What now for transgender healthcare in Ireland after publication of the Cass review?

Transgender healthcare has become a contentious topic, particularly in relation to children and young people who are distressed about the difference between their biological sex and gender identity.

Activists and representative groups argue that the availability of services in Ireland is not sufficient, while clinicians working in the National Gender Service (NGS) warn that current practice creates a “harm and risk” to children and young people passing through it.

Though considered a “polarised” issue, there is one thing on which campaigners from all sides of the Irish political spectrum appear to agree: the current healthcare system is not working for those affected.

In recent weeks, paediatrician Dr Hilary Cass published her final report on gender healthcare in the UK. The review, commissioned by NHS England, is seen as a landmark report on gender identity services for under-18s.

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It found that thousands of vulnerable children who questioned their gender identity were let down by the NHS providing unproven treatments and by the “toxicity” of the debate about trans rights.

[ HSE to consider UK’s Cass Review on gender as part of healthcare update ‘informed by best evidence’ ]

Dr Cass found the UK’s only NHS gender identity development service used puberty blockers, which prevent puberty from happening, and cross-sex hormones, which masculinise or feminise people’s appearances, despite there being “remarkably weak evidence” of them improving young people’s wellbeing.

In her report, which made more than 30 recommendations, the consultant paediatrician stressed the findings were not intended to undermine the validity of trans identities or to challenge people’s right to transition, but rather to improve the care of the fast-growing number of children and young people with gender-related distress.

She said “extreme caution” should be applied when administering hormones to under-18s, that all children should be offered fertility counselling and preservation before going on to a medical pathway, and that follow-through services should be established for 17- to 25-year-olds.

The review, though based on UK services, has an impact in Ireland.

More than 230 Irish children and young people suffering from gender dysphoria – where a person feels a mismatch between their biological sex and their gender identity to the extent that it causes unease, dissatisfaction, anxiety or depression – have been referred to the UK-based Tavistock clinic under Ireland’s treatment abroad scheme since 2012.

Fewer than 10 Irish children are currently receiving puberty blockers as part of their gender healthcare through Children’s Health Ireland.

The Tavistock Clinic has since been closed following a finding in Dr Cass’s interim report that having a single national provider “is not a safe or viable long-term option in view of concerns about lack of peer review and the ability to respond to the increasing demand”.

She said it should be replaced by smaller, regional centres.

‘The biggest thing the Cass review clarified, which was also clarified in the Swedish systematic review, is that the evidence isn’t clear. And so we are working somewhat in the dark, which means we have to prioritise being safe and careful’

—  Dr Paul Moran, consultant psychiatrist at the National Gender Service and a member of the Cass review group

But what does all of this mean for the children and young people in Ireland who are seeking transgender healthcare?

The HSE is developing a clinical programme for gender healthcare and will develop an updated clinical model of care for these services over the next two years.

Dr Karl Neff, an endocrinologist with the NGS, was recently appointed clinical lead for transgender healthcare.

“This is a relatively new area of healthcare and the work will be informed by the best evidence on clinical care for individuals who express gender incongruence or dysphoria,” a HSE spokesman said.

“A very important part of the work will be to review emerging and evolving international evidence, including the just-published Cass report.”

The spokesman said the model of care will be developed in a “consultative way” and will engage with stakeholders, healthcare professionals and patients “who will be involved in the design of services and advise on the delivery and evaluation of services”.

[ British Labour says it will implement Cass findings on care for trans children if it wins election ]

“Developing a new model of care for gender healthcare for the Irish population will be a complex process but we are committed to building a service based on experience and clinical evidence, respect, inclusiveness and compassion, and a service that holds the person at the centre,” the HSE added.

In the interim, the HSE said children and young people will have their endocrinology specialist care within Children’s Health Ireland. These patients will continue to be assessed abroad until the service in Ireland is up and running in 2026, with the current pathway directing “referrals to the new UK NHS Children and Young People’s Gender services due to open shortly”.

According to Minister for Health Stephen Donnelly, this new system “has been badly needed for a long time”.

