Jerry Buttimer (Cork South Central, Fine Gael)
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The purpose of our meeting this morning is to discuss transgender health issues. I welcome all our witnesses, our guests, Ms Vanessa Lacy, Mr. Broden Giambrone, Dr. Philip Crowley, Ms Caoimhe Gleeson and Ms Louise Mullen. They are all very welcome to our meeting.

Before we commence I remind the witnesses of the position regarding privilege. Witnesses are protected by absolute privilege in respect of the evidence they give to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to do so they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given. Witnesses are asked to respect the parliamentary practice that where possible they should not criticise or make charges against any person or entity by name or in such as way as to make him or her identifiable. Members are reminded of the long-standing parliamentary practice and ruling of the Chair to the effect that members should not criticise, comment on or make charges against any person or persons outside the House or an official by name or in such a way as to make him or her identifiable.

It gives me great pleasure to welcome all our guests this morning. As we approach the end of Pride Week in Dublin, it is appropriate that our committee convenes this morning to discuss the transgender health issues. I invite Ms Vanessa Lacey to make the opening remarks.

Ms Vanessa Lacey:

I thank the committee for this opportunity. I was wondering how many people would here given that the members are very busy at the moment, so I appreciate-----

Jerry Buttimer (Cork South Central, Fine Gael)
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I apologise for interrupting but Ms Lacey has reminded me that I should have said that apologies were received from Deputies Regina Doherty, Fitzpatrick, Dowds and Senator Henry. Deputy Kelleher sent his apologies earlier but he is here and it good to see him.

Ms Vanessa Lacey:

I spoke too soon.

Jerry Buttimer (Cork South Central, Fine Gael)
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I apologise for intervening again but Senator Healy had to leave to attend another meeting.

Ms Vanessa Lacey:

It is getting worse than "Countdown" here, I am like Carol Vorderman.

I thank the members, particularly the Chairman, Deputy Jerry Buttimer, for arranging this meeting. The idea for it emerged from a conference we had in Waterford in February. I appreciate this opportunity and also thank Paul for all his help.

To introduce myself, my name is Vanessa Lacey and I am the health and education office for Transgender Equality Network Ireland or TENI. I also sit on the committee for transgender health care in association with the HSE as well as other voluntary organisations of which I am a part, including Integration Waterford which includes all marginalised communities in our area of Waterford city - it looks at diversity and bringing that forward.

I want to say a little bit about language and differences. I am talking about gender identity. This is a deeply rooted feeling of being male or female whereas the term "transgender" is an umbrella term and refers to those people whose gender identity is different from what was recorded at birth.

In regard to myself, I appear before the committee today a very proud Waterford woman and a proud Irish woman. However, I am not a stereotypical Waterford woman or Irish woman. At the end of this month I will be 49 years of age. I was born in Waterford city. At birth I was identified as male. My parents and the midwives did not know my gender identity and the hospital staff or GPs could not have known my gender identity. However, my gender identity for as long as I can remember is female and always was. I do not get any prizes for that, that is the way it is, it is human diversity. It is nobody's fault, it is how life was for me.

As a young child growing up, I did not think there was anything wrong until my expression of my gender was either frowned upon or I was punished for it. In the 1960s and early 1970s in Waterford, being the way I am and being way I have grown up to be was not the run-of-the-mill. It was frowned upon so I conformed to my parents' and society's expectations. I went to a Catholic boys school and then I went into secondary school. I left school at 14 years of age after failing every examination I could possibly sit because I could not concentrate on what was going on. I conformed again and I was lucky enough to have two wonderful relationships with people, both of them female, and I was married and I have two wonderful children. My wonderful children have supported me through this process and this process has taken six years.

However, I have lost contact with most of my family members. My mother died two and a half years ago and prior to that she did not talk to me. Coming back to what I am going to speak about and to make the matters plain for everyone, I would point out that two and a half years ago my mother died and three years before she died my brother asked me if I was wishing to carry Mam's coffin. I said, "No. Not really, I have not really thought about it". He said, "That is good because I cannot imagine any member of this family wanting to put their arms around you".

It is estimated that 1% of the population experience some form of gender variance. That equates to around 50,000 people in Ireland. However, a small percentage of people transition to a new gender role or seek medical help for transgender-related experiences. As a country we are only coming to understand gender identity and the needs of our transgender community. I will highlight some of the issues. The World Health Organization defines health as not simply the absence of illness but the presence of wellness. Ireland's transgender population does not enjoy good health. In a recent survey carried out in Ireland it was found that 78% of transgender people had seriously considered ending their lives and, believe it or not, a startling 40% of people attempted to take their life at least once. The national average for suicide is 1.6% and this begs the question, how many transgender people are included in this 1.6% and how many people today are planning to take their own lives due to feelings of despair with regard to their gender identity?

I also seriously considered taking my life because I was afraid of the shame I would bring on my family. This is the impact of the lack of awareness of this issue in society. The high rates of depression, anxiety and suicidality are exacerbated by the fact that transgender issues have historically been doused in stigma, stereotyping and discrimination. The term used for this is "transphobia". This will take many years to combat and eradicate, allowing transgender people and their families to seek necessary treatments, procedures and legal documentation and move on with their lives in safety and inclusivity.

Access to health care is one of the most urgent issues facing the transgender community. Some transgender people feel so desperate and trapped in another gender that they need to undergo a transition from one gender to another in an effort to lessen the deleterious factors on their mental health. This may include accessing mental health services, hormone therapies and surgical procedures. Up to December 2012, transgender people received hormone therapy through St. Colmcille's Hospital in Loughlinstown, which is the major centre for endocrinology in Ireland. The patient figure in this regard has tripled since 2006. Currently, 160 transgender people are receiving this therapy. There is anecdotal evidence that some transgender people seek hormone therapy in the UK and other EU countries and that some purchase hormones through the online black market. Hormone treatments have been proven to alleviate stress and anxiety and are a medical necessity. It is vital that individuals are able to access these services in a safe and timely manner.

There is no doubt that this service needs to be expanded. The case for vibrant and healthy services is clear, as the long-term financial effects of the treatment can potentially be cost effective, allowing the person to return to the workplace or school environment, free to be himself or herself, in a society that is growing in awareness and accepting of diversity. Under the instruction of Dr. Philip Crowley, the HSE has made positive steps to develop pathways and provide a service to transgender people and their families. A transgender health working group was developed in 2011. This group consists of members of the HSE, Dr. Crowley, Ms Mullen, Ms Gleeson, Mr. Perry, Mr. Giambrone, myself and a member of GLEN. We appreciate everyone's services.

In 2012, research was carried out to ascertain the level of transgender awareness within the HSE, the statistics on which are interesting and are included in the packs which members have received. Following this, a series of events was arranged in the first half of 2013. As I mentioned earlier, a conference was held in February, to which we invited the president elect of the World Professional Association for Transgender Health. We have since developed and are delivering training to HSE staff and members of other organisations throughout the country who are in touch with transgender people. We are happy to be working in collaboration with Dr. Crowley's office.

