Gender identity (Guidelines)

The 2012 National Gender Reassignment Protocol (GRP) was updated in 2024. The new document in relation to gender identity healthcare is called the Gender Identity Healthcare Protocol for Scotland.

The protocol should be used by health boards to inform local standard operating procedures for how gender identity healthcare is accessed and provided. If a health board does not offer a gender identity clinic the protocol confirms that it still has a responsibility to its patients to ensure respective roles, responsibilities and referral and discharge routes are clear and formalised. It is acknowledged that many health boards that do not offer a gender identity clinic, but refer to a gender identity clinic in another health board, already have formalised agreements in place in the form of service level agreements.

In NHS Highland patients over 18 years of age seeking gender identity healthcare can be referred to the Highland Gender Identity Clinic (within Highland Sexual Health) based at The Royal Northern Infirmary in Inverness. The referral process is outlined in the next section.

People under 18 years of age can be referred to the Young Person’s Service at the Sandyford Clinic in NHS GGC. The service will only accept referrals from a clinician. Patients will no longer self-refer to the service.

Following the Chief Medical Officer establishing a multidisciplinary clinical team to consider, in the context of Scottish services, the recommendations of the NHS England commissioned Cass Review on gender identity services for young people; Public Health Minister Jenni Minto confirmed that the Scottish Government has accepted all the findings of the Cass Review: Implications for Scotland report, published in July, and that work is underway to implement its recommendations.

These recommendations include:

• Gender identity healthcare services for children and young people being provided in paediatric clinical settings.
• The provision of these services via a distributed network, or regional model, rather than on one site.
• An end to self-referral, with young people being referred to specialist services by a clinician, in common with other specialities.

In a statement to the Scottish Parliament, Ms Minto outlined work that is underway to implement the recommendations, including the publication of new National Standards for Gender identity healthcare: Adults and young people by Healthcare Improvement Scotland.

It is currently unclear what provision, if any, will be available in NHS Highland for gender questioning and gender diverse young people. This guidance will be updated if any changes in provision are made.

The Gender Identity Clinic (within Highland Sexual Health) is based at The Royal Northern Infirmary in Inverness and sees any adult patient with gender incongruence.

• Patients 18 and over: refer via SCI Gateway to the Gender Identity Clinic.
• Patients under 18: Please make referral to the Young Person’s Service at the Sandyford Clinic in NHS GGC

Patient is assessed at the Gender Identity Clinic.

1. Gender Identity Clinic makes internal referral for psychological assessment including diagnosis of gender incongruence and readiness assessment for various gender affirming treatments.
2. Gender Identity Clinic coordinates access to gender affirming treatments which may include non-medical treatments (e.g. facial hair removal, speech and language therapy) and medical treatments (e.g. feminising and masculinising gender affirming hormone treatment, fertility preservation, non-genital surgeries and gender reassignment surgeries), some of which are available within NHS Highland and others provided externally.
3. Gender Identity Clinic does not provide treatment for comorbid mental health conditions which should be managed as per usual procedures, i.e. through primary care or secondary care mental health services.
4. Gender Identity Clinic liaises with primary care for ongoing management of the patient.

For further information on the provision of feminising and masculinising gender affirming hormone treatment for transgender, non binary and gender diverse (TGD) people see: Endocrine and Fertility Preservation Guidance (see resources). 

This may be useful for those situations where primary care prescribers are asked to continue the management of patients who have sought treatment in the private sector. The decision whether to continue management of these patients is the responsibility of the prescribing clinician but further advice can be sought by contacting the Gender Identity Clinic directly. If appropriate, these patients can be referred to the Gender Identity Clinic as per standard process. 

Timings for blood tests are also detailed in the Endocrine and Fertility Preservation Guidance.