Gender Identity Services for Children and Young People (Cass Review)

– in the Scottish Parliament am 6:23 pm ar 8 Mai 2024.

Danfonwch hysbysiad imi am ddadleuon fel hyn

Photo of Annabelle Ewing Annabelle Ewing Scottish National Party 6:23, 8 Mai 2024

The next item of business is a debate on motion S6M-13090, in the name of Meghan Gallacher, on implementing the Cass review in Scotland.

Photo of Meghan Gallacher Meghan Gallacher Ceidwadwyr 3:15, 8 Mai 2024

Yesterday, I attended the Health, Social Care and Sport Committee’s meeting to hear directly from Dr Hilary Cass following her review of gender care services for children and young people. I had hoped to ask a question but, despite emailing the committee on Friday, I was told that time had run out. Unfortunately, that was just the latest in a series of questions that I have raised on the topic that have been rejected or denied. The fact of the matter is that children, young people, parents and campaign groups deserve answers, which is why my party has brought a debate on the issue to the Parliament.

Talking about gender in Scotland has become toxic, but we need to be clear that the Cass review is not about ideology. It is a scientific evidence-based review of the medical care that we have been giving to vulnerable young children. It is a monumental and fearless piece of work. I say “fearless” because, even amid the toxicity of the gender debate, the crucial report did not shy away from its difficult findings—namely, that we have been letting down a generation of vulnerable and distressed children.

One would think that the publication of a damning report on the medical care of children would jump straight to the top of any Government’s in-tray and that politicians of all stripes would be united in wanting to ensure that mistakes and poor practices were stopped immediately and that the required improvements were put in place. However, the response from the Scottish National Party Government could not have been more lacklustre.

From the moment that the Cass review was commissioned four years ago, the SNP Government sought to dismiss it as being irrelevant to Scotland, even though the medical approaches that were being reviewed were almost identical to those that were being used here. The Government disregarded the interim report, which cast doubt on the safety of puberty blockers for children, and, when the final report was published last month, it dithered, delayed and obfuscated until clinicians took the decision out of its hands by announcing that NHS Scotland would pause the use of puberty blockers for under-18s.

Although the use of puberty blockers is undoubtedly one of the key aspects of the Cass review, the nearly 400-page document makes a total of 32 recommendations to improve gender care for young people in Scotland. The recommendations include offering children fertility counselling before they proceed down a medical pathway; assigning a child a medical practitioner to take charge of their care and ensure that they get the personalised help that they need; support for parents, carers or siblings if needed; and a requirement to keep a national data set on gender services in order to continually update best practices.

The SNP has continued to be deafeningly silent on those and a host of other reasonable, commonsense recommendations. I made a promise to families who have been failed by gender care services in Scotland, and I intend to keep raising the issue until the Scottish Government implements all 32 recommendations of the Cass review without delay.

The Cass report should fundamentally change how we look at gender care in Scotland. It should be approached with caution and care, and it should be given holistically, viewing a child as a rounded individual and tailoring the approach to their unique needs. Yes, the report concludes that there is little evidence to support use of puberty-suppressing hormones, but it also details that children and young people might not be offered the right psychological support and assessments when experiencing gender distress. Medical intervention is not always required, but that has been common practice for many individuals. Meanwhile, children’s mental health has been left to deteriorate.

Although the Sandyford clinic has finally paused its use of puberty blockers and cross-sex hormones for those who are under the age of 18, gender care services need a complete overhaul. The Scottish Government needs to make that a priority because, as things stand, the waiting times for children and young people to see a clinician at a gender clinic can be over four years. Child and adolescent mental health services waiting times are through the roof, and the SNP has remodelled the funding of gender care services, which has resulted in a cut to the budget of those services.

I say to members, regardless of their opinion on the Cass review or on gender care services, that the Scottish Government is failing young people.

Photo of Rachael Hamilton Rachael Hamilton Ceidwadwyr

Does Meghan Gallacher believe that there is no excuse for the SNP not to implement the recommendations of the Cass review now that it has broken up its tragic coalition with the Greens?

Photo of Meghan Gallacher Meghan Gallacher Ceidwadwyr

Absolutely. This is an opportunity to reset, refocus and actually prioritise young people who need the Government’s support.

The Cass review is a four-year-long, near-400-page report on the care that we give to some of our country’s most vulnerable children. The fact that we have been failing them for so long is bad enough, and we should all reflect on that. However, to ignore the scientific evidence-based report for the sake of dogma and ideology would be unforgivable. This is about the health, safety and wellbeing of our young people. There are no other national health service services that we would allow to continue unchanged after such a report had been brought forward and had shown that they were failing, and this service should be no different.

Next week, I will hold an event in Parliament with Marion Scott from the Sunday Post . That will be an opportunity for MSPs, ministers and cabinet secretaries to speak with families who are affected by gender care and to hear how they have been failed by the processes that are in place in Scotland. I urge all MSPs, regardless of their persuasion or political party, to speak to the families who have bravely stepped forward to tell their stories.

It is clear that we need to implement all 32 recommendations of the Cass review, as our motion says. That is simple, but it will show that we in this Parliament care about young people who are experiencing gender distress. The message that I have for MSPs is that, if they do not back our motion today to implement the full recommendations of the Cass review, they will need to explain to the families why they have not done so, because those families are the ones who have been impacted by the Scottish Government’s lack of decision making and action.

Photo of Annabelle Ewing Annabelle Ewing Scottish National Party

Ms Gallacher, I ask you to move the motion, please.

Photo of Meghan Gallacher Meghan Gallacher Ceidwadwyr

I move,

That the Parliament welcomes the report submitted by Dr Hilary Cass on gender identity services for children and young people; recognises the report as a valid scientific document, and calls on the Scottish Government to implement the recommendations of the report that are applicable to NHS services in Scotland.

Photo of Jenni Minto Jenni Minto Scottish National Party 3:22, 8 Mai 2024

Just over two weeks ago, I stood in the chamber to emphasise what is undeniably a fact: that young people who are questioning their gender or accessing gender identity healthcare, and their families and those who love them, must be at the centre of all our discussions about the delivery of that care. I hope that we will all keep them in our hearts and minds during the rest of the debate and, in doing so, remain compassionate, understanding and respectful.

