Mental Health Services: Discussion (Resumed)

Chairman

I welcome to the meeting from Migrant Rights Centre Ireland, Mr. Pablo Rojas Coppari - I have difficult names to pronounce today – who is the policy research officer. From BeLonG To, I welcome Ms Moinne Griffith, executive director, and Mr. Dylan Donohue. From Pavee Point Traveller and Roma Centre I welcome Mr. Patrick Reilly and Ms Brigid Quirke. On behalf of the committee I thank you for your attendance today. You will be invited to make brief opening statements and they will be followed by a question-and-answer session.

I wish to draw the attention of witnesses to the situation relating to privilege. Please note that you are protected by absolute privilege in respect of the evidence you are to give to the committee. However, if you are directed by the committee to cease giving evidence on a particular matter and you continue to so do, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise or make charges against any persons or entity by name or in such a way as to make him, her or it identifiable.

Members should be aware that under the salient rulings of the Chair they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

Any submission or opening statement that witnesses make to the committee will be published on the committee website after this meeting.

I will invite each group to make an opening statement. We will start with Mr. Pablo Rojas Coppari.

Mr. Pablo Rojas Coppari

I distributed a submission earlier. I presume all members of the committee have received it. Some committee members might be familiar with Migrant Rights Centre Ireland. We are a national organisation, which was established in 2001. We have approximately 17 years' experience working with migrants and their families in Ireland. Often we describe our work as being at the intersection of precarious employment and precarious immigration status. We work with many migrants who work in low-paid occupations as well as with migrants who are most at risk of vulnerability associated with legal status or lack of legal status.

As such, ours is the principal organisation working with undocumented migrants in the State. That is how we mainly would have engaged with communities in the past. We have a focus on economic migrants, but we represent people on all issues that affect all categories of migrants.

We are not a service provider in mental health service terms, but we provide employment and immigration law services. As indicated in my submission, we are associated with Médecins du Monde or Doctors of the World in a health-related project that particularly examines the socioeconomic determinants of health outcomes. It considers both physical and mental health. As such, we have been developing materials and gathering data in that regard. I also make reference to the work of Cairde, a health advocacy organisation. Members are probably familiar with its report on the mental health of minority ethnic groups. I also refer to the work of Mental Health Reform, a coalition of organisations, of which MRCI and others have been part, that considers mental health needs of migrant communities in Ireland.

I will outline the matters of concern to us but, first, I refer to the data collected as part of our project with Médecins du Monde. It highlights that the prevalence of negative mental health is similar to that among the overall population. Among migrants reporting negative mental health there is an increased sense of isolation and a lack of support. Among those who describe themselves as having very bad or bad mental health, 66% indicate a lack of support and say they do not have anyone on whom they can rely, or they have a limited number of people on whom to rely for support. As members know, mental health issues affect everyone in the population. It is important that people have access to support networks and services. Particular categories of migrants have limited access to both services and support. We cannot talk about causation, but there is a correlation between lack of support, lack of access to services and isolation and poor mental health outcomes. With migrants who declared positive mental health outcomes, the level of network support was twice as good as among other populations.

I have divided issues of concern into three categories. The first is the provision of mental health services for the broad immigrant population. It arises mainly from the report published by Cairde in 2015 which identified the following key barriers to accessing mental health services. This relates to experiences of racism and discrimination that people face when trying to access services. There are certain difficulties in terms of entitlements and financial barriers. Access to mental health services very much depends on entitlement to access HSE services. This is a function of the type of legal status a person has. Persons with precarious legal status cannot rely on services provided by the State, while undocumented persons may not access mental health services.

There are also barriers arising from language and the provision of culturally appropriate services. We have identified a lack of interpretation services and intercultural training as a barrier in accessing mental health services. This amplifies the sense of stigma and shame which might be linked with poor mental health outcomes and having the need for mental health services. This is prevalent in all cultures, but in certain ones it is more relevant.

The other points relate to specific categories of migrant with which we work. The first is the victims of human trafficking. MRCI specialises in the provision of services and representation for victims of trafficking for forced labour, although we can relate it to other forms of trafficking, including for sexual exploitation. Victims of trafficking have often experienced different traumas and may suffer from post-traumatic stress disorder. When referred to our national referral mechanism, they are provided with a health programme that is limited to physical health. There is a dedicated anti-human trafficking service within the HSE, but it does not offer counselling services or more specialised mental health services. Among the victims we support, we noted their need for mental health services. They requested such services on a number of occasions, but they were not provided with them. On a number of occasions they were referred to mainstream mental health services, which have long waiting periods which leads to re-traumatisation while they are involved in a process of reflection and recovery. On a number of occasions the lack of immigration status or financial means presented a barrier and, more often than not, their needs were not met. The mental health needs of victims of human trafficking are quite specific because of the experience of trauma and violence that could be associated with it. Certain needs are akin or similar to the needs of those who experience torture. We need to look at the provision of special counselling services for those who have undergone the experience of human trafficking.

I will ask Ms Rashimi to speak about the mental health needs of undocumented migrants. For those not familiar with the issue of irregular migration in Ireland, the MRCI survey, Ireland is Home, estimates that there are between 20,000 and 26,000 undocumented migrants in the State. There are up to a further 6,000 undocumented children. In MRCI we have developed support networks for both undocumented adults and young people.

Ms Rashimi

I thank members for their time.

I will share my perspective as a young person with the added experience of being undocumented. Growing up is hard on everyone. Particular challenges come from being from an immigrant background and being different. Growing up undocumented brings its own set of challenges to a sense of self and well-being. My fellow members of Young, Paperless and Powerful, a youth group set up by MRCI for undocumented young people, agree that there are challenges in accessing mental health care about which practitioners and policy makers need to know. I am sure the committee agrees that no young person should have to grow up with the weight of the world on his or her shoulders, a reality that hangs over someone's head every day in every relationship. Growing up undocumented means that fear becomes part and parcel of a person's daily life in dealings with the State, health care services and schools. If someone finds the resources to be able to sit down in front of a mental health care practitioner, he or she cannot mention his or her legal status because of a fear about the consequences. This undermines the healing process and the positive impact counselling and therapy could have. Growing up undocumented means that it is impossible to plan for the future and live the life we want. From the youngest age, the future is deeply uncertain. Progressing to third level education is unlikely because of the fees and paperwork barriers involved. Employment options are very limited and someone must settle for the work he or she can manage to find. That is a far cry from young people's aspirations and capabilities.

This has a hugely negative effect on a person's well-being, sense of self-worth, self-esteem and confidence. It is also a huge loss in human potential.

Mr. Pablo Rojas Coppari

I will outline the recommendations and let Ms Rashimi conclude. We cluster our recommendations in four groups. The list has been given to the committee. The first looks at building the capacity of migrant minority ethnic groups by implementing specific programmes addressing stigma but it also looks at awareness raising and specific training for health providers to work with minority ethnic groups and migrants. I refer also to improving access to mental health services by ensuring cost is not a barrier, particularly at the intersection of low pay and migration.

Providing interpretation services and cultural mediation programmes is another of our recommendations, as is increasing the accreditation of mental health practitioners from other countries and minority ethnic groups. We also looked at introducing specialised services for victims of human trafficking. This is also applicable to undocumented migrants to ensure legal status is not a barrier for anyone needing to access services, be it young people or adults.

