Special Report: Failure to publish report means long delays to access transgender services

Activists claim the three-year waiting list for access to the National Gender Service are due to the failure to publish a Department of Health-commissioned report on transgender healthcare services
Special Report: Failure to publish report means long delays to access transgender services

Noah Halpin, founder of the This Is Me Transgender Healthcare Campaign, who was Simon Harris’s ministerial appointee to the National Transgender Healthcare Steering committee.

Activists claim the three-year waiting list for access to the National Gender Service are due to the failure to publish a Department of Health-commissioned report on transgender healthcare services, writes Aine Kenny.

Also in today's Special Report:

  • Case Study: 'I didn't have time to wait' - Fionn Collins from Dublin talks about how the long waiting list for trans healthcare has forced him to go privately and put him in serious debt.
  • 'I’m lucky to live in a country where trans people have legal recognition but there’s no reason why we can’t have better healthcare too' - Aoife Martin talks about the complications around trans healthcare in Ireland

People seeking to access the National Gender Service face up to three years on a waiting list, with confusion over a Government-commissioned report on transgender healthcare services pinpointed by activists as one reason for the delay.

The National Transgender Healthcare Steering committee was set up by former health minister Simon Harris, and held its first meeting in July 2019. Its aim was to examine the current service and make recommendations to improve it.

The committee was chaired by the HSE's national clinical adviser and group lead for mental health at the time, Dr Siobhán Ní Bhriain and was made up of ministerial appointee and transgender activist Noah Halpin, the Transgender Equality Network Ireland, clinicians, and representatives from the HSE and the Department of Health.

It reported back to the Department of Health on February 28 this year, but radio silence ensued, according to Noah Halpin, who was Simon Harris’s ministerial appointee to the committee.

Mr Halpin said there had been no communication from the Department of Health or from the new Minister for Health, Stephen Donnelly. He said:

When Simon Harris was minister, he kept the lines of communication open and always fulfilled his commitment.

"There was a previously-agreed upon reporting relationship and open channel of communication regarding concerns, updates and information relating to the committee, due to me being the ministerial representative on the committee."

Failure to publish the report means that its conclusions and recommendations cannot be discussed by the committee members, as they are bound by a confidentiality clause.

Confusion

 On November 17, Social Democrats TD Róisín Shortall submitted a parliamentary question to the Minister for Health, asking for an update.

The minister's response was: "I am informed that, due to the impact of the Covid-19 pandemic, additional time is required to collate the information for the final report. I am advised that the report will be published as soon as possible."

However, when the Irish Examiner questioned the Department of Health on the status of the report, it said: 

Most of the report’s seven recommendations are in progress or ongoing and the minister intends to request an update from the HSE on their implementation."

When asked how the report was already being implemented when the Minister for Health had stated just a week prior that the report was not finished, the department spokesperson said: "There was a commencement matter on the report in the Seanad."

Frank Feighan, Minister of State for Public Health, Well Being and National Drugs Strategy, appeared in the Seanad last week and noted the concerns being expressed by, among others, Senator Regina Doherty, on the issue, saying he would raise it in his department.

Taoiseach Michéal Martin also addressed the issue in the Dáil during the week, saying the pandemic was not an excuse for failure to publish the report, promising to find out why the report had not been published and to act on its findings.

Key outcomes 

The Department of Health told the Irish Examiner that the health minister acknowledges two key outcomes achieved by the steering group: the development of a job description for a consultant psychiatrist in child and adolescent psychiatry, to develop the transgender identity services for those aged under 18; and support for a governance committee across the Ireland East Hospital Group and Children’s Health Ireland.

"The seven recommendations of the report pertain to the HSE, and as the report makes clear, most of its recommendations were in progress at the time it was being finalised. Due to their operational nature, the minister has no role in their implementation.

"However, the minister has now sought an update from the HSE on the implementation of the recommendations since the report was finalised."

When asked if the report had been implemented despite it not being published, the HSE said to refer to answers given by the Department of Health.

Waiting lists 

Meanwhile, the waiting lists to access the National Gender Service are getting longer, with the wait increasing since 2019 from 15 months to up to three years from first referral.

The HSE said there had been an increased demand for services at the National Gender Service at St Columcille’s Hospital in Dublin.

Year-on-year, the referral rate has increased significantly to a current annual rate of over 280 people. 

"This continuous increase of referrals has occurred without a parallel increase in service capacity. This is being remediated by recruitment of additional staff."

