The State of Scottish Gender Identity Clinics

At last, it is official: trans healthcare in Scotland is fundamentally broken. Research commissioned by the Scottish Government to evaluate the impact of its short-term injection of funds to try to stabilise the system was recently published (full version). It is a thorough piece of work, and essential reading for anyone who wants to understand the current situation and how we arrived here. It is not all bad news: two of the GICs, Lothian (Chalmers) and Highland, are in relatively good shape, with the arrival of clear leadership and some imagination in delivery. Greater Glasgow and Clyde (Sandyford) and Grampian are, frankly, a mess, for different reasons. Sandyford is overwhelmed, chaotic and lacks leadership, while Grampian has struggled to have a service at all during the review period. But both the (relatively) positive progress and the more predictable horror stories in fact show the precarity and unsustainability of the current system and the scale of the threat to trans lives.

Some Context

Let's start by reviewing why we are here. The Bute House Agreement between the Scottish Government and the Scottish Greens included a number of provisions relating to trans people, in particular Gender Recognition Reform (blocked by the Tories and Labour at Westminster), banning of conversion practices (dropped by the SNP) and attempts to improve trans healthcare by i) stabilising the system and addressing the horrific waiting lists of (now) up to five years or more for a first, triaging appointment, ii) a review of the system (including, for once, the, the actual lived experience of trans people themselves) with a view to long-term stability. It is the first of these that is evaluated in the report.

The report reviews the history of the four GICs in question, and one of the very striking things is just how random trans healthcare has been in Scotland to this point. The word ‘organic’ is frequently used by the authors to refer to the respective developments, but ‘unplanned’ is what they mean. So Sandyford is the largest provider and is still responsible for (or at least taking referrals from) a ridiculously large swathe of Scotland, and previously provided significant support for the other partial services. As far as I can see, Highland only managed to provide a full service as a result of the additional funding, and thus took some load from Sandyford; Lothians' imaginative refresh likewise seems to have confirmed its full independence, but the vulnerability of the service is made manifest by its pause in surgical referrals in the recent past (without, as the report tells us, informing patients, naturally). Grampian, like Highland, has been very fragile and reliant on a very limited set of staff; it has taken longer for it to sort itself out, and there have been a number of hiatuses.

One of the other ways in which Sandyford is unusual is for having a clinic for young people, as a result of which it has become a target for transphobes' propaganda and their friends in the media. I am only going to talk about adult healthcare here, since effective care for young people is finished as long as Labour continue the Tories' ban on puberty blockers. This will, however, no doubt add more strain to the adult services when young people try to access the care they have been denied and join the adult waiting lists. That said, one point did emerge very clearly about the Scottish Government's response to the internationally-discredited Cass report. At the time that Sandyford put an indefinite moratorium on prescribing puberty blockers, there was a very public case of passing-the-buck, where the Scottish Government, Greater Glasgow and Clyde and Sandyford all blamed each other. It is quite clear from this report that the initiative for this decision came from the Scottish Government and, of course, service users were excluded from those discussions.

Opening the Closed Shop

Trans healthcare in the UK has been bedevilled by a series of contradictions, between the all-powerful consultant (most Scottish GICs started as personal projects) and the multi-disciplinary team, between specialists and generalists, and between clinicians and patients. For example, as long as I have been involved with Sandyford, it has emphasised in its publicity that it is a multi-disciplinary team, but in reality it is substantially dominated by psychiatrist and psychologists, as the report makes clear. Sandyford's bid for additional monies was aimed at recruiting more of these, which it notably failed to do. It also added some admin (without much obvious improvement on the patient experience) and a clinical pharmacist, a post which seems to be the one nod towards offloading routine care from the usual suspects. By contrast, both Highland and Lothian have clearly shown more imagination in recruiting nurse practitioners and those with a background in general practice.

The tension between specialist and generalist, and between different types of clinical and non-clinical staff is, to my mind, one of the long-running themes of the report. The way that healthcare and legal protocols have evolved in the UK mean that some specialisms are unavoidable as things stand, but the day-to-day (or, more likely, year to year) monitoring of patients hardly needs their input, and it is good to see some GICs finally recognising that. Nonetheless, for all that there is mention of patient-centred care, it is striking how far this report quotes practitioners reflecting on their own processes, systems and status, not the needs and experiences of the actual patients.

