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Elephants in Perthshire

John Higgon discusses the way in which the Scottish Government manages public consultation on its flawed gender identity service model.

The Scottish Government is consulting on standards for gender identity healthcare services, but they are being highly selective about which standards they are seeking comments on.  It is as if they had decided for some strange reason to introduce elephants to Perthshire, and are now asking for the public’s views solely on what the elephants should be fed, rather than whether it is a good idea to have elephants roaming around in Perthshire. 

For example, the consultation seeks the public’s views on ‘staff education and training’, but ‘specific treatment and therapy options or clinical pathways’ are beyond the bounds of the consultation.  You might think that staff education and training cannot really be split off from specific treatment and therapy options.  After all, healthcare services usually provide evidence-based interventions by means of staff that are trained to deliver those interventions.  How can you train staff when you don’t know what you should be training them to do?  But this is the Alice In Wonderland world of trans healthcare, where usual rules don’t apply.  Take, for example, what counts as evidence for the development group:

“Evidence base A systematic review of the literature was carried out using an explicit search strategy devised by an Evidence and Information Scientist from the Research and Information Service. Databases searched include Medline, Embase, Cinahl, PsycINFO and the Cochrane Library. The year range covered was 2012-2022. Internet searches were carried out on various websites.”

All very well and good, you might think.  A properly qualified scientist has conducted a search of academic and clinical databases looking for high-quality peer-reviewed evidence relating to the issue under development. But just when you were beginning to have some confidence in the process, you learn that “the main searches were supplemented by material identified by individual members of the development group”.  Straightaway, then, we have two kinds of information that the group is looking at – first, the peer-reviewed information from the scientific databases where academic and clinical journals are housed, and second, well, who knows

There are eight standard areas.  These are:

·      shared and supported decision making 

·      reducing inequalities in gender identity healthcare and services

·      access to gender identity healthcare

·      collaborative leadership and governance

·      staff training and support

·      referral into specialist gender identity services

·      gender identity services for young people

·      assessment and care planning



Under Standard 1 - shared and supported decision-making - we are told that people should be “supported to make informed and shared decisions about their care”.  Yet, we know that the evidence in many areas of gender healthcare is lacking.  How, then, can anyone make an informed decision regarding their care?  Helpfully, the draft standards remind us that “all people should be recognized as experts in their own care”.  We’re all experts now, so who needs evidence?  Later in this standard, service users are to be “recognised and respected as experts in their care, needs and preferences”.  There are significant risks, we think, in conflating care, needs and preferences in this way, and in assuming that a patient is equally expert in all three.


 Later still in this first standard, it is indicated that service users should be able to discuss their care with “kind, empathetic, well-informed, compassionate and unbiased staff”, but this again begs the question – in the absence of a solid evidence base, how can any staff member claim to be offering well-informed or unbiased advice?  Surely the most that a well-informed staff member can say is, “We don’t really know”.


Staff will also be encouraged to “signpost to additional services, including third sector organisations”.  Will these be gender-affirmative organisations, or gender-critical ones, or – given the absence of evidence – will staff be left to decide this for themselves? In my very long experience of working within the NHS, staff will direct patients towards gender-affirmative organisations such as LGBT Youth Scotland, Mermaids and the rest, and certainly not towards the Bayswater Group, Thoughtful Therapists, the Clinical Advisory Network on Sex and Gender (CANSAG) or our own group.  Why is this?  It’s because these affirmative organisations have cornered the market in providing education to public bodies, and in that context, they have advertised their services as not only education providers but providers of support to particular client groups.


Standard 4 - Organisations demonstrate effective and collaborative leadership, governance and partnership working in the planning, management and delivery of gender identity healthcare.


Governance in clinical settings refers to the way in which an organisation assures itself that the services it is providing are safe.  As we have seen previously, this is intimately tied up with the evidence base for any given intervention.  So one would think that research would come very high on the agenda for Scottish gender services.  However, of the eleven requirements made of organisations, only one (the last on the list, as it happens) specifically mentions research, and then in a rather half-hearted manner: organisations should “support and encourage research activity, where this is undertaken”.  We would have preferred to see the need for high-quality research put right at the heart of this standard.  How can a service know that it is delivering high-quality healthcare when there is no agreement on what constitutes ‘good’ in this area?


Standard 5 - Staff have the training and skills to deliver the right care and support for people accessing gender identity services.


ScotPAG members know from their experience, whether in health, education or social work, that training in the area of gender is almost exclusively provided by third-sector activist organisations that adhere to a particular political, rather than scientific, view of gender.  The problem is that these groups present this political view as if it were science.  Meanwhile, serious scientists fail to get their research published, not because it is poor-quality research but because it fails to line up with the new gender ideology.  It’s the trans-exceptionalism that I referred to when I mentioned the Alice In Wonderland world of trans healthcare.  In this context, how on earth can staff be given the training and skills to deliver the right care to people using gender services?


