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

Footnotes

1 Scottish Government, NHS Gender Identity Services: Strategic Action Framework 2022-24, December 2021.

2 Ibid.

3 This amount was allocated to territorial NHS Scotland Health Boards with gender identity clinics. This figure does not include SG funding that was allocated to Health Improvement Scotland, NHS Education for Scotland or National Services Scotland (which are national boards) to improve gender identity healthcare. Scottish Government, National Gender Identity Healthcare Reference Group winter 2023 to 2024 update, 23 November 2023; improvement funding allocations provided by the Scottish Government.

4 Scottish Government, Statement by Minister for Public Health and Women’s Health Jenni Minto, 23 April 2024.

5 Scottish Government, “Scottish Government Equality Outcomes: Lesbian, Gay, /bisexual and Transgender (LGBT) Evidence Review,” Scottish Government Social Research, 2013.

6 National Records of Scotland, “Scotland’s Census - Sexual Orientation and trans status or history”, June 2024.

7 James Morton and Rebecca Kent, “Gender Reassignment Protocol Audit, Community Engagement Focus Group Report of Findings,” Scottish Transgender Alliance, January 2014.

8 The needs assessment incorporated a variety of methods, including a literature review; data analysis of national surgical data, gender identity clinic data and service user data (the latter from a survey of service users carried out by Scottish Trans Alliance); and interviews with GIC and NHS staff, and other stakeholders. Thomson, R., J. Baker and J. Arnot (2018) Scottish Public Health Network Health Care Needs Assessment of Gender Identity Services, SPHN Report.

9 Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024, p28.

10 Leven, T. “Health needs assessment of lesbian, gay, bisexual, transgender and non-binary people: Full Research Findings Report”, prepared for NHS Greater Glasgow & Clyde, NHS Lothian and Public Health Scotland, May 2022; and Leven, T. “Health needs assessment LGBT+ people: Transgender and non-binary supplementary report,” NHSGGC, June 2022.

11 Cooper, K., et al, ‘The phenomenology of gender dysphoria in adults: a systematic review and meta-synthesis’, Clinical Psychology Review, August 2020.

12 Leven, T., May 2022 and June 2022, ibid; Thomson, R., J. Baker and J. Arnot (2018) Scottish Public Health Network Health Care Needs Assessment of Gender Identity Services, SPHN Report.

13 Leven, T. “Health needs assessment LGBT+ people: Transgender and non-binary supplementary report,” NHSGGC, June 2022.

14 Scottish Government, ‘Gender Reassignment Protocol, Letter to Boards, July 2012.

15 Scottish Government, ‘Gender Identity Healthcare Protocol for Scotland’, 3 September 2024.

16 Scottish Government, NHS Gender Identity Services: Strategic Action Framework 2022-24, December 2021.

17 Scottish Government, “National Gender Identity Healthcare Reference Group,” Scottish Government, March 2022.

18 Scottish Government, ‘Gender Identity Healthcare Protocol for Scotland’, 3 September 2024.

19 Healthcare Improvement Scotland, Gender Identity Healthcare: Adults and Young People. Standards, September 2024.

20 NHS Education for Scotland, ‘Transgender Care Knowledge and Skills Framework’, September 2024.

21 Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024.

22 Cass Review, Independent review of gender identity services for children and young people: Final Report, NHS England, 2024.

23 Scottish Government, ‘Gender Identity Healthcare’, 23 April 2024.

24 Scottish Government, Cass Review – implications for Scotland: findings report, 5 July 2024.

25 Calenbuhr, V., ‘Complexity Science in the Context of Policymaking,’ in V. Šucha and M. Sienkiewicz (eds) Science for Policy Handbook, Elsevier, 2020,118-127.

26 Braithwaite, J. et al, ‘Complexity Science in Healthcare’, Australian Institute of Health Innovation, Macquarie University, 2017.

27 See Lijphart A. ‘Comparative Politics and the Comparative Method,’ American Political Science Review, 1971, 65(3):682-693.

28 See Anckar, C., ‘On the Applicability of the Most Similar Systems Design and the Most Different Systems Design in Comparative Research,’ International Journal of Social Research Methodology, 2008, 11(5), 389-401.

29 Scottish Government guidance on compensating research participants for their time made be found online

30 Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024.

