Enhanced Level (Adult Services)
Enhanced Level
The enhanced and expert levels are for staff working in specialist gender identity or gender identity healthcare services.
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Difference between enhanced and expert: We expect that all clinical staff who oversee gender-identity healthcare are likely to be working at or towards the enhanced level. They may come from different backgrounds, including primary and secondary care, and may or may not work in all domains. Staff working at the expert level will be providing care where there is greater complexity related to the person’s gender or possible options, and for recommendations for genital reassignment surgery (orchidectomy, hysterectomy/oophorectomy, vagino/labiaplasty, metoidioplasty and phalloplasty). |
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Workforce development: A key objective here is to provide a graded and accessible pathway for people considering working in this field. In Scotland, most gender-identity healthcare clinicians do this part time, usually in conjunction with another job. The enhanced level is intended as a gateway for skilled level staff looking to improve their knowledge and skills, or as an entry point for people providing formal gender-identity healthcare under the national protocol. |
| What staff know (knowledge) |
| What staff are able to do (skills) |
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Domain 9 - Assessment |
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9.1 Familiar with and understand issues faced by trans people in relation to medical transition and of the pathways and interventions that can support them. |
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Offer assessment and exploration of someone’s experience that is:
and takes account of their accessibility needs and all other intersectional matters. |
| 9.2 Aware of the importance of links between someone’s gender identity with other elements of their life, including relationships, social supports, family life, cultural and employment, and how these may impact them. |
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Facilitate history taking that helps someone explore their relevant challenges, considering why they are happening and helping them to make sense of these. Explain the reasoning behind questions, being transparent about why information might be helpful and how it will be used. |
| 9.3 People may engage with gender-identity healthcare services at different stages and for different reasons. |
| Adopt a collaborative and needs-led approach focused on understanding someone’s goals and expectations. |
| 9.4 Gender incongruence can be associated with distress, and that this distress may be experienced in many ways and be variable in its presentation. |
| Take a sensitive and trauma-informed approach. |
| 9.5 Understand the principles of mental health assessment, strategies that may be helpful and available options for support. |
| Identify situations with a person where additional mental health support would be helpful and support the person to access this or make relevant referrals. |
| 9.6 Understand the physiological and psychological changes that adults relate to puberty, subsequent use of hormones to develop different characteristics, and other interventions someone might consider including surgical options. |
| Lead an informed discussion about interventions or factors relating to changes relating to pubertal changes or changes caused by endocrine therapy, including those that have already happened and the possible effects of future interventions. |
| 9.7 Can consider the effects of relevant health conditions. |
| Explain the impact of any health conditions and access specialist advice where needed |
| 9.8 Know relevant protocols, guidance and evidence relating to gender incongruence. |
| Inform discussions based on appropriate protocols, guidance and evidence. |
| 9.9 Understands differential principles relating to gender incongruence. |
| Identify situations where further discussion may be appropriate. |
| 9.10 Know the importance of bringing all aspects of the assessment together in order to provide context and inform a meaningful exploration of options. |
| Consolidate this information to provide a comprehensive assessment of someone’s physical, psychological and social needs and, where appropriate. involving their wider support networks. |
| 9.11 Aware of criteria for accessing care in line with the NHS Scotland Gender Identity Healthcare Protocol. |
| Can support someone in careful consideration of their readiness to access gender identity healthcare and their eligibility in line with the relevant NHS Scotland protocol, and collaboratively create a care plan that is based upon their needs. |
| 9.12 Are familiar with the evidence base as it applies to their scope of practice. |
| Can explain the evidence base as it is relevant to the person’s situation. Is able to contribute to efforts to improve the evidence base. |
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Domain 10 - Hormones and Fertility |
| 10.1 Understand criteria for considering endocrine treatment and are familiar with local and national guidance. |
| Establish whether someone may be eligible to access endocrine treatment under the NHS Scotland Gender Identity Healthcare Protocol |
| 10.2 Understand the guidance and evidence relating to benefits and risks of endocrine treatment. |
| Lead a detailed discussion with someone about the potential benefits and risks of any proposed endocrine treatment |
| 10.3 Understand the individual factors relating to someone’s decision to access endocrine treatment and the factors that may influence this. |
| Explain that the basis for proceeding is primarily based upon someone’s self report and there is no guarantee that endocrine treatment will offer benefit to them, or to the extent desired |
| 10.4 Are aware of possible issues relating to existing endocrine treatment regardless of how accessed, and understand baseline test requirements in all situations. |
| Review medication use including prescribed medications and self-sourced hormones and arrange baseline tests as per the National Guidance |
| 10.5 Know how to cross-reference existing regimen or recommended strategies to local and national guidance. |
| Cross-reference any self-sourced hormone use to an equivalent NHS regimen, or identify an appropriate starting regime. |
| 10.6 Understand the factors relating to fertility preservation. |
| Lead discussion about fertility preservation according to local and national guidance. |
| 10.7 Know about options for preserving fertility and referral pathways. |
| Explain options about the process of specialist referral to fertility preservation services, and offer referral where requested and indicated. |
| 10.8 Understand how to interpret baseline observations and how to access further support where necessary. |
| Can provide feedback regarding baseline tests and observations and other criteria to support someone to come to a fully informed decision based upon their individual circumstances. |
| 10.9 Understand how to assess capacity to consent. |
| Can establish that someone has capacity to consent to treatment, or arrange referral where this is certain. |
