I propose to take Questions Nos. 158, 188 and 189 together.
Transgender-specific guidelines have been developed by WPATH (World Professional Association for Transgender Health) and the Endocrine Society (who updated their guidelines in 2017). These guidelines were devised by experts in transgender healthcare, along with members of the International Transgender, Transsexual and LGBT community, and supported by the Transgender Equality Network of Ireland (TENI).
The guidelines recommend a comprehensive multidisciplinary psychosocial assessment prior to commencement of hormone therapy by endocrinology services. The assessment focuses on more than just assessment for the possible diagnosis of Gender Dysphoria. The guidelines highlight several criteria which must be met prior to referral for hormonal intervention. It is important that co-morbid conditions are identified and addressed, and that people access the supports that they need to manage co-morbid difficulties, which can impact on response to medical transition (including hormone treatment).
International best practice involves an assessment by a multi-disciplinary team and shared decision making in the best interests of the individual. Both WPATH and the Endocrine Society Guidelines 2017 specify the assessment must be carried out by a mental health professional (s) with experience in transgender healthcare and possess specific skills. Endocrinologists and General Practitioners (GPs) do not possess these skills, and require access to the multidisciplinary team as described. GPs would only see a small number of gender variant individuals during their lifetime in clinical practice, and would not be in a position to build up the requisite skillset outlined in WPATH and Endocrine Society Guidelines or have the time resource to conduct a comprehensive evaluation.
Informed consent is essential, whereby benefits and risks of hormone treatment and surgery are discussed with individuals seeking these interventions. Although regret rates are low, it can happen and can also lead to high levels of psychological distress. Healthcare providers work with people to try to prevent negative outcomes. The emerging evidence on good outcomes following medical and/or surgical transitioning is based on use of multi-disciplinary psychosocial assessment, fulfilment of criteria for hormones and on-going psychological support throughout the process. It is important that psychological support is available to individuals before, during and after transitioning.
Prescription of hormone blockers and cross-sex hormones for transgender people is relatively new. Significant side effects can occur with cross sex hormones including irreversible physical changes and infertility. There is a lack of long-term research on outcomes. For these reasons the decision to prescribe should only be made by specialists (i.e. Endocrinologists) in consultation with other professionals involved in the assessment process. Shared decision-making is in accordance with best practice internationally. Prescriptions can then be supported by local GPs with specialist guidance.
The Best Practice approach as outlined above is endorsed in the Service Development Model as developed by the Quality Improvement Division of the HSE in 2017, in collaboration with TENI. This model is providing the framework for the development of National Gender Clinics and MDTs for children and adults, funded by the Acute Hospitals and Mental Health Divisions of the HSE. Recruitment will commence to develop these national teams in 2018. This investment in new posts in 2018 which includes one consultant endocrinologist (adult services), one consultant endocrinologist (paediatric services), one social worker (adult services), one speech and language therapist (adult services), one senior psychologist (adult services), one senior psychologist (paediatric services), one clinical nurse specialist (Paediatric services), two administrative support officers (adult and paediatric services) is a concerted measure by the HSE to address the waiting times and immediate service needs of children, adolescents and adults in transition. The HSE, across a number of programmes including mental health, acute hospitals, primary care and social inclusion, is committed to building services for this community in accordance with International Best Practice.
The HSE is a member of the group established to review the operation of the Gender Recognition Act, and the Department has no plans to make a submission to the review group. The number of persons waiting to see physicians regarding hormone replacements therapy and the number of physicians treating persons for hormone replacement therapy are service matters. I have referred these issues to the HSE for direct reply to the Deputy.