The Civil War Over Gender Services in Irish Public Healthcare

Inside Ireland’s Health Service Executive (HSE), the equivalent of the UK’s National Health Service, there is a civil war over gender services. The battlegrounds in this war concern the protocol that will be used to treat Irish children and adults with gender dysphoria—who gets to decide it, and will the concerns raised by doctors be addressed?

The first question is whether adult and child gender services should follow the World Professional Association for Transgender Healthcare (WPATH) guidelines. In recent years, psychiatrists and endocrinologists with decades of experience treating patients with severe gender identity distress in the HSE’s adult National Gender Service (NGS) have been steadfastly refusing to follow WPATH guidelines despite intense pressure both from within the HSE and from transgender activist groups and senior politicians. One NGS psychiatrist, Dr Paul Moran, said in 2018 that WPATH guidelines “are clinically unsafe, and unsuitable for use in a public healthcare gender clinic”. Professor Donal O’Shea, an endocrinologist in the NGS who, like Dr Moran, has been providing specialist healthcare for adults with gender dysphoria since the 1990s, has stated that aligning with WPATH guidelines “would result in significant harm accruing to those with gender confusion”. (Genspect share the view of the Irish NGS that the WPATH guidelines risk significant harm and that WPATH has discredited itself with the WPATH Standards of Care Version 8 issued in September 2022.)

Opposing the NGS in the civil war are senior managers Dr Philip Crowley, National Director of the HSE Quality Improvement Team, and Dr Siobhán Ní Bhriain, HSE National Lead for Integrated Care. Unlike the doctors in the NGS, Drs Crowley and Ní Bhriain do not have decades of experience treating individuals who have gender dysphoria. Speaking at the Transgender Health Discussion of the Joint Committee on Health and Children Debate in 2013, Dr Crowley said “we are, relatively speaking, clueless in regard to the issues” and recommended that the HSE should partner with external transgender lobby group Transgender Equality Network Ireland (TENI). Dr Crowley’s recommendation for a partnership between the HSE and TENI has had its problems: according to a press report in July 2022, the HSE had to suspend funding to TENI after TENI repeatedly failed to meet deadlines to file audited accounts and concerns were raised about social media posts by TENI staff that were considered abusive of NGS staff. The division between Drs Crowley and Ní Bhriain and the NGS is so serious that, in 2022, NGS doctors advised the Minister for Health that they believe that Drs Crowley and Ní Bhriain have “consistently worked to undermine” the NGS model of care.

This civil war will determine the future of care in Ireland for adults and youth with gender dysphoria. As it stands, according to doctors in the NGS, Drs Crowley and Ní Bhriain have blocked progress of an NGS business case to expand NGS gender services for adults and to begin treating adolescents. This blockade is impacting patient care. Demand for services at the NGS have surged in the past decade: in 2012, NGS doctors were seeing 50 patients a year; by 2022 they were receiving 400 new referrals a year on top of existing cases. That same year, there were more than 1,000 people on the NGS waiting list and new patients have to wait three years for an appointment. NGS doctors warned the Minister for Health that if their business case is not approved, the NGS would have to take the “difficult decision” to close its waiting list.

The NGS currently provides healthcare in Ireland for adults with gender-related issues out of a clinic in Dublin. There are no specialist services for under 18s with gender related issues in Ireland, and since 2012, 233 Irish under 18s have been referred with severe gender related distress to the UK-based NHS Tavistock Gender Identity Development Service (GIDS).

The quality of care given to these Irish children in the UK is a central question in this civil war. In 2019 the NGS carried out an audit on 18 Irish patients who had been referred to the Tavistock GIDS service and who subsequently aged into the NGS adult service when they turned 18. The NGS completed the audit to document deficiencies they identified in the level of care given to Irish children and adolescents. Of the 18 patients reviewed, seven (39%) had no accompanying assessment report showing their diagnosis and treatment plans. 11 patients (61%) had serious mental health or social problems aside from gender issues. The NGS sent the audit to the HSE in 2020 to highlight the NGS concerns that “it had become clear that the GIDS were not competent to adequately assess children’s suitability for medical transition”.

