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InvestigatesTransgender healthcareMANY TRANSGENDER AND non-binary people told us they are being forced to pursue gender-affirming healthcare outside of the official channels due to serious issues with the National Gender Service (NGS).
Yesterday, transgender people told The Journal Investigates about their traumatic experiences in approaches to their healthcare at the NGS, which is the only provider of healthcare to transgender adults in Ireland.
The clinical programme currently followed by the HSE is one which some international countries have moved away from, as it does not follow the current way that the World Health Organisation (WHO) treats transgender people.
The HSE told us that a new clinical programme for gender healthcare is being developed, which will consider “emerging and evolving international evidence”.
They also said decisions relating to their healthcare were sometimes based on employment status or whether they are ‘transgender enough’.
These traumatic experiences are pushing some people towards a grey market of hormone replacement therapy (HRT) drugs purchased through a variety of online sources.
Self-medicating like this is known in the transgender community as DIY HRT.
Our team spoke to almost 20 transgender adults about their experiences accessing gender-affirming healthcare in Ireland.
Many told us they are actively accessing healthcare outside of the official channels, oftentimes blaming the years-long wait for care with the NGS or saying that they can’t put themselves through a process which some describe as an interrogation.
They also say the stories from others in the trans community of the types of questions asked and decisions relating to healthcare have led to a lack of trust.
But some GPs have been recommended by the NGS to not provide blood tests to monitor hormone levels to those who are self-medicating.
These tests are an important safety measure for those using DIY HRT.
A spokesperson for the Health Service Executive (HSE) told The Journal Investigates that transgender healthcare services in Ireland are “limited” and admitted that they “are not meeting people’s full range of needs”.
They added that a new clinical programme for gender healthcare is in development that will consider “emerging and evolving international evidence” and “be developed in a consultative way” with stakeholders.
The HSE also added that “waiting times are unacceptably long for the NGS” and acknowledged that “this has caused significant distress” for people.
They also said that their model of care “is based on a comprehensive multidisciplinary assessment that takes into account all aspects of a person’s health and wellbeing over their lifetime, rather than focusing only on gender”.
They added that the benefits of providing gender-affirming healthcare “should exceed any apparent risks”.
Emma*, a transgender woman, has been on the NGS waitlist for two years but started ordering HRT through online sources well before this.
She had heard about the length of the waitlist from friends and told The Journal Investigates that she wasn’t able to wait for healthcare.
“I wasn’t mentally in a place where I felt like I could handle [it].”
Emma feels abandoned by the healthcare system.
I can’t think of any other sphere of healthcare where this is considered acceptable.
DIY HRT involves ordering hormone replacement therapy drugs, such as estrogen or testosterone, from online pharmacies or other sources abroad.
Operating outside of the medical system like this comes with risks, as there aren’t as many checks to ensure the product you receive is genuine and safe to use.
In the absence of this medical oversight, online communities and resources from fellow transgender people try to reduce the risks involved.
This can include insight into dosages, injection supplies and even laboratory testing of HRT products.
Nonetheless, many transgender people will readily admit that this is riskier than receiving healthcare through official channels.
It’s just a risk many are willing to take, as the alternative would be no healthcare for many years.
The long waitlists are of particular concern for older trans people.
Isabel, a trans woman, started DIY HRT when she was 60. She told The Journal Investigates that accessing healthcare through the NGS was not a viable option for her due to the time it would take.
Isabel said that time starts to become more of a significant issue at her stage of life and that by accessing healthcare through DIY, she was in complete control.
I was in control of my own destiny.
“I was in control of time in particular, and it also meant that I wasn’t at the whim of someone else,” she said.
Everyone we spoke to told us that the incredibly long wait times for the NGS is one of the reasons they started DIY HRT.
But it’s not the only reason.
Tara, a transgender woman, told The Journal Investigates that “desperation” for healthcare and the inability to access it through the NGS is what drove her to DIY HRT.
While the wait times were a significant factor for her, she said the stories from other transgender people about their experiences with the NGS pushed her away from the service.