As cross-committee recommendations, we would like to see a recognition that irregular status can produce poor mental health outcomes. There is a recommendation for the Government to implement the recommendation of the Committee on Justice and Equality for the introduction of a regularisation scheme for undocumented migrants, as well as the recommendation from the Committee on Children and Youth Affairs and the UN Committee on the Rights of the Child for the introduction of a regularisation scheme for undocumented children, young people and their families.

Ms Rashimi

We need to recognise the added value of youth work interventions as a key component in well-being and positive mental health for young people at risk, especially in vulnerable situations such as being undocumented.

Chairman

I thank the witness. We move on to Ms Griffith who is representing BeLonG To.

Ms Moninne Griffith

I am executive director of BeLonG To which is Ireland's national LGBTI youth organisation. I have been there for two years. I have also been a member of the Government's task force on youth mental health and I am on the oversight of the Government's LGBTI+ youth strategy. Much of my work over the past two years has been focused on the mental health and well-being of LGBTI young people in Ireland. Dylan Donohue is with me today. He is a 16 year old person from IndividualiTy, which is our Dublin-based transgender youth group. He has a particular interest in the mental health and well-being of young transgender people in Ireland, and has recently won a prize at the BT Young Scientist and Technology Exhibition for his work in this area.

BeLonG To works with about 150 young people over a fortnight through our Dublin flagship service. We also support a network of more than 30 LGBTI youth groups throughout the country, co-hosted with some of the national youth groups such as Foróige, Crosscare and Youth Work Ireland. We run anti-bullying campaigns like Stand Up, which is the largest anti-bullying campaign in secondary schools in Ireland. It addresses some of the root causes of the harm done to young people's mental health and well-being in schools.

Our services are holistic. We recognise LGBTI is just one part of a young person's identity. We work closely with our colleagues in the Migrant Rights Centre of Ireland and Pavee Point because our LGBTI young migrants, immigrants and Travellers experience sometimes double or triple stigma because of their sexual orientation or gender identity. We provide an array of services. Youth work is very important for LGBTI young people, as is peer-to-peer support. Our Monday chat service is a one-to-one non-counselling support service for young people. We are running a pilot with Pieta House where counselling is provided free of charge to young people who are self-harming or experiencing suicidal ideation. Another aspect of our role is running mental health training courses for mental health professionals in partnership with Jigsaw.

In our youth groups, mental health workshops for young people are mandatory. We run them in each quarter throughout the year. To give the committee some context, since the marriage equality referendum, we have seen an increase of more than 100% in the number of young people coming into our service. I think that is because they feel accepted and recognised. However, many of the young people coming to us come because they are experiencing a crisis. Many LGBTI young people will never come into our service because, thankfully, they have loving supportive families and communities. They have come out and are happy in themselves. However, for those who do come into our service, very often they require a good deal of support to come to terms with who they are and to come out to their parents and in their schools.

We have also surveyed the young people who use our services regularly on a needs analysis. Mental health issues come up repeatedly as the number one issue. That is not surprising. Many in the room already know about the LGBTI Ireland report published last year. It was paid for by the National Office of Suicide Prevention, which generously supports us, especially our mental health work and the work we do throughout the national network. It found that, in comparison with the My World national youth mental health study, LGBTI young people have three times the level of self-harm, experienced three times the level of attempted suicide and are four times more likely to experience severe or extremely severe stress, anxiety and depression.

Among LGBTI young people aged between 14 and 18, 56% have self-harmed and 70% have had suicidal thoughts. One in three has attempted suicide. That is something our youth workers are dealing with on the front line every day in our youth groups. A very strong link was found between a young person having experienced LGBTI-based bullying and serious mental health difficulties. We knew this anecdotally but the report was able to prove the link. One in four has missed or skipped school to avoid negative treatment due to being LGBTI. Those who have experienced this bullying have much higher levels of depression, anxiety, stress and alcohol and drugs misuse. They are also more likely to self-harm and have suicidal thoughts.

Some of the challenges we recognise belong to them. The usual problems accessing mental health services for young people in Ireland, such as waiting lists and gaps in primary health care, affect LGBTI young people throughout the country as well. However, the added barriers and challenges are the lack of awareness or understanding or capacity among some mental health care professionals who have not had the training or are not aware of the particular needs or situations experienced by LGBTI young people in Ireland.

We have a particular problem with transgender young people accessing mental health services, and Dylan may speak more about this, but this is something that is urgent. To access health care and legal gender recognition, transgender young people must get a diagnosis of gender dysphoria. In practice, because there is no one else in the country able to do this at the moment, this means they are pushed into the child and adolescent mental health services, CAMHS, pipeline. They are sometimes waiting 18 months to two years to access that service depending on where they are living in the country. The CAMHS is one for acutely unwell young people. Some of these transgender young people are not experiencing acute mental health illnesses. However, this is the only pathway they have to get this diagnosis so they can access health care or legal gender recognition. The stress of waiting, as can be imagined, can mean that if they did not have mental health problems at the beginning of the process, they may end up having them after such a wait.

Young people in BeLongG To have told us how, even after accessing CAMHS, health professionals ask them what they are doing accessing the service. They tell them that they are not suicidal or self-harming, and then send them back out without the diagnosis that they need. Sometimes the professionals do not have the capacity or the training and the young person never receives the health care they need. It is very urgent. I understand that the HSE is looking into developing a specialist unit in Ireland that could provide a wrap-around psychosocial service to young transgender people that would provide them with all the services they need in their health care, mental health care and so on. This should be made available to them as soon as possible.

We know that the causes of mental ill health among LGBTI young people are not because they are LGBTI. We know from the report that this is related to stigma, which unfortunately remains in Ireland despite the significant progress in areas such as marriage equality and gender recognition. We know it relates to fear of rejection, social exclusion and bullying. We know that this is happening in our schools, communities and even in some of our homes, despite significant progress being made recently. We also know that there is not enough resourcing or investment in early intervention and prevention or primary care that would deal with some of the speed bumps in the road that LGBTI young people encounter and that may have an adverse affect on their mental well-being. If those are not in place early enough, by the time that they come into us they are already in crisis, and we must refer them on to an already overburdened system where sometimes they cannot access the care that they require.

One major barrier to young LGBTI people accessing mental health care is the requirement for parental consent for 16 and 17 year olds. This affects all young people, regardless of gender identity or sexual orientation. In the case of LGBTI people who are not out to their parents because they are unready or because their parents may not be supportive of their sexual orientation or gender identity, this could pose significant harm to their mental health and well-being if they come out. We see this very much as a barrier. I know it is being looked at in the review of the Mental Health Act. It is something we see as a significant barrier for young LGBTI people.

Among the things we suggest might help the mental health and well-being of LGBTI young people are the removal of the requirement of consent for 16 and 17 year olds and the introduction of the UK-style Gillick principles whereby when a young person wants to access mental health care supports and treatment, the health care professional can deem whether he or she has the capacity to consent to that treatment. We also suggest LGBTI-proofing policies, procedures and practices within the mental health care system. Information and awareness training should be increased so that there is increased capacity among mental health care professionals to provide the supports and services that are required to meet the specific needs of LGBTI young people. Funding should also be increased to youth organisations which undertake this often life-saving LGBTI youth work at the early intervention and prevention stage.

I will now hand over to Dylan in case there is anything he wishes to add.

