Paul Murphy (Dublin South West, RISE)
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Our healthcare system in general is in crisis. Almost a million people are on public hospital waiting lists. It is even worse for trans people. We have the worst trans healthcare in all of the European Union, according to a recent report by Transgender Europe. There is denial of services in primary care settings and a ten-year waiting list to access public services. Those people who seek to access services through the public service are faced with intrusive psychiatric assessments. There is inadequate care, discrimination and the exclusion of transgender people from policy development. The healthcare situation is getting worse for trans people in this country, not better. People report that it is worse now than it was 15 years ago. We have no national gender-affirming healthcare policy or guidelines and no services for trans young people in Ireland, leaving many in extreme distress.

All of that is in contradiction of the programme for Government. I will ask a clear question. The programme for Government states it will:

Create and implement a general health policy for Trans people, based on a best-practice model for care, in line with the World Professional Association of Transgender Healthcare (WPATH) and deliver a framework for the development of National Gender Clinics and Multidisciplinary Teams for children and adults.

Has this commitment been abandoned or replaced? The very opposite to what is outlined in respect of WPATH is taking place. That is meant to be a non-pathologised approach to care based on informed consent. Instead, what is happening is a de facto, hyper-centralised system in the form of the National Gender Service, NGS, and the setting up of massive roadblocks to deny people the healthcare they need and should be entitled to. The standards being applied are in direct conflict with people's rights to bodily autonomy, self-determination and healthcare.

To look at that in some detail, I will take the issue of waiting lists. The NGS likes to claim it has a three-and-a-half-year waiting list, which would be bad enough, but it has more than 1,600 people on the waiting list and has never handled more than 160 people in a year. It is, therefore, clear it has a decades-long waiting list. If somebody can manage to get through that ten-year-long list, and does not have access to private resources to go abroad for healthcare, that person is faced with incredibly intrusive and invasive psychiatric assessments.

The things people are asked are appalling. One person reported: “For over three and a half hours my psychological evaluation took place. I was asked about masturbation. I was asked about my parents’ divorce. I was asked how I performed specific sexual acts. All of these questions made me feel completely dehumanised." A trans woman said: “She asked me about what porn I like, what role I take during sex, do I prefer men or women, did I play with dolls as a child, did I play sports.” This is a 26-year-old woman whose mother was invited and involved in this process. This woman is an adult; there is no role whatsoever for a mother here. It is absolutely scandalous.

This starts at GP level, where it is very clear that GPs are not being empowered or informed and, in fact, are being told that they cannot provide the healthcare that is needed. There is an example of an Ukrainian trans man, who after doing all the necessary tests and so on, was denied the blood tests and medication he needed because the GP told him he had to go to the NGS and will, therefore, have to wait on this long list.

James Browne (Wexford, Fianna Fail)
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The Minister, Deputy Stephen Donnelly, has spoken previously on the topic of gender healthcare. He has acknowledged that this is a small and vulnerable group of people who need to have access to proper, appropriate and integrated care, including acute care and community care. He has also acknowledged that they do not currently have access to that in Ireland and has stated that he is determined to change that.

In that context, the Minister would like to confirm that the HSE has recently appointed Dr. Karl Neff as clinical lead for the multidisciplinary team that will lead the development of a new model of care under the auspices of the national clinical programmes. The Minister was delighted to be able to provide €100,000 in funding for the establishment of this team. Now that this appointment has been made, the HSE is initiating a new clinical programme for gender healthcare and, over the next two years, an updated clinical model and implementation plan for gender healthcare services will be developed. This work will be informed by the best evidence-based clinical care for individuals who express gender incongruence or dysphoria. Now that the full Cass report has been published, it will be reviewed along with other emerging and evolving international evidence, as part of this work.

