How can the NHS deliver safe and effective gender identity healthcare for young people when it is hindered by "major shortfalls" in children's mental healthcare and "fearfulness" among healthcare practitioners?

'Toxicity'

Speaking to MSPs on Tuesday, Dr Cass said that most NHS staff faced with a young patient expressing gender dysphoria have tended to "bypass" them with a referral straight to the Gender Identity Development Service instead.

Health professionals "feel nervous because they don't feel they have the skills, they're worried about the toxicity of the debate, they're worried about saying or doing the wrong thing", said Dr Cass.

This echoed some of the findings of the Cass Review, which noted that this approach "has had the unintended consequence of de-skilling the rest of the workforce and generating unmanageably long waiting lists".

While the Cass Review was specifically concerned with practices in England, Scotland's own huge waiting lists for children and young people at the Sandyford clinic (more than 1000 on the waiting list and average waits of four years to first appointment) speak to a similar reluctance among clinicians here to support these patients via Child and Adolescent Mental Health Services (CAMHS) or other paediatric services.

Why?

The review described the toxicity of the debate as "exceptional", saying there were "few other areas of healthcare where professionals are so afraid to openly discuss their views".

Some staff outwith gender services said they were fearful to accept referrals in case they found themselves accused of potentially illegal "conversion practices".

It doesn’t help that CAMHS waiting lists are also over-burdened.

Meanwhile, there is discord between medics: "Some feel strongly that a majority of those presenting to gender services will go on to have a long-term trans identity and should be supported to access a medical pathway at an early stage. Others feel that we are medicalising children and young people whose multiple other difficulties are manifesting through gender confusion and gender-related distress."

This "emotive and politicised" atmosphere – coupled with "the weakness of the evidence base and a lack of professional guidance" – has made it much harder for new services to recruit, exacerbating waiting lists.

GPs

What happens when NHS waiting lists spiral? The private sector steps in.

The Cass Review noted that young people on lengthy NHS GIDS waiting lists for assessment had resorted to buying medicines, either through independent healthcare providers or by "obtaining unregulated and potentially dangerous hormone supplies over the internet".

Campaigners have warned that one of the consequences of pausing puberty blockers and other medical interventions is that even more young patients in distress will feel forced down this path.

This is likely to be felt by GPs.

According to the Cass Review, the existing situation has already resulted in GPs "being pressurised to prescribe hormones after these have been initiated by private providers", noting that "there is a lack of clarity around their responsibilities in relation to monitoring" but that "no clinician should prescribe outside their competence, nor should GPs be expected to enter into a shared care arrangement with a private provider, particularly if that private provider is acting outside NHS guidance".

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Holistic care

The remedy set out in the Cass Review are regional hubs with a "broad multi-professional workforce" to end the situation where gender incongruence is treated in silo and potential confounding factors (trauma, mental health, undiagnosed autism, repressed sexuality etc) are excluded from the equation.

Young people should be "treated holistically and not solely on the basis of their gender presentation", with access to "psychiatrists, paediatricians, psychologists, psychotherapists, clinical nurse specialists, social workers, specialists in autism and other neurodiverse presentations, speech and language therapists, occupational health specialists and, for the subgroup for whom medical treatment may be considered appropriate, endocrinologists and fertility specialists".

It remains to be seen whether the Scottish Government will adopt such a model north of the border and – more problematically – how easy it will be to staff it.