Mr. Dylan Donohue

I will reiterate some of Moninne's points. A trans-specific clinic must be established in Ireland for transpeople across the country. CAMHS does not have the space for transpeople to go through its system and it does not have the specialists. Psychologists in mental health services need to be aware of how to handle having a transperson using their services. For instance, when I went to CAMHS I was called by the wrong name and pronouns the whole time and staff continued to do so when they referred me on to the gender identity clinic. Waiting lists for CAMHS and other mental health services are really wrong, and having waited, many people are then told that CAMHS cannot do anything for them, that they do not know how to handle a transperson. Many transpersons are under the impression that going to CAMHS and similar places will give a gender dysphoria diagnosis which will allow them to go on and get treatment and so on. That is not how it works but they are not told that they need to go further than CAMHS to get a gender dysphoria diagnosis. Transpeople are thrown around the system until someone decides finally to deal with us.

Chairman

Thank you. I now call Mr. Patrick Reilly.

Mr. Patrick Reilly

I am the mental health worker in Pavee Point. I am also an Irish Traveller. Pavee Point Traveller and Roma Centre has been working to challenge racism and promote Traveller and Roma inclusion in Ireland since 1985. The organisation works from a community development perspective and promotes the realisation of human rights and equality for Travellers and Roma in Ireland. The organisation is comprised of Travellers, Roma and members of the majority population, who work together in partnership to address the needs of Travellers and Roma as minority ethnic groups experiencing exclusion, marginalisation and racism. Working for social justice, solidarity and human rights, the central aim of Pavee Point is to contribute to improvement in the quality of life and living circumstances of Travellers and Roma. This includes targeted resources and recruitment to ensure access to effective, equitable and respectful quality mental health care and services.

I and my colleague, Ms Brigid Quirke, are delighted to have the opportunity to make this presentation to the committee. While we thank the committee for including Travellers and Roma in its discussion today, we would like to note that we have been invisible thus far. We urge the committee to take our recommendations on board and ensure that we are explicitly included in the committee's final report.

We welcome the commitment of the Minister for Health, Deputy Harris, to re-establishing the Traveller health advisory committee and the development of the new Traveller health action plan based on the findings of the all-Ireland Traveller health study. We urge the committee to prioritise these actions and ring-fence a budget for their implementation as a matter of urgency.

Given the limited time and the complexities of the issues we wish to highlight, we will focus explicitly on Travellers today. However, we would encourage the committee to examine the mental health needs of the Roma community at a later stage in its deliberations. We have copies of the national Roma needs assessment for members' consideration and our Roma colleagues would welcome further discussion on the mental health findings and key recommendations.

There are approximately 40,000 Travellers in Ireland, accounting for less than 1% of the total population. Were the entire population of Travellers to sit in Croke Park, it would fill less than half the stadium. Our recommendations here are practical, feasible and, if implemented, could have a real impact on Traveller's health. Last year Traveller ethnicity was officially acknowledged by the State. Travellers throughout the country celebrated and welcomed this announcement. However, the harsh reality is that Travellers still experience challenges, which include discrimination, exclusion, poverty, poor quality of education, lack of employment opportunities, and a lack of accommodation, which leads to overcrowding, which is seven times higher than among the settled population. Added to this, there are approximately 2,000 Travellers on the roadside without basic facilities, which means no toilets, running water or electricity. These are members' constituents and the people whom they represent. In 2018, this is something that we expect in a developing country, not a rich, developed nation like our country. Traveller health inequalities are well documented, with the all-Ireland Traveller health study findings indicating that Traveller health is comparable with the levels found in the settled population of the 1940s. This means that Traveller men are living 15 years less than settled men and Traveller women are living 11 years less than settled women. The mortality rate among Traveller men is four times higher.

The rate of mortality of Traveller women is three times higher than that of women in the settled community, and that of infants, or children under one year of age, is four times higher. The evidence indicates that Travellers are dying at much higher rates at all ages and across genders, with 97% of Travellers not living to their 65th birthday. Coupled with the experience of discrimination on a daily basis, this leads to poor mental health. Travellers have worse mental health outcomes than any other group in the country, which is why they have been prioritised in policy documents such as Connecting for Life and A Vision For Change. However, they have experienced no change on the ground. The all-Ireland Traveller health study found that 60% of Travellers reported their mental health in the preceding 30 days as not good, compared with 20% of the settled population.

The rate of suicide among Travellers is six times higher than among the settled population and accounts for approximately 11% of all Traveller deaths. Last year, I attended the funeral of a Traveller man who had committed suicide and there spoke to another Traveller who pointed out that we no longer make any wonder of it when a Traveller commits suicide because it is so common in our community. That would rightly be totally unacceptable in any other community and mine should be no different. If we had access to the same resources and services as the settled population, the outcomes would be better. We can do better for Travellers and they deserve that.

To do so, we must address the issues experienced by Travellers when engaging with services, including acknowledging that they are sometimes treated with a lack of respect and dignity, about which over 40% of Travellers were concerned. Over 50% of Travellers worried about experiencing unfair treatment and had concerns about the quality of care they received, and 40% of Travellers experienced direct discrimination in accessing health services. Some 70% of service providers agreed with those findings and suggested that Travellers receive substandard services because of their ethnicity. We are not making this up. These are findings from the all-Ireland Traveller health study.

As noted in our submission, Traveller health has not received any new moneys since 2008. We welcome the launch of the current policy on Travellers, the national Traveller and Roma inclusion strategy 2017-2021. It was developed by Traveller organisations in partnership with the Department of Justice and Equality and we have widely endorsed it. However, no recommendations can be implemented without a budget and there is no budget attached to the strategy, which adds to the ongoing frustration for Travellers as there is little evidence of progress. The Traveller primary health care projects funded by the HSE are of benefit to Travellers. The study states that 83% of Travellers receive their health information from these projects, which are a lifeline for my community. They must be resourced and seen as an investment by the State.

Active Traveller consultation, participation and proofing of any further development of services, policies and strategies is required, and this must be must be resourced, monitored and evaluated. The committee has received our detailed submission, which includes clear recommendations regarding access, recruitment and funding. However, in the interest of brevity, we wish to highlight two overarching recommendations. In terms of ensuring a robust, evidence-informed service, we must prioritise the implementation of the ethnic identifier across all primary mental health services to monitor equality of access, participation and outcomes to suicide prevention and mental health services for Travellers, Roma and other priority groups. As regards working in partnership with Travellers, nothing should be done about us without us. There must be an engagement and effort to work in partnership with Traveller organisations and primary health care Traveller projects comprising peer-led, culturally appropriate projects to develop and deliver a positive mental health awareness and suicide prevention campaign. These structures have existed for at least 15 years, with 30 projects operating nationally. Ten such projects are ongoing in community health care organisation, CHO, areas 6, 7, and 9, in which I work, and I was disappointed to be in the Gallery a few weeks ago while the chief officers giving evidence failed to acknowledge Travellers and-or the work of these projects, which they fund and operate in partnership with us.

We urge the committee to recommend strongly the implementation and resourcing of the national Traveller and Roma inclusion strategy without delay. The re-establishment of the Traveller health advisory committee is crucial and must be implemented as a matter of urgency. Travellers are dying and we cannot understand the lack of progress on the ground. The question that must be addressed is whether the reason for the lack of progress is political.

I thank the committee for the opportunity to attend and for listening to our presentation. We would welcome any questions or matters for clarification and we invite members to visit Pavee Point and our primary health care project.

Chairman

I thank Mr. Reilly. The stories we have heard are very distressing, as are the facts and figures outlined by the witnesses. As Chair, I am ashamed that I was unaware of the issues outlined.