31 Mayne, J., “Useful theory of change models”, Canadian Journal of Program Evaluation, 30(2), 119-142, 2015.

32 Scottish Government, “National Gender Identity Healthcare Reference Group: terms of reference”, 24 May 2022.

33 Other SG funding for gender identity healthcare was used to commission work by Healthcare Improvement Scotland to develop national standards for adult and young people’s gender identity services, for NHS Education for Scotland to develop a Transgender Care Knowledge and Skills Framework, for Public Health Scotland to establish robust national waiting times data collection, monitoring and reporting, and additional research to improve services. See: Scottish Government, ‘NHS gender identity services: strategic action framework 2022-24’, December 2021.

34 Scottish Government, ‘NHS gender identity services: strategic action framework 2022-24’, December 2021.

35 NHS Scotland’s Realistic Medicine vision and approach can be found here: https://realisticmedicine.scot/

36 Argyll and Bute HSCP is part of the NHS Highland Health Board area.

37 Information provided by Sandyford GIC, August 2024.

38 NHSGGC, Draft Paper: Independent Reports into care Outwith NHS GG&C, “Areas/questions of interest to the Committee,” evidence submitted to the Scottish Parliament Equalities, Human Rights and Civil Justice Committee, 24 June 2022.

39 Ibid.

40 This financial framework was developed several years ago and no longer fully reflects the increased costs experienced by Sandyford. NHSGGC, Draft Paper: Independent Reports into care Outwith NHS GG&C, “Areas/questions of interest to the Committee,” evidence submitted to the Scottish Parliament Equalities, Human Rights and Civil Justice Committee, 24 June 2022.

41 Information from Sandyford Clinic, received in August 2024.

42The website can be accessed here: https://www.sandyford.scot/sexual-health-services/gender-service-at-sandyford/

43 Funding allocation letters to territorial NHS Health Boards, provided by the Scottish Government.

44 NHSGGC application for SG funding to address waiting times and support people waiting, gender identity healthcare, July 2022.

45 Ibid.

46 Information provided by Sandyford GIC, June 2024; Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024.

47 Nathan Hudson-Sharp and Hilary Metcalf, “Inequality among lesbian, gay, bisexual, and transgender groups in the UK: a review of evidence,” National Institute of Economic and Social Research, July 2016.

48 Scottish Trans, Non-binary people’s experiences of using UK gender identity clinics, Scottish Trans, 2016.

49 Rachel Thomson, Jessica Baker, and Julie Arnot, “Scottish Public Health Network (SPHN), “Healthcare Needs Assessment of Gender Identity Services,” Scottish Public Health Network, May 2018, 79.

50 NHSGGC, Draft Paper: Independent Reports into care Outwith NHS GG&C, “Areas/questions of interest to the Committee,” evidence submitted to the Scottish Parliament Equalities, Human Rights and Civil Justice Committee, 24 June 2022.

51 Ibid.

52 Information from Sandyford GIC, received August 2024.

53 For more information on how GPs work with gender identity services, see: Royal College of General Practitioners (RCGP), The role of the GP in transgender care, RCGP, October 2024 update.

54 NHSGGC, Draft Paper: Independent Reports into care Outwith NHS GG&C, “Areas/questions of interest to the Committee,” evidence submitted to the Scottish Parliament Equalities, Human Rights and Civil Justice Committee, 24 June 2022.

55 Questionnaire received from Sandyford GIC, June 2024.

56 Information provided by the Scottish Government, July 2024.

57 Information provided by Sandyford Clinic, received in November 2024.

58 The count per clinic of people waiting less than 3 years has been omitted to avoid possible derivation of small numbers within longer wait categories. Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024.

59 Information provided by Sandyford GIC for this evaluation, received on 27 August 2024.

60 Respondent demographics: 19 men (including trans men); 14 women (including trans women); 10 non-binary; and four other.

61 Letter from Humza Yousaf to the Scottish Parliament Equalities, Human Rights and Civil Justice Committee, 21 Nov, 2022.

62 Information provided by Sandyford GIC, August 2024.

63 Funding allocation letters to territorial NHS Health Boards, provided by the Scottish Government.

64 NHSGGC application for SG funding to address waiting times and support people waiting, gender identity healthcare, July 2022.