There is a clear and well-established approach to the development of this model of care, which, as well as reviewing the best available clinical evidence, will also incorporate input from healthcare professionals, patient advocates and those with lived experience. This is a message that I really want to get across - a key part of the development of this model of care will be consultation with stakeholders. As the Minister, Deputy Donnelly, said previously, we cannot have a situation where we are developing a model of care for a group of people who are not involved and whose voices are not heard. He can assure the Deputy that the HSE is anxious to ensure that all stakeholders are heard as part of this process.

The model of care will incorporate a multitiered approach, where care will be delivered at the most appropriate level of medical complexity. While the model of care is being developed, people will continue to receive healthcare in the community and under the endocrinology service in the adult and paediatric centres in Ireland East Hospital Group and Children’s Health Ireland, CHI. In terms of current services, children and young people who require specialist psychological or psychiatric assessment and support are now referred to the children and young people gender national referral support service in the UK, which will triage those referrals to one of the newly developed services in London and Liverpool-Manchester. This service will work with CHI if endocrine review is required. The adult gender service is based in St Columcille’s Hospital, Loughlinstown. It provides services for people over the age of 16 years.

The Minister, Deputy Donnelly, is committed to the development of a well-governed and patient-centred healthcare service for adults and children in the transgender community.

Paul Murphy (Dublin South West, RISE)
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The Minister states, and I agree with this, "we cannot have a situation where we are developing a model of care for a group of people who are not involved and whose voices are not heard" and that "a key part of the development of this model of care will be consultation with stakeholders" and so on. He also states that this is a message he really wants to get across. What would be better than getting a message across would be to actually do it. This is not what has happened. Trans people have been excluded from all this discussion that has taken place.

The HSE had a meeting on 9 February 2023, which was billed as the future of transgender care in Ireland and which was without a single trans organisation at the table to represent their community. The Minister of State can tell me whether the Government has agreed to it but the HSE has unilaterally abandoned the programme for Government's commitment to a WPATH-based model of care without consultation with the trans community. It did not consult any trans organisations on any aspect of deciding to spend more than €1.4 million on a new transgender model of care, hiring a new clinical lead or participating in a clinical study collaboratively with the UK.

The Minister for Health promised to meet with Trans Healthcare Action, which has done amazing work on this. I hosted a briefing in the AV room recently with that organisation. He promised to meet its representatives three months ago and that meeting still has not taken place.

Trans healthcare can be provided well. We had a doctor from Catalonia at the AV room briefing who provided a picture of 36-day waiting lists and 71% of adults receiving HRT on the first appointment. It is based on informed consent. That is what we need to do. We need primary care access. We need to inform, educate and empower GPs so this is a locally provided service, as all healthcare should be at a primary point. We need informed consent and evidence-based practice. We need community co-production, which is not currently taking place; that is, real consultation and engagement with trans people. The Government should be leading on this, as opposed to allowing the HSE to abandon its promises.

James Browne (Wexford, Fianna Fail)
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I will bring the Deputy's comments to the attention of the Minister for Health. The issues raised in this discussion are important and the Minister wants the Deputy to know that all of us in this House want to assure the transgender community is given proper, appropriate and integrated care and support they need to live authentic, fulfilling lives. I certainly agree with that. The new model of care will aim to do just that. The development of the new model of care for gender healthcare services is expected to be a complex process and the HSE and the Minister's Department will work closely together to support the process, ensuring transparency and keeping the patient at the centre of the process.

Consultation with stakeholders will be a crucial part of this work. I hear the Deputy's comments and will bring them to the Minister's attention. However, it is important the HSE is given time to develop a model of care that is based on the best clinical evidence and that will deliver the best outcomes for persons with gender incongruence or dysphoria. It is not possible to pre-empt the outcome of this process by determining at this stage what this model of care will look like once developed. The long-term aim is to provide a wide range of services for all people with gender incongruence or dysphoria, from care locally in the community to more specialised and complex care. The Minister is committed to building a service based on experience, clinical evidence, respect, inclusiveness and compassion and he is committed to the development of a well-governed and patient-centred healthcare service for the transgender community.