As I said in my statement,

“it is vitally important that the recommendations”

in the Cass review’s final report, which was published in April,

“are carefully considered”.—[Official Report, 23 April 2024; c 14.]

The Scottish Government has consistently welcomed the report’s publication. The review itself was chaired by a past president of the United Kingdom’s Royal College of Paediatrics and Child Health—a senior and well-respected clinician. Many of us will have heard her helpful and clear evidence at the Health, Social Care and Sport Committee meeting yesterday, and I recognise the Cass review’s final report as a scientific, evidence-based document.

When Dr Cass was asked yesterday for her key conclusions from the review, she said two things: first, that the evidence base in this specialist field of medicine is weak, and we need to work as collaboratively and broadly as we can to improve that evidence base, and secondly, that children and young people need a broad multidisciplinary approach to their care. I think that all of us in the chamber would agree with those two points.

The Scottish Government has already provided grant funding to the University of Glasgow to carry out research into the long-term health outcomes of people who access gender identity healthcare. That will play a part in improving the evidence base. Person-centred and holistic multidisciplinary care has been at the heart of our chief medical officer’s realistic medicine approach for many years, and our clinicians know how important it is to see the whole person whom they care for.

The final report is detailed and wide ranging. It is important that its recommendations are carefully considered in the context of how services are delivered in NHS Scotland, and to consider what further steps may need to be taken.

Photo of Jenni Minto Jenni Minto Scottish National Party

I am going to make progress.

As I made clear in my statement, a senior multidisciplinary clinical team within the chief medical officer’s directorate in the Scottish Government, which includes paediatric, pharmacy and scientific expertise, is carrying out that careful consideration. As Parliament would expect, that work is already under way. The chief medical officer will provide a written update to Parliament on the outcome of that clinical consideration process before the summer recess.

I will take Rachael Hamilton’s intervention now.

Photo of Rachael Hamilton Rachael Hamilton Ceidwadwyr

Thank you, minister.

In her statement, the minister said that discussions between clinical stakeholders on what further involvement may be appropriate were on-going, and that the chief scientist office was involved. How long will that take? Can the minister put a timeline on those discussions, please?

Photo of Jenni Minto Jenni Minto Scottish National Party

The chief medical officer will provide a written update to Parliament on the outcome of that clinical consideration process before the summer recess. I am sure that colleagues across the chamber will welcome that assessment and will understand, just as NHS England has stated, that, given the comprehensiveness of the report, that will take some time.

Photo of Ash Denham Ash Denham Scottish National Party

The minister has just set out that the CMO will seek to provide a written statement to the Parliament on the progress that is being made, but I ask the Government to consider that it might be advisable for the CMO to appear in Parliament to aid that scrutiny.

Photo of Jenni Minto Jenni Minto Scottish National Party

Currently, the CMO is going to provide a written statement, and that is the way that I think the update should be delivered to Parliament.

I know that colleagues across the chamber would not want a knee-jerk reaction to a 400-page report that did not properly consider how services in Scotland are delivered or what work on training or on standards is already under way.

Photo of Jenni Minto Jenni Minto Scottish National Party

I need to make progress.

As part of our work, the Scottish Government is clear that there needs to be transparency. We therefore agree that the CMO will write to the Parliament, as I have said, reporting in full all of the clinical findings of the senior multidisciplinary clinical team, and to prepare a progress report on the existing strategy for reducing long waits for children and young people to access specialist gender services. On that basis, and to find consensus, we will accept the Labour Party’s amendment.

I hope that all of us can agree that that consensus will be helpful for the young people involved, their families, clinicians and health professionals who deliver gender identity healthcare.

It did not take the publication of the report for the Scottish Government to start a broad programme of work to improve gender identity healthcare. It is important to note that, in Scotland, we are already making progress on several of the aspects of gender identity healthcare that are highlighted in the Cass review.

Dr Cass reminded us in her report that

“A compassionate and kind society remembers that there are real children, young people, families, carers and clinicians behind the headlines.”

I hope that that sentiment is one that we can all keep in mind in today’s debate and as we progress.

I move amendment S6M-13090.4, to leave out from “implement” to end and insert:

“thoroughly examine the recommendations of the NHS England commissioned report, and its applicability to NHS Scotland services, and to update the Parliament on the outcome before the summer recess.”

Photo of Jackie Baillie Jackie Baillie Llafur 3:28, 8 Mai 2024

The Cass review is a considered, evidence-based report that was drawn up by experts. It was led by Dr Hilary Cass, former president of the Royal College of Paediatrics and Child Health, and it involved clinicians and young people themselves. We must not ignore Dr Cass’s conclusions, no matter how difficult they may be, as failure to implement all those that apply to the NHS in Scotland would let down both staff and a generation of young people and their families.

Let me turn first to the Scottish Government’s response. The pretence that the Government knew nothing about the review and needed lots of time to consider the report does not hold water, frankly. Meetings took place with Dr Cass, senior clinicians and the Scottish Government well before publication of the final report. Just to be clear, the deputy chief medical officer was there, along with a host of senior Government officials. Let us not forget that there was also an interim report, which set out the direction of travel quite clearly.

The lack of leadership from the SNP Government has been woeful. The unseemly backwards and forwards between the Scottish Government and health boards about who would make the announcement about the pause in puberty blockers was, I thought, quite disgraceful. Instead of taking ownership, the minister chose to leave the burden to the same clinicians who have expressed concerns about the toxicity of the conversation on gender services that is leaving them vulnerable and exposed. It is no wonder that NHS Greater Glasgow and Clyde has struggled to recruit consultants at the Sandyford clinic. Staff at the Sandyford clinic do an incredible job, but they are not adequately supported to do so.

The Scottish Government published the NHS gender identity services strategic action framework in 2021, and we welcomed it. The national gender identity healthcare reference group was set up in March 2022 to oversee implementation of the framework, and I note that the deputy chief medical officer co-chairs the group. The reference group’s latest minutes report that the negative impact of the on-going polarised public discussion has taken a toll on the recruitment of staff in gender services. Dr Cass echoed those concerns in her report, stating that there are

“few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.”

The Government must take leadership in that area.

However, the framework also impacts on recruitment and it has a knock-on effect on waiting lists. I remember that, when the framework was published, waiting lists were sitting at about four years. They are now sitting at about four and a half years for young people and five and a half years for adults. That is unthinkable. Why is the minister bypassing the already established national gender identity healthcare reference group? Why is the new group being set up when there is one with all that expertise sitting round the table? How is it intended to link the two, or will they exist in splendid isolation from each another?

