Tuesday, 27 March 2018
Health Services Provision
I thank the Minister of State for his time today. I am raising the issue of health care for transgender people in Ireland and the widespread deficiencies that exist in terms of standards, access and trans-specific knowledge in the Irish health service. As the Minister of State will be aware, Ireland ratified the current version of the European Social Charter 18 years ago, and submits regular reports to the Council of Europe's European Committee of Social Rights, which determines compliance with the charter. In Ireland's 14th national report on the implementation of the European Social Charter, submitted for 2017, transgender issues are not mentioned even once. When the Irish Human Rights and Equality Commission commented on the report, it said that health care for transgender persons in Ireland is inadequate, in terms of meeting their needs, reflecting complex processes, inadequate provision of services and inadequate levels of knowledge and awareness among health professionals.
This analysis was agreed with by the European Committee of Social Rights, which reiterated these concerns in its 2017 annual conclusion. That two respected human rights bodies have come to the same conclusion regarding transgender health care in Ireland today is why I have tabled this Commencement matter. The bottom line is that we are failing transgender people in Ireland under article 11.1 of the European Social Charter by not providing guaranteed access to health care in practice. This needs to change, and I would appreciate it if the Minister of State would outline in detail the steps being taken by the Government and the Department of Health to rectify this.
Transgender people have a very specific range of health care needs. It is critically important that relevant and appropriate services are available in order to facilitate and meet those needs. These include: gynaecological and urological care, reproductive options, voice and communication therapy, mental health services, and hormone and surgical treatment. The World Professional Association for Transgender Health lists these as essential services to assist transsexual, transgender and gender non-conforming, with safe pathways to achieving lasting, personal comfort with their gendered selves. It also lists the importance of social and political climates that provide and ensure social tolerance, equality and the full rights of citizenship, and in this respect at least, there have been great improvements in Ireland recently.
It is four years since the enactment of the Gender Recognition Act 2015, and we can all feel collectively proud of that ground-breaking legislation, as Ireland became one of the first countries in the world to enshrine self-declaration of gender into its law. That law told transgender people in Ireland that we respected their identities, their autonomy and valued and included them as equal citizens in this State. However, legal recognition is only the beginning of the realisation of true equality for transgender people in Ireland.We need appropriate and accessible health care at a minimum to allow for greater realisation of trans identities.
With the Gender Recognition Act, we rejected stigmatising and unnecessary medical diagnostic models for the legal recognition of gender. Yet such models are still in place in determining access to trans-specific health care, and this must end.
In terms of hormone replacement therapy, the unacceptable waiting lists were highlighted in this House by Senator Warfield a number of weeks ago. However, delays are not the only concerning part of such provision in the Irish context. There is a clear reliance on a psychiatric diagnosis which falls outside the World Professional Association for Transgender Health, WPATH, guidelines, which instead advocates for best practice in line with an informed consent model. This over-reliance on psychiatric diagnosis, as distinct from a psycho-social analysis, of how the State treats trans-people for hormone replacement therapy is problematic and needs to be changed.
I understand there is currently only one diagnosing psychiatrist and prescribing endocrinologist operating in Ireland. While I understand a recruitment process is under way, the concern is that simply hiring more psychiatrists for this area will reinforce the medical diagnostic model which I have outlined, and this is not international best practice. This service should be opened up and decentralised. The World Professional Association for Transgender Health recommended that general practitioners be empowered to dispense the therapy as they are all trained to do so. General practitioners administering hormone replacement therapy to assist gender people is a common occurrence. Will the Minister of State give a commitment today to investigate the feasibility of this even on a pilot basis?
I also understand that despite the HSE claiming that no separate list exists for transgender individuals seeking hormone replacement therapy that, in practice, such a separation does exist, and this is one of the root causes of the huge delays. Will the Minister commit today to investigating this claim and ending that practice?
I met representatives of the This Is Me transgender health care campaign last week who outlined these concerns to me in detail. Will the Minister of State or the Minister for Health, Deputy Harris, meet representatives of the campaign, hear their concerns and consider their constructive proposals on how this could be resolved.
