There is no evidence that Irish children and young people with gender dysphoria were “fast-tracked” to hormonal treatments and other types of medical intervention, an internal review by the HSE has found.
The review found that the Irish care pathway for children and young people with gender dysphoria “mitigated” some of the risks that have been identified in the system in the UK.
The HSE review was commissioned in the wake of an interim report published last year by Hilary Cass, a consultant paediatrician appointed in England to review the gender service there.
The English service was centred around the Tavistock clinic in London that, in her report, Dr Cass found was struggling to cope with the demand for its services, had an issue with staff retention, and had to deal with a patient population that had complex needs.
She said divergent views about whether gender incongruence in young people was “an inherent and immutable phenomenon”, or a “fluid and temporal response” to a range of factors, had led to differing clinical approaches among care professionals.
Young Irish patients were sent to Tavistock for psychological and psychiatric assessments, as no equivalent service existed here. In the 10 years since 2012, according to the HSE report, 233 Irish children and young people were referred to the English clinic, with funding coming from the Treatment Abroad Scheme (TAS).
In the wake of the Cass report the decision was taken in England to deliver care to young people by way of six regional centres, while also continuing to operate a gender service in Tavistock, which would no longer take direct referrals.
Under the new regime, new Irish patients being sent to receive assessments in England are “triaged” by a board before being assigned to one of the regional centres.
The HSE has been approached by family members of children and young people who have complained about the lack of access to gender services, but they have not complained about the quality of the Tavistock service, either to the HSE or to Tavistock, according to the HSE report.
The report said there have been no “category 1 adverse incidents” reported in relation to patients of the Irish youth or the adult gender services. A category 1 adverse incident is a harm incident categorised as “major” or “extreme”.
The Irish clinical pathway involves general practitioners, the child and adolescent mental health service (CAMHS), and others, the report said. Since 2019 applications to send patients to Tavistock went to the HSE’s National Clinical Adviser and Group Lead for Mental Health for approval. Patients who attended Tavistock continued to receive care from CAMHS for other problems they might have, and any endocrinological interventions were overseen by an Irish consultant.
These and other factors meant that many of the risk factors identified in the Cass report were mitigated in relation to the Irish service, the HSE report said.
In the UK primary and secondary care staff have reported pressure to adopt an “affirmative approach” to their patients. There was “no evidence that a gender affirming approach has influenced hormonal therapy in Ireland”, the HSE report stated.
As was the case in the UK, there were “divergent opinions” in Ireland about the meaning of gender dysphoria, it said.
In the UK it has been reported that the long waiting times for accessing the gender service means that patients are often anxious to proceed to treatment quickly once they are seen.
While there were also long waiting lists in Ireland, “there is no evidence that hormonal treatment or other physical intervention has been fast-tracked”, the HSE report said.
Following the presentation of the report to the HSE’s executive management committee in February, a decision was taken to review Ireland’s model of care for the treatment of gender dysphoria. A copy of the report was released to The Irish Times after a request was submitted to the HSE.
While preparing the report the authors spoke with the family of a child who had been availing of paediatric care for 10 years. Having completed a social, legal and medical transition, the patient, now aged 18, is waiting for an appointment with the adult service (where new patients are waiting for more than three years to get their first appointment).
The family, according to the HSE report, said: “The mental strain and emotional distress experienced by their children and their family over the course of their transition was immense. Their child experienced social isolation, bullying at school and mental illness.”
They also said the approach of the professionals at the Tavistock clinic was “cautious and procedural rather than gender affirming” and that they were frustrated by how long they had to wait before being prescribed puberty blockers.
A spokesperson for Belong To, which campaigns for services for adolescents and young adults with gender dysphoria, said it was “extremely concerned about the current state of adolescent gender-related healthcare services in Ireland, and the resulting impact on the mental health and wellbeing of trans and nonbinary young people”.