Background and scope | Right Decisions

Background

People experience and express their gender identity in different ways and at different points across their lifetime. Some people may access services for support as they question their gender identity. Others may be seeking to start the process of transitioning, retransitioning or detransitioning. Some people accessing gender identity services may require ongoing care, support, monitoring and treatment throughout their lives.

Throughout the standards, the term person/individual is used inclusively and covers transgender and non-binary people.

Gender identity healthcare is a term used by NHSScotland to refer to the care and support people can access if they experience distress caused by gender incongruence or gender dysphoria. It includes interventions that may be non-surgical, surgical and pharmaceutical.¹^-³ There are currently four gender identity clinics in Scotland that provide specialist clinical support delivered by multidisciplinary teams. These services are based in NHS Grampian, NHS Greater Glasgow and Clyde, NHS Highland and NHS Lothian. The service for young people is located in NHS Greater Glasgow and Clyde and accepts referrals from across Scotland.

In recent years, there has been an increase in the number of people accessing specialist gender identity services in Scotland.², ³ Recent evidence has identified the need for gender identity services to improve capacity and access.³^-⁵ People report experiencing challenges when accessing gender identity healthcare, including:

inconsistency of gender identity service provision across Scotland
inequality of access across different geographical areas
frustration with length of time for initial assessment and between appointments
lack of accurate information regarding likely waiting times
‘misgendering’ or ‘deadnaming’ in correspondence and other errors in information recording.⁴, ⁵

Access to high-quality, evidence based and equitable healthcare is essential to improving the health and wellbeing of society.⁶^-⁸ Healthcare services should ensure appropriate and responsive delivery and interventions for everyone who needs them.⁶

The aim of these standards is to ensure national consistency in the multidisciplinary delivery and coordination of high-quality gender identity healthcare which is based on current evidence and best practice. The standards aim to support current and future service provision and national improvements.³

Scope of the standards

The standards apply to all adults and young people who are:

accessing or wishing to access gender identity healthcare
transferring between healthcare services to ensure continuity of care
people who are exploring their gender identity in relation to possible gender incongruence or dysphoria.

The standards also aim to support, where appropriate, families and representatives of people receiving or engaging with gender identity healthcare.

Standard 10 specifically reflects the additional responsibilities and requirements for gender identity services supporting young people.

Who the standards are for

Not all gender identity healthcare is delivered by gender identity clinics or specialist services. These standards apply to all services involved in the delivery of gender identity healthcare including, community pharmacy, mental health services and primary care.

The standards apply to both NHSScotland and independent providers delivering gender identity healthcare. NHS boards may delegate relevant gender identity healthcare responsibilities to Health and Social Care Partnerships or Integrated Joint Boards.

It is expected that the standards will be adhered to across all health settings including NHSScotland settings and independent healthcare.

Where a principle or criterion applies to a specific setting this has been highlighted throughout the document. The standards should be reviewed pragmatically by service providers. Individual criteria will be applied by service providers in different ways in recognition of the breadth of gender identity healthcare and support delivered across health and social care in Scotland.

All other partners involved in the delivery of gender identity healthcare are encouraged to adopt the standards as good practice. The standards cover and are relevant to:

Standard	Relevant to
Person-centred care and shared decision making	All staff and services.
Reducing inequalities	All staff and services.
Collaborative leadership and governance	Organisations or services with responsibility for gender identity healthcare service delivery.
Staff training, education and support	All staff and services.
Access to gender identity healthcare	Staff who refer from primary care to gender identity healthcare services. Gender identity clinics or related specialist gender identity services.
Assessment and care planning	Gender identity clinics or related specialist gender identity services.
Referral to gender identity services	Staff who refer from primary care to gender identity healthcare services. Gender identity clinics or related specialist gender identity services.
Specialist gender identity healthcare	Staff with specialist skills and competencies. Primary care including pharmacy. Gender identity clinics or related specialist gender identity services.
Mental health and wellbeing	Staff who refer from primary care to gender identity healthcare services. Gender identity clinics or related specialist gender identity services.
Gender identity services for young people	Staff and organisations delivering gender identity services for young people.

Policy context

The Scottish Government has committed to improving access to, and delivery of, gender identity services in Scotland. This commitment is set out in the NHS gender identity services: strategic action framework 2022-2024. As part of this work, Healthcare Improvement Scotland was commissioned to develop national standards for adult and young people’s gender identity healthcare.

The standards support national work³ including:

national waiting times data collection, monitoring and reporting for gender identity services by Public Health Scotland
the NHS Education for Scotland transgender care knowledge and skills framework
the NHSScotland gender identity healthcare protocol
national planning for young people’s services.

The Scottish Government published the Cass Review Implications for Scotland report in July 2024. The report includes recommendations for NHSScotland. These standards should be considered alongside those recommendations.

Related guidance

The standards are based on current evidence and best practice and considered to be a requisite of high-quality care in all settings. They have been mapped to key policies and legislation to ensure there is alignment in language, scope and principles of safe, effective and person-centred care. These references are not an exhaustive list. Organisations, services and staff should continue to refer to all appropriate and applicable professional and regulatory guidance, policy and best practice relevant to the respective healthcare setting.

The standards should be read alongside:

Format of the standards

Healthcare Improvement Scotland standards follow a defined format. Each standard includes:

an overarching standard statement
a rationale explaining why the standard is important
a list of criteria describing what is needed to meet the standard
what the standards mean if you are a person accessing care and support
what the standards mean if you are a member of staff
what the standards mean for organisations
examples of what meeting the standard looks like in practice

The standards have been co-created with staff, key stakeholders and people with lived experience. More information about the development of the standards is set out in the sections Development of the standards and The standards development group and editorial panel.

Implementation

Healthcare Improvement Scotland has published these standards to inform self-evaluation. Services may use these standards to plan and measure improvement. These standards complement existing Healthcare Improvement Scotland quality assurance programmes.

It is anticipated that organisations work towards implementing these standards to assure themselves, and relevant clinical and care governance structures, that they are delivering safe, effective and person-centred services. Healthcare Improvement Scotland may use these standards in a range of quality assurance and inspection activities. They may be used to review the quality and registration, where appropriate, of health and social care services.

The Healthcare Improvement Scotland Quality Management System Framework supports health and social care organisations to apply a consistent and coordinated approach to the management of the quality of health and care services.

As services embed change and evaluate learning, these standards may be revised to ensure they continue to reflect current evidence, policy and best practice. The standards will be reviewed to ensure that they remain fit for purpose, effective, person-centred and reflect Scottish Government policy and legislation. Any review should consider the evidence base, learning and intelligence, including the experiences of people who use services.

Terminology

Wherever possible, we have incorporated generic terminology, which can be applied across all gender identity healthcare services and providers. See the glossary.