TENI's objective is the development of a safe and accessible health service for transgender people. However, serious barriers remain. These can be overcome without huge financial strain. It may only take willingness to engage and collaborate. The key is engagement and collaboration. We have a good relationship with the HSE and welcome that we can meet with and discuss issues with it. Collaboration and engagement is key in this area.

In regard to children and young people, members will be aware from the press conference on Tuesday at which Senator Zappone's Private Members' Bill was launched that there has been an increase in the number of children coming out as transgender. For example, in 2012, TENI was contacted 80 times by families whose children and teenagers were exploring their gender identity. There is currently only one support for families of transgender people. It is called TransParenCI. It is a fantastic group which connects families with others with similar experiences. It was developed 18 months ago and has during that time become one of the biggest transgender family support groups in Europe. It is a positive development.

For some children, access to age-appropriate treatment is a medical necessity. For young people under the age of 16 years who have been diagnosed with gender dysphoria and are supported by family members, it is indicated that treatment with hormone blockers and cross-sex hormones can substantially relieve the negative symptoms of their condition and allow the young transgender person and his or her family to continue with their lives. Unfortunately, these services are not yet available in Ireland. This saddens me.

In some instances, young people go through child and adolescent mental health services, CAMS, and, if lucky, they are referred to the Tavistock clinic in the UK. I was informed three weeks ago that three cases were recently referred to that clinic. In other cases, clinicians are unaware of what actions to take and the child's life is put on hold, often with drastic consequences. Deputy Buttimer will recall that at the conference in February, a parent spoke of how her daughter had attempted suicide on a number of occasions, the last attempt being almost fatal. Luckily, the girl was saved and referred to the programme in the UK. Some parents take their children abroad at substantial cost to them. Others take the initiative and access treatments from overseas or on the Internet, which treatments can be dangerous if the chid is not medically monitored. These drastic measures are taken when the family's primary focus is to keep the child alive until the age of 16, when they can access medical treatment as an adult. This treatment has been researched and proven. It is important it is made available, even if this means experts training others in this area. We have contact with these experts and this can happen. Again, it is a matter of collaboration and engagement.

The medical treatment of young transgender people is often seen as controversial. However, research carried out to date suggests that these treatments and procedures are safe, that hormone blockers are reversible and that psychologically the patient does not suffer further dysphoria. There is clear preliminary data from the EU and US which indicates that young people have positive mental health outcomes following access to this treatment. These supervised treatments have many benefits. The child can develop and comfortably live in the desired gender and ultimately will be able to move on with his or her life and education. As human beings, we perform much better if we can be ourselves.

How can the committee help? As the rates of transgender people coming out are rising throughout the world, Ireland's health service must be competent in addressing the needs of its communities and families. Developing and rolling out training is key to enabling health care workers gain skills and feel confident in this area. As this training becomes widespread, it has the potential to upskill service providers, enabling them to provide a service locally. This can have the benefit of easing the bottleneck that currently exists in the endocrinology unit in St. Colmcille's Hospital. Expanding this service can have enormous benefits for all. In this regard, we would certainly require the collaboration - I apologise for my continued use of the word "collaboration" - of Professor O'Shea and his team. However, this is about more than Dr. O'Shea and his specialist team. Various departments within the HSE need to be involved as, collaboratively, we can provide this service with little impact on the economy.

In the longer term, education is key to decreasing and eradicating transphobia. TENI is engaging with educators in this regard with a view to developing educational tools that explain gender identity to all ages. I recently with a member of St. Patrick's College in regard to the provision of age-appropriate books on this issue to its students. It is hoped the students will have access to these books from next year. Education is the future.

If this issue is addressed holistically, it will certainly contribute to the welfare of the transgender person, and the education and support will contribute to decreasing and eradicating transphobia. I urge the committee to help us to facilitate this process and bring trans-related health care into line with that of other European states.

As I stated earlier, there is no service provision for younger transgender people in Ireland. However, and I will conclude on a positive note as I do not like to leave anything on a negative note, we are addressing this issue at present and there have been talks with CAMS and also with the paediatric endocrinology department of an Irish hospital. I cannot give any confidential information or I would probably be shot. If these talks lead to a reality, Ireland will be in a position to deliver a safe and quality service to transgender people using an informed consent model. There is a long way to go in these talks and that is why I did not mention the hospital, but I am positive that this will happen. Again, it comes down to the engagement and collaboration but I am very confident this will happen. These young people are our future and supporting them to be themselves will reap benefits for this generation and the next. It will allow families and people to move on with their lives. If we remove the stigma from this issue, people will realise there is no threat and there will be no fear of this. We can provide the health care and educate people and just move forward. This matter should not be an issue. We must move forward with this.

I thank the committee again and apologise if I took too much time.

Jerry Buttimer (Cork South Central, Fine Gael)
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Thank you. As always, you are well able to talk.

Ms Vanessa Lacey:

It is just hard for me to shut up.

Jerry Buttimer (Cork South Central, Fine Gael)
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Thank you for your moving personal testimony. It is always compelling to listen to you and I thank you for coming to the meeting this morning. I welcome the director of TENI, Mr. Broden Giambrone.

Mr. Broden Giambrone:

I wish to echo Vanessa's comments and thank you, Chairman. You have been a great ally to the transgender community and we really appreciate your support. I also thank the committee for joining us today.

There are urgent health care needs facing the transgender community of all ages in Ireland. However, I will take a few minutes to talk about another crucial issue that affects the transgender community, which is legal gender recognition. At present, transgender and inter-sex people in Ireland are unable to obtain birth certificates that show their true gender. Ireland has an obligation, as yet unfulfilled, to provide a pathway by which amended birth certificates can be issued. The State's obligation arises from international and European commitments on human rights. It is more than five years since the High Court declared Ireland to be in breach of the European Convention on Human Rights. So far, we have failed to find a remedy to this situation and the transgender community has waited too long.

Gender recognition is a public health issue. Birth certificates are foundational documents and are required for daily living. They are required for official purposes such as obtaining a personal public service, PPS, number, accessing social welfare and getting married. Individuals regularly come to TENI who are unable to travel because they cannot get identity documents in the correct gender. People have been denied placements in college because their leaving certificates are under one name and gender identity and the college has dismissed them because it thought that was an error. It is not an abstract thing but a very practical matter for many people.

A person whose gender does not match their identify document runs the risk of daily difficulties, but they also run the risk of being consistently outed as their birth gender. This can result in transphobia, discrimination and, in the worst case, violence. The transgender community across the world has high rates of violence perpetrated against it. In large part, this can be due to the confusion around the gender that people present and the gender as which they are legally recognised. The possibility of having legal gender recognition acknowledged by the law can have a profound impact on the daily lives of transgender people. It can facilitate people's ability to enter education, gain employment and access health care and other social services. Ultimately, it leads to a better sense of well-being. As Vanessa said, the rates of suicide attempts and suicidality in Ireland are off the charts. They are higher than anything I have ever seen. At 40%, we have a real obligation to do whatever we can to make people's lives easier.