Multiple transgender people that The Journal Investigates spoke to described the appointments with the NGS as “interrogations”.
They also told us about being questioned about their personal lives, such as the type of pornography they watch and details about their sex lives with their partners.
The clinical lead for transgender healthcare in Iceland, Dr Beth McElrea, told The Journal Investigates that questions like those asked by the NGS are, in her view, “completely inappropriate” in the context of current WHO guidelines.
“I did not trust the Irish medical system at all,” Tara said, who added:
They treat you as if you don’t know yourself.
This lack of trust for the NGS was echoed by many of the transgender people we spoke to.
Some people told us receiving an autism or ADHD diagnosis is another reason to avoid the NGS, as many have heard of healthcare being delayed or even denied because of those conditions.
A spokesperson for the HSE told The Journal Investigates that “autism is common in our service with over 30% of people presenting either neurodiverse or autistic”.
Eoghan*, an autistic trans man, said that if you’re “autistic and trans you’re going to be scrutinised far, far more”.
“I guess the implication is that autistic people might not be able to understand their own gender. I can’t get over how stupid that is,” Eoghan said.
The Journal Investigates also heard from Adam*, a trans man, who was told his care with the NGS would not move forward without an autism assessment.
The psychiatrist was very focused on the fact that I was neurodiverse, saying ‘we will not go any further until you get an ASD assessment’.
Adam said he ended up paying €1,200 for the assessment so that he could be seen by the NGS again.
When this was put to the HSE, a spokesperson said: “Being autistic in itself does not mean that someone cannot start hormone therapy or have gender affirming surgery and many autistic people go on to start hormone therapy and/or have gender affirming surgery with us.”
For those on HRT, an important safety aspect is getting regular blood tests.
This simple test can reveal issues around dosages by making sure a person’s hormone levels are balanced and aren’t too low or too high.
The service is typically offered by GPs, but many transgender people who are using DIY HRT told The Journal Investigates they struggle to find a GP willing to help.
Some GPs have also received letters from the NGS instructing them not to provide blood tests to transgender patients taking HRT outside of the NGS, including from private clinics.
The letters, seen by The Journal Investigates, state that the NGS does “not recommend” that GPs monitor hormone concentrations if asked by a transgender patient, as they are “not proven to risk manage care in this clinical scenario”. The letters add that other blood tests can be provided.
These letters were not sent to all GPs, but were directed to doctors who had transgender patients.
For those receiving healthcare within the NGS, its website states that hormone levels should be monitored every three to six months for the first few years on HRT.
This means many trans people are using DIY HRT without the safety net of their GP monitoring their hormone levels.
The HSE did not respond to questions on why these letters are sent to GPs.
A spokesperson did, however, say:
“We cannot comment on individual patient cases or consultant practices when to do so might reveal information in relation to identifiable individuals, breaching the ethical requirement on us to observe our duty of confidentiality.”
Gwen, a trans woman, was already getting blood work from her GP for a separate medical issue. When she asked if her hormone levels could be monitored as well, she was told no, because her GP had received a letter from the NGS.
She now has to pay for blood tests from a private provider in Ireland to ensure her levels remain stable as no GPs in her area were willing to perform the tests for her.
Such is the secrecy that surrounds transgender healthcare in Ireland, a private list of trans-friendly GPs is maintained by community groups to aid those seeking help connect with a medical professional.
Many trans people told The Journal Investigates of their frustration accessing basic forms of healthcare when in reality, they say, it’d be a very simple thing to provide.
“I feel lonely. I feel abandoned,” Emma said, adding:
I feel like nobody’s ever really going to take care of us except ourselves.
“The HRT we use is exactly the same as any other person in their 50s. Nobody’s confused about how it works.”
HRT is also a common treatment to relieve symptoms of menopause and perimenopause.
Alex*, a non-binary person, feels like there is a lot of fearmongering and demonisation of trans people accessing healthcare through DIY when in most cases they feel like they don’t have any other option.