We will now have a question and answer session. The lead questioners will have seven minutes and witnesses are asked to answer as quickly as possible. I call Deputy Martin.

I thank the Chair. I will ask my questions quickly in order that the witnesses have time to respond. I thank them for their presentations and commend them on the valuable work they do. I offer Dylan my congratulations on his recent success in the BT Young Scientist and Technology Exhibition.

As the Chair stated, we have heard further regrettable evidence of how the poor and marginalised are last in the queue for crucial services, which is shameful for us as a country.

My first questions are to Mr. Rojas Coppari or Ms Rashmi. A Vision For Change states that no one can achieve true mental heath recovery without having a meaning to life and access to employment. What has been the toll or impact of the years that so many in direct provision centres have been deprived of the right to work and the dignity of earning an independent income? Has there been an increase in mental illness among those who have been deprived of that right or are there any data in that regard? Those who have managed to make their way from war-torn countries are highly likely to suffer from post-traumatic stress disorder. Are any mental health providers given specific treatment to support such people or specific training to support victims of human trafficking?

What is being done in regard to language barriers? There have been reports of children interpreting for migrant parents who present for medical attention. Is that happening in respect of mental health services? If so, that is highly inappropriate and would cause huge stress for the child and for the parent who requires the child to interpret.

Does Mr. Coppari or Mr. Reilly know if training workshops are available for psychologists and psychotherapists to acquaint them with the unique and intrinsic cultures of minority groups whose members may seek therapy? What culturally inclusive training is being delivered to mental health providers?

The 2012 HSE intercultural strategy stated the need for an ethnic identifier for service users, but Mr. Reilly in his submission highlighted that is still not standard, which I presume makes managing or determining outcomes very difficult. Without knowing those outcomes, how difficult is it to tailor supports for people from the Traveller community or minority backgrounds and to ensure that staff are trained to meet their specific needs? What funding is allocated to mental health supports for the Traveller community, migrant groups and LGBTI groups on an annual basis? Do we have data outlining the exact funding in that regard?

I recently spoke to Ms Geraldine Dunne, the managing director of Southside Travellers Action Group in Dún Laoghaire-Rathdown, to ask her about the needs of the community in that area. She mentioned the lack of supports for teenagers and youths, which, unsurprisingly and regrettably, is an issue of huge concern. In the opinion of Mr. Reilly or Ms Quirke, how could that best be addressed?

I do not understand why a representative of the Traveller community was not on the youth mental health task force. The witness said that this was sought on several occasions. Therefore, what reason was given? It beggars belief. I do not understand why there was no representative and would like to know the exact reason given. How was that explained?

Many of my questions arise from Dylan's and Ms Griffith's project. As a former teacher, I am wondering what training for teachers is in place with regard to gender and LGBTI sensitivities. Dylan's project refers to a number of surveys but one shows that 20% of the 277 people surveyed stated that their teachers did not use the correct name or pronoun. Was that a case of the teacher choosing not to use it? Was it that the teacher said that he or she would not use the preferred pronoun? If so, it needs to be addressed. Have the witnesses any ideas on how it can be addressed? It is not acceptable.

Has BelongTo approached the National Association of Principals and Deputy Principals on how schools can develop policies relating to LGBTI students for staff? What has been the response? Is anything being developed?

Am I doing okay with the clock?

Chairman

The witnesses' answers need to be as concise as possible. I will start with Mr. Reilly. Would he like to answer Deputy Martin's questions first?

Ms Brigid Quirke

I will recap to ensure that we have them all. There was a question on the ethnic identifier. It is true that there was a national Traveller health strategy for 2002 to 2005. The inclusion of the ethnic identifier was recommended and we piloted it at that stage. From 2002 to 2018, it has been 16 years. Following a successful pilot with a 100% response rate, it was to be mainstreamed but we are still waiting for it to be mainstreamed. With the arrival of new communities, the ethnic identifiers are really more urgent. The Deputy is correct that we cannot disaggregate data or identify where the gaps are, particularly on quality of access, participation and outcome. It is clear that minority communities need additional inputs in terms of positive duty and ensuring the same outcomes to services. We are not all born equal, starting at an equal point, so we need that affirmative action. Subgroups have been established and it has been reinforced in the national Traveller and Roma strategy. We have been involved ourselves. The NGOs have taken on its piloting and the rolling out because the State was not doing it. We now work with Pobal, the prison service and some of the hospitals. We go out and do the training and the identification. We encourage them to believe that it is possible and can be done. The NGOs have been driving it and we are now hoping that it will be mainstreamed.

In its absence, we have the all-Ireland Traveller health study, which is an extensive study done over three years. A total of €1.5 million was spent by the Department of Health to find out the exact needs of Travellers. It has very specific detail and there are four reports and five volumes of data which still have not been accessed or utilised. We were given to understand that it would be turned into a Traveller health strategy. The previous one was not implemented because there were no data. Now we have data and they tell us there are no resources. It is, therefore, a very frustrating experience on the ground.

On infrastructure, the 30 Traveller primary health care projects are really good. We set out our own health data collection system. We try to document where there are barriers to services. In lieu of official data being collected, we collect data at local level to try to ensure that we maintain that knowledge. It is urgent and critical because only then can we see the barriers. We can see if there has been an improvement in the effectiveness and efficiency of services. In terms of resources, we can also see whether money is being spent in the right places, having an impact and creating the outcomes that would benefit everyone.

The Deputy asked about youth in terms of speaking to our colleagues in Southside Travellers Action Group. The youth programme at Pavee Point has been closed down. The funding was cut back. During the recession, as the committee will be aware, a lot of Traveller organisations, NGOs and community organisations disproportionately lost a lot more resources. For example, education was a priority. I was part of the study team in UCD and the study stated that, if there was only one recommendation to address Travellers' health, it would be to invest all our money in education because improving opportunities for people is the key to creating change. The study was launched in September but 85% of the Traveller budget was cut in the budget and we have yet to get it back. Therefore, the homework clubs, visiting teachers and all the things that were helping to retain Travellers in school in terms of progression to secondary school were gone. Again, that is critical. The Deputy is right that there are social determinants to mental health and health inequalities and we have to address those, including accommodation and education.

I do not have figures on the specific budget on mental health. It is done through the primary health care projects. Each of them would have mental health initiatives. There is one new initiative to be considered through the national Traveller and Roma inclusion strategy, which was employing nine Traveller-specific mental health workers. I think they are doing interviews this week. We are not too sure that that is the panacea. Our issue is that the projects on the ground are recognising people but the issue is the mapping. That has come up in a lot of services and was often raised during the committee's deliberations when I was reading over them. People do not know where to go and where the services are. In particular, suicide is falling between the two. The mental health services say it is nothing to do with them because it is not a mental health problem as the people are not diagnosed with a mental health problem and that it is the responsibility of primary care. Primary care does not have the capacity to deal with it, however. We have written case studies on this. We spent a whole weekend telephoning 30 NGOs and the National Office for Suicide Prevention but no one was available. I was with a person who was suicidal and, when I asked if we could go to accident and emergency, I was asked by the people there if she had cut her wrists. I was told that she needs to have done something. I asked if we could go in if I asked her to cut her wrists. It is a ridiculous system.

We have applied suicide intervention skills training, ASIST, and safeTALK. It is fine to train people but they have nowhere to refer people to. Mr. Reilly is chair of the mental health subgroup and we have been trying for the past eight years to do mapping and signposting so that we could find out. Even people within the service, however, do not know where one is supposed to go. To me, it is an urgent matter that the committee might consider further. I understand it was raised earlier.

