David Cullinane (Waterford, Sinn Fein)

I welcome the opportunity to set out Sinn Féin's position on gender identity and trans healthcare. I welcome all of the guests in the Public Gallery as well. Too many trans people in Ireland are being left waiting years for care. This is not about numbers or statistics. It is about people's lives, well-being and dignity being put on hold. The delays, the uncertainty and the sense of being bounced around a system that is not fit for purpose cause real harm and distress. We cannot, should not and will not stand over that.

Let us be clear about the scale of the crisis. Trans people in this State can be left waiting years and years for appropriate healthcare - not days, weeks or months but years. I know of some people who were on waiting lists for 14 years or more. Over 2,000 people are now on a waiting list for gender identity healthcare. The national gender service in 2024 had a wait time that could range from between three and ten years and, as I said, I know of people who have waited longer. This is the reality that trans people and their families are living right now, and we should and must say it plainly. Those waits are completely unacceptable. They are a form of denying healthcare by delay. They push people into a prolonged period of uncertainty, distress and avoidable harm. What does it mean to a person who is added to a long list? It means that if a trans person is added to a list today, they tell us and they feel genuinely a sense of hopelessness. They know they are going onto a list where they may not ever be seen or will certainly not be seen for years. It leaves them in limbo and without adequate supports in the meantime.

This cannot be described as a humane system. In fact, it is the opposite. It is not a healthcare system worthy of the name and is certainly not an equal system. I say clearly that Sinn Féin approaches this issue from a foundation of equality, rights and compassion. Trans people are entitled to live safely and openly, to have their identities respected and to access healthcare on the same basis as everyone else. Our health policy in Sinn Féin is explicit about that. We recognise transgender people's right to recognition and to the best possible supports and care.

We recognise that healthcare is a fundamental right for every citizen, including trans people, and we recognise that adult trans people must be able to access evidence-based gender-affirming care in a timely and respectful way. For me, this point really matters. Appropriate healthcare is not some optional extra. For many trans people, gender-affirming healthcare supports their physical health, their mental health and their ability to participate in daily life. When people can access timely and well-supported care, it is in the best interests of that person, their families and society as a whole, but it also improves outcomes. This is what evidence-based healthcare is meant to do - help people to live healthier, safer and more fulfilling lives. We approach this as we should approach every healthcare issue, from the standpoint of need, evidence and human dignity.

I support reform in this area, as does my party, and I support a new model of care for gender identity services. I want to see an holistic, properly resourced, modern service that is safe, accessible and delivered closer to people in their own communities. I support an expanded role in primary care in this area, but I also know it has to be resourced to meet the needs of the trans community. We want waiting lists to be cut dramatically. We want more specialist capacity, more trained clinicians and clear national pathways so that people are not left in limbo. That has to mean concrete change, not some vague aspiration as was talked about earlier. It has to be mean properly staffing specialist teams so that the national gender service is no longer a barrier to care. It has to mean regional and community-based healthcare so that care is not centralised into a single overstretched pathway that simply does not work. It means equipping primary care with training, clinical guidance and the resources needed to support trans people safely and respectfully from the first point of contact. For many trans people, that is not the case, and they are not treated with respect. It also means publishing clear national standards so that people are not left guessing how the system works or where they stand within it. We would not accept that in any other part of the health service.

I recognise that a clinical review of the model of care is under way and I commend everybody involved in that. I have also met senior officials involved in this area, so I know there is a significant body of work under way. I welcome that. It is crucial that this review, and any review, into gender identity services and healthcare be carried out on the basis of genuine consultation and listening to the lived experience of the trans community. This review must be completed and its findings, where appropriate, implemented. However, we cannot allow review to become a substitute for action. I welcome the Minister's comments that interim measures can and should be taken as we await a new model of care. I understand that will take some time, but we can take steps now to improve the situation because the situation right now, today, is unacceptable. We need reform urgently. We also need investment and delivery, because any plan is only worth the investment that is behind it.

I also underline the importance of listening. Consultation cannot be a box-ticking exercise. Trans people are experts in their own lives. They know where a pathway breaks down. They know what it feels like to be delayed, dismissed or treated as if their reality is up for debate. If we want a service that works, we must build that service with the people who rely on it. Listening also means recognising the emotional aspect of their lived experience. When trans people tell us the current pathway feels like gatekeeping, which it is, and feels unsafe, which for many it is, and feels designed to slow down rather than support them, we do not and should not argue that out with them. We have to accept what has been said, learn from it and fix it. At the same time, reform has to be done right. Healthcare must be guided by clinicians and grounded in evidence. The pathway for any person must be respectful and dignified but also clinically robust. I do not see this as a contradiction. The Minister made similar points earlier. It is what good healthcare looks like. Some people experience the current system as gatekeeping, as I said, and certainly distressing and very slow. We must listen to this, and we must act. I hear that clearly. I have met many trans people, groups that represent trans people and others. Those experiences we hear have to shape how services change. They have to be at the heart of how those services change.

