Skilled Level
Skilled Level
The skilled level builds on the knowledge and skills from the essential level.
People will work at the skilled level across healthcare, both in clinical and non-clinical roles.
In primary and community care there might be GPs, nurses or health visitors with a special interest in gender identity, practice managers who have more detailed knowledge of gender identity healthcare records and how to update them. Some community staff or pharmacists might work in link roles with a knowledge of gender-identity healthcare.
In secondary care, staff at this level might be providing more regular care to trans people and could include; staff working in fertility preservation, maternity, endocrinology, dermatology, speech and language, and some surgical services.
We also envisage some staff work at a skilled level in non-clinical roles from areas such as equality and diversity, human resources, medical records and information governance.
| What staff know (knowledge) |
| What staff are able to do (skills) |
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Domain 5 - About People |
| 5.1 Can understand the relevance of someone’s gender identity and expression, and any impact or considerations this may have on their care. |
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Use knowledge to better inform someone's care. Avoid assumptions about gender identity and sexuality. Listen to and facilitate discussions someone may wish to lead about sexuality and/or gender identity. |
| 5.2 Appreciate the differences between gender identity, sex recorded at birth, gender expression and sexuality. |
| Are familiar with key themes in the development of gender identity and can use this to inform in-depth and/or specific discussions where relevant. |
| 5.3 Appreciate the complexity, importance and nuance of language when discussing gender identity. |
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Use appropriate language, including use of someone's preferred language and terms. Sensitively check with someone around their use of language where relevant. |
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5.4 Know about:
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| Take a broad individualised approach with regard to transition that is primarily determined by the person and them being fully informed |
| 5.5 Are aware of relationships to other characteristics or to conditions. |
| Where relevant, include information and discussion about gender identity and experience in history taking. |
| 5.6 Understand treatments covered by the relevant NHS Scotland national protocol and associated interventions as relevant to their scope of practice. |
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Signpost someone to help them explore gender-identity healthcare interventions. Avoid referring to gender identity as a medical condition. In correspondence, write about the person's eligibility to access care under the relevant NHS Scotland national protocol rather than a formal diagnosis of gender incongruence. |
| Domain 6 - Communicating |
| 6.1 Understand the principles of active listening and building a therapeutic relationship built upon trust. |
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Apply the principles of active listening to support a personalised approach to care built upon principles of trust, dignity and respect. Have meaningful conversations with someone which helps them make informed choices about their healthcare and treatment options. Ensure that all interactions with someone are based upon a clear understanding of what matters most of them. |
| 6.2 People may use specific language about anatomy or events in order to avoid distress or dysphoria. |
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Recognise where someone is specific language and where appropriate mirror this to minimise distress. In certain circumstances where mirroring risks confusion, use discretion and sensitivity to minimise distress. |
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6.3 Understand the sensitivity and specific requirements about confidentiality and gender identity. Are aware that someone’s gender history is deeply personal. There is specific legislation which may make it a criminal offence if you disclose a person’s trans status without their consent. |
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Only share necessary information with other health and care professionals and agencies when the interests of patient safety and public protection override the need for confidentiality. Lead discussion explaining the boundaries of confidentiality. Explain or signpost to the risks where someone exercises their right to choose not to disclose their gender identity to other healthcare professionals. Minimise disruption to care caused by someone exercising their rights regarding confidentiality. Make relevant referrals providing essential information within the boundaries of consent agreed. Explain evidence on how gender identity healthcare treatments impact other care aspects and influence decision-making. Clearly explain the need for someone to communicate to other healthcare professionals where this will lead to more effective care. |
| 6.4 Understand how treatments relating to gender identity healthcare might affect other conditions |
| Give information based upon the evidence that is relevant to the situation to support better shared decision-making. |
| 6.5 Have awareness and understanding of the evidence base around gender identity healthcare, including the limitations of available research, as it relates to their role. |
| Use the evidence base to support relevant care with a focus on how this relates to someone. |
| 6.6 Know the importance of networking widely, sharing skills, good practice and research with colleagues and peers. |
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Network widely with colleagues including those involved in providing care to trans people. Wherever possible use the views of people with lived experience to improve the quality of healthcare services. |