We do not have a specific budget as part of others. Other work is about us going into a service telling it to be more Traveller-specific. In terms of training, we run culturally appropriate training such as workshops that are Traveller-specific on culture and how services can be proofed and made more appropriate. We offer this to services but we cannot make them take the training. We cannot go to psychologists or psychiatrists and say they need training. They come and say they need training. We can suggest that it is needed by all providers. That is one of our recommendations on training. We are prepared to deliver-----

Therefore, it is the luck of the draw. One might arrive at a person who has had the training.

Ms Brigid Quirke

Often we find when we offer training that it is the people who are more interested in facilitating Travellers who turn up. It is not the people who have issues who come to the training because it is voluntary. As with sexual discrimination, it should not be allowed. For us to go around and make the whole country anti-racist is impossible. It would go on forever. The positive duty that has been introduced switched the burden of responsibility from NGOs trying to prove inequality and discrimination to the State trying to prove that it is providing equitable and fair services. Hopefully, that change might encourage-----

Chairman

If Ms Quirke does not move, we will have to move on. She mentioned that she does not have the funding figures.

Ms Brigid Quirke

We do not have specific figures but we will send them on if we can get them.

Chairman

I remind Mr. Reilly that our report will come out in March and his input and recommendations will all be part of it. I will move on to Mr. Pablo Rojas Coppari.

Mr. Pablo Rojas Coppari

I will be brief.

Chairman

Telephones are interfering with the sound system. Can they be put on airplane mode, please?

Mr. Pablo Rojas Coppari

As I point out in my submission, there is limited research on the mental health experience of migrant communities other than the Cairde report. That is the only one that examines the issue specifically. Barriers in accessing employment and services will certainly have an impact on the mental health outcomes of different migrant communities. The right to work for asylum seekers and their experience of direct provision will have an impact on asylum seekers and direct provision residents. The MRCI does not work directly with asylum seekers and those in the asylum system. There are strong parallels in the experiences of undocumented migrants and asylum seekers.

The point is not to compare groups but to draw parallels. We know that undocumented migrants do not have the right to work. There are 4,500 residents in direct provision but the number of undocumented migrants ranges from 20,000 to 26,000. They do not have the right to work, housing is not provided for them and they do not have access to any services, such as medical services.

What undocumented migrants lack is visibility. People do not know the extent of undocumented migrants, because there are no dedicated reception centres for undocumented migrants. There is no champion for undocumented migrants and they are completely invisible in both policy and political rhetoric. There is no politician championing the issue of undocumented migrants. That is borne out in what Rashmi said. Isolation and a lack of visibility increase the problem of access to employment, services and poverty, together with other migrant communities.

There are dedicated services for people who experience torture and who are in the asylum system. Spirasi is the main provider of training and services for those who have experienced torture. I am not able to say how much that is in the mainstream of the health service, but there is no similar dedicated service for those who are victims of human trafficking. Obviously sexual trauma can be related to those who experience torture and other forms of exploitation but there are also differences between one and the other. That is something that can be modelled in a training programme.

There is a problem with interpreting foreign languages across services, not just in the provision of health services. The Health Service Executive has a clear policy on interpreting services but the implementation of that policy is still failing. Examples of children interpreting what their parents are saying is probably true when the parent is at the doctor but it is certainly true for people going to the social welfare office or in the school system. The positive element is that the integration strategy acknowledges there is an obligation on the different Departments that provide services to migrant communities to signpost what type of interpreter is available and how people can access that service. If we live up to the standards of the integration strategy, this will improve. There is certainly a gap in that at present.

Last week we heard about a victim of trafficking who has very poor English. When he accessed services, he was told he did not belong because he still cannot speak English having been in the country for 12 years. Not only is there a lack of services, but people experience racism and discrimination and do not always have access to the services of an interpreter when seeking to have their needs met.

Chairman

I thank Mr. Pablo Rojas Coppari. I invite Dylan to respond to Deputy Catherine Martin.

Mr. Dylan Donohue

I will respond to the question on the 20% of students whose names and pronouns are not respected by teachers. From speaking to other transgender people, I would say that in nine out of ten cases, teachers refusing to call them the correct name or use the correct pronoun just do not understand how detrimental it can be to the students' mental health to call them by the wrong name or use the wrong pronoun.

That is key because I was fearful it was a choice not to do so, but Dylan believes it is a lack of understanding and that is why training is needed for staff.

Chairman

That is a very generous remark about the teachers. There should be a way of finding out for sure that it is a matter of pure ignorance and nothing else.

I thank all the witnesses for their presentations. I welcome the visitors in the Gallery. Mr. Pablo Rojas Coppari mentioned stigma in his presentation. While it may be thought that stigma is diminishing, I have always said that stigma has been attached to mental health and suicide since day one. When Rashmi was speaking I could hear his life experience and the battles in his voice. I commend him for that.

Ms Griffith referred to wraparound services, but she will have a very long wait because the services in the country are deplorable at present. We have looked at the staffing issues, but the system is not working. As a committee our role is to improve services but I fear that there are no services in the middle.

I love Dylan's frankness and I commend him for his honesty. I remember watching a documentary in which Dylan appeared with his mother. It is the witnesses who have the life experience and information to inspire the members of the committee. We need to learn from them to try to facilitate everybody.

It is great to be invited into somebody's back garden and I thank Mr. Reilly for that invitation. I would love to visit that health care project and see the bottom up approach to services. We have been speaking about services being provided from the bottom up not from the top down. We need to listen to the people who have experience of the service.

Stigma is a recurring theme, with bullying and discrimination. Today it was reported in the British media that a nine year old boy died by suicide from intensive bullying in school. We have brought this to the attention of the committee. I was a member of the Committee on the Future of Healthcare. This is about education. We need to educate people from their youth to middle age. If we listen to the older people, they will educate us. I congratulate the witness and say well done to them.

Deputy Buckley and I are on the same wavelength in regard to stigma. It is hard to quantify stigma; it is intangible. That is the major difficulty with stigma. It is hard to write about the scale of stigma. Much work has been done and it has been talked about, yet it is still prevalent. We need to be mindful of that. I picked up on it in Dylan's contribution. Does he believe that the stigma he experiences is the result of the specific case he brought or does he feel that in his age group the stigma of mental health issues exists across the board? Does he think the stigma that he experienced and spoke about is equal to or greater than the stigma attaching to mental health?

Mr. Dylan Donohue

I am not sure.

Ms Moninne Griffith

I do not have the statistics.

It is not statistics I am looking for but to get a handle on the general feeling in that age group.

Ms Moninne Griffith

We carried out some public opinion testing to measure what parents' opinions, in particular, would be if a child of theirs came out as trans. I can share this information with the committee when I am back in my office.

Chairman

Please do.

Let me make one final point. We are talking about stigma, discrimination and so on. As a matter of fact, it is not only minority groups that face such difficulties; there are professions within every sector - the education sector and whatever else - in which people with jobs come to bad periods in life, put up their hands and are then punished for telling the truth. That must also be noted. I have come even across such cases involving people working in the education sector.

Chairman

Deputy Catherine Martin asked a question which was not answered. It concerned the reason Pavee Point was not included in the youth mental health task force. Will Ms Quirke and Mr. Reilly give us a reason it was not included?

