Meeting of the Parliament [Draft]

Meeting date: Tuesday, April 23, 2024

Official Report 1025KB pdf

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Gender-identity Healthcare for Young People

The next item of business is a statement by Jenni Minto on gender-identity healthcare for young people. The minister will take questions at the end of her statement; there should therefore be no interruptions or interventions.

14:26  

I start by speaking directly to our young people—in particular, our trans and non-binary young people across Scotland. I know that the past few weeks and months have been incredibly difficult, with increased media attention and toxic online commentary. I understand how shocking, upsetting and destabilising the announcements last week, and the public conversation around them, will have been for you and your families. I want to reassure you that the Scottish Government remains absolutely committed to not just ensuring that on-going support is available for you but reforming and improving gender-identity healthcare. That was a key part of the Bute house agreement, and we will not waver in that commitment.

Before I continue, I make it clear that, as a Parliament, we have a responsibility to protect and support minority groups. We are all human beings; we are all individuals; and we all deserve respect. It is vital that we lead by example in the tone of our discussions, and I hope that that will be reflected in today’s session. I reiterate what the First Minister has clearly said: the Cass review is a detailed piece of work that requires thoughtful consideration.

Last Thursday, NHS Greater Glasgow and Clyde and NHS Lothian—the two health boards in Scotland that have specialist paediatric endocrinology services—issued a joint statement confirming a pause on new prescriptions for puberty hormone suppressants and cross-sex hormone medication for young people with gender dysphoria. That pause is to allow time for further evidence to be gathered to support the safety and clinical effectiveness of those medications, following the Cass review. The statement also confirmed that the small number of young people who are currently receiving those medicines will not be affected by that pause. That mirrors the position in NHS England.

As I have said consistently, it is not for politicians or civil servants to make clinical decisions about clinical pathways. Such decisions should always be made carefully, be based on the best evidence available, and be made only by the clinicians responsible for providing such healthcare. To be very clear, ministers do not make clinical decisions in any field of medicine, and that of gender-identity services is no exception. I fully support health board autonomy in clinical decision making.

The commitment of clinicians to their patients in those services, alongside their wider multidisciplinary teams, is unwavering. Their focus is always on ensuring that the treatment that they prescribe is safe. Too often, they face vitriol simply for doing their job, and it is important that they, too, are supported.

Some members have expressed disappointment that the Scottish Government did not announce the position before the health board statement. Every one of us in the chamber—indeed, every one of us across Scotland—has a right to hear first and directly from the services that care for us if our treatment for any health matter is going to change. That is why it was absolutely correct that, before making a public announcement, NHS Greater Glasgow and Clyde and NHS Lothian took the time to speak to all the young people who would be impacted by the pause, so that they understood what it meant for their care and treatment.

I am sure that everyone in the chamber will agree that, if this were happening to their loved one, that is exactly what they would want, and expect, to happen. I reiterate: those young people and their families must be at the heart of our decisions and thoughts when we discuss this issue. The NHS Greater Glasgow and Clyde young people’s gender service in Scotland remains absolutely committed to providing the best quality care for patients, and referrals. The service will continue to provide holistic care and support to those accessing it and referred to it.

The Cass review is a detailed, wide-ranging report, and I welcome the opportunity to update Parliament on our approach to the recommendations and on the wider work in that field. It is important to highlight that the Cass review was commissioned by NHS England and did not review clinical services or pathways that are provided in the national health service in Scotland. Therefore, by definition, not all the recommendations may be applicable to NHS services in Scotland. That said, it is vitally important that the recommendations are carefully considered to assess the extent to which they are relevant to the approach to gender-identity healthcare in Scotland, and that we decide upon what steps might need to be taken as a result.

Time is required to fully consider all the recommendations, which NHS England also acknowledges. We already have a strategic action framework for the improvement of NHS gender-identity services. As part of that work, the chief medical officer has agreed that the deputy chief medical officer and other senior medical officers will support careful consideration of the Cass review’s clinical recommendations and engage on them with the Scottish Association of Medical Directors and other clinical leaders. A multidisciplinary clinical team within the office of the chief medical officer in the Scottish Government—including people with paediatric, pharmacy and scientific expertise—will assess the clinical recommendations and engage with the relevant clinical community and leadership in health boards in relation to the recommendations. The CMO will provide a written update to Parliament on the outcome of that clinical consideration process before the summer recess.