The truth is that the GIC process remains, for the patients, a test of endurance, not an exploration of our needs in a supportive and relaxed environment. Clearly, some practitioners are pining for the good old days of the Real Life Test, and I was reading one comment about patients being several years into their social transition when they finally arrive at a first appointment as more about being unable to use that lever. Maybe I am being unfair. There are noises from all GICs about engaging with third-sector organisations, but mainly as a way of keeping folk quiet on the waiting lists. This is not to decry third-sector involvement; I think the single most supportive thing Sandyford ever did for me was an experimental use of a third-sector programme for (normally cis) women of a certain age in somewhat chaotic circumstances. This is in large part what convinced me I could do this again. This experiment was, notably, an initiative of the part-time occupational therapist, not the medics.

If certain specialisms remain a legal requirement, but most care hardly requires their input, and can be delivered by, e.g., nurses and pharmacists, the question remains why have Gender Identity Clinics at all. Lothians, notably, has entered into shared-care arrangements with GPs, relating to the taking of bloods and adjusting hormone levels, with GICs as a backstop. This seems incredibly sensible, and hardly radical, but it remains controversial, and it is worth exploring why this should be so.

As the report makes clear, different GICs have different relationships with GPs. My anecdotal experience is that even within the same health board there can be remarkable variety. In my case, Sandyford tells my surgery what to prescribe, and latterly we have moved from having blood pulled at Sandyford to having it done or arranged by my GP practice. This does mean that the bloods are reasonably fresh when I see a Sandyford practitioner, rather than (as previously) up to a year out of date (which is really problematic when they changed my prescription at that same meeting, meaning that there could be two years between changes of prescription). Unfortunately, every time I ask my GP to take some blood, there is a song-and-dance about it; a formal agreement would be a considerable improvement on having to argue the toss every time. This is not because the GP practice is hostile, but communication between GIC and GP is erratic, and there is very little willingness to listen to patients trying to explain the situation.

The funny thing is that GPs, in my experience, don't want to get involved, but, when they do, their professional competence takes over. Hence, my GP practice couldn't remember why they had pulled my bloods, but scrutinised the results and noted that my oestrogen levels were too low (which they were); in a sane world, they would have adjusted the prescription, but I had to wait for the best part of a year for Sandyford to remember I existed and see me again. It's hardly wrap-around care. Gender care is not that hard: there are guidelines for the correct hormone levels, as the GP was well aware, while remaining in glorious ignorance of my actual circumstances. Of course, the idea that we have a single GP is as ridiculous as having a single GIC clinician.

In these sorts of circumstances, a formal shared-care arrangement would make so much sense, but GPs do not want to do it. Reasons adduced in the report include claims of ignorance about gender care, and, above all workload. I am not sure, myself, that a shared-care arrangement would involve me seeing the GP any more than I do now, and indeed it is usually the practice nurse or the local phlebotomists who are doing the actual work. I don't want to minimise the fact that some GPs are transphobic, and we have seen, especially in England, patients being denied care by their GPs. Nonetheless, an explicit policy and clarity of roles is sorely needed, and would remove a lot of the obstructionism, except in the case od diehards.

Let us go further. Two of the things noted in the report were lack of clearly articulated national expectations, not for GPs, but for the GICs themselves, and a programme of education for NHS practitioners. Both are either in place or being developed. I would, however, myself feel that if the education and expectations are clear, then there is no reason why GPs cannot manage the process of gender affirmation as much as a specialist GIC. For one thing that came through from the report very clearly is that the professed expertise of GICs was nothing of the kind. Over and over again, there were accounts of staff training themselves, reading up on the literature, maybe shadowing a colleague, but no real background in gender medicine, and even distinct anxiety about any kind of professional pathway or structured career development. I can attest that a number of the practitioners I have encountered have been quite up-front about their frankly amateur status. In this context, a GP-led system would make a lot more sense than a dysfunctional GIC system.