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6.7 Understand there is diversity within the trans community; and that disabled people, including people with learning disabilities, can be transgender. Understand that many trans people are neurodivergent. |
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Consistently ask someone about their communication preferences before delivering information. Be able to adapt communication to meet someone’s needs. Be familiar with common adaptations to support someone who is neurodivergent (such as changes to the clinical environment). |
| Domain 7 - Promoting Wellbeing |
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7.1 Understand and support someone's planned healthcare pathway and identify opportunities for promoting wellbeing. Are aware of any criteria for proposed gender identity healthcare pathway interventions |
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Identify relevant wellbeing strategies that may include weight management, positive sexual health, smoking cessation, managing substance misuse and mental health support. Where appropriate offer referral or signposting to relevant services, being aware of experiences of trans people, issues of inclusion and other additional barriers, in order to support them accessing their planned healthcare pathway. |
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7.2 Understand the increased risk of suboptimal mental health for trans people. Appreciate that gender incongruence, neurodiversity and/ or suboptimal mental health can coexist. |
| Promote positive strategies for better mental health or signpost to appropriate services. |
| 7.3 Trans people may experience significant health and social inequalities. |
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Recognise situations where people are being affected by inequality and can consider strategies to mitigate this. Where relevant, ensure that care planning is informed by experienced or structural inequalities and mitigate these as far as is possible. |
| 7.4 Know about organisations that provide care and support for trans people. |
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Engage with services relevant to work area that provide care and support for trans people. Actively signpost or refer people to supportive services as indicated and requested. Where appropriate include services for children, young people and their families and caregivers. Can access updates about these services and refreshes knowledge on a regular basis. |
| 7.5 Understand the importance of strong positive role models that support/promote gender identity healthcare throughout the health workforce. |
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Act as a positive role model for trans awareness in local area. Actively promote the Framework and support their personal learning about trans awareness. Encourage others to be actively involved with the Framework and to consider working towards a higher level of knowledge and skill. |
| Domain 8 - Providing Gender Identity Healthcare |
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8.1 In depth understanding of different aspects of transition, and that transition is an individualised experience. Knowledge of organisations that can provide support to trans people considering or during transition and throughout someone's lifetime. |
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Discuss with someone different aspects of transition and support their considerations in what may be right for them. Signpost where appropriate to organisations and services that can offer support during transition. |
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8.2 Awareness of issues surrounding self-sourced hormones and associated risks in a situation where someone is asking for an NHS prescription for hormones where they are currently self-sourcing, including advice from the General Medical Council. Understand what tests are required for hormone treatment and how to manage the results. Understand the impact of endocrine treatment on fertility preservation. Appreciate referral criteria and the contraindications to fertility preservation. (Applies where within staff scope of practice. See Essential level 4.5 for routine prescribing of hormone treatment.) |
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Review medication use, including prescribed medications and self-sourced hormones and arrange tests as per the National Guidance. Cross-reference someone's self sourced hormone use to an equivalent NHS regimen using National Guidance and where necessary seek specialist advice about this from an NHS GIC. Discuss with the person the risks and benefits of endocrine treatment as outlined in National Guidance and be satisfied the person is able to consent to hormone treatment. Explain to someone that hormone treatment may have an impact on their fertility. Explain to someone options about the process of specialist referral to fertility preservation services. Provide or arrange an ongoing prescription and tests for hormone treatment as per National Guidance. Ensure someone is added to or on the waiting list for an NHS specialist service. |
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8.3 Understand needs regarding promoting good sexual health and managing risk. 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. |
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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. Offer relevant screening, treatment and vaccinations based upon risk. Help someone to understand the possibility of unplanned pregnancy and to explore options for contraception. Provide options and arrange follow-up and continuing supply of contraceptive medication. |
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8.4 Know that there are options available for trans people, including trans men and non- binary people, who would like to explore or develop their voice and communication in relation to their gender identity or their transition. Understand the referral pathways for Speech and Language Therapy services. |
| Refer appropriately to Speech and Language Therapy services as required. |
Skilled Level