65 NHS Greater Glasgow and Clyde, ‘Gender Service at Sandyford,’ Sandyford Clinic Website.

66 The count per clinic of people waiting less than 3 years has been omitted to avoid possible derivation of small numbers within longer wait categories. Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024.

67 Ibid, p25. The PHS furthermore note that data quality issues for the report resulted in an undercount of referrals to NHS Gender Identity Clinics in 2023/24. They estimated this to be around 120 to 180 transfers-in throughout the course of the year, “the majority of which are likely to fall within referral source of transfer in from 'NHS GG&C (young people).”

68 Information provided by Sandyford GIC for this evaluation, received on 27 August 2024.

69 Questionnaire completed by Sandyford GIC on 10 June 2024.

70 Meeting of the Parliament 03/09/2024

71 LGBT Youth Scotland, Life in Scotland for LGBT Young People, LGBT Youth Scotland, 2018.

72 Scottish Government, Gender Identity Healthcare Protocol, 3 September 2024.

73 Prior to October 2024, the NHS Highland GIC was based in Sexual Health Services at Raigmore Hospital in Inverness.

74 With exception of Argyll and Bute HSCP, where patients are referred to the NHGGGC Sandyford service.

75 NHS Highland responses to project questionnaire, May 2024; and additional information from the GIC in August 2024.

76 Information provided by Highland GIC, May 2024.

77 NHS Highland funding bid to the Scottish Government for improvement work, 2022.

78 Ibid.

79 Ibid.

80 NHS Highland GIC - responses to project questionnaire, May 2024

81 Ibid.

82 Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024.

83 By comparison, this is double the cohort in 2018 when the service was funded by NHS Highland, showing a significant increase in demand. Information supplied by NHS Highland as part of this evaluation, in May 2024 and November 2024.

84 Respondent demographics: two men (including trans men); one woman (including trans women).

85 Lothian Sexual Health, ‘Gender Identity Clinic Data’. Accessed 14 June 2024.

86 Rachel Thomson, Jessica Baker, and Julie Arnot, “Scottish Public Health Network (SPHN), “Healthcare Needs Assessment of Gender Identity Services,” Scottish Public Health Network, May 2018, 35.

87 Information provided by Lothian GIC, August 2024.

88 NHS Lothian, Chalmers GIC funding proposal to Scottish Government, 2022.

89 NHS Lothian, Gender identity service improvement - 2023/24 – improvement work to September 2023.

90 Information provided by Lothian GIC, November 2024. It was highlighted that this was a decision made by NHS Lothian and not the GIC to not communicate this decision.

91 The NHS Lothian Gender Dysphoria/Incongruence Endocrine Treatment Shared Care Agreement, published on 11 November 2024, may be found online.

92 Questionnaire information received from NHS Lothian (Chalmers) GIC, August 2024.

93 Information provided by the Lothian GIC in November 2024; further data on waiting times is updated and available on the Lothian Chalmers GIC website ‘Waiting Times’ page (available online).

94 The count per clinic of people waiting less than 3 years has been omitted to avoid possible derivation of small numbers within longer wait categories. Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024.

95 Information provided by NHS Lothian (Chalmers) GIC through a questionnaire for this evaluation, 12 August 2024.

96 NHS Lothian, Gender Identity Clinic Data. Accessed 3/12/24.

97 Respondent demographics: 2 men (including trans men); 9 women (including trans women); 3 non-binary; and 1 other.

98 Sums may not total 100 due to rounding.

99 NHS Grampian responses to project Questionnaire, received in August 2024.

100 Information provided by Grampian GIC, August 2024.

101 The previous staffing situation at NHS Grampian GIC was discussed in: Rachel Thomson, Jessica Baker, and Julie Arnot, “Scottish Public Health Network (SPHN), “Healthcare Needs Assessment of Gender Identity Services,” Scottish Public Health Network, May 2018, p36. The NHS Grampian Health Board currently provides recurring funding for gender identity services on the basis of £88,000 per year, on top of SG funding. Information provided by NHS Grampian to the Scottish Government in June 2024.

102 Adele Merson, ‘NHS Grampian facing £77 million budget hole in ‘most challenging year’ ever experienced’, Press & Journal, 12 March 2024.

103 Questionnaire completed by NHS Grampian, August 2024.

104 Staff from the clinic confirmed that two consultant psychiatrists had been seeing patients who had previously accessed services during the period (2023-24) the clinic was otherwise inactive. Email, August 2024.