The Older Woman Problem

One thing that was quite upsetting was some frankly lame excuses for not involving GPs more. One line that was quoted twice (although I think it was differently attributed in each case) was that trans patients (like me) are unreasonable in suggesting that if a GP can prescribe contraceptive medicine to cis women, there is no reason why they cannot prescribe HRT for trans women. The stated anxiety was that the doeses are higher (true, but since everyone is aware of that, the problem is what, exactly?) and the patients can be older. In what sounded suspiciously like a retread of Cass's spurious arguments, it was claimed by this voice that we don't know the effect of long-term hormone use. Now, this is both false (trans women have been prescribed oestrogen since at least the late 1940s) and it is also a complete non sequitur for the issue of GP-led rather than GIC-led monitoring. In any case, as an older woman myself, the GIC flatly refused to prescribe pills: my oestrogen is supplied by patches and it doesn't go anywhere near my liver (if that is the concern). This might be clearly written into any guidelines, if desired. I would also point to HRT for older women, which is apparently unproblematically located with the GP. It is a bogus argument.

Following the Money

Such a radical step of relocating responsibility from GICs to GPs is perhaps optimistic in the short term, and of course the report does not go that far in its best-practice recommendations. Instead, the sunlit uplands might perhaps be found in its suggestions of genuine multi-disciplinary teams, genuine patient-centred approaches, genuine wrap-around care and genuine involvement of GPs on a consistent basis. If Lothians can do it, or at least make a start in that direction, it might be rolled out across the country. It would certainly be an unimaginable improvement. Sad to say, it is unlikely to happen any more than a GP-led model, and for the same reasons: money and political will.

The only reason we have two currently-functional GICs is because of the temporary uplift in Scottish Government funding. It is short-term, released year by year and does not constitute core funding. Of the original £9 million earmarked, the GICs did not succeed in bidding for all of it, while in the case of Grampian, their failure to use what they did bid for meant that it was used to address the Board's general deficit, not for trans healthcare at all. Still, the Scottish Government has extended the programme for another three years, and so it is to be hoped that those who have been able to use that money creatively can continue to do so. But what then? A lot will depend on what happens in next year's Scottish Parliament elections. It is hard to imagine that any of the transphobic parties would lift a finger to save Scotland's GICs. It need not be a case of banning trans healthcare, as so many of us fear, but simply of not renewing this exceptional funding and watching the GICs collapse.

Some of this might be addressed by making the gender healthcare mission core to the NHS, and being clear about who is funding what, and the expectations in terms of outcomes (e.g. bringing trans waiting lists within NHS norms). The need for core funding is a repeated refrain in the report. More than that, there is a pressing need to take the load off Sandyford. It is neither in the interests of staff nor of patients to have gender services provided by a clearly overwhelmed and, in many cases, geographically distant service. This means that other health boards have to step up and provide their own services, or at least to localise more services within their own geographical limits (perhaps, indeed, with GPs?). My reading of the report is that just as Sandyford seemed reluctant to move away from a traditional model, it was ambivalent about letting go of patients. This may be unfair; a more reasonable concern, perhaps, is that persuading other health boards to set up meaningful services spontaneously is unlikely to happen. One can but agree.

Moving to a consistent regional model (as cough recommended by Cass for young people, albeit without, you know, actual services) makes sense, but has both financial and political implications. Local boards will need to be directed, and there will need to be a national plan. Implementing shared-care arrangements with GPs consistently across the country has financial and political implications. Workload anxieties will either need to be allayed or sweetened. It requires a steer not just from NHS Scotland, but from the Scottish Government, to make guarantees about trans healthcare and to spend money long-term on it. That in itself is going to have the transphobes gunning for the Scottish Government once again; I doubt very much that the SNP has the stomach for it, at least not in this parliament. The departure of Kate Forbes may mean that the SNP is more receptive in the future to the human rights of trans people. To be partisan, the only way this is going to happen is if the Scottish Greens are in a position of strength in the next parliament—and if the members feel they can or should trust the SNP again, which remains to be seen.

A Sustainable and Humane Future

The fact remains that the current system of Gender Identity Clinics is haphazard, expensive and (on current levels of funding) unworkable. Even when it functions as intended, or at least as it did when demand was less, it never offered a service that users wanted nor had their interests at heart. I have had the dubious pleasure of experiencing both Charing Cross in the 1990s (awful, but it did, at least, stick to its timetable) and Sandyford from the mid 2010s when it was less swamped, until now (sclerotic and chaotic). None of this is what we, as trans people, want and need. If we are going to make this hard distinction between young people's care and adult healthcare, then is it not time that we started treating adults like adults? The problem for policymakers and clinicians alike is that being trans is no longer considered a disorder, but rather as something which can be addressed by clearly defined procedures. Providing or referring for those treatments should be part of the repertoire of general practice. It is cheaper, more efficient and, above all, it is what trans people want.