Trans rights — Healthcare — Action

Trans Healthcare Now

With waiting lists spanning up to 10 years and a pathologising approach of care, it is clear that the model of trans healthcare in Ireland is not fit for purpose. Sarah McKenna Barry caught up with those on the forefront of the movement to learn what a model of trans healthcare could, and should, look like. Photos by Babs Daly.

Transgender Equality Network Ireland

As Daire Dempsey (pictured, above), the CEO of TENI outlines, the trans community in Ireland are accessing healthcare through a number of different channels. In terms of the public route, many trans people seek gender-affirming care through the National Gender Service. However, the current waitlist spans several years, and many activist groups have expressed serious concern over elements of the psychiatric assessment.

“There’s a myriad of issues within the service,” Daire says. “[The NGS] has received a lot of media attention because of the extremely long waiting list, but obviously, there have also been widespread reports of negative experiences within the service, with people feeling not believed by clinicians or spoken down to or being asked invasive questions about their histories. And, as far as I’m concerned, a waiting list of up to 10 years is effectively an absence of service.”

“People are going into debt to accesss the surgeries they need to live happy, healthy, dignified lives.”

Elsewhere in the public system are a handful of endocrinologists who may take on trans patients for hormonal therapy. “It’s very patchwork, and it’s based on demand, and demand always outstrips their capacity to do that, so this is by no means a national care provider,” Daire says.

Many trans people in Ireland seek gender-affirming care and, in particular, gender-affirming surgeries abroad, though this route is only accessible to those with the financial means and to those who have the ability to travel.

“It’s just phenomenally expensive”, Daire says. “People are taking out loans, they’re going into debt, they’re crowdfunding to access surgeries they need to live happy and healthy, dignified lives. And then you add in the cost of travel and accommodation and time off work, and it just gets really expensive.”

With tremendous barriers to both public and private trans healthcare in Ireland, many community members are self-medicating by purchasing hormones online, though they may not be fully supported by their GPs should they choose this route. Meanwhile, young people are left with no access to trans healthcare in Ireland.

“There’s no public gender service for young people,” Daire says. “We’re in a minority of countries that don’t have any kind of youth service. There’s nowhere for young people to get any kind of medical support, but there’s also barely anywhere for young trans people to go for any kind of mental health care either. There are some private providers abroad who might support young trans people, but that depends on the level of support that young person has.”

In terms of what a functioning model of trans healthcare could look like in Ireland, Daire points to the need to address the issues that come with a single specialised service, such as the NGS.

“You end up with a bottleneck in that service,” they say. This, the CEO notes, has knock-on effects.

“It creates and maintains and reinforces the idea that trans healthcare is a super specialised type of healthcare, which is stigmatising,” they say. “A lot of the time, what we see in other countries is that trans healthcare and, in particular, access to hormone therapy should be based regionally, and it should be available locally. It should be dispersed across the country so that you, as a trans person, should be able to access the care you need in your local area, and going hand in hand with that, you should be able to access it in primary or community care.”

This model, Daire notes, has proven to be effective elsewhere.

“We have seen really successful models in other countries, even the Indigo Clinic in Manchester, for instance, which is a pilot where they trained GPs to provide HRT for trans patients, and it’s not far outside what GPs are already doing.”

In addition to providing healthcare in primary and community settings, informed consent, which is embedded across most other forms of healthcare, is also best practice.

“Most types of non-emergency healthcare are based on informed consent,” Daire says. “Let’s say you, the patient, have an issue, you go and talk to your doctor about it, and there will be some kind of assessment. Then, you and the doctor have a conversation about what the different options are, what the different risks and benefits are, and you make an informed decision about what is the best route. It’s not that the patient has the only say, it’s that the patient is informed about what their options are.”

TENI is also advocating for a shift away from a pathologised model of care and, instead, towards an understanding that being trans is just a part of healthcare.

“It’s just part of the wonderful diversity of the human experience,” Daire says. “It’s not a mental illness, it’s not a psychiatric disorder, it’s not something that always needs specialised care, it’s something that we can receive care for along with all our other health needs. We go to GPs for all our health needs, and the idea of taking on hormone treatment for a trans person sounds really intense and scary but what it generally involves is the initial prescribing and a blood test, and within the first two years people have their blood tested and then their prescriptions are reviewed maybe every three months or six months, then it goes to once a year.”

