The next item of business is a statement by Jenni Minto on gender identity healthcare for young people—an update and new national standards. The minister will take questions at the end of her statement; therefore, there should be no interventions or interruptions.
15:55
I am pleased to have the opportunity to provide a further update in person to the Parliament on this work. I will start by speaking directly to trans and non-binary young people in Scotland.
I know that waiting times to access the specialist services that provide support for gender dysphoria, alongside the on-going changes to how those services are provided, are worrying for you and your families. I have heard that directly from you in the meetings that we have had, and I have read it in the correspondence that I have received from you and those who love you.
I also know that high levels of on-going speculation and interest in those services, along with accompanying—often toxic—commentary, whether online, in print or in person, can magnify your worry. I hope that that will be borne in mind by those who wish to comment on this sensitive subject.
To members in the chamber, I note that it is vital that we lead by example in the tone of our discussions, not just today but in all our words and work. It is clear from colleagues’ correspondence with me that I am not the only one hearing directly from, and listening to, young people and their families. Therefore, I am sure that we all agree that they must be our priority and at the heart of all our discussions about how gender identity healthcare is provided and that everyone should be treated with respect.
In my parliamentary statement in April, I advised members that a senior multidisciplinary team in the office of the chief medical officer would consider the recommendations of the NHS England-commissioned Cass review and engage with relevant health boards and that I would provide an update to the Parliament.
As a result of that work, the “Cass Review—Implications for Scotland” findings report was laid before the Parliament on 5 July, which was the earliest opportunity following the pre-election period. The report is an important milestone in how we work together to deliver better gender identity healthcare for young people in Scotland. The Scottish Government has accepted the findings of the report in full, and work has started to implement its recommendations.
One such recommendation is that gender identity healthcare services for young people are
“not provided in an adult sexual health setting (such as the Sandyford Clinic) but are provided within paediatric clinical settings as with other age-appropriate services for children and young people.”
The report also found that, to ensure sustainable services, a distributed network or regional model—instead of one site—would be the appropriate delivery model. We are actioning that at pace to address the immediate fragility of gender identity healthcare for young people and to develop a sustainable longer-term model. We will use the Scottish Government’s new planning and commissioning approach to fragile services and are convening a senior task and finish group to take it forward. The work will be overseen by the NHS Scotland chief operating officer’s directorate in the Scottish Government.
Other recommendations from the report have already been implemented by NHS Scotland. For example, access to under-18s gender identity healthcare is now only through referral from a clinician. That is in line with other child and adolescent specialist services and will help to ensure that any other health needs can be identified and addressed.
In a progress report that I have published today, there is further detail on the actions that have been taken and progress that has been made so far. That includes work on the challenges in the recruitment and retention of staff in these services and the next steps for their commissioning and provision, which will, of course, include the voices of service users.
The CMO’s report and the Cass review underlined the importance of research and data. As I outlined in April, the Scottish Government commissioned Public Health Scotland in 2022 to develop a national data set for national health service gender identity clinics. The first annual data set for both adult and young people’s services will be published this autumn.
The Parliament is aware that we have already 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. The first outputs of those projects are expected towards the end of this year.
Furthermore, in August, the chief scientist for health for the Scottish Government confirmed to their counterpart in the United Kingdom Department of Health and Social Care the willingness of an NHS Scotland team, which will include the Scottish Government, NHS Greater Glasgow and Clyde and the University of Glasgow, to join the National Institute for Health and Care Research UK-wide study on puberty-suppressing hormones as a treatment option for gender dysphoria.
The CMO’s report also highlighted the need for national standards, as well as guidance on training and development for staff. I am pleased that Healthcare Improvement Scotland has today published its national standards for gender identity healthcare for adults and young people. The standards have been developed following an extensive public consultation, as well as targeted consultation with people with lived experience, clinicians and a wide range of professional bodies. They will support clinical services and health boards to deliver positive changes in partnership with people who use the services.
NHS Education for Scotland’s transgender care knowledge and skills framework has also been published today. It sets out what NHS staff need to know about caring for trans and non-binary people and improving training in that area. The framework was created following consultation and engagement. Further development of the framework, focusing on staff who work with children and young people, has started and is expected to be completed in 2025.
I have been clear that, to get this right, engagement with those who are involved in services, whether they are a user or a clinician, is vital. Throughout the process, the NHS has engaged constructively with people with lived experience to ensure that their voices are represented. I have regularly and proactively done the same. As well as regularly meeting young people since becoming a minister last year, later this month I will meet a wide range of stakeholders representing those who are impacted by on-going efforts within NHS Scotland to embed better service delivery and, ultimately, reduce waiting times. I know that colleagues across the chamber are doing the same. They are actively engaged with young people on the topic and committed to making sure that their voices are heard.
