A new report from Voluntary Health Scotland has found that sex and gender inequalities are making thousands of people effectively invisible inside Scotland's health and social care system. Not invisible in a metaphorical sense. Invisible in the way that actually matters: not counted, not studied, not believed, not served.

The (IN)VISIBLE report draws on input from over fifty third sector organisations, and what it describes is not a few isolated gaps. It is a systemic pattern. People are going unheard across multiple points of contact with the health system, and the consequences land hardest on those who were already most likely to be overlooked: older women, disabled women, migrant women, LGBTQ+ people, and trans and non-binary people in particular.

VHS Chief Executive Tejesh Mistry put it plainly: "Too many people are not being seen, heard or believed, and ultimately not receiving the support they need." That sentence covers a lot of ground. It covers the older woman who feels she is a burden for asking about her own health, even after decades of caring for everyone else. It covers the migrant woman who encounters discrimination in the maternity system at the moment she is most vulnerable. It covers the trans person whose healthcare journey generates almost no usable research data, because the systems designed to record and monitor their care were not built with them in mind.

When the data does not include you, the system cannot see you

One of the sharpest findings in the report is about research design. Clinical trials have historically over-selected men, which means treatment protocols, dosing guidance, and symptom recognition have all been shaped around male physiology as the default. Women's symptoms of serious conditions, cardiac events being the most well-documented example, have been systematically misread or dismissed because the research did not describe them. That is not ancient history. It is still happening.

For trans and non-binary people, the picture is starker still. The report finds a complete lack of clinical research into the health changes experienced by trans people receiving gender identity healthcare. A complete lack. Not a gap, not an underrepresentation: nothing. Which means clinicians working with trans people are working without the evidence base they need, trans people are navigating their own healthcare with almost no systematic data to draw on, and the system has no reliable way to measure whether the care it provides is working.

This is what I mean when I say that being uncounted is its own form of harm. It is not a neutral administrative problem. When a health system fails to record trans and non-binary people accurately, it is making a decision, and the consequences of that decision fall on real people trying to access real care.

Stigma does the rest of the work

Some of the barriers the report identifies are structural: flawed recording systems, research that excludes certain groups, services that were not designed with particular communities in mind. But stigma operates alongside those structural failures and compounds them. Men not asking for help with their mental health because of what they fear it says about them. Women who are carers putting their own health last because that is what the role has always required of them. Trans people hesitating at the door of a service because they do not know whether they will be treated with basic dignity when they get inside.

The report's author Sarah Latto describes "stories of stigma, discrimination, and misogyny" that add up to "a narrative of deep-rooted health inequalities." She is right that it is deep-rooted. It is also, as the report makes clear, addressable, if there is political will to address it.

What good would actually look like

The report calls for targeted action from government, the NHS, and across the wider system. It points to the people-centred principles of Realistic Medicine as a framework that is being forgotten under the pressure of overstretched services. Continuity of care, knowing the person rather than just the presenting condition, matters more when the person belongs to a group that has learned to expect not to be believed.

For trans people specifically, good would look like recording systems that reflect who people actually are. It would look like clinical research that includes trans people as participants and subjects, so that the evidence base starts to exist. It would look like staff who have been trained not just in policy but in the reality of trans people's lives, so that the first appointment is not also an education session for the clinician. And it would look like services that acknowledge the particular harm that has been done by years of being excluded and work actively to repair it.

None of that is radical. It is just what good healthcare looks like when it is designed for everyone rather than for a default patient who was never as universal as the system assumed.

The third sector organisations who contributed to this report are already doing the work of reaching people the formal system misses. That matters enormously, and Tejesh Mistry is right to name it. But it should not be necessary for civil society to fill the gaps that a publicly funded health system leaves open. The (IN)VISIBLE report is a map of those gaps. Now someone needs to close them.

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Dr Helen Webberley is a gender specialist, medical educator, and founder of GenderGP. She writes about gender diversity, trans healthcare, and the fight for equality in healthcare systems worldwide.