Mr. Patrick Reilly

We sent correspondence requesting to be part of the consultations at the youth mental health task force. We kept pushing and pushing, but, to be frank, we did not receive a significant answer as to why we-----

Chairman

Did Pavee Point ask for one?

Mr. Patrick Reilly

It submitted correspondence requesting to be included in the consultations, but it got no word back.

Ms Brigid Quirke

We could find out the specifics and with whom we were in contact.

Chairman

Before I pass on the delegates to anyone else, I will ask a number of quick questions.

Mr. Reilly and Ms Quirke mentioned having poor access, or none, to services. Does that include all services? What is the problem?

My other question is for Dylan. I do not know if I understood this correctly. Does one have to go to CAMHS in order to have a gender identity assessment made?

Mr. Dylan Donohue

Yes.

Chairman

Is that correct?

Mr. Dylan Donohue

Yes. Someone goes to his or her GP who refers him or her to CAMHS, which then sometimes refers someone to the gender identity clinic the Tavistock. However, it does not know what to do.

Chairman

Is it seen as a mental health problem and someone is sent to CAMHS?

Mr. Dylan Donohue

CAMHS just takes referrals.

Ms Moninne Griffith

It is because there is no service available. As there is a specialist service that can deal with the matter, it is less that people are pathologised for being trans. I do not think it is about that; it is just that there is no service available. Therefore, what the HSE is looking at and what we are calling for to be prioritised is the provision of such a service that could be provided in a hospital, for example, the children's hospital in Crumlin which has a small clinic, to which people from the Tavistock clinic come. It is now under threat because of Brexit, which is another urgent reason we need an indigenous clinic in Ireland that can work with transgender young people in order that they will not have to visit acute mental health care services. Some of the children involved do not have mental health issues; they just need access to the clinic to be able to receive treatment, perhaps hormone blockers or whatever it is that they require, and in order that they will not be taking up spaces in the system and will have quicker access to services, including the health care services they need. Furthermore, the reason this is so urgent is that young people can come to us at or before puberty and may have socially transitioned, been living in their preferred gender for a number of years and may want to prevent puberty from happening. If they have already been living socially transitioned, going through puberty can have a devastating impact on their mental health and well-being. They cannot access the hormone blockers they need until they have gone through this system with CAMHS; therefore, they could be waiting two years.

Chairman

That is terrible.

Ms Moninne Griffith

We are talking about young people who are going through puberty when there is no need for them to do so.

Chairman

Before I pass on the delegates to Deputy Martin Kenny, did Ms Quirke want to respond?

Ms Brigid Quirke

Yes. I will give the figures and Mr. Reilly will then say something.

The all-Ireland Traveller health study asked whether people had issues in accessing services. The figures relate to utilisation of all health services. A total of 40% which is quite significant were not always treated with respect or dignity; 50% had concerns about the quality of care provided, while over 40% faced direct discrimination. These compare with figures in international studies of 17% for black Americans and 14% for Latin Americans; therefore, they are incredibly high.

Mr. Patrick Reilly

I work with Travellers on the ground. When it comes to accessing services, what I hear is that they are not meeting Travellers where they are at. Travellers have low levels of educational attainment; things like filling in forms and reading and writing can be enough to make them walk away. We must be respectful and mindful that what might work for one community might not work for another. As the primary health care and mental health care workers throughout Ireland, these are the things we are trying to do to work with the services to help them to identify this. I will give a brief example. I know a Traveller man whose postman had issues in entering his site. As a result, he was missing hospital appointments. As far as the hospital was concerned, he was not turning up. It is these things that are missed and we are there to highlight them. It was not the case that the Traveller man had not bothered to turn up; it was just that the postman would not enter the site because there were too many dogs or he did not want to do so. We are still living with that experience today. There are sites all across Ireland that still have it today and we are trying to highlight it for services.

I thank all of the delegates for their very insightful presentations. I have two specific questions, one of which is for Ms Griffith.

On the age of consent, someone must be 18 years to facilitate the relevant mental health services. If it were 16 years, what difference would it make? Has legislation been tabled in this Dáil in that regard? I am not sure whether it has been.

My other question is for Mr. Reilly and concerns the incidence of suicide among Travellers. I heard the statistic referred to last year and it is beyond shocking. Sometimes words do not say enough. It is a black and white issue and has a real impact on the reality for the Traveller community. This is probably a simplification, but if there was one thing that could challenge what is going on in the Traveller community, particularly the incidence of suicide, what would it be? What would Mr. Reilly try to change?

Mr. Patrick Reilly

I agree totally that the suicide rates are beyond shocking. As I said, they would be unacceptable among any other community. To answer the question, there is not just one thing I would change. Looking at the range of social determinants, if someone has a poor education, he or she will have poor work. If someone has no work and no money coming in, he or she will have a poor lifestyle. We really must look across the board. All of the determinants play a part and link with one another. We see families who are living from week to week on their budgets. They are only trying to survive on what they have. It is not just one issue; it is a matter of looking across the board at accommodation, education, employment and health, which all play a significant part in the incidence of suicide among Travellers. I hope that answers the Deputy's question.

Ms Brigid Quirke

Discrimination is also a factor. It takes many forms - direct, indirect and institutional. Again, as Mr. Reilly said, services are designed for the majority population and assume a level of literacy, education, income capacity and transport which excludes people at the margins. However, this is done without intent. That is where one needs to develop proper proofing mechanisms to Traveller-proof services and policies to make them inclusive. Discrimination is insidious and impacting on young people. We have a very high suicide rate among youth. One can imagine the level of self-esteem of young people if they are called names and not recognised and their culture is not supported or endorsed. We learn to be confident of our history as Irish people in going through school, but if someone goes through school without being acknowledged, he or she is made to feel he or she has to deny his or her identity, as many Travellers do. This has an effect. Traveller culture is in transition. This puts a lot of pressure on young people. Discrimination is across the board and part of the social determinants.

Chairman

Before I pass on the delegates to Senator Colette Kelleher, I wish to ask Ms Rashimi one question. Will she talk us through, step by step, what someone with a mental health issue and who is undocumented does? Does he or she go to a GP or what happens?

Ms Rashimi

I cannot speak for everyone but it would be the normal process of going to a GP and being referred on to a counsellor or a mental health care practitioner. It is an issue, however, that at every single point - no matter where - a person cannot disclose his or her illegal status. A person cannot disclose it to his or her doctor or to the counsellor.

Chairman

You cannot?

Ms Rashimi

The perception is that we cannot say it to another person due to fear of the consequences and because we do not know how the person would react to hearing it and we do not know what they would do. It is something we feel that we cannot share with someone. If an undocumented person is in the sort of space where he or she might want to open up to another person there is this thing over his or her head. It affects us because we cannot talk about it and it undermines the whole process of being there.

Mr. Pablo Rojas Coppari

On top of the pressure of being undocumented there is also the fact that to access any service from the HSE, be it for mental or physical health, a person needs to be ordinarily resident in the State. This is determined by the HSE by the type of legal status that a person has in the country. Whereas mental health and physical health providers have the discretion to overlook the fact that a person does not have legal status in the country and to continue providing health services - and luckily a lot of them still do - they can refuse. There are certain services where the discretion can no longer be applied and people can no longer be referred to the service because they do not have the correct immigration status and so on. There is also the risk of incurring extra costs because if one does not have full access to the health system, as would a full resident, one could end up getting billed. As Ms. Rashimi has said, a lot of people do not disclose their undocumented status and a proper diagnosis cannot be ascertained.