The NGS doctors were not alone raising concerns about the Tavistock GIDS clinic. Whistle-blower clinicians working within GIDS had begun raising concerns as far back as 2004, eventually leading National Health Service (NHS) England to commission Dr Hillary Cass’s independent review into gender identity services for children. The Cass Review issued an interim report in March 2022, and Dr Cass told the BBC that “the current model of care was leaving young people “at considerable risk” of poor mental health and distress, and having one clinic was not “a safe or viable long-term option”. The Cass Review interim report led to a decision to close the Tavistock gender identity clinic. Despite all of this, in August 2022, Dr Ní Bhriain, stated that the Tavistock gender identity clinic was safe and the HSE would continue to refer patients there.

Following the publication of the Cass Review interim report and the decision to close the Tavistock gender clinic, there was brief glimmer of hope that the HSE would follow NHS England’s good example and commission an independent, impartial and objective review of gender services for Irish children. The HSE did commission a review, but regrettably, it was not independent, impartial, or objective. The HSE National Quality and Patient Safety Directorate (NQPSD) who were tasked with completing the review published their report in March 2023. Key issues with the report include the following:

1. The HSE Report Fails to Acknowledge the Existence of Two Competing Models of Care within the HSE

The report opens with the statement “In Ireland, a Model of Care (MoC) for all transgender services was developed by the HSE between 2014 and 2016” and closes with a recommendation: “It is clear that Ireland needs to update our MoC”. Stating that there is a MoC for all transgender services is misleading. It implies that all HSE transgender services in Ireland are following a single MoC. However, as highlighted earlier, the NGS adult service is following a different MoC. The 2014-2016 Model of Care referenced in the report is the MoC developed by Dr Crowley that follows WPATH, not the Model of Care developed by the experts in the NGS that does not follow WPATH. According to healthcare best practice, there should be seamless continuity of care when a patient transitions from pediatric to adult services. So long as fundamentally different MoCs are operating in the HSE’s child and adult gender services, seamless continuity of care is impossible. This HSE review was meant to focus on “improvements that should be considered to strengthen and standardise ensuring safety and best practice.” Failing to mention the ongoing dispute between child and adult MoCs is a glaring omission.

2. The HSE Report Ignores Key Evidence About Fast-Tracking of Hormones

The HSE Report claims “there is no evidence that hormonal treatment or other physical intervention has been fast tracked”. This statement ignores the audit completed by doctors in the NGS sounding the alarm about exactly this. NGS doctors sent the audit to the HSE in 2020 and reported they had seen “children, who the Tavistock have recommended starting on hormones, be very unwell and not ready to start hormones”.

3. The HSE Report May Conceal Significant Adverse Outcomes

The HSE Report says that there were “[n]o Category 1 adverse incidents reported in relation to children or young people who have used this service,” but it does not discuss Category 2 or 3 incidents. The HSE Incident Management Framework Guidance defines a Category 1 adverse event as a clinical or non-clinical incident rated as Major or Extreme as per the HSE’s Risk Impact Table. A Category 2 incident is defined as a “moderate” clinical incident in which an “outcome for affected person is symptomatic, requiring intervention (for example, additional operative procedure or additional therapeutic treatment), an increased length of stay, or causing permanent or long-term harm or loss of function”. Excluding Category 2 incidents from the report may be concealing serious adverse outcomes causing permanent harm or loss of function.

4. The HSE’s Interview of a Single Set of Parents Is Grossly Inadequate

According to the HSE Report, 233 children and young people have been referred to the Tavistock clinic, yet for this report, the HSE interviewed just one set of parents. One parent interview out of 233 cases is grossly inadequate in a review of a practice that involves of significant clinical complexity. It is not controversial to state that different factors can drastically affect outcomes in treatment for gender dysphoria. Some relevant factors include a history of trauma, psychiatric comorbidities, whether an individual was born male or female, age of onset of gender dysphoria, prescription of puberty blockers and/or hormones prescribed and length of use, discontinuation of treatments, etc. The child of the parents who were interviewed was in HSE pediatric care for 10 years, completed social, legal, and medical transition, and at age 18 is now on the waiting list for adult NGS. The age of this single patient cannot provide a clear picture on the longer-term outcome of this treatment. The Cass Review Interim Report notes that “[s]ince young people may not reach a settled gender expression until their mid-20s, it is too early to assess the longer-term outcomes”. A retrospective study of detransitioners from a UK NHS adult gender national gender clinic found regret among 6-10% of cases and stated that there is some evidence that people detransition on average between 4 and 8 years after completion of transition and express regret after 10 years.

