Cass Review and Gender Identity Healthcare

I want to start by speaking directly to our young people, and in particular our trans and non-binary young people across Scotland. I know these last 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, not just to ensuring ongoing support is available for you, but to reforming and improving gender identity healthcare. This was a key part of the Bute House Agreement, and we will not waver in that commitment.

Before I continue, I am 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 will be reflected in this session today.

Let me reiterate what the First Minister has said clearly, 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 with 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. This pause is to allow time for further evidence to be gathered to support the safety and clinical effectiveness of these medications, following the Cass Review.

The statement also confirmed that the small number of young people who are currently receiving these medicines will not be affected by this pause, mirroring the position in NHS England.

As I have said consistently, it is not for politicians, nor civil servants, to make clinical decisions about clinical pathways. These decisions should always be made carefully, be based on the best evidence available, and be made only by clinicians responsible for providing such healthcare.

To be very clear, Ministers do not make clinical decisions in any field of medicine, and gender identity services is no exception.

I fully support Health Board autonomy in clinical decision making.

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

I know some members in this chamber have expressed disappointment that the Scottish Government did not announce this position before the Health Board statement.

Presiding Officer, every single one of us in this chamber, indeed every single one of us across Scotland, has a right to hear first, and directly from the services caring 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 time to speak to all the young people who would be impacted by this pause so they understood what this meant for their care and treatment.

I am sure that everyone in this chamber will agree with me that if this was happening to their loved one that is exactly what they would want, and expect, to happen.

I reiterate, these 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, and referred, into it.

The Cass Review is a detailed, wide-ranging report, and I welcome the opportunity to update Parliament on our approach to recommendations and wider work in this field.

It is important to highlight that the Cass Review was commissioned by NHS England and did not review clinical services or pathways provided within the NHS in Scotland. Therefore, by definition, clearly not all the recommendations may be applicable to NHS services in Scotland.

That said it is vitally important that these recommendations are carefully considered to assess to what extent they are relevant to the approach to gender identity healthcare in Scotland, and to decide upon what steps may need to be taken as a result.

Time is required to fully consider all of the recommendations, something NHS England also acknowledges.

We already have a Strategic Action Framework for the improvement of NHS gender identity services. As part of this 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 these with the Scottish Association of Medical Directors and other clinical leaders.

A multi-disciplinary clinical team within the Office of the Chief Medical Officer in the Scottish Government, including 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 those recommendations. The CMO will provide a written update to Parliament on the outcome of that clinical consideration process before the Summer Recess.

It’s important to note that in Scotland, we are already making progress in a number of aspects of gender identity healthcare highlighted in the Cass Review.

So let me be clear – work has already begun, and I will remain engaged throughout.

For example, Dr Cass highlights the need to address increased capacity in services.

The Scottish Government is committed to invest £9 million to support the improvement of NHS Gender Identity Healthcare in Scotland.

That funding will be delivered over a five-year period, so that national improvement work already underway will be embedded and built upon. This aligns with feedback 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 over £2.8 million to support work to improve access to gender identity healthcare in Scotland, with over £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 these 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 – part of ensuring 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 standards 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. We agree. Long before publication of this 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.

This includes six projects where the health outcomes of both adults and young people are considered - covering cardiovascular health, hypertension, sexual health, mental health and longer-term well-being. The outputs of these 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 ongoing to determine what further involvement is appropriate.

Presiding Officer, it did not take the publication of this review for us to start a broad programme of work to improve gender identity healthcare.

In addition to the work that I’ve 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 this 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 to ensure their voices are represented in our work to improve this care.

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

Presiding Officer, I understand how difficult and heart-breaking 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 is a sentiment we can all keep in mind, today, and as we move forward.