“I should be able to go to my GP and talk about my transition and what I want from my transition and why I want to go on hormones”, they said.
Instead, Alex said they face “having to buy it online, or going to the NGS and being almost interrogated”.
The system the NGS is using means that trans people have to almost earn their medical transition, Alex said, adding:
I feel angry and frustrated that trans people are basically being left to kind of rot.
“You actually cannot stop people from transitioning if that’s what they want,” Alex said, adding that if people are motivated enough, they will go and get HRT.
They will just go and find less safe ways or illegal ways to do it.
Almost every trans person we spoke to told us despite their lack of trust in the Irish medical system, they would much prefer to have their healthcare managed by a professional.
For this to happen, however, our investigation clearly demonstrates that it’s not just the wait times at the NGS that need to be resolved.
Our findings build on previous evidence. A 2022 report by Transgender Europe found that Ireland ranked the lowest of any EU member state for availability and accessibility of transgender healthcare.
An update in 2024 found that “the state of trans-specific healthcare in Ireland is very concerning” and that there is a “stigmatising diagnostic process and excessive gatekeeping”.
All of the transgender people we spoke to said they would like Ireland to move to an informed consent model, like in Iceland, Malta and parts of Spain.
This model serves to understand and meet the needs of each individual person, treating them as capable of making decisions about their bodies and healthcare.
It would allow endocrinologists and GPs to explain all of the effects and risks associated with the medical care being sought and provide the ability for the person seeking healthcare to make a decision based on that.
It also moves away from psychiatric assessments and diagnosing transgender people with something that needs to be treated.
Dr Beth McElrea, the clinical lead for transgender healthcare in Iceland, told The Journal Investigates:
Being trans isn’t a medical issue. It isn’t a disease or an illness.
McElrea said that transgender people know their bodies better than anyone else, which is why an informed consent model is seen as the best model of care.
“The informed consent model is a shared decision-making process between the trans person who is an expert in themselves and the clinician who is an expert in the medicines,” McElrea said. “We work together to find the best solution for each individual.”
The government committed to moving towards this model of care in the 2020 Programme for Government, saying they would develop a system “based on a best-practice model for care, in line with the World Professional Association of Transgender Healthcare”.
This commitment, however, was significantly watered down in the 2025 Programme for Government. It said they would “ensure a transgender healthcare service that is based on clinical evidence”.
Transgender community groups and activists told The Journal Investigates they have repeatedly tried to get a meeting with the Minister of Health to discuss the problems with the NGS and how they wish to reform the system.
Former Minister Stephen Donnelly told one group he didn’t have time to meet them and repeated requests to current Minister Jennifer Carroll MacNeill have, as yet, gone unanswered.
A spokesperson for the Department of Health told The Journal Investigates: “The Minister for Health will meet with transgender advocacy groups in the coming weeks and looks forward to engaging with them.”
Alex said that changes to transgender healthcare must start from direct action and the transgender community striving for more. They said:
It’s not going to come from the government or the Dáil. It’s going to come from trans people organising ourselves.
Emma said that everyone having an opinion on transgender healthcare is part of the problem and is making the discourse toxic.
She said that discussions involving transgender healthcare are often “cisgender person argues with cisgender person” without asking transgender people what they want from their healthcare.
Daire Dempsey, policy lead for Transgender Equality Network Ireland (TENI), told The Journal Investigates the HSE is developing a new national clinical program for trans healthcare.
This new model should be informed by international best practice, but crucially, Daire said, “it also has to be informed by really meaningful community consultation”.
A spokesperson for the HSE told The Journal Investigates that this new model of care “will be developed in a consultative way, engaging with stakeholders”.
Daire said this consultation represents an opportunity for the HSE “to begin to repair the loss of trust between the medical establishment and the trans community”, but added:
“If that is not done well, I think that the disillusionment, the disengagement from healthcare services by the trans community will get worse.”
*Names have been changed.
Reporter: Conor O’Carroll • Editor: Maria Delaney • Social Media: Cliodhna Travers • Main Image Design: Lorcan O’Reilly
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