I reiterate the Scottish Government’s wider commitment to improving gender identity healthcare in Scotland for young people and adults. Since December 2022, the Scottish Government has invested more than £4.4 million in gender identity healthcare improvement. More than £3.6 million of that is being allocated directly to NHS boards that provide gender identity clinics to support them to improve service delivery. Independent evaluation of the impact of that investment on waiting times and the quality of care is under way. A report will be published this winter, and its findings will be used to support future improvements.
We all want to see improvement in waiting times for accessing those services. I hope that the breadth of work that is under way and that has been published today illustrates our commitment to improving clinical services and support for the young people who need to access them and shows that much has been advanced since my previous update to the chamber.
The findings of the Cass review and the CMO’s report on the implications for Scotland recognise that the wider societal discussion about gender identity is complex. They also recognise that the significant public, media and political interest in gender identity healthcare provision for young people might detract from the primary issue of providing the best clinical care necessary for them. That underlines the need for the development of young people’s services to take place
“with children, young people and their families in an active process of co-production.”
We all have a responsibility to make sure that children and young people grow up safe, respected and supported. I hope that that sentiment is one that we can all keep in mind today and in the future.
The minister will now take questions on the issues arising from her statement. I intend to allow around 20 minutes, after which we will move on to the next item of business. I encourage those members who wish to ask a question who have not already done so to press their request-to-speak button.
I thank the minister for advance sight of her statement. Tone and language are important when talking about gender identity healthcare and I echo calls for members to lead by example today.
The minister will be aware that I have held events at Parliament, alongside families impacted by gender care. Their stories are harrowing and each one outlines the importance of the evidence-based Cass review, but, due to the parliamentary recess, families and young people have had to wait weeks for a response from the Scottish Government, following the chief medical officer’s recommendations. During that time, MSPs have been unable to ask direct questions on behalf of their constituents. I hope that that will be reflected on.
The Cass review concluded that there is a lack of evidence to support the use of puberty-suppressing hormones and also says that children and young people might not be offered the right psychological support and assessments when they experience gender distress. The use of puberty-suppressing hormones has been paused in Scotland and, according to the minister’s statement, a UK-wide study is now under way to assess that treatment option. I therefore ask the minister whether the use of puberty-suppressing hormones will remain paused here in Scotland until that study has concluded.
I thank Meghan Gallacher for the tone of her question and wholeheartedly agree that it is important for us, as elected politicians, to ensure that we get our tone correct. Thank you for meeting those families who have been impacted.
I have given this statement on our first day back in Parliament and we published the chief medical officer’s report as soon as we could after the pre-election period.
Regarding your direct question about puberty blockers, you will know that that power is reserved to the UK Government and that we are currently in line with it. We await decisions that will be made by the UK Government’s Medicines and Healthcare products Regulatory Agency. That power is reserved and we will follow those decisions.
I thank the minister for early sight of her statement and thank the chief medical officer and his team for their work on the “Cass Review: Implications for Scotland” report.
I will explore the issues of waiting times and support for staff. The decision to stop self referrals and to have GPs and other clinicians refer their patients to gender identity clinics has already been announced by the Scottish Government. Will the minister say what additional resources, such as support and training, will be provided for GPs working in that sensitive area of healthcare?
Secondly, there are long waiting times at the Sandyford clinic—four years for teenagers and five for adults. We supported the Scottish Government’s strategic action framework three years ago, when Humza Yousaf was the health secretary, but waiting times continue to rise. I am told that there is a recruitment problem at the Sandyford, because the environment is toxic, but the position appears to be better at the Chalmers clinic in Edinburgh. Does the cabinet secretary therefore believe that a national service might be the answer and that it would resolve the lack of staff and the increase in waiting times?
As I highlighted in my statement, I find the waiting times concerning, which is why we have invested additional funding. I spoke about the £4.4 million, £3.6 million of which will go directly to NHS boards.
You are right to highlight the differences between the two centres. My statement also highlighted that there will be a review of that funding to see where there has been success and what the two health boards can learn from each other.
You are also correct to highlight the recruitment issue, which is an issue not only in Scotland but across the UK. To go back to Meghan Gallacher’s comment, the onus is on us to ensure that we reduce the temperature of discussions to ensure that the right people, with the right training and the right desire for the service to work, can be recruited and, importantly, retained.
