The issue of transgender healthcare, especially for youngsters grappling with their biological sex and gender identity, has been a volatile subject in recent years. Advocacy groups and activists claim that the services currently available in Ireland are insufficient. Professionals at the National Gender Service (NGS) further caution about the potential harm and risk that the existing systems could cause to these youngsters.
Despite being a divisive topic, there’s a consensus among Irish advocates across the political continuum: the current healthcare system is failing the affected children and adolescents.
In the last few weeks, Dr Hilary Cass, a paediatrician, unveiled her final report addressing gender healthcare, commissioned by the NHS England. This assessment is viewed as a seminal paper about gender identity services for those under 18. The report highlighted the failure of the NHS in supporting the numerous vulnerable children struggling with their gender identity, blaming the issue on the treatment methods with questionable efficiency and the acrimonious dispute surrounding transgender rights.
The report from Cass revealed that the sole NHS gender identity development facility used puberty blockers (which halt puberty) and cross-sex hormones (which engender masculine or feminine physical traits), despite the lack of substantial proof about their efficacy in improving young people’s wellbeing. The leading pediatric consultant, authoring a report that includes more than 30 recommendations, emphasised that her findings are not intended to undermine the authenticity of transgender identities or challenge the right of individuals to transition. Instead, the aim is to enhance the care for the rapidly increasing number of adolescents and children struggling with gender-related issues.
She advises extreme caution when delivering hormones to those under 18, proposes that fertility preservation and counselling be offered to all children before embarking on a medical pathway, and suggests the establishment of follow-up services for individuals aged 17 to 25.
Although Cass’ survey is UK-centric, it bears significant implications for Ireland, where over 230 children and adolescents diagnosed with gender dysphoria (a condition marked by a discrepancy between biological sex and gender identity causing discomfort, unease, dissatisfaction, anxiety or depression) have been referred to the UK’s Tavistock clinic under Ireland’s international treatment scheme from 2012.
At present, less than a dozen Irish youngsters are being administered puberty inhibitors as an element of their gender wellness treatment through Ireland’s Children’s Health organisation. In the wake of the closure of the Tavistock, an evolution prompted by Dr Cass’s preliminary report criticising national provision as insecure and untenable in the long haul in light of critique concerning the lack of peer scrutiny and flexibility to satisfy the escalating need. She recommended its substitution with more compact, district-based centres.
Dr Paul Moran, consultant psychiatrist at the National Gender Service and part of the Cass review group, highlighted the challenge of murky evidence in this field of healthcare, necessitating an approach anchored on safety and cautiousness.
But how does this affect Irish children and adolescents requiring transgender health services?
The Health Service Executive (HSE) in Ireland is in the process of building a fresh clinical scheme for gender healthcare, and aims to establish an enhanced clinical care approach for these services over next two years.
Dr Karl Neff, a NGS endocrinologist, has been recently designated as the clinical head for transgender health provision. An HSE representative emphasised that this is a relatively novel domain of health services and the future actions will be steered by the finest evidence on clinical treatment for individuals experiencing gender incongruity or dysphoria.
Crucially, the representative stated that the care standard will be moulded in a “consultative manner”, actively including stakeholders, health experts and patients in the service design, to guide in providing and assessing these services.
Although developing a novel care approach for gender healthcare for the Irish population is a multifaceted task, the HSE is dedicated to construct an experience and evidence-driven service that embodies respect, inclusivity, empathy, and is person-centred. Until this is achieved, the HSE has assured that the children and adolescents will be given specialist endocrine care through Children’s Health Ireland.
Patients will continue undergoing assessments abroad until Ireland’s local service becomes fully functional in 2026. The existing system forwards “referrals to the soon to open UK NHS Children and Young People’s Gender services”.
According to the Health Minister, Stephen Donnelly, this revamped model is something that was “direly necessitated for a substantial duration”. He stated, “Ireland lacked the adequate care model required for these juveniles. One of the significant issues delaying it basically was hiring a psychiatrist to oversee it. This has now been accomplished. The formation of the new team is currently underway, and the aim is to commence its implementation over the forthcoming two years”.
