Half of the children and young people currently on the waiting list for Scotland's only paediatric gender service may have some form of neurodiversity and nearly one in three have been diagnosed with a mental health condition, MSPs have been told.
Rhoda MacLeod, head of service for the Sandyford clinic in Glasgow, said it was dealing with a "complex group of young people" who required a more holistic approach to their care but that other professionals had traditionally been reluctant to get involved.
Giving evidence to Holyrood's health committee, Ms MacLeod said that managers had so far contacted 422 of the under-18s currently on the waiting list for the Sandyford's gender service as part of a data gathering exercise.
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Until August this year, it was possible for children and teenagers to self-refer for gender dysphoria and be added onto the waiting list for consultation.
Ms MacLeod said this meant that the clinic "didn't know anything about" most of the 1000 or so patients waiting to be seen.
"They would just give us their name and say they wanted to be on the list," she said.
New rules mean new referrals can only be made by a clinician.
Ms MacLeod said that 70% of the patients contacted so far had agreed to be interviewed.
Their responses indicated that more than 70% are natal females, 50% "have completed assessment" for some form of neurodiversity such as autism or ADHD, and "just shy of a third" report a diagnosis of a mental health condition, said Ms MacLeod.
She added that this "chimes completely with the UK picture" as outlined by the Cass Review in April, which highlighted risks of "diagnostic overshadowing" where gender trumped other considerations despite comparatively high rates of neurodiversity, adverse childhood experiences, and psychological problems such as depression, anxiety and eating disorders among the young patients referred to NHS England's Gender Identity Development Service (GIDS) at the Tavistock in London.
Ms MacLeod said: "This is a complex group of young people that needs a really good, robust, multidisciplinary team approach...we have a very specialist service and nobody else wants to touch 'gender' because they think it's too difficult, it's in the 'too hard to deal with' pile.
"I think the feeling is that as soon as a young person or child mentions their gender questioning, everyone goes 'oh, can't deal with this' - they need to go to the gender service - so they end up on a waiting list.
"Some of the people who are on our waiting list we know are also being worked with by CAMHS.
"They might have social work involvement, no doubt their GP is involved with the family and supporting them, but they're sitting on a waiting list waiting for this service and the problem is you then see everything through that lens rather than looking at the entire young person or child.
"Shifting out into a holistic, child-centred service that has the right professionals in it with experience of working with young people is absolutely the right thing to do."
This mirrors the findings of the Cass Review, she said, which highlighted an "exponential" increase in referrals to GIDS from 2014 onwards with the majority being birth-registered females in their teens, despite the service being designed originally when natal males made up the vast majority of patients.
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Between April 2018 and December 2022, the median age of people referred to GIDS was 14, of whom 73% were natal females.
Previous research also found a 100-fold increase in the reported prevalence of gender dysphoria in people under 18 between 2009 and 2021.
Dr Hilary Cass, who chaired the Cass Review, said factors such increased social media use, exposure to pornography, evidence of deteriorating mental health, and higher rates of autism and ADHD among Gen Z - those born between 1995 and 2009 - may be contributing to the trends.
The Scottish Government has accepted recommendations to move towards a regional service model, with multidisciplinary teams.
Young Scottish patients will also be invited to take part in UK-led clinical trials into the use of puberty blockers and hormone treatments in paediatric gender medicine.
Following the publication of the Cass Review, the prescribing of puberty blockers or hormone drugs on the NHS to new patients under-18 has been paused.
The UK Government has also banned private providers from issuing these medicines "off-label" to young people.
Ms MacLeod said this had been "distressing" for the "small number" of patients who had been ready to progress treatment when it was suspended, but that clinical trials were needed.
She said: "I think it's right to acknowledge that that is very distressing for these individuals and their families.
"We have to weight up the situation we have, with the clinical risks and what we don't know.
"We don't know what the benefits truly are.
"People tell us - we have reports of people saying to us this is beneficial - but systematically, we don't know what the benefits are and what the risks truly are."
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