I understand that National Services Scotland is in the middle of commissioning gender services. Will that include the use of puberty blockers and hormone treatments? If so, from what age? Those are critical questions.

Let me deal briefly with the Labour amendment.

Photo of Jackie Baillie Jackie Baillie Llafur

I am about to close.

We have asked for openness and transparency, with the new working group publishing papers and minutes. I understand that the Government will partially agree to that, which is welcome. After all, it is a Government-established working group and the matter is of such importance that we cannot have secrecy at the heart of Government.

We are also asking for a report on the progress of the framework and the difference that is being made to gender identity services. We believe that that is urgently required. We cannot allow waiting times to spiral out of control, so we need to seriously address recruitment. That requires leadership from the very top.

I recognise that I need to close. What we are doing here is critical for the young people who are experiencing gender dysphoria. It is too important for us to get it wrong.

I move amendment S6M-13090.2, to insert at end:

“, and further calls on the Scottish Government to publish all papers relating to the multi-disciplinary clinical team work in assessing Dr Cass’s recommendations, and to urgently prepare a progress report on the existing strategy for reducing long waits for children and young people to access specialist gender services.”

Photo of Gillian Mackay Gillian Mackay Green 3:32, 8 Mai 2024

It is undeniable that homophobia and transphobia are on the rise, and that is absolutely true when it comes to the weaponisation of the Cass review. The debate today is premature at best. It is absolutely right that the Government takes its time to assess the implications of the report, if there are any, for the Scottish NHS. [ Interruption .]

Photo of Annabelle Ewing Annabelle Ewing Scottish National Party

Members, please show some courtesy and respect to the speaker who has the floor.

Photo of Gillian Mackay Gillian Mackay Green

We have to be aware that the Cass review was a review of services and treatment pathways in NHS England that differ from those in Scotland. As many members have said in the chamber previously, not all the recommendations will be applicable to Scotland and some might be irrelevant, given that the analysis was of a different health service. That is why I believe that the debate is premature at best. For those recommendations that might be relevant, there are choices to be made about whether they require action. Any changes that are made should also include input from trans young people who have been through the service, those who are on waiting lists and their families.

Many have hailed the report as the end of gender-affirming care, but Dr Cass confirmed at the Health, Social Care and Sport Committee yesterday that puberty blockers and hormones are the correct way forward for some children and young people who are seeking gender identity care. It is important that, in providing gender-affirming care, we are clear that medical transition might not be the correct course of action for everyone and that timeframes for transition differ between people. We absolutely have to ensure that services are improved, both in terms of the pathways and the current models of care, and by tackling long waits.

Photo of Paul Sweeney Paul Sweeney Llafur

Does the member agree that a key risk that was raised at this week’s meeting of the Health, Social Care and Sport Committee was the fact that the long waits—the average wait is four and a half years—lead to a lot of young people self-medicating, which itself introduces a lot of risks for young people?

Photo of Gillian Mackay Gillian Mackay Green

Yes—absolutely. The other thing that was highlighted at committee was the on-going distress and mental health issues for those young people who experience long waits.

From listening to the debate so far, many could believe that people’s experience of gender identity services is overwhelmingly negative. For some, their most negative experience is to do with waiting times and not getting the care that they should receive. Although many have said that receiving the gender-affirming care that they needed was life saving and that it brought joy and allowed them to be their true selves, that does not mean that services do not need to be improved.

In addition to waiting times, clinicians’ confidence in providing care is a very current and live issue. In the briefing that Scottish Trans provided ahead of the debate, it notes that, at the moment, far too few healthcare practitioners feel confident about supporting children and young people who are exploring or feeling distressed about their gender identity. Scottish Trans frequently hears from young people who seek support for non-gender-related distress such as depression or anxiety, who are referred on to specialist gender identity services if they also disclose that they are feeling uncertain about their gender identity or that they are trans. That means that they are put on extremely long waiting lists, sometimes for years, and they receive no support in the meantime, which is totally unacceptable. It is vital that, in general, children and young people’s mental health services and wider health services are able to provide support to all young people who fall within their area of expertise. That clearly highlights the need for more training.

One of the commitments in the Scottish strategic action framework for the improvement of gender identity services is the development of a transgender care knowledge and skills framework, which could result in the upskilling of healthcare practitioners across the NHS on the provision of care for trans people. I would be grateful if the minister could provide an update on work on that when she sums up.

I remain concerned about what the on-going debate here and on social media is doing for those young people who are only trying to access the care that they need and who have been thrust into an increasingly heated and partisan political storm. That very small group of young people need our support, not our judgment.

Photo of Alex Cole-Hamilton Alex Cole-Hamilton Democratiaid Rhyddfrydol 3:37, 8 Mai 2024

I am grateful for the opportunity to speak for the Liberal Democrats in this important debate. Although it is a sensitive matter, it is important that we debate such a substantial clinical review. Given that sensitivity, we should approach the issue with a sense of understanding, compassion and tolerance, which Dr Hilary Cass rightly pointed out as being profoundly absent from so much of the debate in our community. Each of us has a duty to model and uphold the values on which this Parliament was founded and, as parliamentarians, we have a duty to consider such matters soberly and to rely on reason underpinned by evidence. However, in undertaking that consideration, we must always remember the people—especially the young people—at the heart of the debate.

In her report, Dr Cass rightly underscores the impact of delays—I thank Paul Sweeney for his intervention on that—and she reiterated that point at committee. Delays can have a profound impact on mental health and can even lead to self-medication and self-harm. In addition, the stigma and toxicity of the debate can, as Dr Cass noted, have an impact on already vulnerable lives. We must heed her words and consider her review without the intolerance and invective that characterise so much of the debate in our communities.

Scottish Liberal Democrats believe that our focus should always be on ensuring children’s and young people’s wellbeing and preventing harm, that every young person should have as much agency as their age and capacity allow, and that their voice should be at the centre of every decision that impacts them. It is also essential that there is a scientific basis for everything that we do.