In 2011, the Government created the interdepartmental gender recognition advisory group, which we call GRAG. It recommended what the process for gender recognition should be. It proposed that in order to be recognised an individual would have to provide a certain amount of evidence. I will not go through all of it because the report is in the public domain but I wish to refer to one issue, the medical evidence and the validation criteria. The group proposed that in order to be recognised one must have a diagnosis of gender identity disorder or have had gender reassignment surgery. This is a highly problematic proposal. First, by tying recognition to a diagnosis of gender identity disorder the Government will automatically exclude people who are inter-sex, because they will not be able to avail of the rights within the recognition. Three births in 200 are inter-sex affected, so this is not a minor community. It is a real issue for people as this is a significant proportion of our population. Furthermore, the nomenclature for the way we define diagnosis is already changing. The American Psychiatric Association has changed from gender identity disorder to gender dysphoria. It would be pointless to put an archaic definition into our law.

However, it is not just about terminology or who will not be included. It is also the fact that the approach has increasingly shifted. International human rights discourse has stressed the need to depathologise gender recognition and to acknowledge that legal rights should not be contingent on medical treatment pathways. Having a diagnosis of a mental illness can really reinforce stigma. Transgender people have often been seen as sick or mentally ill and have had their gender identity seen as something that needs to be fixed. This is not dissimilar to the fact that homosexuality also featured in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders some decades ago. Transgender people are still in it. There is a real stigmatising element in putting that into law. As one transgender person told me, "I am not disordered, I am just me". This issue must be highlighted and we strongly feel that it should not be codified in the legislation being brought forward.

At present, the current best practice in gender recognition exists in Argentina. Last May, it brought forward the best practice gender recognition legislation. It allows an individual to self-declare who they are. They are the arbitrator of their own identities and they can say that, put it forward and have it recognised by the state as such. This avoids the pitfalls of many of the GRAG's proposals, particularly surrounding the medical validation process. We advocate that gender recognition decouples medical interventions from legal recognition. We propose that the State use a statutory declaration process that affirms the transgender person's identity but also provides a legally robust process. It would not require any surgical procedures, hormonal therapies or any other psychological or medical treatments for an individual to be accorded their basic human rights. This position has been supported by the World Professional Association for Transgender Health, which is a professional body of over 650 physicians and mental health professionals who are engaged in clinical practice in this area. They are the international experts. This position has also been supported by the HSE.

At present, the Government is in the process of drafting heads of a Bill that will be put before the committee on education and social protection in the autumn. However, two Private Members' Bills have been produced. Last week, Senator Katherine Zappone, supported by Senator Jillian van Turnhout, introduced a Bill in the Seanad. The Bill was informed by best practice. It came from the transgender community and it is rights compliant legislation. We urge the Government to take up this Bill or to introduce a similar Bill.

There is no doubt that medical treatment and access to health care for transgender people are absolutely necessary. Vanessa made a very strong statement to that effect. However, transgender people, like all people, should be availing of the health system when they have a health need, not to obtain a legal right or to be legally recognised. Transgender people's health needs should be addressed by the health system and their legal needs should be addressed by rights compliant legislation. Anything else would run contrary to principles of human rights and dignity.

We are here to urge all Deputies and Senators to support legislation that will ensure that transgender people have a process to have their affirmed gender recognised under law, without having to go through restrictive or burdensome processes that will negatively impact on their health and their human rights. I thank the committee.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. Giambrone and I take this opportunity to welcome Mr. Ray Mitchell, parliamentary liaison, from the HSE. I now call Dr. Philip Crowley to make his opening statement.

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.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Dr. Crowley. I acknowledge the presence of Ms Caoimhe Gleeson and Ms Louise Mullen and thank them for their work and their advocacy. I should also point out that with us in the Gallery are Ms Orlaith O'Sullivan, Ms Sara Phillips and Mr. Ben Power from TENI and Mr. Odhrán Allen from GLEN. I welcome all our guests.

Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome the witnesses. I have a number of questions I wish to pose for my own information rather than for any other reason. In the context of growing up in Ireland, has Ms Lacey noticed any particular changes in societal views in recent years? We are trying to build a more tolerant Republic that is respectful and open in which groups and individuals will be respected for what they are as opposed to what we would like them to be. Has she noticed any changes in this regard? If such changes have occurred, have they given people further confidence in trying to establish their identities in an open manner? When people express themselves publicly and want to address their gender variance, it falls to the HSE and others to assist them in doing so. Obviously, therefore, the issue of resources is going to be key. In that context, has Ms Lacey noticed the development of a greater level of awareness among, for example, health care professionals?

One of the matters about which I, as a layperson, would be concerned is the high level of mental health issues among people of gender variance, to which Ms Lacey referred. Ordinarily, they can become very isolated and their first port of call can be their GPs or other care professionals. Does Ms Lacey believe enough is being done to highlight the issue of gender variance among medical professionals? Is the process of understanding beginning to feed into the broader health service?

It may be an indication that I have been around these Houses for too long but I still recall a time when people - even some in my constituency - openly campaigned against the provision of assistance to those of gender variance in the form of therapy and surgical procedures. I recall people protesting to the old health boards and stating that it was a waste of resources, etc. To be truthful, what occurred was quite nasty and insidious. I hope that the position in this regard is changing and that there is greater understanding among people in general.

It was stated that 1% of the population experience transgender variance. That is a sizeable number. If we were discussing a figure of 1% in the context of another matter, it might give rise to alarm.

All the 1% figures add up quickly to many individuals and people. Is there a general recognition at the highest level in the HSE, the Department of Health and the Government that this issue is not going away and that it must be addressed and dealt with in a meaningful structured way? I am asking because the gender recognition advisory group, GRAG, has been established. Will Dr. Crowley explain whether it is established under the Department of Health or another body? Where is it established? Does the HSE sit on GRAG and, if not, why not?

One of the witnesses cited Argentina as a model for gender recognition law. Are there any other countries not necessarily nearer but with a similar legal system to ours? Are there other countries of like mind or like make-up in terms of their legal and parliamentary restructures that would serve as a good template for us to examine the options quickly, in view of the fact that we are in breach of EU and human rights law? We need to address it not only because we are in breach of the law but because it is the right thing to do. Will the witnesses cite that?

I was jotting down notes as we have been going along so I do not necessarily have anything prepared. Some years ago there was a debate about the decriminalisation of homosexuality. There have been various debates about sexuality in general in the country, about family make-up and the various forms of family. It never ceases to amaze me that we almost have to be forced to make decisions about conferring rights on people because we believe that by conferring rights on people somehow we are taking away rights from other people. I cannot understand the logic but it seems to arise frequently in our society. There is an idea that if we confer a right or entitlement on one person then we diminish another person's rights or entitlements. That is probably a statement more than a question.