Concerning the Cass report, Mr Donnelly added that the senior clinical officer, Dr. Colm Henry, made the effort to meet with the author after the interim report was released, to better comprehend its repercussions. He emphasized that “every possible enhancement here will be executed.”
However, both activists and clinicians want the methodology of the future care delivery to set itself apart from the current model.
Dr. Paul Moran, a consulting psychiatrist at the NGS and a 2023 member of the Cass Review Clinical Expert Group, has been expressing his apprehensions about the Tavistock application to the HSE for half a decade.
Dr. Moran, alongside Professor Donal O’Shea, informed Hiqa of the HSE’s referral of young individuals for foreign assessments, arguing it endangered these children. Upon Dr. Cass’s review publication, Dr. Moran stated it included 12 advice pieces that “necessitate an immediate response from Ireland”.
Dr. Moran highlighted that “the Cass review and the Swedish systematic review both emphasised the uncertainty of available evidence. Thus, we find ourselves navigating through unknown terrains, which implies that safeguarding and exercising diligence should be our top priorities”.
Among the UK’s immediate-action recommendations, Dr. Moran urged the introduction of neurodevelopmental issue screening, exercising extreme vigilance in hormone use for under-18s, and proper oversight in the assessment process. “In terms of developing services for younger individuals, I propose we first lower the age limit for the National Gender Service’s clientele as we gather more evidence,” he added.
People could be educated to focus on the welfare of adolescents, although it is important to pay heed to the younger, prepubescent group. Many do not require specialised services, unless they display signs of mental health issues. In such cases, they will need assistance from CAMHS (Child and Adolescent Mental Health Services). Dr Moran added that there has been a significant increase in individuals reaching out to the National Gender Service to detransition, (pause or reverse gender transition), and suggested a designated programme to assist these individuals.
Despite this, advocates and campaign groups assert the necessity for a straightforward route to ensure trans youth receive gender-affirming care. Karen Sugrue, a mother of a trans child and a founder of the Mammies for Trans Rights campaign group, expressed that the current system is inadequate due to its failure to provide adequate assistance for trans children. This lack of support is driving children to makeshift healthcare – sourcing hormones online and self-administering injections.
The Health Products Regulatory Authority (HPRA), responsible for confiscating illegally acquired medication cannot quantify the prevalence of ordering cross-sex hormones, as these include testosterone and oestrogen. They cannot definitively tie seizures of such products to gender-affirming care.
In 2019, the World Health Organisation (WHO) stopped classifying trans-related disorders as mental and behavioural, reclassifying it under sexual health. However, Sugrue stated that in Ireland, there is an ongoing necessity to destigmatise trans individuals.
Sugrue advocates that teens and children seeking gender-affirming healthcare should pursue this via manageable stages on a transparent and well-outlined path. This should start with social transitioning, where an individual begins to represent their chosen gender identity, adopting new pronouns and names.
According to Ms Sugrue, young individuals who find positive impacts from social transitioning and are comfortable with their new identity, should be given the access to puberty blockers. Further, if they wish to proceed with the transition, she advocated the use of hormones.
Trans Equality Network Ireland (Teni) proposes that transgender healthcare should be catered to at the primary care stage, implying delivery by local community doctors or general practitioners.
BelongTo, an organisation advocating for LGBTQ+ youth, identified that Ireland has the utility to gain knowledge from best practices around the world, such as the UK’s Cass Review, and subsequently provide a protected healthcare model for the trans youth in the country.
Alliance of trans rights groups, named Trans Equality Together, has made a plea to the Health Service Executive (HSE) for an immediate introduction of a “person-centred model of care”, following the guidelines of self-determinism and informed decision-making.
Indeed, as indicated by the reaction to the Cass report, the discourse and scrutiny around appropriate methods of delivering transgender healthcare will occupy a significant position in the forthcoming years.