Another factor affecting waiting times is the lowering of the age of referrals, from 18 to 17 years old – in late 2019 a decision taken due to pressure on the Adolescent Gender Service in CHI Crumlin, according to a HSE spokesperson.

The UK-based Tavistock Clinic, which was providing care to children and adolescents in Ireland, had been doing so through the treatment abroad scheme for a number of years.

"Their tender was due to end in January 2021, however, they prematurely ended their relationship with the HSE a couple of months ago, and are no longer taking referrals from children or adolescents based in Ireland. This was not a result of this week's hearing in the UK," said Noah Halpin.

However, he believes this is why the delay in the publication and implementation of the report matters.

"Many of the recommendations were surrounding the creation of an Ireland-based system for children and adolescents, in preparation for the departure of Tavistock.

Now, as a result of the delay, we are not prepared for that, and our trans children and adolescents are now left with no service at all."

To complicate matters further, a 2019 service review discovered that 109 people who were on a waiting list for the service had never been offered an appointment. These people were reallocated places on the waiting list in line with the date of their original referral, increasing the overall waiting time for a first appointment for all people waiting to attend the service.

The HSE said the National Gender Service has submitted new business cases for additional staff.

Case Study: 'I didn't have time to wait'

Going private for healthcare can leave young trans people in crippling debt, says Fionn Collins.

Fionn Collins, who's just turned 24 and is from Clondalkin in Dublin, says the waiting list for trans healthcare is so long, he has been forced to go privately, and is now in serious debt.

"I knew when I was 14 that I was trans, I came out to my close friends when I was 18, but I only came out fully at 21."

He first started interacting with the transgender healthcare services in Ireland when he was 20.

"The waiting lists are about two and a half to three years long. I've been on testosterone for a year and a half and I've had top surgery, but I haven't been seen by anyone in Loughlinstown (the National Gender Service) yet."

Fionn says if you go down the public route, you have to wait. "I didn't have time to wait, my gender dysphoria was so bad. In 2018, I was referred to Loughlinstown, and Dr Tomas Ahern, an endocrinologist in Our Lady of Lourdes hospital in Drogheda."

Fionn says he had crippling dysphoria which was interfering with his everyday life.

"I wanted to be who I was. When I found out the waiting list could be three years, I didn't think I would be alive by the end of it."

Fionn went to see a private psychiatrist in Clonakilty, Dr Lisa Brinkmann, to be diagnosed with gender dysphoria. The return trip from Dublin took 12 hours, meaning he had to take a day off work, as well as pay for transport.

With his referral, he then could then go to Belfast to get testosterone under the cross-border healthcare scheme. The waiting list up there was two weeks.

Fionn Collins, Welfare officer for TU Dublin's Students' Union. "I knew when I was 14 that I was trans".
Fionn Collins, Welfare officer for TU Dublin's Students' Union. "I knew when I was 14 that I was trans".

However, this is a refund scheme, meaning Fionn had to pay £170 upfront.

Fionn also wanted top surgery, and had to go to England in September 2019 to avail of this. He worked as well as fundraised for this surgery, which cost £8,500. Unfortunately, the surgery did not go according to plan so he will have to get this re-done in Poland.

"My friends supported me, it was really hard and difficult. I flew over three times by myself, for two consultations and to sort accommodation, luckily I had a friend who let me stay with them. Another friend came over to look after me, and I paid for their flights and food.

It was quite upsetting having to leave to get healthcare. I was so alone and so scared. I have such solidarity with women who've had to leave Ireland to get abortions.

Fionn says including transport, flights, missed work, consultations and procedures, he is about €15,000 in debt. "It is something I think about every day, it stresses me out."

Fionn still has not been to Loughlinstown, as he was one of the people whose referral was lost.

"My referral could only be backdated to July 2019 as they couldn't find my initial referral."

He has seen Dr Ahern, who is able to prescribe him testosterone. However, Fionn still needs more procedures, which he can't be referred for unless he is seen by the National Gender Service. He says he doesn't like fundraising and asking other people for money.

"All I want to do is be able to go into a hospital in Ireland for healthcare, and be able to go home afterwards. I don't want to have to spend all this money, I didn't ask for this."

Fionn says he can't understand why the community gets so much hatred considering the struggle they go through.

