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InvestigatesTransgender healthcareTRANSGENDER PEOPLE WHO move to Ireland from other countries are being told by the National Gender Service (NGS) they must join the waitlist and go through their assessment process before accessing healthcare in Ireland.
This is despite having legally changed their gender and previously accessed gender-affirming care in their home countries.
The NGS is requiring people who have already transitioned to join a years-long waitlist and prove they are ‘transgender enough’ once again.
The Journal Investigates has spoken to almost 20 transgender adults about their experiences with accessing transgender healthcare in Ireland.
Earlier this week, people told us the questioning that takes place during NGS assessments can feel traumatic and upsetting. These questions include asking about what pornography they watch or details about their sexual lives with their partners.
The NGS is the only provider of healthcare to transgender adults in Ireland.
The clinical lead for transgender healthcare in Iceland, Dr Beth McElrea, told The Journal Investigates that in her expert opinion, questions like these are “completely inappropriate”. This is because best practice, informed by the WHO guidelines, has moved away from this type of evaluation.
Since 2019, the World Health Organisation no longer views being transgender as a mental or behavioural disorder. Instead, they now see it as relating to a person’s sexual health.
The assessments were also described as “interrogations” by those who went through them and they felt compelled to share intimate details about themselves for fear of being denied healthcare.
They also told us decisions on who can receive healthcare, can sometimes be based on employment status or whether they had come out publicly to everyone in their life.
Every transgender person we spoke to who went through the NGS spoke of these traumatic experiences and told us it is their belief that the service is not fit for purpose.
We also revealed how some transgender people are turning to DIY HRT, a method of accessing healthcare outside the official channels.
This involves ordering hormone replacement therapy (HRT) drugs through a variety of online sources.
For transgender people who move to Ireland from the EU, this method can be one of their only options for continuing to access gender-affirming healthcare.
Responding to our findings, a spokesperson for the Health Service Executive (HSE) told The Journal Investigates that transgender healthcare services in Ireland “are not meeting people’s full range of needs” at this time, adding that services remain “limited”.
They also said that a new clinical programme for gender healthcare is currently in development. This model of care, they said, will be developed “in a consultative way” with stakeholders and will consider “emerging and evolving international evidence”.
The HSE 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”.
The HSE said that “waiting times are unacceptably long for the NGS” and acknowledged that “this has caused significant distress” for people.
The NGS requires transgender people who have already transitioned and received healthcare and gender recognition in other EU countries to go through their system, including the psychiatric assessments.
Rebel, a trans woman from Italy, told The Journal Investigates that she has lived all over Europe and experienced the different standards of transgender healthcare across the continent.
When she arrived in Ireland, she was in shock when she found out about the state of trans healthcare in this country.
Rebel had already been living as a woman for many years before arriving in Ireland. She had received healthcare from several different EU countries without too much trouble.
She had even gone to court in Italy to legally change her gender, meaning all of her official documents now said ‘woman’.
Despite this, the NGS told her that she could not be prescribed hormones, something she had access to and had been using in other EU countries, unless she went through their system.
“The gender service in Ireland is in no place to tell my doctor that they’re not to help me,” she said, adding:
This is a system that is designed to hold trans people down.
Rebel said that she lived in Poland during the time when the right-wing Law and Justice party was in power and when ‘LGBT-free zones’ were rampant across the country.
“Even in Poland”, she said, “I got a stellar service compared to what I’m getting in Ireland.”
Rebel said that having been legally recognised as a woman, she believes not being able to access HRT like any other woman is a violation of her rights.
“This is not just a system that is failing as a healthcare system. This is a system that is specifically failing trans people in Ireland, and that’s not something that you can ignore.”
The HSE did not respond specifically to questions about Rebel’s experience. However, the spokesperson did say that “evidence for the best and safest type of healthcare in this area is limited”.
A spokesperson for the HSE also said:
“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.”
Rebel isn’t alone.
The Journal Investigates also spoke to Sarah*, a trans woman originally from another EU country.
Sarah, like Rebel, is legally a woman. Her ID and birth certificate both say she is a woman. She is also working in Ireland as a woman and has a prescription for hormones from her home country.
She asked the NGS if there was a way to skip the psychiatric assessments, as she had already legally transitioned in her home country but was told no. She would have to join the years-long waiting list and go through the humiliating experience so many trans people speak about.
“The NGS have such a stranglehold on [trans] healthcare that someone like me, who has had bottom surgery, cannot be considered ‘truly trans’ because in their head they need to assess me themselves,” she said.
Because Sarah has had bottom surgery, she needs HRT to continue to function as her body does not create hormones naturally anymore.
But she cannot access this in Ireland through the NGS, so she’s been forced to turn to a grey market of ordering HRT drugs from online sources and administering them herself.
This is known in the transgender community as DIY HRT. The majority of transgender people we spoke to were either using DIY or actively looking into it because of the many problems with the NGS.
Sarah says if you move to Ireland as a transgender person “you go DIY”, to survive.
When asked about this, the HSE said they could not comment on “individual patient cases or consultant practices”.
She says there’s a stigma in Ireland that all transgender people are depressed.
Instead, she argues, “if you just let us live our lives in peace with the right medication, with the right time, we would be fine.”
For transgender people in Ireland struggling to access healthcare, travelling abroad also comes with obstacles.