Scottish Liberal Democrats accept the clinical validity of the review. It is a substantial piece of work, and it is right that we take time to consider its findings and work through how each of the 32 recommendations might best apply to care pathways in Scotland. Ultimately, we think that it is right that decisions about the safety and efficacy of treatments are always made by clinicians and not by politicians. I say with respect to Meghan Gallacher that I do not believe that such a decision should ever have rested with Government ministers. It should always rest with people such as those who work at the Sandyford clinic.

In response to the recommendations of the Cass review—

Photo of Alex Cole-Hamilton Alex Cole-Hamilton Democratiaid Rhyddfrydol

I am afraid that I do not have time; I have only four minutes.

NHS Greater Glasgow and Clyde has paused the use of puberty blockers at that clinic to allow relevant clinicians to review all necessary evidence and allow more to be obtained. However, that reality is not without its challenges. The decision will represent a massive setback for those young people—who, although they are very small in numbers, nevertheless exist—who have already waited far too long, were already in profound distress and thought themselves on the threshold of that care pathway, only to find that that intervention is now closed off to them. They deserve heightened levels of support around the impact that that decision will undoubtedly have on their mental health. When a young person or their family raises questions about the suspension of that approach, it is right that health boards and clinicians engage, are clear about what the decision means and ensure that there is still access to high-quality healthcare and support.

Dr Cass has recommended the suspension of such interventions because of the lack of a clear, evidential basis to support their use. That is perhaps the biggest challenge of the report, and it is one that Liberal Democrats will not shy away from. No decision in human history has not been improved by the addition of a firm evidential footing. We now owe it to the young people who are at the very heart of the matter to establish that scientific basis with the utmost care and with all possible speed so that they and their clinicians can make the most informed decisions that are possible about their on-going care.

Trans healthcare has always been a poor relation to our consideration of public health of any kind in this place, but it matters. Above all, we need to ensure that any consideration of such issues is conducted in cognisance of the challenge at the very heart of the Cass review, which is to move forward with compassion, with evidence and, above all, without toxicity.

Photo of Annabelle Ewing Annabelle Ewing Scottish National Party

We move to the open debate. I advise members that we have no time in hand and that back-bench speeches are up to four minutes maximum.

Photo of Murdo Fraser Murdo Fraser Ceidwadwyr 3:41, 8 Mai 2024

Sinéad Watson is one of the bravest people whom I have ever met. Sinéad is a detransitioner and someone whom I first heard speak in the Parliament four years ago, at an event hosted by the then SNP MSP Joan McAlpine. Today, Sinéad is 33. Ten years ago, she transitioned to become a man, having had a history of being a victim of sexual assault by men.

She came to believe that her problems would be cured if she underwent gender reassignment treatment and, having presented as gender dysphoric at the Sandyford gender clinic in Glasgow, went down the route of transition. She had years of testosterone injections and a double mastectomy. Today, Sinéad is in permanent pain and discomfort and bears the physical and mental scars of that transition. She now realises that she made a terrible mistake, but the treatment that she underwent means that there is no going back to the body that she once had.

Sinéad is angry that clinicians who should have recognised that what she needed was therapy encouraged her down the route of gender transition; she is angry that the consequences of what she was doing were not fully laid out to her; and she is angry that the prospect that she might at some point in the future want to detransition was never set out to her.

Sinéad, like many detransitioners, wants the Sandyford clinic closed, because of the damage that is being done. She has said:

“I will do what I can to stop this terrible mistreatment of vulnerable young people.”

Sinéad is, rightly, angry with politicians who encouraged transitions for children and young people with troubled backgrounds and a history of mental illness.

The Cass report is a welcome step towards changing our perspective on the treatment of young people with gender issues. We should not be prepared to tolerate any young person going through what Sinéad Watson had to suffer. That is why the rapid implementation of the recommendations of the Cass report is so important, as Meghan Gallacher set out.

Photo of Rachael Hamilton Rachael Hamilton Ceidwadwyr

Hilary Cass said at the Health, Social Care and Sport Committee that the issue of puberty blockers has become “almost totemic” and that it has prevented us from looking at the issues that young people are having around coping with their distress. That is an important point.

Photo of Murdo Fraser Murdo Fraser Ceidwadwyr

I agree with that; there is much more in the Cass review to which we must give our attention. I believe that children and young people in Scotland should not be left behind while children in England are given the protections that are required.

Our new First Minister, John Swinney, has spoken a lot in the past few days about the need for a new approach for his Government. I hope that we will see that, because the comments about the Cass review that we have heard from some Green Party members are simply disgraceful, with one MSP sharing on social media a comment that it was transphobic. It is a rich irony that the party that demands that we follow the science when it comes to climate issues rejects the science when that does not support its political prejudices.

If the First Minister is serious about a new approach and is reaching out to other parties, this is his opportunity to reject the Greens, embrace the Cass review and show kindness, compassion and care for children and young people in Scotland. We should not be permitting the mutilation of young bodies in the name of an anti-science ideology. Those who committed those atrocities, and those in the Parliament and elsewhere who stood by and let it happen—or, worse still, actively encouraged it—should not be forgiven.

Let me say one more thing as I come to a close. Members might recall that, some years ago, in a debate on the SNP’s programme for government, when I referred to the fact that I had met women outside this Parliament who were protesting against the Gender Recognition Reform (Scotland) Bill, I was heckled by the former First Minister, Nicola Sturgeon, from a sedentary position, with the words, “Shame on you”. Well, Presiding Officer, I feel no shame whatsoever for speaking up for the rights of women and girls. Any shame that falls to be apportioned should be laid firmly at the door of the former First Minister, her ministers and all in the chamber who allowed this abuse to occur in furtherance of a toxic ideology. I hope that, in time, they will have the good grace to apologise for the damage that they have done to Sinéad and others. It is the very least that they should do.

Photo of Annabelle Ewing Annabelle Ewing Scottish National Party

I remind members that we have no time in hand.

Photo of Ruth Maguire Ruth Maguire Scottish National Party 3:46, 8 Mai 2024

I was very grateful yesterday to have the opportunity to question Dr Cass at the Health, Social Care and Sport Committee. The landmark Cass review into gender identity services in England is a serious and substantial piece of work that should be considered carefully by everyone with an interest in or responsibility for children’s health.

Understanding that the review did not examine services in Scotland, there are a number of principles that Scotland can learn from. For me, the key thing is that the report calls for services for children and young people with gender dysphoria to

“operate to the same standards as other services seeing children and young people with complex presentations and/or additional risk factors.”

