Non-binary equality action plan

Section 6 - 2. Healthcare

Objective

Non-binary people are increasingly able to access high-quality, person-centred healthcare they need, at a place and time that is appropriate for them.

Context

Evidence from the National LGBT Survey showed that transgender respondents were more likely (84%) to have accessed or tried to access public healthcare services compared to cisgender respondents (79%) in the 12 months preceding the survey. These included general healthcare services, mental health services and sexual health services. Transgender respondents also accessed mental health services more frequently (36%) than cisgender respondents (21%) but were also more likely (14%) to have been unsuccessful in accessing mental health services compared to cisgender respondents (7%).

The report also found that 40% of transgender 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%).

Non-binary respondents were more likely to report that their GP had not been supportive. They were more likely to have been worried or anxious about going to their doctor compared to other transgender identities when accessing mental health services.

The UK’s largest trans study of 889 trans individuals across the UK, Trans Mental Health Study 2012, found very high rates of mental health issues among transgender people, with 88% of respondents showing symptoms of depression and 75% of anxiety, compared with 20% of people in the UK general population.

The supplementary report on trans and non-binary people for the Health Needs Assessment LGBT+ People Report also highlights that there is significant evidence to indicate that trans and non-binary people in Scotland were at “particular risk” of experiencing mental health problems and “were more likely than others to have an illness or disability”.

The National LGBT Survey and the Life in Scotland for LGBT Young People 2022 report showed that non-binary respondents were less likely to have accessed specialist gender services compared to trans men and trans women both in Scotland and across the UK.

Access to healthcare is one of the key issues for trans and non-binary people and it was a major focus of the recommendations from the Group.

We need to improve the way that transition-related healthcare is delivered. We need to improve access to and delivery of adult and young people’s gender identity services and have already committed to do so with a series of actions outlined in the NHS gender identity services: strategic action framework 2022-2024.

We need to make changes to access to healthcare to help improve the health and wellbeing outcomes for trans and non-binary people, which are significantly worse compared to others in Scotland and the UK. Crucially, we need to work with trans and non-binary people to do this. We must listen to their voices and empower them to make decisions about their own healthcare. Everyone should have equal access to healthcare and we must make these improvements to ensure that no one experiences barriers to accessing the services that they need in a timely manner.

Healthcare services should be of a consistent and high-quality standard across Scotland, with equal access for all, whether this be mental health support, sexual health services or fertility preservation. Relevant information and guidance must also be available to help trans and non-binary people make informed decisions about their own healthcare, for example on fertility preservation. Healthcare practitioners must have relevant training in the specific healthcare needs of trans and non-binary people, including on mental health, so that they have the knowledge and skills to deal with their particular needs.

Commitments

Our commitments reflect the recommendations of the Working Group on Non-Binary Equality. Where we accepted a recommendation, the wording of the commitment relating to that recommendation remains the same. Where we partially accepted a recommendation, our commitment reflects the aspects of the recommendation that we accepted. The numbering of the commitments reflects that of the recommendations. The commitments used to develop this section of the plan are as follows:

Gender Identity Healthcare

Commitment 2

Transform the way transition-related healthcare is delivered in Scotland, and designing services collaboratively with trans and non-binary people.

Commitment 3

Develop national standards for gender identity services that are accountable and enforceable.

Commitment 4

Engage with Health Boards to consider sustainable funding for transition-related healthcare beyond the current commitment to the end of 2024.

Commitment 5

Ensure that trans and non-binary people have equal access to transition-related healthcare.

Commitment 6

Transition-related healthcare to be in accordance with current NHS Scotland referral to treatment standards.

Commitment 12

Consider treatment pathways so that access to primary care support and referral is equitable for all patients.

Mental Health and Primary Care

Commitment 7

Ensure person-centred mental health services and support is available for trans and non-binary people.

Commitment 8

Fund mandatory training for mental health providers on trans and non-binary healthcare needs.

Commitment 9

Conduct robust Equality Impact Assessments for mental health policies and actions, ensuring that they address the specific needs of trans and non-binary people.

Commitment 11

Fund mandatory training for primary care providers on trans and non-binary healthcare needs.