It is important to note that, in Scotland, we are already making progress on a number of aspects of gender-identity healthcare that are highlighted in the Cass review. Let me be clear that work has already begun, and I will remain engaged throughout. Dr Cass highlighted the need to address increased capacity in services. The Scottish Government has committed to investing £9 million to support the improvement of NHS gender-identity healthcare in Scotland. That funding will be delivered during a five-year period, so the national improvement work that is already under way will be embedded and built on. That aligns with feedback that has been received from health boards and third sector stakeholders regarding the need to support longer-term sustainability of service improvement.

Since December 2022, we have invested more than £2.8 million to support work to improve access to gender-identity healthcare in Scotland, with more than £2.2 million of that allocated directly to health boards with gender-identity clinics. We will invest a further £2 million this year and a further £2 million in each of the next two years, and we are committed to long-term sustainable funding for those services beyond that point. We are also working with NHS Greater Glasgow and Clyde and NHS National Services Scotland to establish a nationally commissioned young people’s gender service, which is part of ensuring that young people’s gender care in Scotland is as person centred and effective as possible.

The Cass review recommends that gender-identity healthcare must operate to the same standard as other clinical services. We agree. We have already commissioned Healthcare Improvement Scotland to develop new national standards for gender-identity healthcare, and those standards are expected to be published this summer.

A key focus throughout the review is the need for better high-quality evidence in this field, and we agree. Long before the publication of the Cass report, we provided the University of Glasgow with grant funding to establish a programme of research into the long-term health outcomes of people accessing gender-identity healthcare. That now includes six projects in which the health outcomes of adults and young people are considered, covering cardiovascular health, hypertension, sexual health, mental health and longer-term wellbeing. The outputs of those projects are expected towards the end of this year. In addition, the Scottish Government and Scottish health boards are observers to NHS England’s planned study into the use of puberty blockers in young people’s gender-identity healthcare, and discussions are on-going to determine what further involvement is appropriate.

It did not take the publication of the Cass review for us to start a broad programme of work to improve gender-identity healthcare. In addition to the work that I have already highlighted, we have commissioned Public Health Scotland to develop a quarterly aggregate data collection for NHS gender-identity clinic waiting times, and we are supporting NHS National Education Scotland to develop new training materials for staff. Importantly, throughout that work, we have engaged with trans and non-binary people across Scotland who have lived experience of accessing, or waiting to access, gender-identity services in order to ensure that their voices are represented in our work to improve such care.

Building on that, and in response to the understandable concern from those who are impacted both by this change and, more broadly, by the provision of gender-identity healthcare to young people, we will hold a round table with stakeholders representing those affected, and I will continue to engage directly with young people.

I understand how difficult and heartbreaking the announcement last week will have been for the small number of young people and their families who were anticipating that they would soon be able to start these treatments. Dr Cass reminds us in her report that

“a compassionate and kind society remembers that there are real children, young people, families, carers and clinicians behind the headlines”.

I hope that we can all keep in mind that sentiment, today and as we move forward.

The minister will now take questions on the issues that are raised in her statement. I intend to allow around 20 minutes, after which we will need to move on to the next item of business. I would be grateful if members who wish to ask a question would press their request-to-speak buttons if they have not already done so.

I thank the minister for advance sight of her statement.

I spent last week trying to secure a statement from the Government on the Cass review and puberty-suppressing hormones. Every single attempt was voted down or refused. Finally, after confirmation from the health board of a pause in puberty-suppressing hormones for new patients, we have a statement today, but I do not know why the minister bothered, because it will offer no comfort whatsoever to families who have been failed by gender care services in Scotland.

The Scottish Government’s direction of travel on this vitally important issue is as clear as mud. The statement does not confirm whether the Government will implement any of the review’s 32 recommendations, nor does it address the cut to gender care services. The Government claims that it supports young people who are experiencing gender distress, yet members of it have publicly dismissed the findings of an evidence-based expert report.

Today’s exercise in kicking the can down the road and stalling for more time shows that the Government is more concerned about holding together its fragile pact with the dogmatic Greens than about healthcare for vulnerable young people.

When will parents and young people receive a meaningful update? Can the minister assure Parliament that all Government ministers will follow the science rather than ideology?

I thank Meghan Gallacher for her question. I note that the review was commissioned by the NHS in England; we have worked with the review, but Scottish pathways have not been included in it.