I hope that everyone can get behind that principle.

The review report states that children and young people who are referred to NHS gender services must receive

“a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment.”

It also states:

“Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress”

from gender incongruence and co-occurring conditions, which

“should include support for parents/carers and siblings as appropriate.”

Everything that we know about children and young people points to better outcomes with parental, carer and guardian support. I know that many parents will be reassured by the fact that they are mentioned and included in much of the report.

The report talks about how services should establish a separate pathway for the families of pre-pubertal children, ensuring that they are prioritised for early discussion about how parents can best support their child in a balanced and non-judgmental way. It also states:

“When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience.”

I note concerns about the implications of private healthcare on any future requests to the NHS for treatment.

Back in 2022, I hosted a meeting for colleagues that gave them the chance to hear directly from people who had detransitioned, and I take this opportunity to thank Sinéad Watson and Ritchie Herron. They spoke candidly and, at times, emotionally about their experiences, and colleagues from across the chamber who attended valued their courage and generosity in doing so. I am pleased that the review report states that there is a need for

“provision for people considering detransition, recognising that they may not wish to re-engage with the services they were previously under.”

I have thought a lot about Sinéad Watson and Ritchie Herron during the past few years. I hope that improvements to services can help to prevent other people from going through the pain and distress that they have gone through.

In the report, and in committee, there was some discussion about conversion therapy. No formal science-based training in psychotherapy, psychology or psychiatry teaches or advocates conversion therapy. It is important that, if we legislate in the Parliament, we do not restrict the ability of therapists to go about their jobs and explore with people the issues that they are having.

As I said, it is a serious and substantial scientific report, and it needs serious consideration. I will support the Government’s amendment and Labour’s amendment on that.

Photo of Pauline McNeill Pauline McNeill Llafur 3:50, 8 Mai 2024

We should be indebted to Dr Hilary Cass for the sensitive way that she has approached the issue. The fact that she has taken the time to come to Scotland to answer detailed questions is to her credit. It is a watershed moment.

However, Dr Cass has highlighted the Government’s lack of urgency in acting on the report. The methodical and thorough way in which she has examined the issues around gender identity services will serve not only to protect more young people from harm but to demonstrate that there are many different pathways for young people who are distressed about different aspects of their lives that are related to gender identity.

I agree that waiting times for gender healthcare are unacceptably long. However, I do not believe that there is any excuse not to implement the report’s recommendations in full. As Jackie Baillie said in her opening speech, Government ministers have behaved as though the findings have just arrived, but anyone who has been following the review in the press over the past two or three years will have been fully aware of the whistleblowing around the Tavistock clinic and the follow-on report by Dr Cass, so it should have come as no surprise to the Government.

The review report highlights the lack of evidence and raises concerns about the potential harm of treatments—particularly puberty blockers and hormone therapies. Others have pointed out that those are major and life-altering interventions. The report states:

“we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.”

It is deeply worrying that this was allowed to happen in our NHS, which offered experimental treatment to vulnerable children without having proper evidence for its safety. When giving evidence to the Health, Social Care and Sport Committee yesterday, Dr Cass said that the issue of puberty blockers has become “almost totemic” and that it has prevented us from looking at other ways of managing young people’s distress, which is important.

Other leading figures share Dr Cass’s view. The editor-in-chief of The BMJ , Kamran Abbasi, noted:

“A spiralling interventionist approach, in the context of an evidence void, amounted to overmedicalising care for vulnerable young people.”

I am pleased that Dr Cass has flagged up the issue of children being socially transitioned in schools without parental involvement. As she has said, it is not helpful to young people to create an adversarial system.

We need to look at the bigger picture. Almost two thirds of referrals to the gender identity development service in London in recent years have been for teenage girls, so more questions need to be asked about why a higher portion of girls is presenting with gender dysphoria. Based on Dr Cass’s recommendations, we should not make any assumptions about the complex picture until we know the facts.

The Cass review is robust, independent research, which, importantly, is informed by the views of people with lived experience. Gender medicine is built on “shaky foundations”, and it is deeply worrying for child welfare. I urge the Government to get on with implementing the Cass recommendations now.

Photo of Brian Whittle Brian Whittle Ceidwadwyr 3:54, 8 Mai 2024

It is fair to say that the gender rights debate and legislation have been the most contentious that the Parliament has had to deal with during my time as an MSP. I remember well the stage 2 amendments that I was involved with in committee and the stage 3 amendments in the chamber. My amendments were all about ensuring safe healthcare for the trans community and about how we deal with the fair inclusion of the trans community in the sports arena. In both those areas, the obvious importance of biology is evident. In fact, the impact of biology on those issues is as irrefutable as gravity.

However, during that debate, in which we tried so hard to be as constructive and as sensitive as we possibly could, all those facts were discarded. Of all the conversations that I have had about gender recognition reform legislation, the most grounded and sensible conversations have been with the trans community itself, and not with those who pretend to represent it in this place.

To roll forward to the Cass review, this is where some MSPs’ opinions drift into the realms of dangerous ideology over patient safety. The Cass review noted that the long-term effects of treatment such as puberty blockers were as yet unknown and that they could be causing irreversible harm. If that were any other medical treatment, there would be no question but that it would need to be paused for adults, let alone for vulnerable prepubescent teenagers. The report also highlights the need for

“a holistic assessment ... to include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment.”

Healthcare professionals have a duty of care to offer the appropriate healthcare, not what some MSPs in the chamber think is appropriate. Dr Cass warned that the risk of starting the transition at a point when someone is still in the process of development is that treatment will be given to the wrong person. She went on to say that the reason that there is a negative outcome is that medical transition does not come without cost in terms of sexual function, fertility, knowns and unknowns about long-term bone health risks and the limitations of surgery. All those costs are well worth while if someone has a long-term stable trans identity, but it is a high cost to pay in the long term if they do not.

We should not forget that, according to the Scottish Government’s justice legislation, a young person’s neurological pathways are not fully developed until they are 25, so how on earth can we expect a child in their teens, who is in the midst of dealing with hormones that are associated with puberty, to make such monumental, life-changing decisions?