To no one’s surprise, there is a lot of interest in this subject. I would be grateful for brief questions and responses, all of which should be directed through the chair.
I refer members to my entry in the register of members’ interests: I hold a bank nurse contract with Greater Glasgow and Clyde NHS.
The Cass report says:
“A compassionate and kind society remembers that there are real children, young people, families, carers and clinicians behind the headlines.”
With that in mind, and remembering the long waits faced by both adults and young people accessing gender identity services, will the minister say what steps the Scottish Government is taking to recruit the staff required to reduce waiting times?
As I said in my response to Jackie Baillie, we have provided more than £4.4 million for gender identity healthcare improvement since December 2022, including more than £3.6 million to health boards that provide gender identity clinics. However, both the Cass review and the CMO’s report highlight that recruitment in this field is challenging and, as I said in my statement, consideration of staff skills will form part of the already outlined commissioning approach to fragile services. Gender identity healthcare for children and young people is now a part of that.
The Royal College of General Practitioners is clear that the prescribing of gender-affirming hormones should generally be done only by specialists. However, it is often done by GPs, who have shared with me their concerns about safe prescribing to patients who have gender dysphoria. Can the Scottish Government confirm whether, under the new standards, GPs will be routinely expected to prescribe gender-affirming hormones, and whether shared-care protocols will be put in place?
We have been clear in our responses that the specialist centres will be in charge of determining the support that children and young people need in that area. We have to ensure safe prescribing—which is created by the outlined approach and the regulations.
I am sure that, like me, the minister receives a lot of correspondence from concerned young people and their parents each time that there is news about trans healthcare—including puberty blockers and hormones in particular—due to the significant misinformation about and misinterpretation of announcements. What the implementation of those recommendations means for people getting treatment will need to be extremely clear and accessible. Will the minister therefore please provide reassurance to those who currently receive treatment, or are on a waiting list for treatment, about the continuation of their care while the research and data collection goes on, and speak about access to such care for those in rural and island communities?
When the announcement was made about the pausing of the prescribing of puberty blockers, we were clear that those who were on a treatment would remain on that treatment. I represent a rural constituency, as Emma Roddick does, so I absolutely understand the reasons behind her questions.
We are absolutely clear that services should take into account the barriers that may be faced by people, including those who live in island or rural communities. I agree with the multidisciplinary team’s report, which states that those services should be delivered according to the principle of being
“as local as possible and as national as necessary”.
I thank the minister for her statement. There is a clear disparity in the availability of services, based on where people live. To ensure sustainable services, there is an expectation that gender identity healthcare will be provided in a number of different settings. The report refers to a “distributed” network or “regional” model. In her statement, the minister said that that is being actioned at pace. Can the minister be clearer on those models and on the timescale for them?
As I said in response to Emma Roddick, it is absolutely clear that arrangements should be suitable for people wherever they live in Scotland. As I said, I represent a rural constituency. We need to ensure that people can access the right care for them at the right time. That may include the use of digital tools to support people’s access to services. If Carol Mochan will allow, I will come back with a timeframe after this question session.
In her report, Dr Hilary Cass showed that social transitioning in schools sets some children on a pathway to irreversible medical interventions. Surely, children who are taught in schools that they are born in the wrong body are being failed in the duty of safeguarding that is owed to each of them. Therefore, as numerous of my constituents have called to be done, will the minister withdraw the current guidance, remove all gender ideology references from the relationship, sexual health and parenthood resource, and remove third sector activist groups from schools?
I underline that my statement is focused on NHS gender identity healthcare for young people. Those are specialist services that are provided to a small number of young people who need that care.
Children and young people are not taught about their own gender identity in schools. That is a personal matter for any individual and, in the case of young people, their family.
However, it is the role of a school to provide pastoral support to a young person who is seeking it. Our education system must support everyone to reach their full potential, and it is vital that the curriculum is as diverse as the young people who learn in our schools. It is also vital that we help instil the values of respect and tolerance in our children and young people.
The current media and political environments mean that many young trans people are terrified, like never before, to come out. That is compounded with long waiting times for care and the fact that they are now unable to access treatment that they could access this time last year, so it is no wonder that many of those young people need mental health support. I am glad that that is reflected in the documents that were sent alongside the statement.
However, with the approach that is currently being proposed, there is a danger that trans healthcare is seen purely through that lens, and that stigma is compounded for one of the most stigmatised groups in society. How will the Scottish Government ensure that that does not happen, that stigma and transphobia are challenged at every turn, and that this Government is committed to ensuring that young trans people’s healthcare is accessible and that their rights are upheld?