Fertility Preservation

Commitment 13

Ensure that trans and non-binary people have equal access to fertility preservation treatments, including access to the information needed to make informed choices.

Commitment 14

Work with the UK Government to provide clarity to trans and non-binary people about their legal rights regarding fertility preservation, access to assisted reproduction services, and status when creating families, and work to prevent discrimination in realising these rights.

Commitment 15

Fund training for fertility preservation providers on trans and non-binary healthcare needs.

2.1. Gender Identity Healthcare

This section is set out differently to the rest of the plan as we believe that all of the accepted and partially accepted recommendations relating to gender identity healthcare are being taken forward as part of ongoing work.

Under the commitments, instead of setting out actions, we have explained why we believe the commitments are addressed by work currently underway and how we are considering the needs of non-binary people. Partners for this work include NHS Health Boards hosting gender identity clinics, Healthcare Improvement Scotland, Public Health Scotland, NHS National Services Scotland and NHS Education for Scotland.

The specific commitments made in response to the recommendations from the Working Group on Non-Binary Equality are addressed below. However, for the purposes of this plan and to avoid unnecessary duplication across Scottish Government and NHS Scotland, these commitments are being progressed substantively as part of the three-year Strategic Action Framework for NHS gender identity service improvement published in 2021. As our framework runs until late 2024, we envisage that most of this work will be completed in the short term (end of 2024) with the rest in the medium term (end of 2026).

The aims and ongoing actions as part of the framework are consistent with the purpose and aims of this Non-Binary Equality Action Plan. All commissions made as part of the framework’s work have been inclusive of non-binary identities.

Commitment 2

Transform the way transition-related healthcare is delivered in Scotland, and designing services collaboratively with trans and non-binary people.

Improving access to, and delivery of, NHS gender identity services is a dedicated Bute House Agreement commitment. Delivery of this commitment is being led by Scottish Government’s Health and Social Care Directorates, in partnership with NHS Scotland Health Boards.

As part of this substantive work already well underway, Scottish Government published the NHS gender identity services: strategic action framework 2022-2024 (the 'Framework') in December 2021. This describes how the Scottish Government is working to improve access to, and delivery of, NHS gender identity services for trans, including non-binary, people.

To oversee implementation of the Framework’s actions, a National Gender Identity Healthcare Reference Group was established in early 2022. This Reference Group includes NHS Board representation, clinicians, academics, LGBTQI+ organisations and people with lived experience of using gender identity healthcare.

People with lived experience and their representatives are involved in all aspects of this work. The Scottish Government continues to work to embed involvement of those who have experience of accessing specialist healthcare services, including non-binary people accessing transition-related healthcare.

Consistent with this aim, Scottish Government awarded a grant to Scottish Trans, part of the Equality Network, to host a Lived Experience Coordinator. The Lived Experience Coordinator’s role is to proactively engage with trans, including non-binary, people across Scotland who have accessed, or are waiting to access, gender identity healthcare, and to represent their voices across national workstreams.

In addition to the input from the Lived Experience co-ordinator, individual workstreams are collaborating with trans, including non-binary, people in the development of their work:

• Lived experience representatives are on the development group for Healthcare Improvement Scotland for developing standards of care for adult and young people’s gender identity services;
• NHS Education for Scotland are working with people with lived experience as part of their development group for the transgender healthcare knowledge and skills framework for all health and social care staff;
• Public Health Scotland hosted focus groups facilitated by the Lived Experience Co-ordinator to enable trans, including non-binary, people to provide input in relation to the collection, storage and sharing of waiting times data.

This substantive work and its progression is aligned with the aims and vision of this Non-Binary Equality Action Plan.

Commitment 3

Develop national standards for gender identity services that are accountable and enforceable.

As part of its overall aim to improve access to, and delivery of, gender identity healthcare the Scottish Government has commissioned Healthcare Improvement Scotland to develop national standards of care for adult and young people’s gender identity services.

These standards will be shaped by the experiences of people who have accessed or are waiting to access gender identity services.