“We haven’t had the model of care in Ireland that these young people need. The thing that was holding it back mainly was recruitment of a psychiatrist to take it on. That has now happened. The new team is now being built up, we’re looking to roll it out over the next two years,” he said.

On the Cass report, Mr Donnelly said: “The chief clinical officer, Dr Colm Henry met the author when the interim report came out, to really understand the implications of it, and so any improvements we can make here will be made.”

But activists and clinicians want the way in which care is delivered in future to be markedly different from its current iteration.

Dr Paul Moran, a consultant psychiatrist at the NGS and a member of the Cass Review Clinical Expert Group of 2023, had been highlighting concerns about the use of the Tavistock Clinic to the HSE for five years.

He and his colleague Prof Donal O’Shea reported the HSE to the Health Information and Quality Authority (Hiqa) over the referral of young people for assessment abroad, saying it posed a risk to these children.

Following the release of the Cass review, Dr Moran said there were 12 recommendations contained in it that “require some immediate action in Ireland”.

“The biggest thing the Cass review clarified, which was also clarified in the Swedish systematic review, is that the evidence isn’t clear. And so we are working somewhat in the dark, which means we have to prioritise being safe and careful,” he said.

Among the recommendations from the UK report requiring immediate action, Dr Moran recommended screening for neurodevelopmental issues, for extreme caution to be used around the use of hormones for under-18s and for there to be proper governance around the assessment.

“In terms of developing services for younger people, I think we should start with extending down the age [of patients] the National Gender Service sees as evidence grows,” he said.

“We could start training people to look after teenagers. However, for the younger, pre-pubertal group, there needs to be careful consideration. Many of them don’t need specialist services. Let them be themselves and develop naturally, unless they have mental health problems in which case they should have support from Camhs [Child and Adolescent Mental Health Services]. There’s no need in most cases to intervene early.”

Further to this, Dr Moran said there has been a “growing number” of people contacting the National Gender Service seeking to detransition – stop or reverse gender transition – in recent years and he is proposing a specific programme to support these patients.

Campaign groups and activists, however, said there needed to be a “clear pathway” to support trans children and young people to receive gender-affirming care.

Karen Sugrue, the parent of a trans child and a founder of the Mammies for Trans Rights campaign group, said what was not working in the current system was the lack of help for trans children, who are then “DIYing” healthcare.

“They’re looking at the world and the world is telling them there is no help so they are going online and they are buying hormones and they’re self-administering needles,” she said.

The Health Products Regulatory Authority (HPRA), which seizes illegally obtained medications, said it could not say how prevalent the ordering of cross-sex hormones is, because it would include products such as testosterone and oestrogen, and it “would not be possible to state if detentions such as these were in relation to gender-affirming care”.

The World Health Organisation (WHO) in 2019 ended the categorisation of trans-related conditions as mental and behavioural disorders, categorising it instead as sexual health. Ms Sugrue said in Ireland there was still a need to “depathologise” trans people.

Ms Sugrue believes children and young people seeking gender affirming healthcare should be able to do so through “small steps” on a clear, defined pathway.

This should begin with social transitioning, she said, in which a person begins to present as their preferred gender as well as going by new pronouns and name.

Ms Sugrue said if the young person decides that social transitioning has benefited them, and their new identity feels right, they should then be enabled to use puberty blockers. Following this, she said if the individual wants to continue with their transition, they could then move to hormones.

Trans Equality Network Ireland (Teni) has called for trans healthcare to be delivered at primary-care level, meaning through general practitioners and at community level.

BelongTo, a group representing LGBTQ+ youth, said: “In Ireland, we have an opportunity to learn from the UK’s Cass Review, to learn from international best-practice guidelines, and to create a safe model of healthcare for trans young people in Ireland.”

A Coalition of trans rights organisations, Trans Equality Together, called on the HSE to urgently implement a “person-centred model of care” based on the principles of self-determination and informed consent.

How Ireland provides transgender healthcare is set to be a hotly debated, and closely watched, topic in the coming years in the wake of the Cass report.

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