I always try not to stray into questioning personal actions. However, given that the Scottish Government at least recognises the Cass review as a credible piece of scientific work—although the Government has yet to adopt its recommendations—I find it absolutely disgraceful that Patrick Harvie, who was at that point a Government minister, went on national television to try to discredit the review and say that there were so-called experts who questioned it; on that basis, he was perfectly happy to continue as though the review had never been published. He ignored the potential harm to these children and the harm to the trans community.

I say to Patrick Harvie that there are also so-called experts who say that there is no such thing as climate change. I presume that, given his attitude to Cass, he will be listening to those alternative experts. No—Mr Harvie does not get to choose his experts and deny others just to fit his ideology, especially when our children’s health is at stake.

Those of us with children and grandchildren recognise the turmoil of their journey through puberty towards adulthood. They certainly do not need the dangerous views of people such as Patrick Harvie being foisted on them. He should never have been allowed anywhere near a decision when it comes to our children’s welfare and the welfare of the trans community—that is the crux of it. The Greens’ proposed amendment would risk the long-term health of our children at the early stages of their lives, when they are already at an unstable point in their development.

The Scottish Government can see sense now that it is not shackled to the Greens, and it can implement the recommendations of the Cass review that apply to NHS services in Scotland. I urge members to support the motion in the name of my colleague Meghan Gallacher.

Photo of Clare Haughey Clare Haughey Scottish National Party 3:58, 8 Mai 2024

I refer members to my entry in the register of members’ interests—I hold a bank nurse contract with NHS Greater Glasgow and Clyde.

The publication of the Cass report has probably produced more column inches in newspapers, more social media posts and more worry and anxiety in the patient group that it relates to than any other report that I can remember. This important inquiry into gender identity services in NHS England, under the direction of Dr Hilary Cass, should be treated with the utmost respect.

A point that should be emphasised is that the report is about NHS England services, and we must take the time to cross-reference it accurately and thoroughly to our own services here in Scotland. There should be measured consideration of its many recommendations, and their applicability to services in Scotland should be properly assessed. I welcome the decisions by clinicians in NHS Lothian and NHS Greater Glasgow and Clyde to pause prescribing some pharmacological treatments. It is vitally important that clinical decisions are made by clinicians.

Although we all recognise that this can be a polarising topic, we cannot lose sight of the children and young people, and of course their families, who seek help with gender identity issues. The past few weeks will have been a difficult time for those children and young people who have been affected by the recent changes to clinical pathways. It will have been a time of uncertainty about their current treatment and about what treatment options will be available to them.

One of my young constituents contacted me last night. Her words were:

“I’m 13 and I have been on the waiting list for the gender clinic since I was 11. I’m a girl. I don’t want to be forced to develop as a male. I just want to be happy for the rest of my childhood. But now the gender clinic won’t help me.”

I have previously asked the Minister for Public Health and Women’s Health what support is being put in place while there has been a pause in the prescription of puberty blockers, and while clinicians assess the best treatment options and care pathways in the light of the Cass report’s recommendations. I welcome her reassurances that NHS teams and third sector organisations are working to provide additional support to those young people. I am also pleased to see in the Government’s amendment that it will

“thoroughly examine the recommendations”

of the Cass report

“and its applicability to NHS Scotland services”

and that it will

“update the Parliament on the outcome before the summer recess.”

Children and young people such as my constituent need that certainty.

Of course, it did not take the publication of the Cass report for the Government to start a broad programme of work to improve gender identity healthcare, and it is absolutely committed to that aim. Importantly, throughout its work, the Government has engaged with trans and non-binary people across Scotland who have lived experience of accessing, or waiting to access, gender identity services. To build on that, I know that it will continue to engage directly with young people and the stakeholders who represent them. I hope that, in the heat and light of the debate and discourse, that will offer them reassurance that their voices will be represented and that their experiences will be centred in any work that is designed to improve their healthcare.

Photo of Ash Denham Ash Denham Scottish National Party 4:02, 8 Mai 2024

I thank the Conservatives for securing the debate and Dr Hilary Cass for giving evidence to the Health, Social Care and Sport Committee yesterday. However, one hour is not enough to fully engage with Dr Cass’s recommendations. Drastic change is urgently needed to safeguard Scottish children from what I believe is a medical scandal.

The Government must urgently understand the striking difference in patients who are presenting for gender identity services. It has changed from a few young boys to a large and rapidly increasing number of teenage girls, with complex presentation. Often, they are young lesbians or autistic girls, many of whom have serious mental health issues such as depression, anxiety and eating disorders, and who may be self-harming. Those issues are often caused by abuse or neglect. We must investigate the reason for the change in patient profile. Increasingly, girls are opting out of womanhood, and we cannot just shrug that off. We need to look at the issue and address it.

The treatment protocol for gender identity with affirmation and being funnelled towards a medical pathway overshadows the other problems that I have highlighted and neglects, to those girls’ detriment, alternative psychological treatment options. Clinicians tried to raise the alarm from the inside that those girls were being harmed by an approach that was developed for boys. From whistleblowers such as Dr David Bell and safeguarding lead Sonia Appleby, we know what happened to clinicians—they were ignored at best and silenced at worst. In the end, many of them left.

In Cass’s words,

“puberty blockers, cross-sex hormones and even surgery may be a suitable treatment for some. We just do not know which ones.”

Given the severe health risks of the treatment, we need a service model that considers the child’s right to an open future and offers appropriate therapeutic care to each patient.

Detransitioners say that many do not understand the risks of testosterone, such as fertility loss, vaginal atrophy, clitoral growth and pain affecting sexual function. Cass recommends that gender services should learn from and understand detransitioners. That is difficult to do when, understandably, many refuse to return to the service that has failed them.

We must ensure that legislation, education and health services are Cass compliant. The school guidance is inappropriate and should be withdrawn. Are we sending the message that homophobia is unacceptable and that loving acceptance of our body is important? The evidence would suggest otherwise.

The Cass report is a watershed moment. Vulnerable children are at its heart. The Government’s amendment shows that it does not understand the severity of the problem or the urgency that is required to fix it. What does the Government imagine that the outcome of a thorough examination of the most comprehensive, recent and meticulous review of the global body of research will be?

The Scottish Government can prevaricate to placate lobby groups, or it can remove its ideological blinkers and focus on the urgent clinical need to improve how we provide care to support distressed children. There is no excuse for any further delay. Maya Angelou famously said:

“Do the best you can until you know better. Then when you know better, do better.”

