Dr. Philip Crowley:

I thank the Chair and members for their invitation to attend this meeting. I am joined by my colleagues from the HSE, Ms Caoimhe Gleeson and Ms Louise Mullen.

The HSE is working in partnership with Transgender Equality Network Ireland, TENI - the national voluntary organisation which supports transgender people in Ireland - to establish a recognised treatment pathway for transgender people, to support the requirement for gender recognition legislation and to develop information for health and social care professionals working with transgender people. I will indicate later why that is very important.

In the context of the issues which Ms Lacey and Mr. Giambrone have highlighted, I will first deal with the matter of gender recognition legislation. The HSE acknowledges that the decision to change one's gender and subsequently apply for a gender recognition certificate is often twinned with social and familial rejection - as Ms Lacey so powerfully described - and the loss of employment, both of which can result in high degrees of social and economic hardship. Thus it is important to recognise that these decisions are not made lightly, arbitrarily or without considerable sacrifice. However, the HSE also recognise that these decisions have life affirming benefits for the person and often complete a long and complicated journey of seeking to live legally and physically in his or her preferred gender. The HSE considers that the decision to change one’s gender requires a suite of clinical, surgical and psycho-social supports and interventions. It considers the process of gender reassignment and any resultant diagnosis or treatment to be quite separate from an application for a gender recognition certificate.

The HSE endorses a gender recognition process which places the responsibility for self-declaration on the applicant rather than on the details of a medical certificate or diagnosis. In doing so, the emphasis is placed on the process of legal recognition of that self-declaration as opposed to the legal recognition of the medical certificate and/or diagnosis. The HSE considers that this process would be simpler, fairer and, most importantly, pragmatic. It would certainly be easier to legislate for because it takes account of both transgender and intersex people with differing backgrounds and contexts. For example, this process is accessible for an applicant who may have transitioned years ago and who may not have any current medical interactions - nor wish to have such interactions - or applicants who may have accessed all of their care outside of the State, which is becoming an increasing phenomenon among the members of the transgender population for reasons of cost and access. The HSE considers that this process has the potential to minimise unnecessary stigma or hardship on the applicant. That is why we support it.

There is currently no agreed treatment pathway in place for transgender people - including, and importantly, adolescents - and existing essential services to enable the transitioning process, for example, endocrinology, psychology, psychiatry and speech and language therapy, are relatively under-resourced, oversubscribed and predominantly concentrated in Dublin. Certain surgical interventions are not performed in Ireland and can only be accessed in the UK or other jurisdictions. There is general agreement that this is appropriate, particularly in light of the small number of procedures that would be carried out here. The HSE, in collaboration with key advocacy groups and professional bodies, has begun the process of designing and agreeing a recognised treatment pathway for the transgender community, which includes children and adolescents.

There are a number of principles which will underpin the treatment pathway. It will take account of the World Professional Association for Transgender Health standards of care, version 7, WPATH 7, recommendations, particularly with regard to language and the contested area of diagnosis; it will use the term "gender dysphoria" rather than that of "gender identity disorder" in line with WPATH 7 recommendations and the wishes of the community; it will take account of adult, adolescent and intersex issues; it will be designed to ensure that both primary care services, namely, those services accessed through GPs, community mental health teams and allied health professionals, such those who work in the areas of speech and language therapy, social work and occupational therapy, and specialist services, for example, psychology, psychiatry, endocrinology and certain surgeries, can be accessed on a local and a regional basis; and it will be designed to empower professional bodies to provide services and supports through a clear, seamless and simplified process. The HSE recognises and acknowledges that the lack of an agreed treatment pathway is problematic for transgender adults, children and their families. It is, therefore, committed to ensuring that this pathway will be agreed and signed off on by 2014.

Reference has been made to resources and to information on transgender health care. In tandem with the development of an agreed treatment pathway, the HSE, will develop a suite of information and training resources to support health and social care professionals to provide informed care and treatment to the transgender community. The HSE is working closely with TENI in the development of these resources. It will draw on forthcoming guidelines from the UK, as well as from best practice in other jurisdictions.

In 2012 the HSE undertook a survey among our staff to ascertain the level of understanding of transgender issues. We received a fairly healthy 793 responses to our online survey, from which the following findings emerged: 90% have not had specific training in providing services to transgender people - that may not be a surprising revelation but it is fairly stark none the less; 32% knowingly provided health or social care services to transgender people; 19% have a good or expert knowledge of transgender issues; the provision of services to transgender people was greatest in the mental health and therapy counselling areas; 74% want training - this is the most positive finding from the survey; 75% want further information on transgender issues; 70% provided contact details in order that we might remain in touch with them; and 26% provided qualitative data in respect of the issues as they see them.

The HSE recognises that this is a new and emerging issue for many health and social care professionals and understands that clear and consistent information and guidance are required to ensure transgender people receive safe, appropriate and quality care. My colleagues and I will be happy to answer any questions members may wish to pose.