Specialist gender services for children and young people: progress report

Background – 2021 Framework

4. The 2021 Framework contained 17 actions which have been taken forward to improve access to, and delivery of, gender identity healthcare in Scotland. One of these commitments refers solely to provision for under 18s. The 2021 Framework states Scottish Government will 'support the establishment of a nationally commissioned Young Person's Gender Identity Service'. However, several other commitments cover work to support improvement of both adult and young people's services. These include the commitments to:

• Commission Healthcare Improvement Scotland to develop national standards for adult and young people's gender identity services
• Allocate funding which will support existing GICs to use new approaches to address current waiting lists
• Fund enhanced support for people currently on waiting lists, including community and voluntary sector led support
• Bring gender identity services within national waiting times standards
• Commission NHS Education for Scotland to complete development of a Transgender Care Knowledge and Skills Framework
• Commission Public Health Scotland to establish robust national waiting times data collection, monitoring and reporting for gender identity services
• Commit to have funded service improvements or pilots established via the direction of the Reference Group independently evaluated
• Work with the Chief Scientist's Office to develop research proposals, and make funding available, for additional research on long term health outcomes for those accessing gender identity healthcare

5. This report will highlight work taking place against each of these commitments.

Background – Current Provision

6. The newly emerging and changing presentation of the gender identity healthcare patient population, with increasing numbers of under 18 year olds, resulted in the development of the Young People's Gender Service based in the Sandyford Sexual Health Clinic in 2012/3. This initially started as one session per week of Consultant Child Psychiatry and was further developed in 2016 with an increase of two consultant sessions and the introduction of Consultant and Principal Psychologists. By this point, links had been made with Paediatric Endocrinology in NHSGGC and NHS Lothian to establish the medical pathway for Puberty Suppressing Hormones.

7. The service is provided jointly by the Glasgow City Health and Social Care Partnership (HSCP) and NHS Greater Glasgow and Clyde (NHSGGC). It is the only clinical service to provide specialist gender identity healthcare to young people up to the age of 18 in NHS Scotland. A de-facto national clinical service, it accepts referrals from all Health Boards.

8. The service until recently also accepted self-referrals as well as referrals from other clinical services and agencies such as social work and educational psychology. One of the recommendations of the Cass Review - Implications for Scotland: Findings Report,discussed later in this report, was that access to young people's gender identity healthcare services was only through referral from a clinician. Since August 2024 new referrals to NHSGGC gender identity healthcare are now only accepted from a clinician, for both its adult and young people's services.

9. The ability to self-refer to the gender services in NHSGGC was unique to gender identity healthcare in Scotland. While it is understood that that the option to self-refer was viewed positively by some using the service, the increasing demand meant that the service was accruing an increasing and undifferentiated waiting list from across Scotland. This was not in line with other specialist services and, a lack of referral by a clinician meant that those joining the waiting list would not always have been signposted to appropriate support while they wait for their first appointment, and a clinical background may not be available to the service ahead of their first appointment.

2021 Framework - Nationally Commissioning Young People's Gender Services

10. Following the above commitment in the 2021 Framework, in early 2022 Scottish Government commissioned the National Services Division (NSD) of NHS National Services Scotland to begin work to develop a proposal and service specification for a new nationally designated NHS Scotland Children and Young People's Gender Identity Service.

11. NSD scoping confirmed that the service provided by NHSGGC had significantly expanded since its establishment. Data provided by NHSGGC highlighted that 2013, the first year that data is readily available, there were 42 referrals. By 2023 the referrals had increased to 412, the highest year being 2021 with 612 referrals. The current waiting list has around 1,100 patients. Demand for this specialist service has grown significantly whilst clinical and administrative capacity has not been able to match the growing need. This is reflected in its long waiting list for a first appointment.

12. Local work to nationally commission the clinical service prior to 2022 was partly progressed but unable to move forward substantively, primarily due to recruitment and retention challenges.

13. In April 2024 NSD reported to Scottish Government on the commission. Considering the size and potential clinical complexity of the patient cohort, rather than commissioning a national service operating from a single site NSD recommended consideration of a networked regional care model.