Non-binary people's experiences in Scotland: evidence review

Health

Health is a major focus for many of the studies found in this Evidence Review. This includes studies highlighting issues of mental health and wellbeing, access to and experiences of healthcare, experiences in Gender Identity Clinics (GICs) and sexual and reproductive health services.

Access and Quality of Healthcare

The 2019 NHS Greater Glasgow and Clyde/NHS Lothian LGBT+ Health Needs Assessment^[61] found that there was a long waiting time for an initial consultation as well as additional frustration and distress caused by:

• Long waits between appointments.
• Long waits for appointment notes to be transcribed and letters sent.
• Long waits for referrals, or referrals not being made.
• Correspondence being addressed to previous name/gender identity, even after repeated corrections.
• Being given inaccurate information/expectations of waiting times.
• Various other clerical inefficiencies and errors.

Further, the ‘Trans Lives Survey 2021’ found that 55% of non-binary respondents said that their GP did not have a good understanding of their needs^[62]. Existing research highlights negative experiences of accessing healthcare. The report Health Needs Assessment of Lesbian, Gay, Bisexual, Trans and Non-Binary People^[63] found that 40% of trans respondents who accessed healthcare services reported a negative experience, such as specific needs ignored or not taken into account (21%), avoiding treatment for fear of negative reaction (18%), receiving inappropriate curiosity (18%), pressure or being forced to undergo a medical or psychological test (7%) or having to change their GP due to a negative experience (7%).

The Primary Care Survey Report 2017^[64] found that non-binary people experienced the highest prevalence of discrimination from all primary care services. This report also highlighted discomfort in disclosing identity related to the experiences of discrimination when accessing primary care services. However, around 50% of non-binary respondents in this study felt they were met with a positive response from their GP when disclosing their non-binary identity. Conversely, according to another study, over 80% of non-binary patients felt they experienced discrimination or unfair treatment based on their sexual orientation/trans status when accessing GP services, it is unclear why there is a difference in these findings. Saunders et al^[65] found that healthcare outcomes among trans and gender diverse individuals are better when accessing a primary care provider who is knowledgeable about trans healthcare issues.

Trans Actual offered suggestions for improvement, such as a need for recognition of non-binary identities when signing up for GP services^[66]. In addition, visibility of an inclusive attitude through display of LGBT posters and inclusivity training was also identified as a way for non-binary people to feel able to access healthcare^[67].

Mental health and wellbeing

Evidence from the 2021 ‘NHS England GP Patient Survey’ found that trans and non-binary adults are more likely than the general population to experience long-term health conditions, including mental health problems, dementia, learning disabilities and to be autistic^[68]. These findings are not Scotland specific, and the research does not suggest why these experiences are more common in non-binary people, however findings outlined below provide further Scottish specific information.

NHS Scotland’s 2022 ‘Health Needs Assessment of Lesbian, Gay, Bisexual, Trans and Non-binary People’ found that both depression and anxiety was very common for trans and non-binary people, with 72% of non-binary people saying they suffered from mental health issues^[69]. Only 25% of respondents rated their general mental and emotional health positively, which was lowest for non-binary people (9%). Self-harm was most prevalent among trans masculine (83%) and non-binary people (82%).

This report indicates that trans and non-binary people were particularly likely to speak about suicidal thoughts. Whilst the prevalence of suicide attempts was high across all LGBTI+ groups, it was highest among trans masculine and non-binary people, with nearly half of respondents in these groups saying they had made a suicide attempt.

LGBTI+ people are impacted by minority stress, which refers to experiences of stigma, prejudice, discrimination, bullying and the pressure felt by some to conceal their identities in hostile and stressful social environments^[70]. This can have a severe negative impact on mental health. One study found that non-binary trans participants experienced more anxiety and depression and lower self-esteem than those who identified as binary trans^[71]. This study suggested that poorer mental health may be related to wider society holding a view of a gender binary that can be isolating for non-binary people.

Another study found that mental health problems were higher for non-binary and binary trans young people than that of young people in the general population^[72]. Generally, trans and non-binary participants who were assigned female at birth were more likely to report experiencing a mental health problem than those assigned male at birth, regardless of their trans or non-binary gender identity, however there is no research into why this might result in different experiences.

The Mental Health Equality Evidence Report 2023^[73] highlights several findings relating to the mental health and wellbeing of trans and non-binary people which should be considered in addition to this sub-section. This report uses data from several population-level surveys and involved a rapid literature review of a range of sources of UK and Scotland specific evidence.

Gender Identity Clinics

Gender Identity Clinics (GICs) are specialist services which can offer diagnoses, psychological support, and access treatment to address clinically assessed gender dysphoria^[74].

According to LGBT Youth Scotland, 16% of the non-binary participants in their study had been referred to GICs services. LGBT Youth found that their participants reported difficulties accessing GICs due to long waiting lists and this waiting time can be distressing as the respondents suggested they were left without care^[75]. According to the 2024 Scottish Trans’ website the average waiting time for initial consultation with a GIC is around 4 years^[76]. Further, LGBT Youth suggested that the service provision was inadequate and non-binary people felt they had to prove they were “trans enough” to receive care^[77].

Stonewall’s LGBT in Britain Trans Report^[78] stated that 11% of respondents in the survey sought services abroad for medical treatment. This included buying hormones over the internet from other countries. The survey found a further 17% of trans people were considering these options. Engagement to-date has indicated it is common that trans people access unregulated, online services to obtain hormone treatments. This is explained as a direct result of long waiting lists to access NHS services. This research does not explicitly include data for non-binary people; however, these experiences may be applicable.

The Scottish Government published the NHS Gender Identity Services: Strategic Action Framework 2022-2024 to improve access to and delivery of NHS gender identity healthcare across various areas of service delivery^[79]. Intentions set out by this Framework continue to be actioned and/or brought to completion by Scottish Government and NHS Scotland partners.

Sexual and Reproductive Health

Scottish Trans’ report^[80] on trans people’s experiences of reproductive health services suggested that trans people face barriers to engaging with sexual health services which include anxiety, interpreting gendered health information, misgendering from service providers and a lack of knowledge about trans people’s sexual health needs. The participants in this study highlighted that greater access to accurate and reliable information, and compassion from health care practitioners would help to remove such barriers to sexual health services.

In the study^[81], Scottish Trans looked at the qualitative experiences of 146 trans people in Scotland. Although the authors did not provide in-depth analysis of themes, the report showed similar comments about contraception, which was found to be used not only to avoid pregnancy but also to manage menstruation and health conditions. In addition, both trans-men and non-binary respondents perceived their gender identity as affecting their experiences of using and accessing contraception. Participants also noted dissatisfaction with contraceptive services with no participants providing qualitative examples of positive experiences. Other key issues highlighted were misgendering and a lack of understanding of trans health issues.

Only a small group of participants in this study had experiences of pregnancy, with the majority of these participants experiencing unplanned pregnancy, however due to small response rates it is difficult to get a broad picture of trans and non-binary experiences of pregnancy services^[82]. Throughout this report it is highlighted that trans-men and non-binary people’s gender identity affected their experiences of reproductive health services in Scotland. More research is required to gather nuanced understandings of how non-binary people experience reproductive health services.