The Right to Transition: Trans Healthcare in Ireland
By Megan Dennis
Ireland is one of only four countries worldwide in which a trans person may legally change their gender by self-determination, without assessment or intervention from the state. Last year, former Fine Gael Health Minister Simon Harris formed a steering committee to review the integration of the transgender healthcare service in Ireland, making such improvements in the National Gender Service as shortening the waiting list, setting up a virtual clinic, and hiring more specialised personnel. These developments are huge strides forward for trans rights, but they can distract us from the many glaring issues that remain unaddressed. Earlier this year the ILGA, an international LGBTI rights advocacy group, declared trans healthcare in Ireland as ‘inadequate’ in their annual European report. So where is the system letting Irish trans people down?
There is only one purpose-built transgender healthcare facility in the country, the National Gender Service in St. Columcille’s Hospital, Loughlinstown, Co. Dublin. Every transgender person in Ireland seeking treatment to aid their transition must be referred by their GP to this single clinic, and this bottlenecking has multiple negative effects. The waiting list has recently risen from 17 months to over two years, due to the clinic’s losing the referrals of over 100 patients who must now be individually contacted and offered new appointments. The effect of this long wait is devastating.
An increasing number of people are turning to buying hormones online illegally and self-administering, as they simply cannot face the wait. The side effects of improperly dosed hormones can be severe, from anemia to osteoporosis. Those who can afford it often opt to pay for treatment privately in England or Northern Ireland where, although the prices are staggering, the entire process from the first consultation to beginning hormone replacement therapy can take as little as six months and two appointments.
There is also a total absence of surgical options in Ireland: there is not, nor has there ever been, a surgeon who performs ‘bottom’ (sex reassignment) surgeries, and the only surgeon providing ‘top’ (chest reconstruction) surgeries has recently retired. This forces many Irish trans people to go abroad for surgery, paying through the nose and coming home to little or no aftercare.
A less well-documented side effect of this waiting time is suicide. A huge number of people find the mental strain of the long wait unbearable. Since those lost to suicide simply do not appear for their appointment in Dublin, there is no record of how many did not make it in because they took their own life. ‘Speaking From the Margins’, a study on trans mental health and wellbeing in Ireland conducted by the Transgender Equality Network Ireland (TENI), found that 76% of respondents had self-harmed prior to their transition, and 81% had considered or attempted suicide - if these are figures of those who survived the wait, it is not hard to imagine how many did not. Post-transition, these figures drop to 0% and 4% respectively, showing what a fundamental difference it can make when people are not denied access to essential care.
Currently, the main issue for transgender rights groups in Ireland, such as TENI and ‘This Is Me’, is to have the model of care changed. Most countries follow the ‘informed consent’ model recommended by the World Professional Association for Transgender Health, wherein a patient is advised of both the benefits and drawbacks of the treatment options available to them and makes an informed decision on which course to follow. The HSE declares Ireland as following this model, but since there is only one specialised clinic in the country, their preferred method dictates the way in which all trans people in Ireland are provided with or denied healthcare. The model followed in the National Gender Service is an outdated one, in which patients undergo a rigourous process to be diagnosed with gender dysphoria, a psychiatric disorder - this despite the fact that the WHO declassified transgender identities as mental or behavioural disorders in 2019.
Under this model, trans people who have managed to endure the mental strain of over two years waiting for their treatment are subjected to a three-hour session of invasive ‘diagnostic’ questions, many of which are totally unrelated to their gender identities. They are questioned on their parent’s relationship in their childhood, whether they have ever been abused, how they pick up sexual partners, the detailed mechanics of how they have sex, etc.
The standard defense of this model is the fear that patients will regret their transition, and that an intense psychiatric process limits cases of patients wishing to de-transition. In Ireland, less than 1% of people who have transitioned have said they regretted it: in round figures, this amounts to 3 people. Detransitioning is within their rights, and yet it is used as an excuse to delay and deny healthcare to over 99% of people seeking it.
Ireland’s healthcare system is letting vulnerable people down. No one should have to pay for the care they need, but the needs of transgender people are clearly a low priority in our two-tier system, and as a result, trans people living in Ireland are suffering. Access to necessary healthcare is a human right, so why should transgender healthcare be any different?