Misconceptions about what trans healthcare looks like, alongside a general lack of understanding and hostility towards the community, are among the biggest barriers currently facing trans people in Ireland. These factors, compounded with a crisis in the Irish health service in general, are leaving the community at risk. Daire, however, is undeterred. “TENI is a member of a working group of the national clinical programme to develop a new model of care. I think there is a lot of potential for the stars to align,” they say. “There is a moment of recognition for all of the kind of players, which is the trans community and the HSE and the Department of Health, that the current system is failing. It’s a big piece of work, but we are there to represent and fight as hard as we can for what our community needs.”

Trans Healthcare Action

Ciara Witts (pictured, right) is a member of Trans Healthcare Action, a grassroots, volunteer-led advocacy group made up of members throughout Ireland.

“We primarily organise online, so we have members from all around the country – in Cork, Galway, Dublin, as well as more rural areas” she says. “We’re working to try and build an informed consent model of gender-affirming healthcare in Ireland. We want a system where trans people have autonomy over their own bodies and we don’t want psychiatrists to be able to dictate our bodies or gatekeep our healthcare.”

Trans Healthcare Action looks abroad to successful case studies, such as Landspitali University Hospital in Reykjavik, Iceland and Origin, a decentralised gender service operating out of Victoria, Australia. In the latter, a peer coordinator is appointed, providing some much-needed oversight from the community, Ciara says.

“Trans people are directly involved with their care and there’s that emotional connection between patients and the peer coordinator,” she says. “That’s a really important thing that we would love to see in our healthcare in Ireland, especially given that our community has so much negative baggage with the current system, and there’s a lot of distrust. Direct community involvement is needed to make sure that patients can trust their healthcare providers.”

Like TENI, Trans Healthcare Action is also pushing for depathologisation.

“At the moment, you need to convince other people that you’re not lying about yourself,” Ciara says. “It puts a burden on people who might be neurodivergent, who don’t present stereotypically. It can be a real impasse for people who are gender-non-conforming or non-binary. In my personal case, I was denied hormone therapy because I was unemployed.”

This gate-keeping is only making wait times for care worse.

“Much of the [long wait times] is due to the model of care,” Ciara says. “When you insist on having intense, long psychiatric evaluations for every single patient, it uses a lot of resources to treat fewer people. If we look at Iceland, we see that by moving from a psychiatric model of care to an informed consent model, they completely reduced their waiting list. They had a waiting list of over 700 people and cleared it within two years, and now there’s no waiting list.”

An urgent reform of Ireland’s provision of gender-affirming care is vital because accessing healthcare, Ciara says, is life-changing.

“At the moment, you’re spending years of your life fighting against the system to get care for a chronic condition that, for a lot of people, is getting worse,” she says. “The big thing, right, is puberty, but even past that, as you age, there continues to be more feminisation of masculinisation. Trans women could start balding and lose their hair while stuck on a waiting list. Their condition is actively worsening, and they’re stuck there.”

From a policy perspective, Trans Healthcare Action’s Morr O’Malley believes specific changes and greater clarity could be implemented now and would make an immediate difference, especially in terms of harm reduction.

“The Minister and the Department of Health should state that it is within GPs’ and nurses’ remit to provide blood tests and their results to trans people seeking care privately or via self-medication as a harm reduction measure,” they say. “GP practices are already providing these same tests for their cisgender patients and should provide them as readily for their trans patients. Additionally, GP practices stepping forward to say that they are able and willing to provide this basic form of healthcare would drastically improve the situation for trans people across Ireland, as at present many are having to seek new GPs just to be able to get bloodwork done to monitor their hormone levels to ensure their patients are supported in caring for their overall health.”

Morr also calls for the Department of Health to provide clarity on whether or not trans people are excluded from the Free HRT Scheme.

“At present, pharmacists have been instructed to use their discretion, which has led to trans people being excluded based on their appearance and manner,” they say.

