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Why are we critical of SPATH guidance?

Updated: Nov 7

A detailed 8-point critique of the Scottish position on trans healthcare

Scottish Pathway for Trans Healthcare (SPATH)

This pathway has been developed by Scottish NHS National Services and a freedom of information request shows that it has been signed off by the Chief Medical Officer to be used as official guidance in caring for people with gender dysphoria/gender incongruence. There is silence from the government about whether this is now to be implemented or altered in any way.


Why are we critical of this guidance? The following points may help to see why.

1) It is led very much by, and repeatedly refers to, the World Professional Association for Transgender Health (WPATH). WPATH standards of care are written and developed by self-described and self-appointed experts in the field. They do not use the best standards of examining evidence and are at a high risk of bias. An independent study by 6 reviewers of the WPATH guidelines noted that there were no clear recommendations, and they had a weak evidence base (Dahlen S, Connolly D, Arif I et al BMJ open 11 (4), e048943, 2021) Some of the authors of the WPATH standards of care may be more informed by political campaigning than academic or healthcare experience. For example, Susie Green, formerly of the UK Charity Mermaids has no clinical background but helped write the latest chapter on paediatric gender dysphoria.


2) Throughout the SPATH document one finds the words ‘affirming’ and ‘affirmation’. In other words, the philosophy is to agree with what a trans person says about themselves uncritically. The issue of gender affirmation versus gender exploration is particularly important for children. This is because we know that gender dysphoria (GD) can occur rapidly in already very disturbed individuals. Good research has shown that the majority of such children already have major psychological and social problems that need to be assessed and managed as a priority. To merely affirm a novel gender identity is unethical and uncaring. There is a section on ‘psychosocial support’ but nothing on actually exploring the origin of the dysphoria. There is a hint that this would be seen as ‘conversion therapy’, which of course it is not. Concerningly, SPATH specifically says that psychological support is not mandatory at all. A child therefore can be put on irreversible ‘treatment’ with no proper psychological assessment.


3) Throughout SPATH there is the bland acceptance of the use of puberty blockers (PBs), cross-sex hormones and surgery (mastectomies, genital surgery). Known side effects (such as alteration of brain development with PB’s) are not mentioned. Rather chillingly the SPATH document removes the term ‘initial assessment’ and instead prefers: ‘Hormone readiness assessment’, ‘chest masculinisation readiness assessment’ and ‘genital surgery readiness assessment’. In other words, the idea seems to be to prepare patients for these irreversible steps.


4) There is a recommendation that workers in primary care, such as GPs, nurses and occupational therapists, can be trained to assess and initiate treatment for people with gender dysphoria. That such irreversible steps in children can be taken by primary care workers is alarming. The words in SPATH used about these primary care workers are: “…..can be competent to do assessments of readiness for gender affirming healthcare.” Shockingly, the document states that a single opinion is sufficient for referrals for surgery.


5) There is brief reference to the Cass review, which deemed the Tavistock Gender Identity Development Service (GIDS) unsafe. There is, however, no recommendation to change anything in Scotland.


6) There is no mention of detransitioners, who are people who have been through the gender clinics as young people, have irreversible damage and later deeply regret what has happened to them. Those of us who have met some of them, can testify how badly managed they were. In all other branches of medicine there is acknowledgment and scrutiny of mistakes and harm done so that we can learn. Not so with our gender clinics.


7) There is a complete absence of any reference to data collection and research. Given that the gender affirmation model and use of puberty blockers has now been discredited by NICE (National Institute for Health and Care Excellence UK) and the health services of Sweden and Finland, it would seem strange that proper research into such medicalisation, that has such a poor evidence base, is not part and parcel of the guidance.


8) There is no mention of desistence. Desistence is when someone with GD matures and later is happy with their sex assigned at birth. GD in children is usually a phase. This has been reliably shown to occur in about 80% of children with GD. The affirmation model fails completely to recognise this, preferring to encourage clinicians for ‘readiness assessment’ for hormones and surgery. 12 year old children cannot possibly have the ability to consent to irreversible life altering treatment, including infertility and loss of sexual function – but the document assumes they can. And parental consent is not considered essential.

The SPATH document is poorly researched and driven by an over-arching and unscientific affirmation ideology. It should be immediately retracted.


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