The Scottish Government has clearly welcomed the report from Dr Hilary Cass. It is absolutely clear that the decisions have been for clinicians, not politicians, to make, and—as I said in my statement—those decisions should always be made carefully, based on the best evidence available.

I am looking at this matter and putting the children and the families who need support at the heart of the way that I am working. I am getting the best advice that I can from clinicians and stakeholders.

I thank the minister for advance sight of her statement, although I have to register my disappointment at its lack of substance. The Cass report is a four-year-long piece of work that is evidence based and informed by expert clinicians and those with lived experience, so it deserves to be treated seriously. However, this statement feels more like a sop to the Greens to keep the Bute house agreement alive.—[Interruption.]—Does the minister agree with Patrick Harvie when he says that he does not believe that the Cass report is a valid scientific document?

Dr Cass has been discussing her report with clinicians and the Government in Scotland since 2022. Instead of acting on it, the Scottish Government appears to be setting up yet another working group. We already have the national gender-identity healthcare reference group. Is the minister bypassing that group with something new? If so, can she explain why?

Finally, will the minister confirm that she will suspend the commissioning of the young people’s gender service until the review’s recommendations are fully considered?

I repeat: there are 32 recommendations in an almost 400-page report, and we are working through it at the right speed to ensure that we make the right decisions. As I have said, those will be made from a clinical perspective.

As I have also said, in response to Meghan Gallacher, the Scottish Government welcomed the report. I have been reading it, and I recognise that Dr Cass is an eminent paediatric physician. I am listening to my clinicians with regard to the issue and, as I have said before, to the stakeholders.

Members will not be surprised to hear that there is a lot of interest in asking questions. I hope to be able to allow everybody who has pressed their button to ask a question, but that will require questions to be brief and responses likewise.

We know how difficult the news must have been for the young people who have been affected. What is vital now is that we focus on improving the healthcare of that very small number of affected people. I note the minister’s comments about the steps that have been taken in that regard. Can she say any more about that work and provide assurances to the affected young people that this issue remains a priority?

As I highlighted in my statement, I have agreed with the chief medical officer that the deputy chief medical officer and other senior medical officers will support careful consideration of the Cass review’s clinical recommendations. They will engage with the Scottish Association of Medical Directors and other clinical leaders.

We are already doing work on some of the report’s recommendations. Other recommendations relate to specific challenges for NHS England, such as how contracts for commissioned services are managed. However, let me be clear that work on some of the recommendations has already begun. A number of the recommendations will require much more detailed consideration of their relevancy to NHS Scotland systems and processes—for instance, recommendations around data systems.

Some members of the Scottish National Party and Green Government have questioned the integrity of the evidence in the Cass report. Given that gender-identity healthcare is a key part of the Bute house agreement and that Government spokespeople are publicly discrediting it, for the sake of young and vulnerable people, will the minister now consider ditching the Bute house agreement, the coalition of chaos?

I am here to speak directly to the young people and children and their families who have been impacted by the decision. I want to find the best way through for them, and that is why I am working closely with clinicians in NHS Scotland and with researchers.

The review is clearly important and very detailed, and it requires further detailed consideration. However, we must remind ourselves, as the minister has said, that it focuses on services in NHS England, not NHS Scotland.

Does the minister agree that, regardless of anyone’s position on the matter, it is essential that adequate time is taken to consider the report and that any knee-jerk reactions, one way or the other, are avoided?

As I have said, it is a 400-page report, and a knee-jerk reaction to a report that concerns a health system that is different to Scotland’s would not, in my view, be helpful for patients or their families. That said, it is vital that the recommendations are carefully considered to assess whether and to what extent they are relevant to the approach to gender-identity healthcare in Scotland, and to consider what steps may need to be taken as a result.

I thank the minister for her statement and agree that it is right that we proceed carefully and compassionately. Given that Dr Cass’s report is founded on strong scientific evidence, and given that there were interim recommendations, we in the Parliament saw what was coming to us. Why will the Government not be clearer in outlining its position on whether it believes that all the recommendations ought to be implemented? Does the minister believe that sitting on the fence to protect the stability of the Bute house agreement is a tenable position?

Minister.

Further to that—

Minister.

I thank Carol Mochan for her support in recognising that we need to take time to review the contents of the report. As I have pointed out on a couple of occasions, the report was commissioned by NHS England and looked at England. Not all the recommendations link back to Scotland, which is why we are taking that time.