| 10.10 Know about local, national and regulatory guidance and understand consequences for prescribing hormone and related treatment for trans people. |
| Are able to prescribe (within prescriber competence) endocrine treatment taking account of local/national guidance or specialist advice. |
| 10.11 Know about the recommended monitoring for endocrine treatment. |
| Provide or arrange relevant monitoring as per local or national guidance, including notification to someone as appropriate. |
| 10.12 Understand the likely effects of endocrine treatment and how this may be supported by laboratory or other testing. |
| Can offer endocrine treatment follow up taking into account someone's ideas, expectations and concerns and where appropriate supported by monitoring results. |
| 10.13 How to identify when someone's treatment is likely to be stable. |
| Can establish when someone's endocrine treatment is table and arrange appropriate long-term monitoring or advice. |
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Domain 11 - Promoting Wellbeing |
| 11.1 Understand the possible impact of vocal dysphoria on people’s participation in activities of daily living, quality of life, confidence, and readiness to move forward with other aspects of social transition. |
| Refer to Speech and Language Therapy appropriately and/or advise people regarding patient-initiated referral. |
| 11.2 Understand that not all trans people are interested in or able to participate in voice and communication therapy, |
| Discuss options and expectations for voice and communication therapy. |
| 11.3 Understand that not all trans people have vocal dysphoria and someone’s goals can vary widely and should not be assumed. |
| Support someone to consider readiness for participation in voice and communication therapy. |
| 11.4 Understand the importance of, and options for, speech and language therapy for someone wishing to make changes to explore or develop their voice and communication. |
| Explain or signpost to the expected vocal changes following commencement of testosterone therapy. |
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Domain 12 – Facial Hair Removal & Wigs |
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12.1 Understand the importance of hair removal in the treatment of gender dysphoria. Have a good working knowledge of the NGICNS Hair Removal guidance. |
| Discuss hair removal treatments and eligibility for a wig prescription and inform someone about this. |
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12.2 Understand local referral pathways for laser hair removal and electrolysis. Understand optimal timing for commencing hair removal treatment. Understand funding arrangements for these procedures. |
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Refer for hair removal as required. Support funding requirements as needed. |
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Domain 13 – Sexual & Reproductive Health |
| 13.1 Understand needs regarding promoting good sexual health and managing risk. |
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Use appropriately gendered language and terminology to discuss with someone their relevant sexual and/or reproductive health history. Lead sensitive and collaborative discussion to explore and identify potential risks associated with sexual or reproductive health, including the potential impact of endocrine therapy or surgical interventions on relationships and/or sexual health. Offer relevant screening, treatment and vaccinations based upon risk. |
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13.2 Understand that testosterone is teratogenic and neither this nor hormone blockers provide effective contraception. Know about options for preventing unplanned pregnancy and/or managing periods and how these interact with hormone treatment. |
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Help someone to understand the possibility of unplanned pregnancy and to explore options for contraception including interactions with hormone treatment. Provide options and arrange follow up and continuing supply of contraception medication. |
| 13.3 Awareness of the options that may be offered by psycho-sexual therapy. |
| Signpost and appropriately refer where indicated and requested. |
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Domain 14 – Mental Health |
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14.1 Understand that trans people, especially those not receiving supportive gender-identity healthcare, may experience greater distress. Understand the importance of validating and supportive approaches to managing risk and promoting wellbeing. |
| Offer to provide psychological or emotional supports or refer for timely safety planning where indicated. |
| 14.2 People may seek counselling or psychological support at different times related to or distinct from transition. |
| Explain the principles of a stepped approach to psychological support to help someone make informed decisions as to how and what they would like to access. |
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Domain 15 - Surgery |
| 15.1 Have a detailed understanding of the proposed procedure - including its risks and benefits - and the possible effect on someone’s gender dysphoria. |
| Lead a meaningful and individualised discussion, helping inform someone about the risks and benefits of the proposed procedure in reducing their gender dysphoria. |
| 15.2 Understand the practical perspectives around the proposed procedures, need for care/support afterwards, and the importance of good recovery. |
| Discuss the practical aspects surrounding the procedure, including post operative support, longer term aftercare and potential travel implications such as expenses and logistics. |
| 15.3 Aware of relevant sources of information and support that can influence someone’s decision, and understand the importance of them having an opportunity to reflect on these. |
| Help someone reflectively explore the proposed procedure and signpost to other sources of information that may be helpful. |
| 15.4 Understand the criteria for referral taking into account local and national guidelines. |
| Have a supportive discussion with someone about these criteria with a focus on informed consent, risk management and promoting wellbeing. |
| 15.5 Appreciate the need for a formulation linking someone’s needs and experiences to the proposed procedure and for this to be presented in the context of their individual situation to help inform a meaningful and collaborative discussion to support their decision making. |
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Facilitate a discussion that supports robust, informed and shared decision making by bringing together information from the assessment including someone’s:
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| 15.6 Know about referral pathways and any options regarding surgical providers. |
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Support someone to explore any choices around surgical providers and identify and initiate referrals. Identify situations where further assessments may be necessary and arrange these. |
Enhanced Level