Photo of Patrick Harvie Patrick Harvie Green 4:05, 8 Mai 2024

It is not often that I have a lump in my throat speaking in Parliament after I have been doing it for so long. However, with this debate, after so long of this Parliament having a strong and proud track record of supporting LGBT people’s equality and human rights, I feel deeply anxious that that is about to change.

A number of members have spoken about the toxicity of the debate. It has been recognised that Hilary Cass has said the same; even Meghan Gallacher agrees. However, I have to question whether the debate will have improved that or made it worse. I am not sure whether Meghan Gallacher even once in her speech mentioned transgender people as transgender people. In fact, few people who spoke in today’s debate did. Clare Haughey was the most notable exception, and I thank her for her contribution.

I want to mention one constituent who emailed me a few days ago. I will not give any personal details, but it was a young transgender person who wrote:

“I am writing this because I’m scared. I’m writing this because I’m desperate. I’m writing this because I need transgender voices to be heard and to matter when the discussion of our identities and rights are being brought into question.”

Objectively, this debate should be about access to healthcare, waiting times and the need for a clinical pathway with better follow-up and support. Nobody would object to that. Certainly, transgender people who are angry about the poor and inadequate quality of the healthcare that they can access would not object to a debate about that kind of improvement. Gillian Mackay was one of a number of members who recognised that waiting times are entirely unacceptable currently.

However, context matters. It is not just a debate on healthcare improvement that is needed. The context is a wave of transphobia, with marginalised people’s views rarely heard but their lives politicised, their rights weaponised and their very existence refuted. This debate should not ideally be about ideology, but even Dr Cass has recognised that she was probably naive in not acknowledging the prevalence of homophobia and transphobia in our society.

To be clear, most people in our society do not support homophobia and transphobia. Most people support trans people’s equality, and that support is higher among young people, women and lesbian, gay and bisexual people. However, that prejudice is all too prevalent in media and in politics, and it is being stirred up quite deliberately at the very top of the UK Government. We have a Prime Minister who made a cheap transphobic gag at Prime Minister’s questions while Brianna Ghey’s grieving mother was sitting in the gallery, and the Minister for Women and Equalities has called on the public to report organisations for not discriminating against transgender people and put pressure on schools to out young people to their parents even when they do not feel safe. Here in the Scottish Parliament, we have a Tory party that is now targeting LGBT Youth Scotland, which is an organisation that we should all be proud of.

Some of the speeches here today have been just as deplorable, including from those who have voted against LGBT people’s human rights at every opportunity and who have even supported restrictions on reproductive rights and freedoms as well.

What all this generates outside of politics is a wave of hostility and prejudice the likes of which I have never experienced in my many years working and campaigning on LGBT people’s human rights. I regret that the only amendment that reflected on that political context was not selected for debate today.

The Greens will support the Scottish Government amendment. We believe that it is something of an improvement on the motion and feel the same about the Labour amendment, but neither will be enough to make the amended motion supportable. We will oppose it, just as we will try as best we can, even if we are left alone in Scottish politics, to summon up the courage to oppose the toxic culture war that has started elsewhere and which I fear might be coming to Scotland.

Photo of Carol Mochan Carol Mochan Llafur 4:10, 8 Mai 2024

I am pleased to close the debate for Scottish Labour and I thank members across the chamber for their contributions.

On the whole, across the Parliament, we believe that the Cass report is a considered scientific paper and that that message should go out from the Parliament. If members get the opportunity to watch the evidence from Dr Hilary Cass yesterday, they will see that the report has been pulled together by a clinician with an extremely caring side, and that shows throughout the whole hour.

There can be no doubt that this is a subject that a lot of people feel very strongly about. It is also an issue that has become needlessly complex when, in reality, what we want is for the best and the right care to be available for all those people who need it.

It would not do to pretend that the only people who are concerned about the issue are people who we deem to be out of touch. It is a big issue for a lot of people. They are discussing the issue and contacting their MSPs, so we have a responsibility to take leadership in this area.

There are legitimate concerns that must be addressed in how the Government responds to the Cass report. Fortunately, Dr Cass has provided some clarity for us, and we need to heed that clarity. I will make a short mention of my colleague Claire Baker, who as early as 2022 was asking the Parliament to look at the interim report and to show support for the clinicians who we know were left feeling vulnerable. That is why this Parliament and Government should be involved in the decisions around the Cass review.

The findings of the Cass review should be implemented without delay. There are many children and young people with gender dysphoria who need some certainty, and we are in a position to provide them with that. Pausing the use of puberty blockers was the right first step in providing that certainty. My party welcomes that decision, but now we need to move forward and ensure that quick and responsive services are available to those young people, as was discussed by many members—in particular, Pauline McNeill and Ruth Maguire. I also add my thanks to people who have shared their stories, so that we can get it right for future generations.

Unfortunately, we recently had a Government tripping over itself on messaging and substance, and that trend caused confusion. The confusion has affected people’s lives, and that is not acceptable. As my colleague Jackie Baillie indicated, we need some leadership, and we hope that we will get that now.

The SNP now has new leadership. With that comes the opportunity to accept that there were mistakes and that we should look at more sensible approaches. It is our position that we will make every effort to do that with the Government, as members will see from our amendment, and we thank the Government for supporting it.

Our message is that we do not need another working group, because the work has been done. Dr Cass and her team are widely respected, and there is no doubt that the evidence in the report is good. Dr Cass confirmed to us that she has been discussing her work with the minister since 2022, so there is nothing unexpected in the report. The Government knew what was coming, and the evidence session yesterday at the Health, Social Care and Sport Committee confirmed that we could be moving on. The longer we delay, the more young people will experience seemingly endless waits, and no one wants that.

I will finish my remarks there, because I know that we are tight for time. Again, I thank all the members who have contributed to the debate.

Photo of Maree Todd Maree Todd Scottish National Party 4:14, 8 Mai 2024

Presiding Officer and colleagues across the chamber, I start by reflecting on the words of Dr Hilary Cass. She described the public discourse around gender identity and gender identity healthcare as an

“increasingly toxic, ideological and polarised public debate”.