The standards will support health and social care organisations to improve the quality and consistency of care and support they deliver to trans, including non-binary, people. The standards will outline what people should expect from gender identity healthcare services. They will cover key issues relating to the provision of safe, effective and person-centred care and treatment.

Commitment 4

Engage with Health Boards to consider sustainable funding for transition-related healthcare beyond the current commitment to the end of 2024.

Work underway with NHS Scotland partners includes direct allocation of Scottish Government funding to NHS Health Boards to implement long term improvements to gender identity services.

Since December 2022, the Scottish Government has allocated approximately £2.8 million of additional funding to support gender identity service improvement. This includes funding to territorial Health Boards who provide gender identity clinics as well as a range of work with Healthcare Improvement Scotland, Public Health Scotland and NHS Education for Scotland to ensure services delivered are sustainable, evidence-based and person-centred. This work will create the foundations for longer-term service improvement.

Commitment 5

Ensure that trans and non-binary people have equal access to transition-related healthcare.

The Scottish Government believes that it is important that anyone exploring their gender identity should be able to access the right support at the right time when they need it. This includes non-binary people.

NHS Education for Scotland are developing a transgender healthcare knowledge and skills framework for all healthcare staff, and will explore resources and opportunities for training to support trans, including non-binary, patients accessing NHS care.

This work will clarify expectations of knowledge for staff providing different levels of NHS care for all trans, including non-binary, people and will scope available resources and training opportunities for NHS staff. This will ensure trans and non-binary people are given equal access to healthcare in line with the vision of the Non-Binary Equality Action Plan.

Commitment 6

Transition-related healthcare to be in accordance with current NHS Scotland referral to treatment standards.

As part of the Bute House Agreement the Scottish Government has committed to bring NHS Scotland gender identity services within national waiting times standards.

Furthermore, the Scottish Government has commissioned Public Health Scotland to improve data reporting for gender identity services, to establish robust national waiting times data collection, monitoring and reporting.

Working with NHS Scotland Health Boards, Public Health Scotland are putting in place processes and procedures that will enable publication of quarterly data on gender identity clinic waiting lists.

Commitment 12

Consider treatment pathways so that access to primary care support and referral is equitable for all patients.

Aligned with the aims of the Non-Binary Equality Action Plan, NHS Education Scotland is working to develop a transgender healthcare knowledge and skills framework for all NHS Scotland staff. This will clarify expectations for knowledge for staff providing different levels of NHS care, to help provided a better experience for trans people in Scotland and will be fully inclusive of non-binary people.

Alongside this Healthcare Improvement Scotland are developing national standards for adult and young people’s gender identity services. This will contribute to ensuring a consistent service is available across Scotland for trans, including non-binary, people accessing gender identity healthcare.

Primary care in Scotland is mostly provided by independent contractors who are required to be members of various regulated professions. The Scottish Government does not mandate what specific training these professionals have, only that they are members of their profession in good standing. They would be expected to undertake Continuous Professional Development and to be able to assure the relevant regulatory bodies that they are up to date with current best practice at the junctures required by those bodies.

The Scottish Government does not determine the referral pathways used by clinicians in primary care. These are determined at a Health Board level and will reflect local circumstances and requirements. The Scottish Government would expect these pathways to be up to date with current best practice.

2.2. Mental Health and Primary Care

Actions

3.1 We will work with NHS Boards, councils and integration authorities to strengthen accountability for public bodies delivering mental health services in order to support how mental health inequalities are addressed at a local service level, identifying the levers available to effect change in mental health service delivery.

Commitment

7

Timescales

Medium Term

Impact

This will strengthen local accountability and mental health services that take into account health inequalities.

Partners

NHS Scotland

Third sector equality organisations

Actions

3.2 We recently published quality standards for mental health services. These standards will initially apply to adult secondary mental health services and we will work with mental health services more widely to explore how the Core Mental Health Standards could apply across a wider range of services in the future. Building on the work of the CAMHS service specification, a national service specification for Psychological Therapies and Interventions has also been published and a specification for Eating Disorder services is currently in development.

Commitment

7

Timescales

Medium Term

Impact

These standards aim to improve the quality and safety of mental health services and the delivery of psychological therapies and interventions for all groups, including for trans and non-binary people. Services should take account of the needs of equalities groups when implementing the standards.