Adam*, a trans man, spent several years in the NGS system without receiving any healthcare. He eventually took things into his own hands when he referred himself to a private clinic in the UK to access top surgery (a bilateral mastectomy).
This step, however, was not taken well by those in the NGS, Adam said.
Adam had intense gender dysphoria at the time because of his chest. He explained this to those in the NGS, practically begging to be seen sooner. He said:
I told them I can’t live like this much longer.
He told the NGS that he was considering going to the UK to get top surgery from a private clinic because of the long wait times. He was told that they wouldn’t approve of that and that they’d make arrangements to see him again quickly.
Adam wasn’t seen by the NGS for another six months after that.
Frustrated by the lack of urgency in his care, Adam referred himself to a private clinic in the UK. He was seen and assessed by a psychologist who recommended he get the surgery due to his gender dysphoria. He also took out a loan to cover the €15,000 cost of the surgery.
When Adam next saw the NGS, his surgery in the UK had been scheduled. He told the psychiatrist in the NGS that he had received his surgery date.
Adam said the psychiatrist demanded to know the details of whom he had seen in the UK, who his surgeon was and how he had accessed this healthcare.
Adam said he felt cornered in this moment and gave his phone to the psychiatrist, who then took down the details of his surgery.
Despite this reaction from the NGS, Adam travelled to the UK and got his top surgery. “At some point you have to take some bit of control back,” Adam said. “You can’t be constantly begging for scraps.”
I can’t live in the wrong body forever, just because they think I’m not worthy of their help.
After returning from the UK following his surgery, Adam received a letter from the NGS. It had been sent four days before his surgery.
The letter from the NGS, seen by The Journal Investigates, advised Adam not to “commence gender-affirming medical treatments” and to focus on his mental health.
It also said that the NGS would contact his GP and the public psychiatrist he was seeing outside of the NGS system.
Both were aware of his surgery and supportive of it, Adam said, but as they aren’t part of the NGS, they couldn’t provide any referrals to him.
“It felt like they were intentionally trying to block me,” Adam said. “I think they were hoping that maybe my psychiatrist or my doctor would stop me.”
Adam’s mother, Niamh* told The Journal Investigates that she was very disappointed and let down by the care Adam received from the NGS.
As a healthcare worker with the HSE, she wanted Adam to go through the official channels and encouraged him to stay with the NGS. However, having now seen the standard of care he received, “I feel a bit guilty”, she said.
I feel very let down because it’s a system I work for myself and when I’m coming to them for help for my child, I can’t get it.
She agrees that the letter from the NGS was sent “trying to prevent [Adam] from having gender-affirming surgery”. Even though it arrived after Adam’s surgery, it was still very distressing.
Both Adam and his mother said that his mental health struggles were caused by his gender dysphoria and that by getting the surgery, they were addressing that.
Delaying it, or not going through with it, as the NGS suggested, was not an option for them.
Our team asked the HSE about Adam’s experience, but a spokesperson said they could not comment on “individual patient cases or consultant practices”, citing a “duty of confidentiality”.
“He has done everything they have asked and he’s gotten very little in return,” Niamh said. “I don’t feel there’s a way forward with the gender services at the moment,” she added.
She feels that those in the NGS don’t see Adam for who he is.
While he is autistic and has mental health struggles, those things “don’t make him any less of a man”, she said.
Our investigation has highlighted numerous problems with current transgender healthcare in Ireland.
We spoke to many transgender people about their experiences with the NGS and struggles to access healthcare.
They told us of their lack of faith and trust in the system and as a result, many are taking healthcare into their own hands.
Daire Dempsey, policy lead for Transgender Equality Network Ireland (TENI), told The Journal Investigates that the NGS has put many barriers to accessing healthcare for transgender people to overcome.
Before you can access healthcare, they said, transgender people must address other aspects of their lives, such as mental health struggles.
This, however, misses the point of a ‘holistic service’ because “a lot of the time the mental health concerns come from not being able to access gender-affirming care”, Daire said.
Having socially transitioned, being out to everyone in your life, having a stable job, having stable housing can’t be a precursor to healthcare, Daire said, because many of those things go hand in hand.
“I think we’re putting the cart before the horse. I don’t think it’s reasonable to expect people to meet all these criteria in order to access gender-affirming healthcare.”
These barriers also mean that many transgender people feel they have to present as model patients in order to be taken seriously, Daire added.
Transgender people are not going to disappear and are going to access healthcare any way they can until the system improves, Sarah, a trans woman, said.
A spokesperson for the HSE told The Journal Investigates that “while gender is one important aspect of the risk/benefit assessment, we spend a lot more time on non-gender aspects like social health”.
They added that “occupational function” is part of the assessment in order to “understand a person as a whole person in a social context”.
This is done, the spokesperson said, to reduce risks of “a decline in social function, general wellbeing, and a deterioration in mental health”.
Sarah said she can’t see any other option but to resort to DIY healthcare.
“It’s just people who are desperate for healthcare,” she added, “we don’t have another option here. You put our backs against the wall. You gave us no avenue.”
*Names have been changed.
Read our full series on transgender healthcare here >>
Reporter: Conor O’Carroll • Editor: Maria Delaney • Social Media: Cliodhna Travers • Main Image Design: Lorcan O’Reilly
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