As I said, leading up to this statement, all the conversations that I have had have very much included and put at the centre the young people and their families. I have a meeting in the next couple of weeks to ensure that the way that we are moving forward is correct.
I have said this before, but I will repeat it—there is a responsibility on those of us who are elected, as well as on our news broadcasters, to ensure that that toxic environment is not maintained.
To follow on from my colleague’s question, the narrative surrounding the conversation of gender identity healthcare must move away from the harmful and toxic state in which it currently sits.
Will the minister outline work that the Scottish Government will undertake to ensure that the young people at the heart of the discussion are supported positively both in and out of healthcare environments?
As is set out in the progress report that was published today, a range of support has been put in place for young people who are accessing and waiting to access gender identity healthcare. That includes waiting list validation, onward referral to additional services where appropriate, community-based third sector support to address social isolation and inactivity, and mental and emotional wellbeing support.
I am grateful for the tone that the minister has adopted today. She and I share the ambition to get this right in a timely manner and remove some of the attendant heat.
Emma Roddick rightly referenced the children at the heart of this matter, many of whose care pathways will have paused and who will have spent several months in profound anxiety about their future.
I was gratified to hear that the Government is still seeking an evidential base and that part of that will be the lived experience of those who have received gender-affirming care. What efforts will her Government deploy in order to put the voices of the children who are on waiting lists at the heart of those considerations?
I have already indicated that I have such meetings regularly, as do my officials. It is incredibly important to hear the voices of those people.
It is also important to recognise the research side of that. The Scottish Government has commissioned research through Glasgow university, and part of that research is looking at issues such as hypertension in young people.
Can the cabinet secretary outline what the Scottish Government’s statement means for the future of the Sandyford clinic? Will it be closed? Will it be relocated? Can she share a timeline for those changes?
Will she also confirm whether GPs were consulted on the NHS Education for Scotland transgender care knowledge skills framework?
The Sandyford gender identity clinic is not going to be closed, as it offers a wide range of sexual health services. However, the report of the multidisciplinary team has recommended that, in the future, specialist gender identity health services for young people be provided not in an adult sexual health setting but in paediatric clinical settings.
As I referenced in my statement, under the Scottish Government’s new planning and commissioning approach to fragile services, work will take place to address the immediate fragility of gender identity healthcare for young people and develop a sustainable longer-term model in line with the recommendation that these services be delivered in a paediatric setting. As I indicated, all the reports and frameworks that we have published today have been subject to consultation with appropriate people.
Children and young people with gender dysphoria can present with a range of complex psychosocial challenges and mental health problems, which can impact on their gender-related distress. Can parents and children in Scotland now be reassured, with services being provided in paediatric settings, that all issues will be explored fully in order to provide diagnosis, clinical support and interventions—medical or otherwise—that are appropriate for the age, stage and needs of the child or young person?
I thank Ruth Maguire for that important question. It is of the utmost importance that these services are delivered to the highest standard for the young people who use them. The new national standards that I referenced include a standard—standard 10—to specifically address the delivery of gender identity services for young people and outline the need for young people to have timely access to safe, high-quality and person-centred gender identity services that understand, respect and uphold their rights.
Adult and child patients must have healthcare that is appropriate to their clinically assessed medical presentation. Can the Government confirm what the milestones will be for Scotland’s Cass compliance for the 32 recommendations? What clinical evidence informed the national standards? Can the minister confirm that GPs, primary care clinicians and health boards fully support the national standards and their funding, training and implementation? Reports that are reaching me suggest that that is not the case.
A clear ask of the chief medical officer and his multidisciplinary team was to review the recommendations in the Cass review to ensure that they were being properly implemented as appropriate in Scotland, and that is what I have been reporting on today. There is also the progress statement. Clinical organisations were consulted. I am not across the information about health boards complaining or raising issues. Perhaps Ms Regan would be happy to write to me on that, and I will be very happy to explore it.
Following on from the questions that have been asked by Tess White, Fergus Ewing, Rachael Hamilton and Ash Regan, will the minister take the opportunity to spell out the governance structure for the oversight of Scottish gender identity services? In other words, who is responsible?
Responsibility for all healthcare lies with the health boards, and the Scottish Government works with them to ensure that that is met. We have had very clear consultation across the board, including with GPs, to ensure that the four reports that have been published today provide the right standard for Scotland to move forward with regard to gender identity healthcare.
I thank members for their co-operation. We managed to get everybody in who wanted to get in. There will be a brief pause before we move to the next item of business, to allow front-bench members to change positions.
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