carefully considered to assess to what extent they are relevant to the approach to gender identity healthcare in Scotland, and to decide upon what steps may need to be taken as a result.”^[179] She confirmed that NHSGGC and NHS Lothian, the two Boards with specialist paediatric endocrinology services, had paused new prescriptions for puberty hormone suppressants and cross sex hormone medication for young people with gender dysphoria. This pause was “to allow time for further evidence to be gathered to support the safety and clinical effectiveness of these medications, following the Cass Review.”

Following the publication of the Cass Report, the CMO in the SG created a multidisciplinary team (MDT) to consider how the recommendations for the Cass report apply to the Scottish context. The MDT’s report was published in July 2024, and some of the key themes are as follows^[180]:

• the capacity of the gender identity service for children and young people in Scotland should be expanded through a distributed service model, based in paediatric services and with strong links between secondary and specialist services. The service model should be developed in the same way as other specialist services for children and young people by applying the principle "as local as possible and as national as necessary”
• access to services should be through referral from a GP after an initial assessment, as is the case for a referral to any other child or adolescent specialist service. A senior clinician should take responsibility for the care of the individual, by taking a lead role in MDT discussions and in the coordination of the care, governance and safety of the service. An individualised care plan should be agreed with the child or young person and/or their family as appropriate. Follow-up support and needs could then be delivered locally
• there is insufficient evidence to support the benefits of puberty-suppressing hormones and that the risks of harm remain a significant potential concern. Whilst puberty-suppressing hormones may be the right treatment for some young people, there is insufficient evidence to know which children or young people will benefit most. Clinicians in NHSGGC and NHS Lothian identified concerns about the use of gender-affirming hormones in those under 18 years of age and paused the use of these medicines in those aged under 18 years in Scotland. The CMO team advised there should be caution and a clear rationale for providing gender-affirming hormones for individuals aged under 18 years as part of a shared decision-making conversation. Further UK-wide research should evaluate the use of gender-affirming hormones in young people

The CMO MDT team anticipated that their recommendations would have implications for gender identity services capacity, and this would need to be resourced. In particular, they felt that much of this care should be normalised within the existing paediatric services with existing staff expertise, supplemented by training and specialists.^[181] The CMO report also acknowledged that “for many individuals who had significant hopes for medical treatment this message may be difficult to hear. We would stress that this decision reflects clinical and scientific safety concerns that progressing down medical pathways without an adequate and robust evidence base could lead to harm and regret if long term side effects of medical treatments are not known.”^[182]

Beyond the CMO report, there has been considerable debate over the safety and appropriateness of puberty-suppressing hormones. The UK and Scottish governments both supported a temporary pause on puberty-suppressing hormones for young people until more research is available (including further clinical trials), attracting the support of the Royal College of Psychiatrists, the Royal College of General Practitioners, and the Royal College of Paediatrics and Child Health. Other organisations such as the British Medical Association (BMA) have voted to retain a neutral position until they conclude their own evaluation of the Cass Review.^[183] Meanwhile, LGBTQIA+ organisations such as Scottish Trans and LGBT Youth Scotland have opposed the ban on puberty blockers, highlighting the benefits of gender-affirming hormones for young people.^[184]

Additional guidance was made available to staff working in gender identity healthcare services in Scotland in the second half of 2024. In September 2024, the SG published the Gender Identity Healthcare Protocol (GIHP), which updated the previous Gender Reassignment Protocol of 2012, and the HIS Gender Identity Healthcare Services Standards. Also that month, NES published the Transgender Care Knowledge and Skills Framework, to “support the delivery of healthcare to adult trans and non-binary people across all settings in NHS Scotland.”^[185] The Framework is applicable to all staff, setting out what NHS staff need to know to care for trans and non-binary people, from receptionists, nurses and GPs to staff working in GICs. The Framework was developed in the context of the Realistic Medicine vision of person-centred care, and it has four levels: essential (knowledge and skills that everyone needs); skilled (for staff with significant contact with trans people); enhanced (for staff providing specialist care); and expert (for staff providing complex specialist care).

In November 2024, Public Health Scotland published official statistics in development on waiting times for first outpatient appointments at GICs in Scotland.^[186] The report found that at least 1,680 referrals were made to NHS GICs for an outpatient appointment in 2023-24. On 31 March 2024 there were 5,640 people waiting on a first outpatient appointment for an NHS GIC, an increase of 7% from 30th June 2023. Of those people waiting, 4,209 (75%) people had been waiting for up to 3 years for their initial appointment and the remaining 1,431 (25%) had been waiting for more than 3 years. The report is based on quarterly data collected in 2023-24.

Conclusion

This literature review has highlighted prominent issues in the delivery of, and access to, gender identity healthcare services in Scotland and the UK. This includes: the growth and change in the composition of people identifying as trans and non-binary in Scotland; the rapidly changing policy and clinical context around gender identity healthcare, for adult and young people’s services; issues that patients face when accessing services, in particular, the mental health impacts of long waiting lists; pressures on staff to deliver high-quality services at a time when the policy and clinical context is changing and training is still underdeveloped; and recent efforts to improve service delivery, develop standards and create support for services.

At the same time, the research on gender identity healthcare services remains under-studied and underdeveloped, with a general lack of high-quality data, and a need for more extensive research on healthcare services and impacts on care in Scotland generally. Furthermore, the current research tends to focus on service users and their lived experiences of engaging with GICs in Scotland. While this perspective is vital to have, it is also fundamental to understand the experiences of those working in these services. This perspective is less documented, but equally important in order to better understand barriers and opportunities to ensure thriving gender identity services.