I refer members to my entry in the register of members’ interests. I hold a current NHS Greater Glasgow and Clyde staff nurse bank contract. The people who should be at the front of our thoughts are the young people who are affected by this change. What steps are being taken to support the young people who have been affected—those who are accessing and those who are waiting to access services about their care—and their families?

I thank Clare Haughey for her question and for bringing it back to those young people who have been affected by the change. In addition to the work that I have highlighted to contact and support young patients in the Sandyford young people’s gender service who are most impacted by the change that was announced last week, NHS Greater Glasgow and Clyde has engaged with people on the YPGS waiting list to identify any unmet needs. It is also working with third sector organisations to provide additional support, specifically for those who are on the waiting list for the service, as well as dedicated staff to act as conduits between those on the waiting list and expanded support.

In addition, the Scottish Government is supporting NHS Greater Glasgow and Clyde and NHS National Services Scotland to consider how best to provide national specialist young people’s gender care in Scotland.

We need to remember the young people who are at the heart of this, many of whom will be in a state of profound distress. We need to get to a space where every one of them gets access to the quality care that they need. There are aspects of the report that some will find challenging, not least the stated lack of an existing evidential base for care pathways that have now been paused. There is therefore an urgent need to commission more medical research to promote greater understanding in the field. What role does the minister foresee for NHS Research Scotland and the chief scientist office in building that timely and comprehensive evidence base, ensuring that young people and their clinicians can make informed decisions about their care?

I agree that it is a challenging report. As I highlighted in my statement, we have granted the University of Glasgow funds to do some research in the field, but we also work very closely with the chief scientist office.

Dr Hilary Cass highlighted that the

“increasingly toxic, ideological and polarised public debate”

does nothing to serve the young folk accessing this care, their families nor the NHS staff who care for them. Does the minister agree that it is vital that we all do everything that we can to take the heat out of the issue and to redouble our efforts to deliver the best outcomes for young folk accessing this care?

I absolutely agree. As the First Minister highlighted last week, the toxicity of the debate is perpetuated by adults, and that is unfair to the children who are caught in the middle.

As Hilary Cass highlights, we must remember that

“there are real children, young people, families, carers and clinicians behind the headlines.”

We know that the heated debate not only impacts young people and their families but clinicians and, interestingly, even Dr Cass herself. It is the responsibility of all of us to take the heat out of the debate and to put the focus where it should be—on the young people who need this care.

Many young people will be concerned about the effect of last week’s decision to pause the prescriptions of hormones on their healthcare journey. Our solidarity should be with them. We need to work as quickly as possible to ensure that the concerns of the clinicians are resolved so that they can provide care with confidence. Scottish Trans has suggested that we should consider setting up our own research study. Can the minister outline what steps the Government is taking to resolve the current situation and how we can ensure that lived experience is at the heart of any action going forward?

I thank Ms Mackay for her engagement on the issue and her shared concern for the young people who are most impacted by the change.

As I highlighted in my statement, NHS Scotland is already engaging as an observer with NHS England’s research study regarding puberty blockers, and discussions are on-going among clinical stakeholders on what further involvement may be appropriate. The chief scientist office in the Scottish Government is also involved, given its expertise in clinical research. I hope that we will be able to update Parliament on the outcome of those discussions soon.

In addition to the NHS England research study, we have already provided grant funding to the University of Glasgow, as I mentioned in response to Mr Cole-Hamilton’s question.

Hearing from those with lived experience of accessing or waiting to access gender-identity healthcare is vital. To support our national work to improve those services, we have put in place a lived experience co-ordinator to engage and consult with trans communities across Scotland. As I laid out in my statement, I remain absolutely committed to my own engagement with young people who are affected.

The Cass review highlights the clear acknowledgement of detransition as a growing phenomenon that cannot be ignored; in fact, it was mentioned in the report more than 80 times. I noticed from today’s statement that the chief medical officer and the Scottish Government will take time to assess the recommendations. That is yet more time in an already lengthy period in which detransitioners have largely been ignored, often victimised and repeatedly castigated. Is detransitioning included in any of the work that has already been commissioned by the Scottish Government? Will it be included in any additional commissioned work, including the round-table session that the minister mentioned in her statement? When will Parliament be updated on plans to support detransitioners?