Standard 6 – Referral into specialist gender identity services


Organisations ensure there is a robust referral pathway into specialist gender identity services


This looks quite clear and reasonable, and yet, buried in the weeds of the accompanying text, we find reference to the role of primary care in deciding when to refer to the gender identity service and when a referral to a non-specialist service may be more appropriate.   The guidelines leave it up to local organisations to flesh out these important and complex decision-making processes.  Local organisations will also “support the person during the referral process, including signposting or referral to other services such as mental health support”.  Once again, experience suggests that NHS staff will be referring to gender-ideology 3rd sector organisations rather than to gender-critical ones, despite the lack of evidence supporting one approach over the other.


Standard 7: Gender identity services for young people


Young people have timely access to safe, high-quality and person-centred gender identity services which understand, respect and uphold their rights


Within this standard, it is indicated that “for young people who receive endocrine therapies, there is provision of accurate information, including the potential benefits and risks of different care options, to support consent and decision making in line with national guidance”.  Well, given that there are only three studies examining the cognitive effects of puberty blockers when given to children with gender dysphoria, it should at least not take too long to provide children with the relevant information.  Once again, the standards are putting the cart before the horse.  They require clinicians to explain to their patients the risks and benefits of a particular intervention, when nobody yet knows exactly what those risks and benefits are.


Later in this section it is indicated that “where young people, their families or representatives require psychological and/or social support, this is delivered and managed by their own NHS board of residence”.  We believe that this is entirely the wrong approach.  It implies that the psychological can and should be split off from the gender issues, whereas the very reverse is true.  Gender dysphoria is a psychological experience.  Gender services cannot simply turn a blind eye to the psychological issues that are over-represented in their clinical population – issues such as shame associated with same-sex attraction.  The Cass review, mentioned in the introduction to the draft guidelines consultation, but not included in the references, discussed the dangerous effect of ‘diagnostic over-shadowing’, whereby the ‘trans’ label came to dominate the clinical picture to the exclusion of all else.  HIS seems to think that this is something to aspire to.


Standard 8: Assessment and care planning - People have a holistic, effective and person-centred assessment and care plan.


The draft guidelines say that the “initial assessment should be comprehensive and holistic, covering the person’s  individual needs and desired outcomes, avoiding assumptions about what support or treatment may be wanted;  existing or previous care and treatment plans;  health and wellbeing including continuity of care, for example named clinician;  capacity and consent; and  need for further support and/or treatment


This is by no means a holistic assessment.  At the very least it should also cover themes such as sexuality, history of sexual abuse or witnessing of gender-based violence, family history, presence of autistic traits that might hinder abstract thinking, and, for children and young people, the ability to give consent at a stage in life where many relevant issues (fertility, sexual function) are not yet fully ‘on the radar’.  This psychological assessment, by the way, should be required for all children and young people as part of the usual assessment process – not only for those who express doubt about medical transition.  Or perhaps Standard 7 has covered this, and all of these issues can be safely dealt with by local psychology services, split off from the gender services?


Perhaps most worrying is the acknowledgement that, even after the ‘holistic assessment’ has been conducted, “some people may decide to halt or reverse aspects of their gender identity healthcare. An individual’s decision will be personal and a person-centred and compassionate approach should be taken by staff and services”.  Indeed.  But why not go further, and insist that gender services flag these instances as applicable to Standard 4.7 (organisational learning) or 4.10 (reporting of adverse events), particularly if the patient has undergone irreversible treatment of some kind?  Being person-centred and compassionate just doesn’t cut it in cases where a young person comes to regret the cross-sex hormones that have resulted in their infertility, or the surgery that has resulted in their loss of sexual function.


To summarize, the Scottish Government has missed a golden opportunity to re-think gender services, and it has very little excuse for having done so.  It pays lip service to the excellent and in-depth Cass review, but this does not even appear in the references section of the draft guidelines.  It fails to appreciate the very limited and poor-quality evidence on which existing gender healthcare systems have been based.  Consequently, it fails to put long-term outcome research where it should be, at the heart of any new gender service.  It fails to address the differences between the ‘new cohort’ of young people identifying as trans and the ‘older cohort’ of mainly middle-aged men, and it shows a remarkable lack of curiosity about the role of co-morbidities in the current trans-identifying cohort.  Worse still, the terms of reference of the consultation effectively prevent any engagement with these issues. 


New gender services are on the way, and – among other things – the draft guildelines suggest that their users will be able to claim travel expenses in line with travel expense policy.  The elephants are coming, now what shall we feed them?

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