My final question is for Dr. Crowley. He made reference to the HSE working, supporting and understanding. Is there capacity within the HSE at present to train clinicians and care professionals? I am not making a political point, but is it seen for what it is in terms of mental issues, therapy, counselling, surgical supports and endocrinology and everything that flows from that? Is it genuinely seen as an important issue? I thank the witnesses for their presentations.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I welcome all on the panel this morning, including Ms Lacey and Mr. Giambrone, who addressed the committee on behalf of the Transgender Equality Network Ireland, TENI, as well as Dr. Crowley and those who have accompanied him from the HSE.

The statistics the panel have highlighted in respect of suicidal ideation among the trans population are most alarming. Suicide prevention is regularly an issue of address at the committee. I have it to say that the details raised have escaped the discourse to date, even at this committee. I welcome the fact that the members of the panel have highlighted them this morning because it is important that the seriousness of the matter is understood.

One point struck me from listening to and examining the contributions of Ms Lacey and Mr. Giambrone. I am unsure how to extrapolate the detail but I imagine it is like everything else relating to suicide and suicide attempts, that is, it is likely that we are not reflecting the full extent of it because we do not know the full extent. That is what it comes down to. As a society, we must come to terms with the fact that we have a high incidence not only of suicide but of suicide attempts and the underlying causes of suicidal ideation. We should be prepared, as a society, to step up to the plate and acknowledge that we are collectively contributing to this by our respective failures to understand, learn and broaden our awareness. Nowhere is this more in evidence than in respect of the testimonies that the panellists have given this morning.

I thank the panellists for their presentations. The fact that we are addressing the issues that impact on the trans population this morning is indicative of a changing outlook throughout society generally and that is to be welcomed. I commend people from all political backgrounds who have participated in this morning's engagement.

The panellists have left me with some concerns in respect of two of the contributions. Ms Lacey made reference to Senator Zappone's recently published Bill and Mr. Giambrone made reference to the fact that there have been two such Bills. However, he did not go on to say that Deputy McLellan and myself are proudly members of the party that published a gender recognition Bill only six weeks ago. I will not ask Mr. Giambrone to tell me what is deficient in it here and now, but he may have some comments. Our team worked very hard on bringing it forward and we are proud to stick our flag on it. I encourage all political parties and the political system to step up to the plate on this issue again. Political leadership is required as well as a willingness to do things. I commend my party colleague, the lead Deputy on the legislation, Deputy Aengus Ó Snodaigh. I am the health spokesperson but we collaborated on it. Deputy McLellan, who sits with me on the Joint Committee on Health and Children, and I are proud of the body of work that went into it.

I reckon the Chair will ring his bell shortly but I have a number of questions. Before I go to some of the questions one alarming point came across in Ms Lacey's contribution. She spoke about the services available to young people under the age of 16 years. It merits highlighting because in the next paragraph Ms Lacey stated that the family's primary focus was to keep their child alive until the age of 16 years. It is time for Ireland to waken up.

Ms Vanessa Lacey:

Absolutely.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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That is horrendous and I took the view that it needed to be highlighted this morning once again.

One common theme that comes across from the contributions of the two panellists and from the contribution of Dr. Crowley as well is the need for training and a growing understanding, awareness and acceptance. That is what it all comes down to, but I am heartened by the findings highlighted by Dr. Crowley, including the finding that 74% of the respondents are seeking training. That is encouraging.

I understand how difficult all of this can be across the board and without exception, irrespective of the circumstances of people in terms of financial backup and support and familial backup and support. What is the position among people from poorer backgrounds? What about the medical card dependent community? This affects people across the board. I am asking the question because it does not come across in what I have seen to date. Are trans people and transition procedures covered by the medical card? What services, treatment and therapies are available on the medical card? What after care and continuing care is available to those dependent on the public health system? Does the HSE and the Department of Health fund TENI or any other support group and, if not, why not?

Jillian van Turnhout (Independent)
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I, too, wish to extend my welcome to both TENI, Dr. Crowley and the HSE. I am relatively new to this issue and because it is relatively recent I am still struggling with my vocabulary.

I say that because it is an issue that is not widely discussed. I have tried to talk to friends, family members and others about it. I feel I am relatively new to the issue and they feel they know nothing about it other than what they read in a sensational media report which does not provide the knowledge and briefings we get as Oireachtas Members. For me, it brings home the reality that while we are having a really important discussion here, there is a wider societal issue. I was very struck by Ms Lacey's very moving testimony and the importance of her right to her identity. There is also the importance of family life, especially for children. Even as we grow older, family life and those family ties are very important.

Given my children's rights background, my questions are first on children and the process of identification and understanding. Where do they seek support? How do the parents help the child to have the vocabulary to understand that they are going through a process of realisation? I am saying this as an Oireachtas Member who is fortunate to get all the briefings and background. I get the vocabulary piece. In rural or urban areas the information facilities and supports are not there for the families and children. I am sure Senator Zappone will inform the witnesses of her excellent Bill, which I was very happy to support. At the launch on Tuesday it was very moving to hear from two young people with distinctively different experiences. One was being bullied in school and ended up with the only option of being schooled at home. That indicated a real failure of today's Ireland. When I listened to Ms Lacey, I became conscious that because so much of our education is delivered in single sex schools, we have to find a way to balance and deal with the issue.

I would also be interested to explore more about the inter-sex issue, particularly around birth certificates and carrying through.

No mention was made of older people. Can I just assume there are no issues there? Obviously I have been very focused on children, but given that Irish society is waking up to this issue in some way and that a ripple effect is taking place, will some people now come to a realisation that helps them to understand their identity and who they are?

I have a question about asylum seekers. From my meetings in direct provision centres and talking to different individuals, this is one of the issues leading to people seeking asylum. However, they are very often are put in very inappropriate accommodation perhaps with people of nationalities that would not have any tolerance of this issue. Is that an issue that has been raised?

In 2014, when these HSE plans are all cleared, they should come before the committee for discussion.

Jerry Buttimer (Cork South Central, Fine Gael)
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Five other members are offering. I call Deputy Kelleher.

Billy Kelleher (Cork North Central, Fianna Fail)
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I apologise to the witnesses, but I must go to the Dáil Chamber. However, I will get the answers from the transcript of the meeting and from the committee secretariat. I ask the witnesses not to take offence. I am just trying to show how busy we are.

Jerry Buttimer (Cork South Central, Fine Gael)
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We have five other speakers. I will take the first three together. I call Ms Lacey.

Ms Vanessa Lacey:

Can I-----

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Let me explain. The only reason I asked that is that I must speak on a Bill this morning and Deputy McLellan will continue for me. However, I am anxious to hear the responses.

Ms Vanessa Lacey:

Will I still answer Deputy Kelleher's question?

Jerry Buttimer (Cork South Central, Fine Gael)
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Yes.

