Two recent articles in the Telegraph: NHS Scotland plans to ‘fast-track irreversible surgery for trans patients’ and Women’s health clinics could be renamed to avoid upsetting trans patients have focused on a report called the Scottish Pathway for Trans Healthcare (SPATH). This was one of several documents provided by NHS Greater Glasgow and Clyde in response to our Freedom of Information request, and details the proposed national treatment guidelines for transgender patients. NHS Scotland have said the guidelines are due to be sent to the Scottish Government for final approval.

Documents included in the FOI:
SPATH Recommendations, September 2022
SPATH Update, April 2022
SPATH Initial Briefing, February 2022
Sandyford GIC’s response to ICD-11 reclassification of gender dysphoria

The guidance is the end result of a request from the Chief Medical Officer in July 2021 to review the current Gender Reassignment Protocol and update it in line with best practice, taking into account the latest World Professional Association of Transgender Health (WPATH) guidelines, and the recent reclassification in ICD-11 of the mental health condition of gender dysphoria to a sexual health condition of gender incongruence.

As expected from a treatment protocol heavily based on the discredited WPATH standards of care, there are numerous concerns with SPATH, including the following:

‘Barriers’ to surgery should be removed with surgery seen as a preventative measure rather than to cure distress:

  • No psychiatric diagnosis of gender dysphoria, patient assessed only for readiness for the hormone or surgical procedure requested.
  • Only one opinion needed to refer patient for surgery except in ‘complex’ cases.
  • Counselling or psychotherapy “not a prerequisite” before irreversible surgeries.
  • Specialist GPs, rather than gender identity specialists, should be able to refer patients for surgery.
  • Senior clinicians or psychiatrists treating a patient’s complex mental health problems barred from involvement in assessing readiness for surgery.
  • More surgeries recommended by WPATH may become available on Scottish NHS in future (eg. voice feminisation surgery).
  • Patients placed on medical pathways after brief assessment as lower level interventions like voice therapy/wigs are deemed “extremely low risk”.

GPs should be able to prescribe hormones and non-specialists to assess patients:

  • Family doctors should be able to sign “shared care agreements” with gender clinics to prescribe drugs as part of an “enhanced service”.
  • Backs a pilot project for those “self-sourcing” their own hormones to get priority referrals to clinics, despite admitting this could incentivise use.
  • A “safer alternative” should be provided by GPs where patients are self-prescribing.
  • A wide variety of health professionals can develop competencies to carry out assessments of readiness for gender affirming healthcare, including doctors working in primary or secondary care (such as GPs with special interest, psychiatrists, sexual health specialists, and endocrinologists), nurse practitioners, psychologists, and allied health professionals (such as occupational therapists).

Services for children to continue with “affirming” approach despite Cass review:

  • A long-term approach to treating children will have a “trans affirmative approach” (Cass warned about this).
  • Literature to be developed for children, including under 13s, telling them about the “importance of gender affirming care”.
  • Opens door to GPs prescribing puberty blockers, saying role of primary care “to deal with treatment following assessment” should be considered, “reducing the need for specialist clinicians”.
  • Hormone/puberty blocker rules to be implemented despite Cass’s early findings of scant evidence for their use, only to be reviewed 12-18 months after SPATH published.
  • Fund partnership work with third sector organisations to provide patient support, including group work and befriending. Badged as from the NHS to “provide credibility”.
  • No consideration of care for detransitioners.

NHS Scotland should “move away” from “gendered healthcare”:

  • Report says “systems within NHS Scotland need to allow for increasing gender identities for patients, specifically including non-binary identities. This should be done as part of a general move away from gendered healthcare.”
  • Claims transmen may feel uncomfortable seeking contraception or smear tests when the services “target audience” is incongruent to their gender identity, such as a “women health clinic”.
  • “If clinically appropriate, laboratory reference ranges should be decoupled from gender markers and instead be relevant to the individual”.
  • Suggestion of “inclusive” signage, forms and leaflets, and appropriate staff training.
  • Where CHI number is changed, responsibility placed on the patient to decide when it is appropriate to disclose their sex to “ensure patient safety” or for “determining appropriate care”.