What's happening with children's gender care in Scotland?

A landmark review of gender services for under-18s in England and Wales has warned that children have been let down by a lack of research and "remarkably weak" evidence on medical interventions.

Dr Hilary Cass's review followed concerns about care at the Gender Identity and Development Service (Gids) - based at the Tavistock clinic in London.

It was NHS England's only specialist gender clinic for children and young people but is now being replaced with new regional centres.

The Scottish government says it will consider her findings while reviewing services in Scotland.

Like other parts of the UK, Scotland has seen a rapid rise in the number of young people questioning their identity or experiencing gender dysphoria.

For many, this will only require support from family, friends and school but some become so distressed they seek medical help.

The only specialist service for under-18s is the Sandyford clinic in Glasgow.

People can self-refer or can be referred through their GP.

Figures released to BBC Scotland news under a Freedom of Information request showed that at the end of 2023, 1,100 patients were on the waiting list.

The longest wait is 1,692 days, about four-and-a-half-years.

In her report, Dr Cass says the increase in the numbers of young people who have a trans or gender diverse identity, is the result of a "complex interplay between biological, psychological and social factors".

She warns that the "toxicity of the debate" around gender has had a negative impact on the quality of care they receive.

She says many doctors are afraid of working with them, because of the controversy around medical treatments, and that this means they are not getting the individualised care the NHS should provide, including mental health assessments and screening for autism and other neurodevelopmental conditions.

One of the most controversial issues for children and young people with gender incongruence is around prescribing puberty blockers or cross-sex hormones.

Dr Cass says the lack of evidence on the long-term impact of taking hormones from an early age has let children down.

Her recommendation is that hormones should only be prescribed with "extreme caution".

NHS England recently announced that puberty blockers would no longer be routinely prescribed to children outside of clinical trials.

Details of those trials are still to be announced.

A routine ban has not been announced in Scotland but the Scottish government says it is working with NHS England as it develops plans for clinical research in this sphere.

Fewer than 100 children - who had already started a prescription - are now taking puberty blockers on the NHS in England.

In Scotland, the number is likely to be far smaller.

NHS Greater Glasgow and Clyde, who run the Sandyford Clinic, said: "We carry out a multidisciplinary assessment over a number of appointments, including a robust psychological assessment.

"There are times following these appointments where some patients are referred to endocrinology for puberty blockers.

"They would be further assessed for suitability. Puberty Blockers are just one point of intervention and they are currently used in small numbers."

Dr Cass says she is also concerned that some young people who can't access support on the NHS are obtaining "unregulated and potentially dangerous hormone supplies over the internet", or using private providers without a clear plan for long-term monitoring, and recommends that the UK government should consider ways to prevent inappropriate prescribing.·

NHS Scotland is reviewing gender services for both adults and children. New protocols for adults have been delayed but are expected to be published before the summer.

For children, the government says it is developing a separate pathway.

Dr Cass's report only looked at NHS England, but in December, she gave a presentation to the Scottish government's National Gender Identity Healthcare Reference Group, which is overseeing this work.

Factors affecting Scotland include the similar challenge experienced in England, of recruiting from a limited number of skilled and expert staff to specialist services, and the impact of this on an already stretched NHS.

The group is also considering the structure of clinical services both locally and nationally, as well as potential collaboration between the Scottish government and NHS England on its puberty hormone suppression study in children and young people.

The government's National Services Division is continuing work formally to commission a young people’s gender identity service for Scotland, including consideration of ongoing support "embedded" at local and regional level, alongside pathways for referral to an expert national service.

Dr Cass says in England and Wales there has been what she calls 'diagnostic overshadowing' with too many children being referred straight to national gender services, when they may get quicker and better help elsewhere.

It's just one of the 32 recommendations that Scottish policy-makers will take into account.

In response to the Cass report, a Scottish government spokesperson it had closely monitored Dr Cass's review and had met her on a number of occasions to share information about improvement work in Scotland.

“While the Cass Review extends only to services provided by NHS England, we will now take the time to consider the findings of the final report in the context of how such healthcare can be best delivered here in Scotland,” they said.