105 Questionnaire completed by NHS Grampian, August 2024.

106 The count per clinic of people waiting less than 3 years has been omitted to avoid possible derivation of small numbers within longer wait categories.Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024.

107 Information from the Grampian GIC, received in August 2024.

108 Respondent demographics: 3 men (including trans men); 2 women (including trans women); 4 non-binary; and 1 other.

109 Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024.

110 Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024.

111 A slight majority of respondents (54%) were currently on a waiting list to access services at a GIC, while just over a third (34%) were currently accessing GIC services and 8% had accessed services in the past. Nearly four in ten respondents (38%) identified as women (including trans women), while around three in ten (28%) identified as men (including trans men) and over a fifth (23%) identified as non-binary. Most respondents (61%) were based in a city, while over a fifth (23%) lived in a town, one in nine (11%) lived in a village and a further 5% lived in a remote area.

112 Respondent demographics: 21 men (including trans men); 28 women (including trans women); 17 non-binary; and six other.

113 Rachel Thomson, Jessica Baker, and Julie Arnot, “Scottish Public Health Network (SPHN), “Healthcare Needs Assessment of Gender Identity Services,” Scottish Public Health Network, May 2018

114 Scottish Government, ‘Cass Review - Implications for Scotland’, July 2024.

115 An example of a shared care agreement from Tavistock can be found online.

116 Lothian GIC service improvement document 2023/24.

117 See the NGICNS website

118 N. Adams and D. Ganesan, “The State of Trans Specific Healthcare in the EU. Looking beyond the Trans Health Map 2022”, TGEU (Transgender Europe), September 2023.

119 The TGEU Trans Healthcare Map (2022) can be accessed online.

120 N. Adams and D. Ganesan, “The State of Trans Specific Healthcare in the EU. Looking beyond the Trans Health Map 2022”, TGEU (Transgender Europe), September 2023, 20.

121 Calenbuhr, V., ‘Complexity Science in the Context of Policymaking,’ in V. Šucha and M. Sienkiewicz (eds) Science for Policy Handbook, Elsevier, 2020,118-127.

122 Braithwaite, J. et al, ‘Complexity Science in Healthcare’, Australian Institute of Health Innovation, Macquarie University, 2017.

123 Checkland, P., Systems Thinking, Systems Practice, John Wiley and Sons, Chichester, 1998.

124 See Lijphart A. ‘Comparative Politics and the Comparative Method,’ American Political Science Review, 1971, 65(3):682-693.

125 See Anckar, C., ‘On the Applicability of the Most Similar Systems Design and the Most Different Systems Design in Comparative Research,’ International Journal of Social Research Methodology, 2008, 11(5), 389-401.

126 Total sums are higher than 74 as some survey respondents reported having accessed services at multiple GICs.

127 Scottish Government, ‘Research - paying participant expenses and compensating for time: Guidance’, 2024.

128 The word ‘transexual’ is used in this context only because it falls under the direct quotation from the Scottish Government’s Social Research report from 2013, and the writers of this report understand the outdated nature of this term.

129 Scottish Government, “Scottish Government Equality Outcomes: Lesbian, Gay, Bisexual and Transgender (LGBT) Evidence Review, “ Scottish Government Social Research, 2013.

130 Rachel Thomson, Jessica Baker, and Julie Arnot, “Scottish Public Health Network (SPHN), “Healthcare Needs Assessment of Gender Identity Services,” Scottish Public Health Network, May 2018.

131 National Records of Scotland, “Scotland’s Census - Sexual Orientation and trans status or history”, June 2024.

132 For research seeking to understand factor shaping an increase in the trans and non-binary population, see for example: L. Heath and S. Bunn, “Factors shaping gender incongruence and gender dysphoria, and impact on health services”, UK Parliament Research Briefing, August 2023; Barton, C., “2021 census: What do we know about the LGBT+ population?” House of Commons Library, UK Parliament, 2023; Fielding, J. et al., “Individuals seeking gender reassignment: marked increase in demand for services,” BJPsych Bulletin, Vol 42, 2018; Littman, L., “Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria,” PLoS ONE, Vol 13, 2018; and Mocarski, R. et al., “The Rise of Transgender and Gender Diverse Representation in the Media: Impacts on the Population,” Communication, Culture & Critique, Vol 12, 2019.