I thank the Senator for raising this important issue for transgender persons in Ireland. I recognise the deficits in the service provision to the transgender community and the unprecedented increase in the demand for services, particularly among children and adolescents. To address this, the HSE has developed a model of care for transgender children, adolescents and adults. The model was developed in consultation with the key treating clinicians, planners, policy-makers, advocates and service users. The model outlines the key services required to address the needs of the transgender population, including children and adolescents. It builds on the current service provision and identifies emerging service demand. It also draws on evidence-based international best practice.
I understand actions are under way to resource and support health care services at hospital, community and primary care levels in order to develop a national service for adults, adolescents and children in the transgender community. Eight key posts will be recruited in 2018 for adult services, including a consultant endocrinologist, a consultant psychiatrist, two senior psychologists, a clinical nurse specialist, a social worker and a speech and language therapist. A further three key posts in child and adolescent service will be filled, including a consultant endocrinologist, a senior psychologist and a clinical nurse specialist. These actions will address the waiting times and immediate service needs of children, adolescents and adults in transition.
The HSE, across mental health, acute hospitals, primary care and social inclusion programmes, is committed to building services for the transgender community in accordance with international best practice. The issues raised by the Senator are very important if she thinks the model being used is not the accurate or correct one. We have had that debate in the disability sector for many years. People were trying to use the medical model instead of a social care model to deal with people with disabilities. I would be interested to hear the Senator develop that point.
An undertaken has been given to building services for the transgender community in accordance with best international practice.Further work will be undertaken to identify additional priorities to be developed and resourced in 2018. In addition, the Health Service Executive has supported Transgender Equality Network Ireland, the national advocacy service for the transgender community. It provides funding for the posts of training and education manager and family support worker. These posts have provided education and training for staff across the HSE. Furthermore, the HSE has supported a training programme for speech and language therapists to develop the skills to support transgender people.
Transgender-specific guidelines have been developed by the World Professional Association for Transgender Health and the Endocrine Society. The guidelines recommend a comprehensive multi-disciplinary psycho-social assessment prior to commencement of hormone therapy by endocrinology services. They highlight several criteria which must be met prior to referral for hormonal intervention. It is important that co-occurring conditions be identified and addressed, including mental health difficulties, self-harming behaviour, suicidality and autistic spectrum disorders. Accessing supports to manage co-occurring difficulties can impact on the response to medical transition. I believe informed consent is essential whereby the benefits and risks of hormone treatment and surgery are discussed with individuals seeking these interventions. The emerging evidence on good outcomes following medical and/or surgical transitioning is based on the use of a multi-disciplinary psycho-social assessment, the fulfilment of criteria for hormones and ongoing psychological support throughout the process.
The Department of Health and the HSE are committed to providing health care services to meet the complex needs of transgender people and ensuring adequate levels of knowledge and awareness among health professionals to meet these needs.
I thank the Cathaoirleach. I will make a number of quick points. Will the Minister of State agree to look at the fact that there are separate lists for hormone replacement therapy, HRT, with cisgender people being placed on one list and transgender people being placed on another, instead of everyone being one the one list? This is causing delays. The HSE is trying to state it does not happen, but members of the transgender community are the ones who are trying to access the service and, therefore, best equipped to know if it is their experience.
There is an ongoing recruitment process, but it is still very much led by psychiatry. Will the Minister of State examine the possibility of Department of Health officials meeting members of the This is Me campaign because they have solid proposals to make, an understanding and insight into the reason this is a problem, rather than having a much more holistic approach focused on the issue as if it was a mental health disorder. They are constantly sent through psychiatry services before they can access HRT. Will the Minister of State consider the possibility of departmental officials meeting members of the This is Me campaign and investigate the separation of lists for HRT.
I will raise the issue of separate lists for the transgender community with the Minister, Deputy Simon Harris. I agree strongly with the Senator that the current system is psychiatry-led, but the only way to resolve these issues and change the entire model of care is for the Minister, representatives of the HSE and departmental officials to meet members of the This is Me campaign. I will put these proposals to the Minister. I am also available to meet members of the group.