Ms Vanessa Lacey:

There have been changes in society since I grew up in Waterford in the 1960s. Three and a half years ago before TENI could employ people through Atlantic Philanthropies, transgender issues were probably 30 years behind lesbian and gay issues. However, I am delighted to say that we have probably caught up ten of those years in the past three and a half years and we definitely have a momentum behind us and have certainly reached a tipping point. Society's attitudes are changing as we raise awareness and that is extremely positive. One of the main components of that is a group we have created out of that. Far from being a Frankenstein's monster, it is something absolutely beautiful. I refer to the family group, TransParentCI.

There is often a question about people regretting this process. The two main reasons would be gatekeepers stopping people from access to treatment and loss of family. As I have said, I will never get my mother back and will never get her peace of mind back. However, I believe others will in future.

We do not yet have data on mean ages. Whereas two or three years ago the mean age of people attending the groups was in their 40s and female identified, now younger people are coming out all the time and their families are supporting them through the parent support group. The resources are very limited but the family, health care and education are key. If it can be addressed holistically, it is a win-win situation and can be done really cheaply. It will not cost much money at all - it is a buy-in and we can provide training as we have outlined in our submission.

The second question was on health care providers and their attitudes. I am trying to break down barriers with them by showing a human face to demystify some of the issues and I am getting people to open up a bit. I have already presented to child and adolescent mental health services - it was important to get in there - and also to paediatric endocrinology as well as other services. Some people are willing to engage and others are not. Unfortunately, engagement with the main endocrinology service in Ireland is a problem. However, there is miscommunication with biggest providers of health care to transgender people in Ireland, GPs, who cannot even get a response to a telephone call, e-mail or letter. That can have serious consequences, especially when one has all the other issues with one's family, one's life and one's children.

When the GP cannot get a response to a question about a prescription, we are talking serious business. I know at the moment members are dealing with the abortion debate which is extremely serious and I commend them on all the work they are doing on that. However, let us not allow this situation to become worse in five years' time where there is a suicide letter left because of something as simple as a communication from health care practitioners. If anything I want to leave that message here today. It is a very serious issue that needs to be addressed. Communication, collaboration and engagement are key.

Access to colleges training GPs is a problem. We need to get the doors open and provide a service. We are competent to provide very good training and have had good feedback on our training. We do baselines and evaluations at the end of it so we have a good indication we are providing that. There is transphobia in services.

That is where the Health Service Executive could come in and say we should listen to these people who are experts in their field and that this is not some sort of whim. That is a serious suggestion that can be taken from this meeting.

Suicidal factors is an extremely serious issue in that 40% of people are looking at it. Those three questions filter in to some of the questions asked by Deputy Ó Caoláin. It is serious. I do not want to sound like a parrot repeating something but it is about access to health care, legislation, transphobia, educating people and young people being unable to access hormone treatment. That happened recently where the family had to get their general practitioner to contact someone in Barcelona to get a prescription to give a hormone blocker to a child because the child was suicidal. That is a service we should provide here.

I apologise to Deputy Ó Caoláin for not mentioning the Sinn Féin Bill. I should have mentioned it but I will cheer him up now by saying-----

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Please do. I am the grump here.

Ms Vanessa Lacey:

Here is another one across from him. During the Atlantic Philanthropies period, I worked in development work and we created TransParenCI, among other groups. We also created the Trans Groups in Ireland through which all the transgender groups throughout the country, including the parents group, would meet every three months and discuss problems, challenges and what they would do as a strategy. I am delighted to say that we are now an all-Ireland group, the Trans Groups Alliance of Ireland, and we work hand in hand with others across the Border. That is the future for us. We have had great experiences in that, and I hope that has cheered up Deputy Ó Caoláin-----

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Absolutely.

Ms Vanessa Lacey:

-----because it has cheered me up too. The issue of medical cards is a serious one. We are delighted that many of the treatments are provided through the HSE. Today is 4 July. On this day two years ago, at this time, I was under general anaesthetic in Charing Cross Hospital. Today, I am alive and extremely happy, although I am giving out about various issues, but at least I have the opportunity to do that. I am extremely happy that I undertook to do that, and I thank the surgeons for keeping me alive but, and there is always a "but", a number of areas stand out that are not covered, and one that is extremely important is laser therapy. That must be on the agenda, as well as voice therapy and other such treatments. Those are the two most important issues, especially when laser therapy can prevent complications developing after surgery. It is not typical to have laser therapy just for the removal of facial hair. It is to allow free movement in society. Also, it is extremely important to have laser therapy in other areas before surgery.

To answer Senator van Turnhout's question on transparency and family support, it is the key. I put a great deal of time into developing that group, and if I stop working tomorrow, I will know that I have developed that wonderful group which is moving from strength to strength. In 18 months we have brought them away for a weekend where they did therapeutic work with the fathers, mothers, siblings and children of transgender people, because it stops the situation I spoke about earlier. When all family members are brought in, it demystifies the situations around it. We are telling them the care pathways that are available, and that allows them to move on. We are dealing with it in a holistic manner.

On the education front, education is the key to ending transphobia because we are educating society. I would love to see age-appropriate books not just in second and third level education but in primary school. The key is to explain to children with age-appropriate literature that this is an identity issue. That will ensure children as young as two to five years of age are aware of their gender identity.

Mr. Broden Giambrone:

I will be brief. On the first question on gender recognition and like-minded countries, we are looking at Argentina because, as we say, that is the North Star. Europe does not have that North Star. The proposed recommendations of the gender recognition advisory groups are drawn from the United Kingdom's Gender Recognition Act of 2004. That was an important and progressive Act when it came in, but nine years on, it has become clear that it contains some major shortcomings, and pitfalls have arisen. Not everyone who should be able to avail of their right to be recognised in the UK is able to do so through that scheme for many of the reasons we have highlighted today, including issues such as the validation process, the panel process, and many of the imported schemes. That is probably seen as one of the more progressive ones but we have it on good authority and also from anecdotal evidence from the transgender community that it is not working. We are in a position now where we can make legislation work for the transgender community in Ireland.

Countries across Europe are now examining their gender recognition Acts. What is interesting is that, for the most part, most countries in Europe have gender recognition. In countries like Sweden it was introduced in the 1970s. While that was progressive in the 1970s, it is now considering updating it. Countries like Sweden and the Netherlands are in the process of examining introducing more human rights-based legislation. In the coming years, we will see more countries moving in that direction but, unfortunately, because the process was brought in at an earlier date, we are now looking at moving it forward progressively in Ireland because there is nothing in place, and that is a unique opportunity for us.

While the system in Argentina is different and is in a different context, it shares many of the same issues faced by Ireland. Looking to Argentina is useful. In the past year, more than 1,000 people have had their gender recognised and no issues have arisen. People have been able to avail of this process and the sky has not fallen in. There is a real utility in looking at that as a model.

