Professor Donal O'Shea:

I thank the committee for the invitation to present. I have listened with great interest to all the presentations, which have been informative to me and, I hope, to the process. I am an adult endocrinologist and, therefore, I deal with adults who have gender dysphoria. I have liaised with our faculty of paediatrics and with one of the UK experts in the paediatric management of gender dysphoria as part of my ongoing work. Numbers were alluded to earlier and the group is not capturing everyone. It needs to capture all because there are 50 new cases in the paediatric age group in Ireland every year. Gender dysphoria has replaced the term "gender identity disorder" in the recently revised American Psychiatric Association's classification of disorders. "Disorder" has been removed from the terminology and there was talk that the entire condition would be removed from the classification of diseases, which would have been seen as a positive step by many but which might have left it without a medical management framework. A great deal of medical input is required for many of these individuals.

In Ireland the diagnosis is confirmed by a mental health professional - a psychiatrist or psychologist - and then there is a referral for hormonal therapy which is available here. Medical services are not wide enough in this country yet but they are improving. After approximately two years on hormonal therapy and-or living in role, the individuals are referred for surgery. Some surgery is available in Ireland - breast and uterine surgery - but full complex surgical reassignment is carried out either in the UK or Belgium through the HSE treatment abroad scheme. The waiting time is approximately two years from referral. We have had 246 patients through our adult service in Loughlinstown hospital over the past ten years, of whom 25% are or have been married.

The learning in our unit from the past ten years that might inform the proposed legislation is that it is in the best interests of this overall group of patients that a medical supporting statement form a part of the validation process. It would have to be minimally intrusive and from a recognised, regulated specialist in the area. This would protect a minority of patients within the overall group who think they have the condition but who do not. Self-declaration alone would support this minority in what is a personality disorder and potentially worsen their outcome. Legislating for any minority is difficult. In legislating for gender dysphoria, we need to be aware of the potential impact on a minority within that cohort that I have seen over the past ten years have bad outcomes. Many of the patients with gender dysphoria who attend our clinic do not have contact with other transgender patients or support groups because they want to move forward exclusively in their preferred gender. The issue of age in this legislation is important from a constitutional point of view but the most important age from a medical point of view is puberty, which obviously cannot be legislated for. Before puberty, there is a reported 20% desist rate, which is change of mind after the process moves forward. Following puberty this falls rate to less than 5%.

Transitioning and the diagnosis of gender dysphoria does not require hormones or surgery and any letter of support would not have to include that stage or concept. My reading of the current heads is that the intersex group, which is extraordinarily complex, would be comfortably catered for within the legislation, as drafted. I am grateful for the opportunity to comment.