Chairman

I apologise for cutting across Deputy Kenny. Would Ms Griffith like to respond to Deputy Kenny's query?

Ms Moninne Griffith

On the issue of consent for mental health services, currently in Ireland a person who is 16 years of age can consent to surgical and medical treatment. In theory one can consent to having plastic surgery but not consent to accessing a counsellor or mental health treatment. This is a huge disparity. If access were standardised it would benefit young people and health care professionals. If everyone knew that at 16 years old a young person can consent to whatever health care they need, that would help.

It would make a big difference in the case of young LGBTI people because there are very young people who are being prevented from accessing mental health care services, some of which are youth friendly, free and open to other young people, such as Jigsaw and Pieta House. These facilities still cannot open up their services to young people under the age of 18 without parental consent. Some of these young people are most vulnerable because they are not out to their parents or the parents themselves have mental health issues, addiction problems or are not available to give the consent. Standardising the age of consent for mental health services to the age of 16 would make it easier for these very vulnerable young people to access health care. It would also clear up this vagueness and grey area for health care professionals.

Chairman

Has legislation been introduced in this regard? No.

What is the age for consent in Britain?

Ms Moninne Griffith

In Britain they apply the Gillick principle where 16 and 17 year olds can have consent but a health care professional makes his or her own professional assessment for those under the age of 16 to see if they have the required capacity to consent to treatment. I believe this makes absolute sense because health care professionals will say that some 14 year olds have much more capacity and are way more mature than some 19 year olds. It is quite artificial having an age as a limit and indicator of a person's capacity to consent to treatment. It is really about the individual and should be determined case by case.

I thank all of the groups who presented today. The purpose of this committee is to look at the challenges of mental health in Ireland. It is clear that some groups have many more challenges than others and are suffering and experiencing mental health issues disproportionately. The representatives today have spelled it out, in particular the striking presentation from the Migrant Rights Centre Ireland, MRCI, about the situation of people who have been subjected to human trafficking. The representatives have noted that the HSE team does not have the capacity to provide mental health services and that victims face difficulties in accessing mainstream services. The committee could make the specific recommendation very clearly that those teams supporting people experiencing human trafficking should have access to mental health services as a right.

Rashimi spoke very eloquently about the issues facing people because of the undocumented status, and called for the committee to support recommendations from other committees and from the UN to regularise people's situations.

The BeLonG To report was also very striking. It compared the wider population of young people in Ireland and LGBTI young people had two times the level of self-harm, three times the level of attempted suicide and four times the level of severe or extremely severe stress, anxiety or depression. These are very arresting statistics and we as a committee must pay attention to them when making our recommendations.

I congratulate Dylan. I met him before when we spoke in the Seanad, along with his mother Kirsty. I thank him for the very eloquent performance.

The Traveller suicide and mental health statistics continue to shock. We read them over and over again and nothing seems to be happening. In the committee's recommendations and reports we have to send a very strong message about this. I shall read them into the record again because I believe it is really important: the Traveller suicide rate is six times higher than that of the settled population and the suicide rate is seven times higher for Traveller men and five times higher for Traveller women than in the wider population. Another shocking statistic is that 97% of Travellers die before their 65th birthday. That this is being tolerated in a country as prosperous as Ireland is nothing short of shameful. There are only 40,000 Travellers in the State. This is not a problem, an issue or a challenge that we should not be able to reach.

I am also struck by the links with education. I recently submitted a Commencement Matter to the Minister for Education and Skills, Deputy Richard Bruton. Only 167 people from the Traveller community have ever had third level education. All of these things are interconnected. I am especially interested in the Pavee Point Traveller and Roma Centre's advocacy for the primary health care Traveller projects and how important they have been. This committee can make sure that its recommendations put those projects on a secure footing. I am aware, for example, that every year the project in Cork lurches from one financial crisis to another and is dependent on what is left over in the social inclusion budget. This was not mentioned by any of the community health care organisations when they came in, yet this is a critical lifeline to a community that is dying on its feet in every which way - in terms of mental health and otherwise.

We hear you. The Minister for Health, Deputy Simon Harris, will appear before the committee in a couple of weeks. If there is anything that I have not said, or if there is anything the representatives would like us to say to the Minister, will they please put it on the record before they leave the committee today?

Ms Brigid Quirke

We appreciate that support for sustaining the primary health care projects. We had 40 primary health care projects; ten have closed down due to lack of funding. One issue is that a lot of the women work part-time because the projects engage many of them. Now, because of the changes in the minimum wage, the hours are being reduced. We are trying to see if their roles could be protected because they are making a contribution to the State.

We would appreciate some support around those issues. The Minister for Health, Deputy Harris, has agreed to re-establish the national Traveller health advisory committee, which produced the strategy. The new action plan for the National Traveller and Roma Inclusion Strategy, NTRIS, is obviously very important, but plans like this must be resourced. The Traveller health strategy, which was produced in 2002, had no resources. The recommendations in it are still valid but were never implemented. We want an assurance that there will be implementation of strategies and an appropriate budget attached.

I refer to the specific pathway for young people transitioning, so that they are not directed to child and adolescent mental health services, CAMHS. There are problems for people who want to go to CAMHS but cannot, and there are people for whom it is inappropriate. We can examine that and make a specific recommendation.

Chairman

Outside this committee, if any of the witnesses want to approach us to make a deeper connection, or get us to do something, I am sure all the members here would be more than delighted to help.

I thank the witnesses for appearing before us and giving us their very informative presentations. They will be very helpful to us when we are drafting our report. I have a couple of questions for each group.

I will begin with the representative Migrant Rights Centre Ireland, MRCI. Senator Kelleher touched on this question. Have the witnesses drilled down into specifics of what specialised services would be needed to address the type of trauma that victims of human trafficking experience? I noticed the phrase "THB victims". Could the witness explain that term to me? Moreover, does the MRCI have evidence that some people who have been trafficked into Ireland are in prison, perhaps for crimes that they were forced to commit? If so, do they have any access in prison to the types of services that the MRCI would recommend for them specifically as trafficked people?

Does the MRCI have any experience of the appropriate treatment for women and girls who have experienced female genital mutilation, FGM? Is that coming up as an issue? I know that several women who have migrated here have been affected. I am not sure if I should use the word "victim". Certainly, I would see them as victims, but the culture from which they come does not see it that way. Is a specific type of treatment required in those cases? Is there a pipeline to which they can go if they happen to be in a direct provision centre? Are there avenues for them to access the type of help they need?

I also have questions for the representatives of BeLonG To. They mentioned a communications plan their organisation has in mind, intended to raise awareness among parents of the resources that are available to them. What do the witnesses have in mind? How would they reach this audience? I find that as a politician, there are lots of things about which I want to tell people. Sometimes I wonder why people are not aware, because I keep trying to reach them in so many different ways but I cannot seem to hit the target of getting the information out as much as I want. What are the witnesses' plans in that regard?

I thank Dylan for his presentation. It is wonderful that he has such confidence. I am not sure that at 16 years of age I had the confidence to speak in front of a crowd of politicians. I have read his report. It is a marvellous survey in which he goes into tremendous detail. It will be enormously helpful to anybody grappling with policy to have something like that available. It is a great resource. Did Dylan find any resistance when he produced his survey? I notice that he got quite a lot of support from his school and from BeLonG To, but did he find any resistance anywhere else? I ask more out of curiosity than anything else.