On the final point, it is an opportunity for Ireland to lead the way in terms of human rights in this field. That would not cost anything but it would make a huge difference for a small group of people, and it does not have any significant pitfalls. It is important to keep that in mind.

In terms of the Sinn Féin Bill, I echo Ms Lacey in issuing my sincere apologies for not mentioning that. That was a fantastic Bill published on 23 May by Deputy Aengus Ó Snodaigh. I would like to commend him highly and Stephanie Lord, who did a significant body of work on that Bill, particularly in looking at the Argentinian model and trying to import that into an Irish context. Similarly, the Bill examines issues of self-determination, the integrity of transgender people, and human rights. That is another excellent model and I would encourage everyone to look at that Bill.

On the intersex issues raised, intersex issues are highly stigmatised in Irish society, even more so than transgender issues. For people who do not know, when we say "intersex" we mean a person who is born with or develops reproductive or sexual anatomy in a different way. Transgender people's identity is different from what was assigned at birth. For intersex people and intersex conditions, that is a little different. It is a highly invisible community but these identities can be quite fluid. There are more than 40 intersex conditions, some of which do not even have names. When someone is born with the condition, the doctors make the best guess they can based on those, but that can change. This area of medicine is not at its fullest and therefore what we see is that people might come to a different identity in childhood or in adolescence. That is the reason it is vital we have a gender recognition Act that can accommodate these individuals because if we do not do that, situations can arise where people are denied access to schools, which can put a major burden on their families.

The inability to support intersex families can further stigmatise people. This is a significant issue and both of the Private Members' Bills we are discussing would go a long way towards providing support for these individuals and families. The asylum-seeking community is another issue and something which has only recently been highlighted for TENI. People seeking asylum face multiple discrimination. They often face discrimination in their countries of origin and also face it when they come to Ireland. Individuals who have faced persecution or discrimination in their countries and are now claiming asylum here have come to us. They run into many issues regarding sex-segregated facilities. They have documentation from their country of origin which they could not change there because there is no gender recognition process. When they come to Ireland they cannot change their documentation here. Not only do they struggle with coming to a new country but they are further stigmatised in Irish society. This can be a real challenge.

Dr. Philip Crowley:

Several questions were specifically directed to me and I will attempt to answer them briefly. The HSE is committed to meeting the needs of the transgender community and I hope our presence here today alongside TENI is a clear demonstration of this fact. A question was asked whether we participated in the gender recognition advisory group. I understand it was an interdepartmental committee so the Department of Health was represented. We made submissions to it, as did a number of the specialists who work on our behalf to deliver services.

With regard to access to care, the medical card covers the services provided in Ireland to the community and should be provided with regard to people's needs without any discrimination. This is not to state access is not an issue and I will return to this point. It is fair to state services have developed through the pioneering efforts of a number of forward-sighted individuals who trained in the UK and gained expertise in the particular needs of the transgender community. We do not think this is adequate for the emerging community, which is why we have commenced the process to develop an agreed treatment pathway with more than one centre. At the same time we would not seek to have a huge number of centres where expertise becomes diluted. As with everything, and as we know from previous debates, there will be a balance between access and quality of care. We will try to increase access by creating more expertise and signing up other experts, particularly in endocrinology and mental health services outside of Dublin, which is critical for the community. This process is under way and we need to continue to dedicate ourselves to it. If asked we will bring to the committee the outcome of this process.

With regard to whether we fund TENI, we do not fund a large number of advocacy organisations but we do provide a small amount of funding to TENI to support the work of Ms Lacey because we see this particular community benefits hugely from the informed support someone such as Ms Lacey can bring, which is far ahead of what many of our staff could bring to members of the community. It creates a bridge between the community and the services which, as we start to develop them on more competitive basis, is critical. This is why we provide funding for the post.

Ms Lacey asked about laser therapy and voice therapy. It is easy not to take such therapies seriously. Ms Lacey can explain much more eloquently how critical such services are to making a successful transition. I understand we do not fund these therapies at present and they may be the victim of a sense they are purely cosmetic. I certainly understand this is not the case and it will be part of what we must examine in developing an agreed treatment pathway.

Colm Burke (Fine Gael)
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I thank the witnesses for their comprehensive presentations. With regard to the survey which showed 90% of service providers have not had specific training, for which group in the health care sector does Ms Lacey believe training should be prioritised? Will Dr. Crowley tell the committee what is the programme for the next one to two years in terms of the provision of training? According to the survey, 74% of people indicated they wanted training. Is there a planned approach on this and when is it likely to be rolled out? Which sector needs to be prioritised to ensure those dealing with this issue have the required training and skills?

Catherine Byrne (Dublin South Central, Fine Gael)
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I am constantly reminded when I sit in this room of how privileged I am to be a member of the committee. I have repeated this a number of times but it is a fact. We sit here as public representatives but when we leave this room many of the groups which have made presentations to us have left an impression.

I need to make many notes because I have a head like a sieve. Ms Lacey and the other witnesses are welcome. I found Ms Lacey's words moving and uplifting. Knowing who one is inside is very important, no matter what one looks like on the outside, and this is something everyone can learn. I am sure the witnesses are aware that at present the committee is discussing the Protection of Life During Pregnancy Bill. The section on suicidal tendency has openly divided members of my party and others in various groups. Listening to the presentation I was struck to hear 78% of the community have considered suicide because they feel different. This is an enormous figure and I was very disturbed to hear it.

The Chairman does not like me telling stories because he thinks I go on too long but I will keep this short and sweet. I grew up in a large family and I was a girl in the middle of boys. I was the tomboy on the road because I did not look for a doll or a pram but played cowboys and Indians and football out the back. I am still identified by many local people as a tomboy because I wear trousers and have short hair. For whatever reason I met a lovely boy who became a lovely man and who is now my husband. I have a handsome son and four lovely girls. When I meet people who are different, whether it is how they dress or look, I am reminded that inside of them there is a deep sense that who one is is who one is.

I visit various schools to speak to transition year students and I am amazed at the questions they throw at me about who they are and where they are going. I always state that being oneself is probably the most important thing any of us can be. I have great hope in the young people of the country. They are open and non-judgmental about the colour of one's skin or how one speaks or looks.

Ireland is in for a huge change in the coming years. It will be a different and better Ireland. We have started this change. We can see the difference that pupils from other countries make in a school. When I was growing up one looked at an atlas to see where Africa is, but now pupils sit beside somebody from Africa or elsewhere.

There is great hope, particularly given our young people. Sometimes we see them negatively but, from my experience in the community and of giving talks at schools, the situation is different. There is nothing wrong with being different. Whether we believe in the man above or not, we were all different when we were created. He broke the mould after every one of us. It is important that we each have our own identity.

I will not comment on what our guests have requested, as I have heard it from everyone. I am interested in reading poetry and books, although I am not an intellectual who sits with a book every night of the week. Usually, I leave here for home very late and read the first two pages, and my husband takes my glasses off in bed.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy should not go any further than that.