Partners

Mental Health Quality and Safety Board

NHS Health Boards

Third sector partners, including Mental Healthy Equality Forum

Actions

The standards have an equalities, human rights and person-centred approach. We expect them, alongside strengthened local accountability, to support how health inequalities are addressed at a local level and effect change to mental health service delivery.

Actions

3.3 We will continue to develop a series of impact assessments, including an Equality Impact Assessment (EQIA), for the proposed actions in the new Mental Health and Wellbeing Workforce Action Plan. This will ensure that they address both the challenges facing the mental health and wellbeing workforce as well as ensuring that the workforce are supporting the needs of trans and non-binary people.

Commitment

8

Timescales

Medium Term

Impact

This will ensure the vision, outcomes and commitments in the forthcoming strategy and action plan are underpinned by a diverse, resilient, skilled and sustainable workforce. This will allow workers to feel valued and supported and able to promote and provide better mental health and wellbeing outcomes for the people of Scotland, including trans and non-binary people.

Partners

Employers

NHS Education Scotland

Actions

3.4 We will improve Equality, Diversity and Inclusion training for the Mental Health and Wellbeing workforce to incorporate up to date messaging within existing training and relevant information on equalities, including non-binary, transgender and LGBTQI+ equality.

Commitment

8

Timescales

Medium Term

Impact

This will ensure practitioners are more aware of and can offer more culturally competent and sensitive support and services to better meet the needs of specific groups, including LGBTQI+ people.

Actions

3.5 We will look closely at developing capability and capacity in the completion of Equality Impact Assessments (EQIAs) as part of the programme of equalities and human rights work being taken forward in the Scottish Government’s Mainstreaming Strategy.

Commitment

9

Timescales

Short Term

Impact

This will ensure that equality and inclusion is fully embedded in all aspects of policy making.

Actions

3.6 We will put in place structures within the Mental Health Directorate to ensure we meet Commitment 9 going forward as part of the programme of work being taken forward by the Mental Health Equality Champion Network.

Commitment

9

Timescales

Short Term

Impact

This will ensure the needs of protected groups are being considered, including trans and non-binary people, when new or revised policies are introduced.

Actions

3.7 We have commissioned NHS Education Scotland to develop a transgender healthcare knowledge and skills framework for NHS Scotland staff, including those working in primary care and mental health services.

Commitment

5, 11, 12

Timescales

Medium Term

Impact

This will clarify expectations for knowledge for staff providing different levels of NHS care. It will also scope available resources and training opportunities for NHS staff.

Partners

NHS National Services

NHS Education Scotland

NHS Boards

2.3. Fertility Preservation

Actions

4.1 We will develop patient information leaflets for fertility preservation by 2024.

Commitment

13

Timescales

Short Term

Impact

This will promote equitable access to information on fertility preservation treatments, which will enable trans and non–binary people to make informed decisions as to whether fertility preservation is something they wish to consider (not all will want a family) before starting treatment or undergoing surgery.

Partners

NHS Scotland

Actions

4.2 We will finalise and implement the fertility preservation guidance for all groups of patients that may require access by 2024.

Commitment

13, 14

Timescales

Short Term

Impact

This will make information on fertility preservation easier to access and more coherent, empowering trans and non-binary people to make informed decisions.

Partners

NHS Scotland

Actions

4.3 NHS Inform will be updated with information on fertility treatments (assisted reproduction services) that are available for trans and non-binary people in Scotland by 2024.

Commitment

14

Timescales

Short Term

Impact

This will ensure that information on fertility services is easier to access and more coherent, empowering trans and non-binary people to make informed decisions.

Partners

NHS Inform

Fertility Scotland National Network

Actions

4.4 Fertility Scotland National Network will arrange training webinars once the fertility preservation guidance has been published for early 2024.

Commitment

15

Timescales

Short Term

Impact

This will ensure fertility preservation providers and those referring to the service have the knowledge and skills needed to support trans and non-binary people accessing fertility preservation treatments.

Partners

NHS Scotland

Fertility Scotland National Network