133 Rachel Thomson, Jessica Baker, and Julie Arnot, “Scottish Public Health Network (SPHN), “Healthcare Needs Assessment of Gender Identity Services,” Scottish Public Health Network, May 2018.

134 Mikulak, M., et al, ‘Health professionals’ identified barriers to trans health care: a qualitative interview study’, British Journal of General Practice, 71 (713), 2021.

135 Ibid, 941.

136 See: Wright, T., et al, ‘Accessing and utilising gender-affirming healthcare in England and Wales: trans and non-binary people’s accounts of navigating gender identity clinics’, BMC Health Serv Res 21(609), 2021; Stotzer, R. L., Silverschanz, P., & Wilson, A., ‘Gender Identity and Social Services: Barriers to Care’, Journal of Social Service Research, 39(1), 63-77, 2011; and Ellis, S. J., Bailey, L., & McNeil, J., ‘Trans People’s Experiences of Mental Health and Gender Identity Services: A UK Study,’ Journal of Gay & Lesbian Mental Health, 19(1), 4-20, 2014.

137 Ellis, S. J., Bailey, L., & McNeil, J., ‘Trans People’s Experiences of Mental Health and Gender Identity Services: A UK Study,’ Journal of Gay & Lesbian Mental Health, 19(1), 4-20, 2014.

138 UK Government Equalities Office, “National LGBT Survey: Summary report,” Gov.uk, (the survey was launched July 2017 and updated in February 2019).

139 Ibid.

140 Ellis, S. J., Bailey, L., & McNeil, J., ‘Trans People’s Experiences of Mental Health and Gender Identity Services: A UK Study,’ Journal of Gay & Lesbian Mental Health, 19(1), 4-20, 2014.

141 Ibid.

142 Healthcare Improvement Scotland, “Gender Identity Healthcare: Adults and Young People, draft standards,” Healthcare Improvement Scotland, December 2023, 4.

143 James Morton and Rebecca Kent, “Gender Reassignment Protocol Audit, Community Engagement Focus Group Report of Findings,” Scottish Transgender Alliance, January 2014.

144 Scottish Trans, ‘Scottish Trans and Non-Binary Experiences: Research Report’, July 2024.

145 Rachel Thomson, Jessica Baker, and Julie Arnot, “Scottish Public Health Network (SPHN), “Healthcare Needs Assessment of Gender Identity Services,” Scottish Public Health Network, May 2018, 12.

146 Traci Leven, “Health needs assessment of lesbian, gay, bisexual, transgender and non-binary people: Full Research Findings Report”, prepared for NHS Greater Glasgow & Clyde, NHS Lothian and Public Health Scotland, May 2022.

147 Traci Leven, “Health needs assessment LGBT+ people: Transgender and non-binary supplementary report,” NHS Greater Glasgow & Clyde, June 2022.

148 Ibid, 65.

149 Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024, p28.

150 Ibid, 33.

151 Rachel Thomson, Jessica Baker, and Julie Arnot, “Scottish Public Health Network (SPHN), “Healthcare Needs Assessment of Gender Identity Services,” Scottish Public Health Network, May 2018, 34.

152 Traci Leven, “Health needs assessment LGBT+ people: Transgender and non-binary supplementary report,” NHS Greater Glasgow & Clyde, June 2022, 66.

153 Ibid, 33.

154 LGBT Youth Scotland, ‘Life in Scotland for LGBT Youth People: Health Report 2023’, May 2023.

155 Rachel Thomson, Jessica Baker, and Julie Arnot, “Scottish Public Health Network (SPHN), “Healthcare Needs Assessment of Gender Identity Services,” Scottish Public Health Network, May 2018, 11.

156 Ibid, 79.

157 Traci Leven, “Health needs assessment LGBT+ people: Transgender and non-binary supplementary report,” NHS Greater Glasgow & Clyde, June 2022, 33.

158 Ibid, 69.

159 Scottish Trans, ‘Scottish Trans and Non-Binary Experiences: Research Report’, July 2024.

160 Traci Leven, “Health needs assessment LGBT+ people: Transgender and non-binary supplementary report,” NHS Greater Glasgow & Clyde, June 2022, 68.