5. The HSE Report Glosses Over Data Collection Problems in Ireland

The Cass Review reported that the lack of routine and consistent data collection within the Tavistock gender clinic means“it is not possible to accurately track the outcomes and pathways that children / young people take through the service.” In response to this issue, the HSE Report listed a risk mitigation afforded by the HSE clinical pathway as a “[v]ery low volume of cases in Ireland managed by single team”. This suggests that the HSE concluded that the data collection issue highlighted in the Cass Review is not an issue in Ireland. 233 patients is a low number compared to the UK figures, but it is still enough to justify formalised systematic data collection.

Moreover, according to the HSE report, “Irish patients [are] referred for psychological/psychiatric assessment only” and “[p]rimary and secondary care teams are involved in the care of Irish children/ young people”, meaning that Irish patients follow a different pathway to that followed by UK patients. The fact that Irish patients follow a different pathway with Irish clinician involvement is precisely why it is critical that the HSE take responsibility for data collection for Irish patients. If, as the HSE Report says, Irish care teams have been involved in the care of young people, then Irish care teams bear some responsibility for the missing assessment reports showing patient diagnosis and treatment plans for seven (39%) out of the 18 patients in the NGS audit.

One of the purposes of the HSE Report was to “pay particular focus on HSE pathways of referral and any improvements that should be considered to strengthen and standardise ensuring safety and best practice”. The report, however, does not recommend any specific improvements in data collection on gender services for children and young people by the HSE. The HSE Report recommends that the HSE should collaborate internationally and “share data,” but it is unclear how the HSE would share data without putting better processes in place to improve data collection.

6. The HSE Report Did Not Address the HSE’s Failure to Act on Patient Safety Issues

The HSE Report referenced the NGS audit of 18 patients who had been referred to the Tavistock gender clinic and noted that the NGS mitigated risks posed to Irish patients by the care provided in the Tavistock clinic by follow-up assessment and treatment provided by the NGS.

In an email accompanying the audit sent to the HSE in 2020, Dr Moran of the NGS said “it had become clear that the GIDS were not competent to adequately assess children’s suitability for medical transition… It was also clear that there was a high level of co-morbid mental illness, social adversity and functional impairment among these children, which the GIDS assessment either did not recognise, or did not address”. Dr Moran described referrals from Tavistock as “a complete disaster”, as inadequate assessments were carried out on all 18 patients in its audit and this required the NGS to carry out full assessments and to develop treatment plans for each, to deal with the range of issues, such as self-harming or violent behaviour. The HSE Report did not ask the key questions: Did the HSE take any action in response to serious patient safety concerns raised by the NGS in 2020? Did the HSE only take action when the Cass Review and planned closure of the Tavistock became national news in Ireland in 2022?

In Hannah Barnes’s February 2023 book Time To Think, which details the collapse of the Tavistock’s Gender Service for Children, Dr Paul Moran and Professor Donal O’Shea described how they faced a “kind of institutional laziness” in the HSE when they raised concerns about the children’s service—a hope “if we ignore it, it will go away”.

The March 2023 HSE report suggests that the “if we ignore it, it will go away” philosophy is very much alive and well within parts of the HSE. Charlie Flanagan, a member of the Irish parliament, described the report as “wholly inadequate and insufficient” and called upon the Minister for Health to commission an independent review. Genspect second that call. Until there is a truly independent review of gender services in Ireland like the Cass Review that objectively assesses the evidence and recommends a cohesive way forward, the division within the HSE and the consequent negative impact on patients of gender services in Ireland will continue.

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