The function, demand, limits and future of the National Gender Service

The National Gender Service (NGS) is based at St Columcille's Hospital in Loughlinstown in Dublin. There has been some form of gender service in Loughlinstown for almost 20 years. The primary purpose of the NGS is to provide specialist support to people seeking medical interventions to help them affirm their gender.

Terminology in the field of gender is always evolving, and different clinicians, clients and communities will have their own language preferences and practices. Transgender (often shortened to trans) is the term most commonly used by clients and clinicians at NGS to describe the experience of having bodies that do not align with gender identity. Those of us who are transgender and born with a female body do not identify as female, and those of us who are transgender and born with a male body do not identify as male. This discordance between the physical self and gender identity will often, but not always, result in psychosocial distress. The medical term for this distress is gender dysphoria.

Some transgender people will use hormones and/or surgery to help alleviate this distress, or to help them feel more comfortable in their gender. The process of using hormones or surgery in this way is termed medical transition. Contrary to popular understanding, many transgender people never use any hormones or surgery as they feel comfortable in their gender without medical intervention. However, some transgender people wish to progress to medical transition and so are referred to the NGS.

The demand for medical transition has increased substantially in the last five years. When a gender service was initially offered at St Columcille’s Hospital almost 20 years ago, referral rates did not exceed 10 people per year. Referral rates increased gradually, and in 2008 the service first breached the 10 referrals per year mark. In that year, a total of 12 people were referred.

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Referral rates increased much more rapidly in 2014-2017. In 2005-2014 a total of 218 people were referred. By 2017 we were receiving more than 200 referrals per year. While these numbers are beginning to plateau, the referral rate continues to increase year on year (albeit at a lower rate of increase).

While the service has expanded recently, the demand continues to exceed our capacity. We are receiving more than 300 referrals per year and do not have capacity to see 300 people per year. Without sufficient staff, we are unable to see people for their initial assessment as quickly as we would like, and waiting times continue to increase. Similarly, we are unable to offer the wide range of support services for people as they move through their medical transition. We have submitted a number of business cases seeking additional posts so that we can reduce the waiting time for initial assessment and offer a wider range of services. Decisions on these cases are pending.

In parallel with this rise in referral rates, the complexity of clinical need has increased. When we reviewed the care needs of people attending the service in 2014, social care needs were hardly mentioned. Now, social care needs are common and often complex. This is partially a reflection of the change in age demographics. Up to 2014, people seen in the service were usually aged 30 or older. Now the majority of people referred to the service are in their late teens or early 20s, and at this age are often dependent on others for fundamental needs such as housing and income.

Clinical needs

Another key emerging clinical need is functional impairment, which was not recorded as a requirement in 2014. Functional impairment refers to the ability to engage in necessary or meaningful tasks. These tasks can be as simple as daily chores or more complex such as engaging in the world of work or education. For an increasing number of people attending the service, engaging in these tasks can be difficult. There are many potential reasons for this. Autistic spectrum disorder (ASD) is only one, but is increasingly common in our service. In 2014 the prevalence of ASD was less than 3 per cent whereas now more than 30 per cent of people attending have clinical features of autism or ASD.

Identifying every individual’s clinical needs prior to medical transition is important. While medical transition can produce many benefits, it is, as all clinical interventions are, associated with a significant risk of complications. The complications of medical transition that are most common are not specifically gender related. The complication termed transition regret (when someone has gone through medical transition and regrets it as they no longer identify as transgender) is rare. The more common complications of medical transition relate to a decline in mental health or social function that occurs when a person’s needs have not been met prior to and during their medical transition. In severe cases, the complications of medical transition include homelessness, disability, acute psychiatric illness and suicide.

Therefore, a comprehensive psychosocial assessment of need is vital prior to medical transition so that clinical needs that require support prior to or during medical transition can be identified. In order to identify and address these needs, a model of care for the NGS was developed by the HSE Mental Health Division in 2016, and approved by the Ireland East Hospital Group steering group for the development of a national gender service in 2018. This model is based on a comprehensive multidisciplinary psychosocial assessment prior to medical transition, with ongoing multidisciplinary review and support as the person moves forward through their medical transition. This model has now been in place for three years.

Contrary to popular belief, the initial assessment at the NGS is not solely focused on assessing a person's gender or their gender dysphoria. While understanding a person's gender is important, the assessment needs to be much broader than that. An assessment for medical transition should be a psychosocial assessment of need that covers all of the fundamental aspects of a person's life that will potentially be affected by medical transition, and that ensures the person is ready for all of the ups and downs that come with medical transition. Therefore, the assessment explores social health, occupational function and mental health. Sexual health is also explored. The hormonal therapies and surgeries used in medical transition will affect intimate relationships, sexual function and fertility, and so these issues need to be discussed prior to any medical intervention. (An outline of the assessment process can be found on our website (nationalgenderserviceireland.com

Surgery

At the assessment stage we find that most people have needs that are easily met within the service. For those that do have clinical needs that require support, we can usually help them to move forward through a medical transition without complication. We work with other healthcare providers and agencies as needed to ensure that a person’s health and wellbeing is well supported prior to and during their transition.

When medical transition begins, there are a number of options to consider. Medical transition usually includes gender affirming hormone therapy. This refers to the use of sex hormones (testosterone or oestrogen) with or without blockers. Blockers are medicines used to disrupt or suppress a person’s sex hormone production. These hormone therapies, either sex hormones or sex hormones with blockers, produce physiological and physical effects that can help some people feel more comfortable in their gender.

Gender affirming surgery is another option. Most people attending the NGS decide not to have surgery. For those that do, we have surgical pathways for all of the major gender affirming surgical options including gender affirming chest surgery (mastectomy or breast removal and mammoplasty or breast enhancement), and gender affirming genital surgery (including reconstructive surgery of the genitals to form a vagina or phallus). Sadly, given a lack of public sector access to these operations in Ireland, most people travel abroad for surgery with funding support via the Cross Border Directive (for chest surgery) or the Treatment Abroad Scheme (for genital surgery). There is very limited private sector access to chest surgery in Ireland and no access to genital surgery.

This lack of service provision needs to be addressed. We need to provide a programme here for those seeking gender affirming surgery. Gender affirming surgery can be very beneficial but as an experience can have a significant emotional toll on the person while they are recovering. It would be much better to have the option of having these operations closer to home, with their support network close by. It would also be clinically safer and would aid in the management of post-operative complications. We are asking for resources to develop an indigenous service. Hopefully, this request will be answered and we can offer an Irish service so that people do not have to travel for these vital interventions.

The NGS is facing multiple complex challenges, and is facing them with insufficient resources. Our goal is to provide a world-class service with a full range of supports and interventions for people moving through a medical transition. With sufficient resources, that goal will be achieved.

- Dr Karl Neff is endocrinologist and clinical lead at the National Gender Service at St Columcille’s Hospital in Loughlinstown, Co Dublin