161 Ibid, 65.

162 Mikulak, M., et al, ‘Health professionals’ identified barriers to trans health care: a qualitative interview study’, British Journal of General Practice, 71 (713), 2021.

163 World Health Organization, ‘International Classification of Diseases 11th Revision’, WHO, February 2022.

164 Robles et al. ‘Validity of Categories Related to Gender Identity in ICD-11 and DSM-5 Among Transgender Individuals who Seek Gender-Affirming Medical Procedures,’ International Journal of Clinical and Health Psychology, Jan-April, 2022.

165 Rachel Thomson, Jessica Baker, and Julie Arnot, “Scottish Public Health Network (SPHN), “Healthcare Needs Assessment of Gender Identity Services,” Scottish Public Health Network, May 2018, 74.

166 Nathan Hudson-Sharp and Hilary Metcalf, “Inequality among lesbian, gay, bisexual, and transgender groups in the UK: a review of evidence,” National Institute of Economic and Social Research, July 2016, 39; 59.

167 Rachel Thomson, Jessica Baker, and Julie Arnot, “Scottish Public Health Network (SPHN), “Healthcare Needs Assessment of Gender Identity Services,” Scottish Public Health Network, May 2018: 66; 72; 109.

168 Traci Leven, “Health needs assessment LGBT+ people: Transgender and non-binary supplementary report,” NHS Greater Glasgow & Clyde, June 2022, 69.

169 Ibid, 73.

170 Scottish Government, ‘Gender Identity Healthcare Protocol for Scotland’, 3 September 2024.

171 Scottish Government, “National Gender Identity Healthcare Reference Group,” Scottish Government, March 2022.

172 Healthcare Improvement Scotland, “Gender Identity Healthcare: Adults and Young People, Draft Standards,” NHS Scotland, December 2023, 5.

173 Healthcare Improvement Scotland, ‘Gender Identity Healthcare: Adults and Young People. Standards’, September 2024.

174 Scottish Government, “National Gender Identity Healthcare Reference Group: winter 2023 to 2024 update,” 22 November 2023.

175 Gender Recognition Reform (Scotland) Bill, Scottish Parliament, 2022.

176 This is a certificate that legally recognises that a person’s gender is not the gender that they were assigned at birth, but is their acquired gender. In accordance with the UK-wide GRA 2004, people over the ages of 18 are allowed to apply for a GRC “on the basis of living in the other gender or having changed gender under the law of a country or territory outside the UK.” In order to apply via the standard track for the GRC under the 2004 GRA, the applicant must: have, or have had gender dysphoria and have lived in their gender congruent identity for the preceding two years; and intend to remain in that gender until death. See: Scottish Parliament (2022), Stage 1 Report on Gender Recognition Reform (Scotland) Bill.

177 David Wallace Lockhart, “Swinney remains committed to gender reform bill”, BBC, 10 May 2024.

178 Cass Review, “Independent review of gender identity services for children and young people: Final Report,” NHS England, 2024.

179 Jenni Minto, “Cass Review and Gender Identity Healthcare,” Scottish Government, 23 April 23 2024.

180 See Scottish Government, “Cass Report - Implications for Scotland”, Chief Medical Officer Directorate, 5 July 2024; and Letter from the Chief Medical Officer to the Convenor of the Health, Social Care and Sport Committee, Scottish Parliament, 5 July 2024.

181 Letter from Chief Medical Officer to the Convenor of Health, Social Care & Sport Committee, Scottish Parliament, 5 July 2024.

182 Scottish Government, “Cass Report - Implications for Scotland”, Chief Medical Officer Directorate, 5 July 2024, 29.

183 Strain, D., ‘Cass Review - Insight from the front line’, British Medical Association, 26 September 2024.

184 Scottish Trans, ‘News Statement: Response to decision to pause referrals to Paediatric Endocrinology from Sandyford Young People’s Gender Services’, 18 April 2024; LGBT Youth Scotland, ‘News Statement’, April 2024.

185 NHS Education for Scotland, Transgender Care Knowledge and Skills Framework, 3 September 2024.

186 Public Health Scotland, ‘NHS Gender Identity Clinics: Waiting Times for First Outpatient Consultation. April 2023 to March 2024. An Official Statistics in Development Release for Scotland,’ 5 November 2024.