I think that we can all recognise that description, and I think that we can all recognise that the nature of how we talk about those issues, including here in the chamber of the Scottish Parliament, really matters. It matters because toxic and polarised discourse does nothing to serve young people who are questioning their gender, nor those young people who are accessing gender identity healthcare, nor their families, nor the NHS staff who are working hard to care for them. I also make a plea for a more temperate debate, with less heat and more compassion.

There is much that I think we can agree on across the chamber. We agree that children and young people and their wellbeing are at the heart of all our concern here. That is why we welcome the Cass report and recognise its significance. That is why a senior clinical team in the office of the chief medical officer in the Scottish Government is already giving careful consideration to each recommendation in the context of how NHS services in Scotland work. We agree that evidence matters. That is why we are already engaged with NHS England on the planned clinical study on puberty blockers and why the Scottish Government has already awarded funding to the University of Glasgow to establish a programme of research on long-term health outcomes for people who access gender identity healthcare in Scotland.

Photo of Sandesh Gulhane Sandesh Gulhane Ceidwadwyr

Which of the 32 recommendations do not apply to Scotland?

Photo of Maree Todd Maree Todd Scottish National Party

It is absolutely clear to everyone in the chamber that NHS Scotland is different from NHS England. We have different structures and it is simply not possible to adopt all 32 recommendations. Recommendation 5 of the report refers to a statutory instrument that applies only to England. Recommendation 9 refers to NHS England national provider collaborative, which recommendation 12 suggests is not yet established. Recommendation 11 covers commissioning and potential subcontracting by NHS England services, and recommendation 30 covers NHS England contract management. I have absolutely no doubt whatsoever that the recommendations and the full report provide evidence that we can learn from in NHS Scotland, but it is simply wrong to suggest that we can adopt all 32 recommendations wholesale.

We agree that high-quality healthcare standards matter and that we all want people to have safe, evidence-based and holistic healthcare. That is why we commissioned Healthcare Improvement Scotland to produce national standards for gender identity healthcare. We all agree, as the Cass review recommends, and as Dr Hilary Cass highlighted when she gave evidence yesterday at the Health, Social Care and Sport Committee, that healthcare professionals who work in this specialist field and beyond need good training and support. That is why we commissioned NHS Education for Scotland to develop a transgender healthcare knowledge and skills framework and to explore resources and opportunities for training for NHS Scotland staff.

We all agree—I hope—that this is not an issue to treat as a political football. The Cass review is a serious report that requires serious consideration. Many of its recommendations are already in train or have been delivered in Scotland as part of the work to implement the strategic action framework for NHS gender identity healthcare services. There will be more that we can learn.

Photo of Maree Todd Maree Todd Scottish National Party

I am afraid that I am in my closing moments.

That is why, through the work of the senior multidisciplinary team of Scottish Government clinical advisers, we are already thoroughly examining the recommendations of the NHS England-commissioned report and its applicability to NHS Scotland services. We will update Parliament on the outcome before summer recess.

Photo of Sandesh Gulhane Sandesh Gulhane Ceidwadwyr 4:19, 8 Mai 2024

I draw members’ attention to my registered interest as a practising NHS general practitioner.

The Cass review was commissioned by NHS England four years ago, with the Scottish Government getting updates from 2022. It is an authoritative body of work. Researchers met an extensive range of stakeholders, including professionals, their respected governing organisations and people with lived experience, both directly and through the support of advocacy groups.

The Cass review made 32 recommendations. It concluded that children are being let down by a lack of research and by weak evidence on medical interventions in gender care. In the Health, Social Care and Sport Committee yesterday, Dr Cass set the record straight on the claims of critics of the review, such as Patrick Harvie and Ross Greer, who relied on significant misinformation to push their agenda. The claim that Dr Cass disregarded 98 per cent of papers presented to researchers is false. We believe that the Cass review is a valid scientific document, and that the science does not change just because you cross the River Tweed.

Meghan Gallacher was absolutely correct in pointing out that the SNP-Green Government dithered and delayed in responding and making a decision about the final version of the Cass review. Thank God that clinicians were brave enough to stop the use of puberty blockers. Ash Regan’s intervention, in which she asked for the CMO to appear before Parliament, was important. Why can we not get at least an interim statement and get the CMO to answer questions?

Jenni Minto stated that the Government was not waiting for the Cass report, but it is clear that the SNP Government did not pause the use of puberty blockers. As Jackie Baillie reminded us, the SNP Government has had meetings with Dr Cass throughout. Gillian Mackay seemed to leave out the fact that Dr Cass said that there was poor evidence for puberty blockers and that there must be a multidisciplinary team approach to ensure that mental health and other issues are addressed.

Stigma has no place in society, as Alex Cole-Hamilton said, but I disagree with Alex Cole-Hamilton about where decisions can be taken. For example, the use of mesh was ceased by this Parliament, not by clinicians. When the interim report was produced, it was possible for the Government to pause the use of puberty blockers and take time to discuss the issue with clinicians to make sure that we got the right decisions.

Murdo Fraser brought up the brave story of Sinéad Watson. Dr Cass addressed that issue by saying that irreversible medication must not be given quickly to children but that that should be done via an MDT approach, addressing any other issues that they have. We must apologise to Sinéad Watson, Ritchie Herron and others who were let down by the gender service that they received.

Nobody here denies that trans people exist and nobody here denies trans people’s rights, but nobody’s rights trump other people’s rights—we must all live together. Dr Hilary Cass gave evidence to the Health, Social Care and Sport Committee yesterday and was very generous with her time. We heard that children are gender fluid, not fixed. Puberty blockers are irreversible.

Significant time and effort went into finding all the research in the area. Most importantly, the evidence is simply not there to continue giving these irreversible drugs. Why must the Government insist that children are labelled? Let children be children. Let children experience life. Let children learn. We should never forget that children are vulnerable and that it is our job to protect them. Scottish children will be forever and irreversibly harmed.

The Green amendment that was rejected shows that the Green Party members are science deniers and that the party cares only about dogma and ideology. The same party describes Scots who do not agree with its views as reactionaries and bigots. That was the position of the SNP as well.

We must base our approach on evidence. It is not transphobic to question or review current pathways. Ideology and dogma have no place in medical treatment. We must protect patients who are vulnerable. We must protect our children. It is right that doctors have paused services at the Sandyford clinic, but we need an urgent response to the Cass report from the Government. We must implement the report’s recommendations in full, or will the SNP bow down to Green dogma and remain beholden to that party?