Trans Contradiction

Access to healthcare for trans people received a wave of coverage following a protest in Dublin last January. The protest hoped to highlight what organisers said is the abject failure of the state to provide adequate access to healthcare.

Trans people looking to access healthcare in the country have always faced a Herculean task. There are only two gender clinics in the state, In Galway and Dublin; they’re both considerably under-resourced, and patients can expect to wait at least a year before accessing endocrine services

In many ways, this is because of an overly medicalised model of treatment where patients must present themselves to their GP to be referred to mental health professionals. They then must obtain a specific psychiatric diagnosis to be referred on to a specialised service which will only accept diagnoses from a limited number of specialists, which it claims is essential to ensuring unfit people don’t transition.

310 patients currently attend at Loughlinstown, Dublin and 70 in Galway, with around 120 people awaiting appointments in Dublin and 40 in Galway. Wait times can range from anything from six months to a year, and often longer, and concerns have been raised about the impact these delays have on the mental health and wellbeing of trans people, along with questions about the suitability of the model being practiced at the clinics.

In response to these issues, the government announced nine new posts within trans healthcare, which have been welcomed by Trans Equality Network Ireland (TENI). However there appears to be considerable confusion about how these new services will ultimately operate and what guidelines treating clinicians will follow.

AT ODDS

Two of the most high-profile clinicians treating trans people appear to be at odds with the government and the HSE with regards to treatment models, and have called into question the efficacy of a treatment model the government said would underpin its new investment.

When she outlined the investment in the Dáil on behalf of the government in February, Minister for Health Promotion Catherine Byrne said transgender-specific guidelines developed by the World Professional Association of Transgender Healthcare (WPATH) and supported by TENI would provide the framework for the new services being developed, which include the nine new posts and the development of gender clinics. Full implementation of WPATH guidelines would significantly widen the number of clinicians considered competent to diagnose and positively impact on waiting lists.

Dr Paul Moran, a liaison psychiatrist who plays a central role in treating people at the Dublin clinic, says the WPATH guidelines “as they apply to assessment and treatment recommendation, are not part of our model of care, are clinically unsafe, and unsuitable for use in a public healthcare gender clinic.” He adds: “They are particularly deficient in relation to co-morbid mental health and qualification of professionals.” (In layman’s terms, co-morbid is when one medical condition co-occurs with another.)

Professor Donal O’Shea, a consultant endocrinologist at Saint Columcille’s Hospital and a leading figure in the trans medical community, characterises the WPATH guidelines as “very lax” and says that “their application would lead to a significant ‘regret rate’.” This statement contradicts Minister Byrne’s assertion that regret rates, where people who transition regret having done so, are low when WPATH is implemented.

“We don’t intend to run the service in line with WPATH guidelines,” says O’Shea. “Aligning with them would result in significant harm accruing to those with gender confusion.”

These statements raise serious questions about the extent to which policy is being decided by the Department of Health or the personal discretion of the clinicians, given how they widely diverge from HSE policy documents and stated government positions. When asked to clarify the discrepancy, a spokesperson for the Department of Health reiterated Minister Byrne’s position, which envisages a central role for WPATH.

INTERNATIONALLY ACCEPTED BEST PRACTICE

The WPATH guidelines are internationally accepted as best practice. Their current version was updated in 2017 and is used extensively when treating trans people. According to Vanessa Lacey of TENI the guidelines represent the organisation’s “bottom line, as they’re evidence-based” and “people-centered”.

The government’s commitment to these guidelines was further underlined in statements made by the Minister for Health and the Department of Health, who have said that the guidelines alongside the 2017 endocrinology guidelines, will form the basis of future services.

According to a statement from Minister for Health, Simon Harris, the WPATH approach was “endorsed in the Service Development Model, which was developed by the Quality Improvement Division (QID) of the HSE in 2017,” and Minister Byrne referred to this document in the Dáil, as did multiple statements from the Department, which appears to place it at the core of service provision.

However, this is also called into question by Dr Moran, who says that that the 2017 QID model bore no relationship to current or future services and adds that the guideline is one of many, but not the one he is using.

“The 2017 proposal describing WPATH as the standard of care is significantly different to the model of care currently in place and being developed,” he asserts.

When asked to explain the differences in approaches Dr Moran says that there are different policy documents and suggests the minister was incorrect to refer to the QID document, as it had not been signed offby anybody and does not reflect the model which is in place or will be developed with the new funding.

Yet, two government ministers have referred to the guidelines when outlining what is perhaps the most significant investment in trans healthcare in decades. The idea that they have not been signed offon, and yet would still feature prominently in government statements, raises serious questions about the cohesiveness of overall policy.

According to Dr Moran, who works closely with O’Shea: “A WPATH-like model of care existed in Ireland prior to the development of our service, which was associated with adverse clinical outcomes for patients and we shall not be using WPATH guidelines (as they apply to assessments) in their current form.”

“ The responsibility of the HSE and the Department of Health is to ensure adherence to these standards.

MINISTER NEEDS TO CLARIFY

Both O’Shea and Moran have welcomed the new funding the government has made available, but Moran says that their services will continue to develop alongside psychiatric service models he uses, which centralise the role of psychiatry in diagnosing trans people.

The disjunction between government policy and Professor O’Shea and Dr Moran’s vision for the service they operate has been criticised by Ruth Coppinger TD.

“The minister now needs to clarify what the position is, given the remarks of Professor O’Shea and Dr. Moran,” she says. “I intend to take this matter up further with the minister and seek a clarification on the approach of the HSE.”

According to Stephen O’Hare, CEO of TENI, the minister’s statement indicates “an aspiration that services would be aligned with WPATH.”

“When the nine new named posts are filled, we would expect that services would be delivered in line with WPATH guidelines,” he adds. “Our view and the views shared by the HSE is that services should be delivered in line with international best practice. We would assess that best practice are WPATH guidelines. The responsibility of the HSE and the Department of Health is to ensure adherence to these standards.”

During preparation for this article repeated attempts were made to seek clarification from the HSE and the Department of Health to ascertain how compliance with government policy is ensured and to gain insights of auditing procedures. No response was provided at the time of publication.

Professor O’Shea agrees that the current service model “has been hopelessly under-resourced,” and that “access has been inadequate.” He agrees that the model currently in operation has created barriers, but he says it’s necessary as a safeguard against people transitioning who are unfit to do so.

“Removing it will result in a whole lot of pain,” he says, while warning of the “collateral damage” of mentally unfit people transitioning without proper screening.

“If you are looking after a marginalised group, then the marginalised group has to make absolutely sure that it’s looking after even more marginalised groups,” he adds referring to people who are on the autistic spectrum or are “gender confused” and “opposed to the true transgender”.

Insofar as O’Shea is there to assist trans people, he would see a wider responsibility of preventing unfit people from making radical decisions, which they might go on to regret.

“The reason for the psychiatrist to be heavily involved is to make sure that it’s not a personality disorder with a focus on gender, that there isn’t an autistic spectrum disorder, because the prevalence of transgender or gender confusion on the autistic spectrum is very high.”

Professor O’Shea did not respond to a request to comment on the considerable gaps between his views on WPATH and the government’s.

Dr Moran describes WPATH as: “An American cultural thing; it’s a very liberal thing,” adding that access to hormone treatment must be controlled to “protect the small minority who are at risk from unrestricted access.”

While there can be no denying the good intentions of all involved, serious clarification is needed from health authorities so that it can be assessed exactly what treatment models are in place, and judge whether or not they are being properly implemented.