Catherine Byrne (Dublin South Central, Fine Gael)
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I am happy to say I will not. The Chairman will embarrass me, and I am not easily embarrassed. I hope my husband is not watching this.

I will conclude on a quote that sums up what our guests have been saying: "In the Violet Room, she closed the door, And when I came out, He was no more." These few lines express everything that our guests have said. I thank them and I enjoyed their presentation.

Sandra McLellan (Cork East, Sinn Fein)
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I am delighted to welcome our guests and to thank them for their presentation. To be honest, it is not a subject about which I am well informed. As other members have stated, we are lucky that various groups appear before the committee and give us the information that we need. Since many of the questions that I was going to ask have been covered, I may make a few points instead of asking questions.

The suicide statistics are frightening. I cannot believe that 40% have attempted suicide and that 78% have had suicidal tendencies. This was an eye-opener. I have never given much thought to when children identify. The two to five years age group was mentioned. I am shocked. I would have expected it to be in the teens. A point was made about what families must deal with, including trying to keep their children alive until they reach 16 years of age. This is new and frightening information to me.

I noticed that 74% would like to be trained. Are there plans to roll this out? It was mentioned that the cost was covered for public patients, but who covers the cost to those who do not have medical cards? Perhaps I missed it.

Transphobia remains a serious issue. Will our guests outline how they challenge it, seek to reduce it and, hopefully, eliminate it in their work?

It was stated that, as hormone treatment had presented positive outcomes, an increased availability would be welcome. Are there plans to increase its provision?

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I thank our guests for their moving presentation, which I have just read. I missed a little of Ms Lacey's part. This week, the select committee is debating the Protection of Life During Pregnancy Bill 2013. There seem to be such absolutes in Ireland. One is absolutely male, absolutely female or absolutely pregnant and would never think of suicide. I thank our guests for shining a light into Ireland's dark corners and for demystifying what is happening.

I am conscious that young people watching this meeting may be wondering where they will go. What simple advice would Ms Lacey and the others give to these young people, to any mother, father or relation who is worried or even to older people?

The network provides a pack. I have looked through the booklets - they are good and informative and tell the stories of different people. They are definitely worth reading. I would appreciate it if our guests could offer that advice.

John Crown (Independent)
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I apologise for not being present at the beginning of the presentation. I wish to make a point and ask a question. In Irish health care, there is a strange intersection of publicly funded institutions that are privately owned and accountable to entities that are not appointed by the public. This is a long way of saying that we have many hospitals that are run by the religious. Is there any indication of systematic discrimination against the needs of trans people by hospitals? I note that the institution where most of the trans-related endocrinology takes place is St. Columcille's Hospital in Loughlinstown, which is staffed by fine people but would not be considered a national centre for anything. I am not saying this disparagingly. My colleagues from St. Vincent's provide the consultant care there and it is a regional hospital that, for historical reasons, provides some of the overflow services for endocrinology and obesity work, which cannot be done at St. Vincent's. Are the main university hospitals stepping up to the plate and doing what needs to be done or is any of them systematically saying "No".

With reference to the point on endocrinologists not answering the issue, our guests might take that matter up with Dr. Crowley and ask why the HSE and the Department of Health have conspired over the years to give us the smallest number of specialists in every speciality of any country in the OECD, typically running at figures that are approximately 70% of the UK's figures, which in turn are approximately one third of the continental figures, giving us a figure of one in five of the recommended number by international standards.

Katherine Zappone (Independent)
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I commend the presentation of Ms Lacey, Mr. Giambrone, Dr. Crowley and his colleagues from the HSE. They depicted a terrific picture of collaboration and partnership, as Dr. Crowley indicated in some of his comments. As a lawmaker, such a progressive partnership and collaboration is heartening and gives me hope as to the development of this area for transgender people.

I wish to ask Ms Lacey a couple of questions. As many of my colleagues indicated, she spoke movingly about her experience. Will she share a little bit more? She stated that she was not recognised in law as an Irish woman. If she was, and when she will be, as it will come, how would it make a difference to her family?

Ms Lacey provided the estimate of 1% of people being transgender and stated that 160 people presented at St. Columcille's Hospital and that 80 young people's families had contacted her. When we enact law for the recognition of transgender people to their preferred identities, will this percentage increase?

How Dr. Crowley outlined his presentation in terms of treatment pathways, the legal issues and the information and awareness training being provided to staff was brilliant. My question on a timeframe for the process is virtually the same as Senator Burke's. The HSE made submissions to the Gender Recognition Advisory Group, GRAG, but some of Dr. Crowley's comments about what we need in terms of law seem to have moved beyond its report's recommendations. That report is two years old.

I have commended Sinn Féin on its Bill publicly and via media statements. I have also discussed my Bill. It is critical that lawmakers have two different approaches. It is important that we act. Legislation could be initiated in both Houses. Dr. Foy was mentioned. It is in respect of her case that Ireland continues to be in breach of international human rights law six years later.

I do not know if members are aware but Dr. Foy has initiated new proceedings because Ireland has not acted when found to be in breach and six years have passed. It is critical that we act.

Jerry Buttimer (Cork South Central, Fine Gael)
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I compliment Senator Zappone on her Bill and thank Sinn Féin also. It is appropriate we salute Dr. Lydia Foy for the campaigning work she has done.

Ms Vanessa Lacey:

I refer to generationality. Senator van Turnhout mentioned older people. We work with people as young as 82 years of age to children as old as six years of age. They all experience very different things. We have an ageing community. We are all getting older but, I suppose, it is great to get old because at least we are alive. Older people, many of whom have lost their families, are getting old, they are going into institutions and they will be alone. We need a service there. That is something which, I suppose, has been overlooked. We need to think seriously about providing a service to older transgender people, as they get older. Younger people being supported by their families will have had a different experience, as will those in the middle and the children of transgender people. We need to take a holistic approach. TransParenCI is totally under-resourced, which is an issue. TENI supports that organisation.

I refer to Senator Colm Burke's question on whose priority it is. I think it is across the board. One would think endocrinology and mental health care are a priority but I think it is across the board to social care and so on. I gave a full day's training to Youth Work Ireland on Friday. It was very interesting and a great training day. Again, it is a priority. All of these things are a priority. This will go on for years because training was not provided before but now it is and I thank Dr. Crowley and the team for that.

I thank Senator Zappone for sharing that. I always say to my 13 year old and to my 17 year old, who has just done his leaving certificate, that education is the key. I gave presentations to fourth, fifth and sixth years in Newpark Comprehensive, Blackrock, which is probably the best school in Ireland. Walking into the room is a terrifying experience because I am a 6 ft. 3 in. transgender woman and I suppose that is very intimidating. I normally bring in loads of sweets to soften people before I start. However, I am conscious that there could be some negativity but I have to say that of hundreds of students, the feedback was amazing. They were like bunny rabbits sitting in the seats and lapping it all up. I got e-mails afterwards commending the training and the experience. This is the way forward. Again, one is just speaking about a difference. It is a very positive thing but one needs to get into the schools to educate the next generation. I love this generation because I have two inspirations at that level, namely, my own two kids. That is key.