Clinical assessment is a legitimate and necessary part of healthcare, especially where decisions involve life-altering or irreversible interventions. This is not about denying care and should not be about that. It is about ensuring the right care delivered safely for each person. Part of having a respectful debate is being honest about what good healthcare requires. This is why my party takes a measured position on the model of care. Informed consent is an essential principle in healthcare. People, of course, must have autonomy, clear information and real choice, and today trans people very clearly do not have that.

It must never be the case that someone is put through needless barriers or treated without respect. However, informed consent on its own cannot replace clinical judgment. The best approach from my perspective is shared decision-making where a person's autonomy is, of course, fully respected and clinicians still determine what is clinically appropriate and safe. This is how we build services that are both compassionate, which they should be, and clinically sound, which they should be. It means clear timely information. It means assessments that are designed not to delay but to improve. It means clinicians who understand trans lives and people, and provide care without stigma.

I also want to address the important issue of international standards, which is subject to ongoing debate. I share the ambition to align Ireland with best practice which is what we should always do in any element of healthcare. However, we must be honest that there is active international clinical debate about elements of care particularly for young people. I do not believe we should lock Ireland into any one international model uncritically. Our job is to ensure that the Irish model, our model, is evidenced based, listens to the lived reality of trans people, is guided by clinicians and built on the outcome of Ireland's own ongoing review, alongside evolving international evidence. It should never be about resisting progress. It must be about ensuring progress is durable and safe for all. Respectful dialogue matters here which is why we need discussion that is calm, evidence based and rooted in rights. Trans people deserve to be heard in that debate. Families deserve clarity. Clinicians deserve space to do their job properly and society as a whole deserves public discussion that is humane, truthful and responsible.

We need to be especially careful with children and adolescents. I recognise the profound distress that some young people experience. We recognise the services for young people are inadequate and need urgent development because nobody benefits from a vacuum of care which is what exists at the moment. Under-18 pathways must be built with stronger safeguards, specialist oversight and an evidence-led approach reflecting the seriousness and complexity of these decisions. Our position is to ensure that the care offered is the most protective and clinically sound pathway possible. We also understand the impact that these long waiting times can have on the mental health of young people. We need services that are available, safe, specialised and properly supported. Those services need to respond quickly while ensuring appropriate safeguards.

The motion also refers to conversion therapy. Sinn Féin supports an effective ban on conversion therapy, including coercive practices targeting trans people. This is a rights and protections issue. Legislation must be drafted precisely and clearly. It must target abusive or ideological conversion practices while not creating unintended consequences that criminalise legitimate clinical practice or parents supporting a child through distress. I believe that a strong ban is achievable, desirable and should be put in place. It must be tightly drawn so that it protects people and supports appropriate healthcare.

On the wider issue of legal recognition, we must be clear that the proposals set out in this motion go well beyond healthcare - I am sure the authors would agree with that. They raise serious legal and policy issues that have to be properly worked through. In particular extending legal recognition to minors and introducing new statutory categories for non-binary recognition cannot be treated as add-ons to a health debate. These are changes with broad implications for law, education, data systems and the rights of others. They require very detailed legislation and careful whole-of-government consideration. We will not support sweeping legal changes brought forward without fully considering all potential consequences. Recognition matters and dignity matters but so do clarity and legal certainty. If reform was or is being considered in this area, it must form part of a separate robust piece of work that can be properly and fully scrutinised rather than through a healthcare motion.

For me the central point is this. Ireland's gender-identity services are failing people. They are certainly failing the trans community and others. This failure is not abstract as was said earlier. It is measured in years of waiting, in distress and in lives put on hold. We need to support a new holistic model of care that is property resourced, clinically led, community delivered and grounded in rights and compassion. We support timely evidence-based gender-affirming care for adults. We support making the system more respectful, more assessable and far faster than it is today. We insist that reform must also be safe evidence based and built with appropriate safeguards for young people.

I say to the Government that we have to stop the drift. We need to complete the review and not to rush it because it is important work. We must listen to the trans community. We also have to listen to clinicians. We have to publish clear guidelines and timelines, and expand capacity now. This is an urgent issue now for people. We need to train and recruit clinicians who understand the needs of trans people and build a modern service that trans people in Ireland deserve. I think we can do this with empathy, with respect and with a commitment to healthcare that is both compassionate and safe.

I will finish where I began with people living this reality. Behind every number that we talk about is a person waiting for a first appointment, a person trying to get on with their education or job, a person trying to hold a relationship together, a person doing their best to stay well, a person just trying to live their life. A system that constantly delays and tells them they have to wait, in some cases for 14 years, is clearly not acceptable. It does not have to be this way. I believe we have the ability in this country to build a modern service fit for purpose. What we lack is urgency. We certainly need the resources and the capacity put into the system. Our message today from my perspective is clear and simple, and needs to be said in that way. I insist on reform that is rights based, properly funded, clinically safe and genuinely shaped by the lived experience of trans people.

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