As I noted, the chief medical officer has agreed to update Parliament by writing on the clinical side before the summer recess. Given that we are talking about all of what is contained in the Cass review, I think that detransitioning should be included. I will feed that back to the chief medical officer to ensure that it is.

One of Dr Cass’s main criticisms of the system in England was a failure to reliably collect even the most basic data. She also said that NHS adult gender services initially refused to co-operate in sharing data. Can the minister assure us that that is not the case in Scotland?

I cannot comment on specific data systems or collection in NHS England’s commissioned services. However, we are committed to improving data collection for gender-identity healthcare in Scotland. As I mentioned, Public Health Scotland has been commissioned to develop quarterly aggregate data collection for NHS gender-identity clinic waiting times, focusing on a number of new referrals and lengths of waits from initial referral to first out-patient consultation with a specialist. Although that is a technical commission, the detail of which is being worked through by Public Health Scotland and territorial health boards, Public Health Scotland currently intends to publish the first of that information in late summer 2024.

As the minister will be aware, the Education, Children and Young People Committee wrote to the First Minister about the Cass review last week. We called for a clear timeline to be established for a Scottish response to the review. The committee also called for a comprehensive children’s rights and wellbeing impact assessment to be carried out. That is because we recognise that the Cass review raised some very complex and sometimes competing children’s rights considerations. Will the minister undertake to carry out such an assessment? When will that be done? How will she ensure that that fully explores the rights of children and young people across Scotland?

I am aware of the letter that Sue Webber sent. I responded to her colleague Meghan Gallacher’s letter this morning, and I copied my response to the Health, Social Care and Sport Committee and the Education, Children and Young People Committee. Along with my education colleagues, I will take some time to look at the contents of Sue Webber’s letter before responding in writing.

The Tavistock clinic, which is based in London, is facing mass legal action claims because some young people feel that they were rushed into a medical pathway. Given that the Sandyford clinic in Scotland uses the same guidelines, what assessment has the Scottish Government made of, and what discussions has it had with NHS bodies about, the possibility of similar legal action occurring in Scotland?

I have had no discussions on that topic, but I will bear in mind what Michelle Thomson has said and respond to her in writing.

Women’s rights groups across Scotland and the rest of the United Kingdom have welcomed the Cass review’s findings. However, last year, the then First Minister said that some of those opposed to her Government’s gender reforms

“cloak themselves in women’s rights to make it acceptable, but just as they’re transphobic you’ll also find that they’re deeply misogynist, often homophobic, possibly some of them racist as well.”

Does the First Minister agree with that assertion? Does the minister believe that those opposed to gender reform and children transitioning are misogynistic, homophobic and racist?

I am responding to Pam Gosal’s question as the Minister for Public Health and Women’s Health. I am focusing on the children and families who have been impacted by the decision last week and on ensuring that clinicians get the right support to make the right decisions and provide the best gender services that we can have in Scotland.

Given the importance of this issue, the public would have rightly expected the First Minister or the Cabinet Secretary for NHS Recovery, Health and Social Care to have made the statement.

On 28 March, I asked the health secretary to pause the prescribing of puberty blockers in Scotland. Now, it seems that he was unaware that clinicians at the Sandyford clinic had made the decision to stop doing so in mid-March.

When will the Government schedule a full debate on the comprehensive findings of the Cass report and its many implications for health, education and law in Scotland? From listening to the minister today, it seems as though the Government has not read or absorbed Cass’s conclusions. Is the Government really saying that it does not accept the report’s recommendations in full?

As I pointed out in previous answers, the Cass report was commissioned by NHS England and looked at services in England. As a result, not all of its recommendations will fit with our pathways in Scotland.

On a point of order, Presiding Officer. In relation to the Scottish Government’s dither and delay regarding the Cass review, will the minister care to correct the record about something that she said in her statement? She said:

“As I have said consistently, it is not for politicians or civil servants to make ... decisions about clinical pathways.”

However, in 2018, health boards were instructed by the then health secretary, Jeane Freeman, to completely stop all transvaginal mesh procedures until new protocols were developed, so I invite the minister to correct the record with regard to the Government saying that it cannot make decisions about clinical pathways.

I thank Rachael Hamilton for her point of order. As she knows, the content of members’ contributions is not a matter for the chair.

There will be a brief pause to allow front-bench members to change before we move on to the next item of business.