'I’m lucky to live in a country where trans people have legal recognition but there’s no reason why we can’t have better healthcare too'

Aoife Martin

On July 15th, 2015, the Irish Government passed the Gender Recognition Act, allowing trans people to achieve full legal recognition of their preferred gender and thereby allowing them to acquire a new birth certificate reflecting this change. The Act allowed people to self-declare their own gender identity. 

This piece of legislation was a milestone, even for a country that just a few months earlier had become the first country in the world to legalise same-sex marriage by popular vote. Ireland, it seemed, was finally growing up and taking its place in the 21st century. 

We are one of the few countries in the world with such progressive legislation – most countries requiring trans people to be sterilised before they are legally recognised – and trans people were right to celebrate its enactment.

Being trans, however, for the vast majority of people, requires much more than signing a piece paper saying you identify as male or female. It requires specialised healthcare, including but not limited to hormone treatment, taking hormone blockers and, for some, surgical intervention. 

Receiving this treatment is a long and often onerous process. Most patients are referred by their GPs to the National Gender Service (NGS) in Loughlinstown. 

Four years ago, when I was referred, the waiting list to see an endocrinologist in the NGS was just under 12 months. Now, I believe, it is closer to 36 months and increasing. For anyone suffering from gender dysphoria this is an interminably long waiting time and can cause a lot of distress.

As well as a long waiting list, patients must undergo psychiatric assessments before receiving the medical care that they need, a process that goes against WPATH (World Professional Association for Transgender Health) guidelines. 

In 2019 the WHO (World Health Organisation) declassified being transgender as a mental disorder and yet the Irish health service continues to use a psychiatric model of care. 

Many countries, however, use an informed consent model and this is something that the HSE should be pursuing. An informed consent model would reduce waiting lists and ease the burden on our health service. 

It would allow transgender patients to be released into the care of their GPs where they could receive the healthcare that they need. Indeed, it seems strange to me that my GP can prescribe HRT to a cisgender woman patient, but she can’t to me, a transgender woman.

Further complications arise if a patient decides that he or she wishes to have gender reassignment surgery. 

Aoife Martin: "No one is advocating for better trans healthcare over other services or at the expense of other services."
Aoife Martin: "No one is advocating for better trans healthcare over other services or at the expense of other services."

Currently, there is nowhere in Ireland where trans people can get surgery and we are forced to travel abroad, often at our own expense. (I should point out here that the HSE does fund gender reassignment surgery under the treatment abroad scheme but that, rather than wait for years, many trans patients opt to go privately and raise the funds themselves.) 

Receiving treatment abroad is not without its own complications, however. Patients, when they get home, can be left to their own devices and often there is no aftercare available. Indeed, some doctors here will often refuse to treat a patient if there have been any post-surgical complications, even minor ones.

Trans healthcare, as you can see, is a difficult and complex path to navigate and I haven’t even touched upon things like laser treatment or facial feminisation surgery or breast augmentation or tracheal shaving or….. you get the picture.

Everything I’ve mentioned so far has been in relation to trans healthcare for adults, but what if you’re under 18? The pathway is even more difficult because Ireland currently does not have service for young trans people. They have been left in limbo.

The Gender Recognition Act brought Ireland to the forefront in terms of how it treats its transgender citizens and there is no reason why we shouldn’t have a world-class healthcare to match. We deserve no less. 

Groups like the This Is Me campaign and TENI (Transgender Equality Network Ireland) continue to do amazing work in raising awareness of this issue and, indeed, both are represented on the National Trans Healthcare Steering Committee whose report, as mentioned in an article above, has yet to be published.

To anyone reading this and thinking but what about other services? Don’t they deserve to be better funded and have shorter waiting lists? The answer to that is that yes, of course they do. 

No one is advocating for better trans healthcare over other services or at the expense of other services. This is not one-upmanship. Outside of trans healthcare trans people also have the same healthcare needs as the rest of the general population. We are on those waiting lists too.

I’m lucky to live in a country where trans people have legal recognition but there’s no reason why we can’t have better healthcare too. It’s not too much to ask.

  • Aoife Martin is a transgender woman who works in the IT industry. She is a passionate advocate for transgender rights who believes that we can make Ireland a better place for transgender people - especially young transgender people. She has written articles for publications ranging from The Irish Times, GCN, Image Magazine, The Journal and Irish Tatler. She has also spoken at events for, among others, Google, Facebook, Expleo, Slack, Trinity College and on the stage of the Abbey Theatre for Nollaig na mBan. In her spare time she enjoys reading, going to the cinema and being opinionated on social media

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