I also thank Pavee Point's representatives for their submission. They mentioned being invisible. Were they referring to the fact that Travellers are not categorised separately in the national figures? Do the witnesses think that would be helpful? I refer also to the political question. I am trying to get my head around what is meant there. Do the witnesses mean that the political system is not supportive of what they are trying to achieve?

Mr. Pablo Rojas Coppari

To clarify, THB means "traffic in human beings". I apologise for using the acronym. In answer to the question about what services we are asking for, I note that victims of human trafficking are not homogenous in their categories nor in their experiences. As such, the types of services which are needed will be very different for those who are victims of trafficking for the purposes of sexual exploitation than for those who are victims of trafficking for labour exploitation. Not only will the experiences of the victims differ, so will the type of reaction. We very often see trauma and post-traumatic stress disorder, PTSD. They are more or less the most well-known effects. I am not a mental health expert.

There are no such services in the country, so setting them up would require looking at other jurisdictions where these types of services are already in place. I am sure there are people in Ireland who have the expertise, but on top of clinical expertise they would need an understanding of the phenomenon of human trafficking and the cultural sensitivities around providing services to people who are from different countries and different cultural and religious backgrounds. Furthermore, they will need to understand the physical phenomena that intersect, such as torture and the physical violence that arise in trafficking.

I am not necessarily saying that this expertise is not already in the country. However, it is about putting together a programme that delivers mental health for victims of human trafficking as part of our national referral mechanism, which is the mechanism set up by the State to provide services, including accommodation, legal counselling, and physical health. Mental health must be added as one of the key parts of the service provision.

The Deputy asked about victims of human trafficking in the prison system. Yes, this is one of the areas in which we work with victims of trafficking and forced criminality. We have worked a lot with people who were trafficked for the purposes of cannabis cultivation. I sincerely doubt that they are being provided with a mental health service, either because they are not offered one, or because it is not available to them. I say that because I would have done much of the assessment. I have gone into prisons across the country and met with them, and I know that basic interpretation services are not there for them. The legal services available to them are extremely limited. Moreover, accessing victims of human trafficking in prison is very hard for agencies like us that have the expertise, because we can only go there if we are invited by a solicitor. If solicitors do not recognise us as being experts, or simply do not want to engage with us, then we cannot approach these people. There are certainly no specialised services in prison for victims of human trafficking. I cannot attest to the quality of the services available to the mainstream prison population.

FGM is obviously not only linked to victims of trafficking. It is a broader cultural phenomenon. There is an organisation called Akidwa that does a lot of advocacy on the issue. If people have experienced female genital mutilation, there are certain health providers and health specialists who can address that. I do not know to what level that is mainstreamed in the health services. I imagine that victims have to be referred to people who have the expertise to address that from a physical point of view and from a mental health point of view. I think that covers the Deputy's questions.

Chairman

Deputy Corcoran Kennedy asked Dylan about any resistance he might have encountered when writing his report. Would he like to answer that question?

Mr. Dylan Donohue

I did not really get any resistance.

That is great. That is what I was hoping he would say.

Mr. Patrick Reilly

In regard to being invisible, my colleague, Ms Quirke, mentioned the lack of an ethnic identifier. I know that I have probably spoken too much about this, but I feel it has to be said.

I sat here a couple of weeks ago with the CHOs for almost three and a half hours and there was no mention of Travellers in that context. Decisions are made for Travellers and they do not have a voice in it. The lack of a voice has a bad impact on ground, and we see that. If ten men are making decisions for women with no women present it is not going lead to a good decision. That is what we mean by invisible. I do not mind if it is me at the table or someone else. Once there is a Traveller voice there I will be happy. Who knows Travellers better than Travellers? I hope that answers the question.

Ms Brigid Quirke

In terms of the political question - and I mean political with a small "p" - they are a small community. The first report on Travellers was carried out in 1965. The first Traveller health study was carried out in 1986. Since then the gap in life expectancy for Traveller men has gone from ten times the differential with the general population to 15 times. Things are deteriorating. That is also indicative of the improvement within the settled community, but the gap is widening. The Traveller situation has been under discussion. There have been policy documents and discussions, but over 50 years later we are no further on. Indeed, we are in a worse situation. Do people not want this to happen? We have all the reports, the evidence and the actions. We write submissions every day on policy documents. We lobby and we try to make sure that the Traveller voice is heard, but as Mr. Reilly said, if Travellers are not actually at the table it is as if they do not exist. It is not appropriate to have someone sitting at every table, but that is what it seems to require.

We had a person who tried to get elected as a Senator. That person sought to apply through the Taoiseach's panel. They then tried the university panel. There were four unsuccessful attempts to try to get a Traveller elected to the Seanad via the Trinity panel. We have one councillor in Tuam because there is a very large population of Travellers there. That is about the only political representation we have. We looked at models in other countries, in terms of the Traveller health study, and found that 40,000 people actually makes up a constituency. Is there a rationale for saying that Travellers should be allowed representation when the totality of their population is taken into consideration?

Chairman

I want to clarify something about the CHOs' appearance at this committee. They were brought in for two reasons: firstly, to explain how they spend their money; and, secondly, to talk about recruitment. They were not able to do that, so they are now submitting a written report on how they spent the money in that area, so I am sure Pavee Point will be listed in that.

Mr. Patrick Reilly

I thank the Chair.

I had posed a question to Ms Griffith about the communications plan. I also forgot to ask about regional access to BeLongTo for young people.

Ms Moninne Griffith

On regional access, we support over 30 LGBT youth groups. We are not in every county, I am afraid. Some of these groups are very small. The funding is through the National Office for Suicide Prevention, NOSP, which provides funding so that a youth worker has four hours to run a weekly or fortnightly youth group. It is patchy, but the young people themselves talk about how important it is and what a lifeline it is to have access to peers and to support.

There are two different communications plans. One is targeted at young people, because it came to our attention that even young people who were self-harming were not accessing services. We have good relationships with mental health services, but when we explored it we discovered that there was a double stigma and that they almost expected to have really bad mental health because they are LGBT. At the moment we are working together with some of our partners in the mental health area. Spun Out, Pieta House, NOSP and Jigsaw have all come together with Thinkhouse PR, which is a youth PR company, and we are carrying out in-depth focus groups with young people to get to the bottom of this problem. We will then look for a further investment so that we can start communicating outwards and telling young people that this is not okay and that they do not have to suffer like this. Services exist, and we can provide access to them for these young people. That is one of the communication plans.

The other plan relates to parents. Our experience is that LGBT young people are coming out at a progressively younger age, especially trans young people. For parents in Ireland, it can be very difficult and very challenging, so we are trying to access those parents at the moment to make sure that they know about our services and our partners who work with us. Anyone on Facebook at the moment will see that we have a big advertisement which targets parents. Facebook partnered with us on this project. There is a bot and a video, and parents can be brought in so that they can access the information. Further down the road we hope to work with family resource centres, FRCs, nationally so that we can get that information out there about the services that are available locally and nationally so that young people and their parents know that they do not have to go through this alone and that the supports and services are available.

Chairman

We have one more question-----

My question was answered.

Chairman

Okay. That is all the questions. If we sat here long enough, we could come up with many more questions. If any of the witnesses feel that they need to talk to us directly or want to push something for their organisation directly we would be more than happy to discuss it. I thank all the witnesses for attending today and for the really important information they have given us, which will greatly help us in our future work.

The joint committee adjourned at 3.26 p.m. until 1.30 p.m. on Wednesday, 28 February 2018.