I refer to transphobia. It comes back to Senator Zappone's contribution. I do not want to keep going on about it but education is the key. Positive media work is important and it has been happening in Ireland. Ireland has been very successful because we have a population of less than 5 million, so it is easy to educate it. We are at a really good point here. By looking at a holistic service, health care and legislation, we can nail transphobia in the schools. We can do it really simply. It is very positive in that respect, living in this wonderful country. I love this country so much. That is the way to go forward. Educating about difference will get rid of transphobia.

I refer to the work I do with Waterford Integration Forum. Marginalised communities come together to educate each other and society. We are all diverse, we are human beings, so it is natural.

In response to Deputy Mitchell O'Connor, I mentioned younger and older people. People have different experiences. I would tell people to contact us to see if we can help them. We are limited by resources. We have two full-time employees and one part-time employee and at times, it is difficult to get to everyone, as the rates are rising. I hope we get more money in the future but that is another issue, although maybe it is the issue.

Senator Crown referred to discrimination in hospitals. There have been cases of discrimination.

John Crown (Independent)
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Is it systematic? Are there hospitals which will not deal with the health issues of transgender people?

Ms Vanessa Lacey:

There have been a couple of cases in one particular hospital.

John Crown (Independent)
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I have been told there is one hospital which has a blanket policy that it will not deal with people who have health issues related to it.

Ms Vanessa Lacey:

I am not aware of that. I know of one hospital and there are a couple of ongoing cases. I cannot say too much but I have given training to some of the staff there, so it has taken steps. It had to take the steps because of the outcome of a case.

Jerry Buttimer (Cork South Central, Fine Gael)
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Without naming the hospital, is it a publicly funded one?

Ms Vanessa Lacey:

It would be.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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Would its board of directors have some kind of an ethos?

Jerry Buttimer (Cork South Central, Fine Gael)
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We might talk about that in private session.

Ms Vanessa Lacey:

Senator Zappone asked how I would devise legislation. I would be able to change my documentation and, to go back to the talk I gave in the Council of Europe a few weeks ago, be legally recognised as an Irish woman. I had my grandfather's medal from 1921. I am quite proud to be an Irish woman and I would like to be respected as part of Irish society, which would feed down to my kids who are extremely proud of me. I am proud of them also. We must have legislation because I want to be part of this society. At the moment, I do not feel quite part of it but I am hopeful this country will do the right thing. I am sure members will do the right thing. If they do, I will bring in some of the sweets I gave to the fourth, fifth and sixth years.

Jerry Buttimer (Cork South Central, Fine Gael)
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We are not available for that-----

Ms Vanessa Lacey:

Really.

Jerry Buttimer (Cork South Central, Fine Gael)
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We are above reproach.

Ms Vanessa Lacey:

The members do not want the ones I brought in.

Catherine Byrne (Dublin South Central, Fine Gael)
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We accept gifts of any kind.

Ms Vanessa Lacey:

I thank members for their questions.

Mr. Broden Giambrone:

In response to Senator Zappone's question on whether a recognition law would mean the numbers go up. As it stands and of the estimated 1%, many of those individuals experience gender variance. Not all of those individuals will pursue medical treatments or would want to be recognised. However, the issue of recognition is not just about changing one's documents. That is a very practical side of it and has real effects on real people's lives, but it is also very much about the State recognising transgender people exist in society. That is a significant component of it as well. It is not an abstract idea. Transgender people exist but they are often invisible. Many people will say to me that they have never met a transgender person, which may or may not be true. I am transgender and most people would never read me as transgender because I am not visibly transgender. People may know more transgender people than they think they do.

Recognition is about documents but it is also about the State seeing one and making the invisible visible and about acknowledging that transgender people pay taxes, go to school and have jobs. When one has recognition, people will be less scared of coming out, less scared of telling their families, less scared of losing their jobs and less scared of all these barriers which prevent people from being able to be who they really are.

By moving this forward in a progressive and inclusive way, it will bring people out of the shadows.

I do not know if the numbers increase but visibility and the number of positive experiences will.

Dr. Phillip Crowley:

I will answer the questions directed at me. There are two aspects to training. One type of training we will require is training a wider cohort professionals to provide expert care. That will evolve from the pathway of care process. If we identify other centres where particular services will be provided, personnel should be peer trained from existing centres and perhaps peer supported for a period of time. In creating access we do not want to diminish quality.

The second aspect of training which is very important is awareness raising, which is an important first step. I would prioritise general practice in terms of awareness raising, training and articles in the forum journal, and we can help to ensure that happens.

There are other priority groups. For example, allied health professionals have key roles. It is an area in which there are a couple of pioneers who are seeking to provide care, which is very centralised, and perhaps through them we can work with colleagues to provide a more accessible service. Administration staff need to be trained in records, which are important and this links to the points made by Mr. Biambrone and Ms Lacey. It is another area we need to prioritise.

In regard to medical cards, I understand people can still access services. The real issue is that people with funding can bypass services by accessing them elsewhere but waiting lists remain. That brings me to Senator Crown's question. I am very disappointed he is not present to hear the answer. He highlighted Loughlinstown Hospital as being the centre for the endocrinology service. That happened by chance because we have a very well qualified specialist who has had access to training. He could be working in any hospital, but perhaps not that to which the Senator referred. I would be very interested to hear what hospital that is. He may be able to tell me outside of the committee. I commend it for the service delivers and would not denigrate it because it is not a university hospital.

In regard to some of the questions on partnership, the directorate I lead is entirely committed to partnership with communities, families and patients. Throughout my career I have sought to create those types of partnerships. I do not believe that with what is coming down the track in regard to what is right, wrong and ethical, we should just deliver care to people. Rather, we should deliver it in partnership with people.

A very capable organisation like TENI is an obvious partnership for us because we are, relatively speaking, clueless in regard to the issues. If we think we are not then we are in trouble. The first step of awareness is understanding what one does not know. That has been very educational for us and is a partnership I hope will thrive, notwithstanding the pressures on us all in our different roles and the need for TENI to be independent advocates, which they will continue to be. We will still, it is to be hoped, have a space where we can work in partnership with it and commit to doing that. I have addressed all the questions directed to me.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the witnesses. I compliment Ms Orlaith O'Sullivan, Ms Sara Phillips and Mr. Ben Power for their work and, in particular, Mr. Odhrán Allen from GLEN who has been a strong champion. I thank them for attending the meeting and wish them continued success, not just in bringing about change but in creating it, their role in advocacy and helping people who are on this extraordinary journey.

I remind members that the Select Committee on Health and Children will meet next week to discuss Estimates. They will get notification of that in due course. Next Thursday we will have a meeting with the Ombudsman for Children, Ms Emily Logan.