A major reform to the current model is not just about reducing wait times, but ensuring better outcomes when trans people are treated. A key part in securing this model is the continued advocacy from allies, Ciara says.

“It’s really important that we have active allies on our side because trans people are quite a small minority, so it’s easy for politicians or the general public to dismiss our needs,” she says. “We need as many people on our side as possible to get people to listen to us and to help people understand the amount of suffering that’s going on.”

Transgress the NGS

Transgress the NGS is a single-issue campaign group whose main aim has remained the same since its establishment a number of years ago.

“We want informed consent,” says activist Farah. “Trans healthcare should be accessible, it should be free for everyone, and we want to take the psychiatric element out of it.”

While many activists are calling for the provision of care through GPs, Transgress member Mike says it’s of paramount importance that doctors across the board are equipped with adequate knowledge to care for trans patients.

“I’m concerned about GPs,” he says. “If I was put to the pin of my collar, and couldn’t take on any extra patients, I might not prioritise making sure I know what trans healthcare is all about. Issues with GPs depress me, especially when my doctor is so good it’s clear to me that we shouldn’t have to worry about GPs refusing us care.”

The inclusion of trans people in the development of a new model is also of paramount importance for Transgress.

“It’s really important to include people who have been through these things because it’s going to be a way more inclusive and informed model,” Farah says. “It can’t just be a box-ticking activity.”

The current system is hostile, says Transgress member Hanna (pictured, top right), who is calling for the model of care, and attitudes towards trans people in general, to be depathologised.

“If you aren’t deemed to be capable of fitting into heteronormative society, you are more likely to be denied gender-affirming care outright,” she says. “Our transness cannot continue to be defined by those who have historically viewed us as mentally ill.”

In discussions surrounding access to care, class emerges as a major barrier.

This, Transgress activist Helen Moynihan (pictured, bottom left) notes, is indicative or broader problems in Irish society.

“Our transness cannot continue to be defined by those who have historically viewed us as mentally ill.”

“Public healthcare in Ireland is a disaster,” they say. “I’d like to see proper public free healthcare accessible for everyone, but our government is extremely neo-liberal and that’s a hugely damaging system.”

These factors underscore the need for accessible, community-based healthcare grounded in informed consent, especially as Farah points out, given what’s at stake.

“People’s lives are on the line every day,” they say. “You can’t fully be who you want to be, and every way that you try to make that happen, you’re blocked, bullied, ostracised or discriminated against. All you want to do is exist and present yourself to the world. We’re losing people left, right and centre.”

The provision of trans healthcare, Farah points out, won’t “take anything from anybody else. It’s not causing the end of the world or a breakdown in society,” they say. “It’s just giving people what they’re entitled to, giving people what they deserve.”

Transgress points to the importance of applying pressure and maintaining momentum.

“At Trans Pride last year, we had 10,000 people on the street,” Farah says. “There are so many supporters, whether they’re trans themselves or allies, and we need to keep that pressure up because the government doesn’t care. The only reason they are putting any discussion on the table is because they’re being pressured by opposition parties, by activists, by organisations like TENI and THA. If we lift that pressure, it’s just going to go the wayside.”

Beyond pushing for policy change, trans healthcare activism has a galvanising effect, and Helen points to the importance of community strengthening in the broader battle for rights.

“Transphobia is rising in the world, and the best thing we can do is be in a strong community, to be resilient against it, and to remind each other that we deserve respect and dignity,” they say.

“Our demands are about decentralisation and GP-led care for accessing HRT, but for me it’s as much about ensuring that we are supporting each other. For queer people who are feeling confused and scared about the direction of the world and transphobia, I would encourage you to go and be physically in your community with your peers. We’re much stronger together.”

TENI is a national non-profit organisation working to improve conditions and rights for transgender people and their families in Ireland. You can get in touch by emailing office@teni.ie, or calling (01) 873 3575.

Trans Healthcare Action is a community organisation, calling for informed consent and care facilitated by primary providers in Ireland. You can stay up to date with Trans Healthcare Action by following them on Instagram: @transhealthie.

Transgress the NGS is an activist group calling for self-determined trans healthcare in Ireland. You can find them on Instagram: @transgress.ie.