Leading doctors lodge formal complaint about HSE treatment of Irish children with gender identity issues

By Louise Whelan

For anyone who is interested, this is an mportant analysis of the complicated state of play in Ireland by psychologist Louise Whelan.

On Friday the 15th of December 2023, the Irish national broadcaster Raidió Teilifís Éireann (RTÉ) broke the news that the two most experienced clinicians involved in “transgender healthcare” in Ireland have taken the unprecedented step of making a formal complaint to the Health Information and Quality Authority (HIQA) about the Health Service Executive’s (HSE) treatment of children and young people with gender identity issues. The HSE provides public health and social care services to everyone living in Ireland, it is the equivalent of the UK’s National Health Service (NHS).

The full RTÉ Prime Time Investigates television programme can be watched here.

The complainants, Professor Donal O’Shea and Dr Paul Moran work within the publicly-funded National Gender Service (NGS) and provide specialist multidisciplinary support to adults with gender identity issues living in Ireland. The NGS takes a holistic approach encompassing gender identity, social health, mental health, day-to-day functioning and general well-being. Referrals undergo a holistic assessment before any medical interventions (hormones), surgical interventions or other care.

The complaint lodged by the NGS doctors highlights concerns regarding referrals of Irish children with gender identity issues to the NHS Tavistock Gender Identity Development Service (GIDS) in London. 229 Irish children with gender identity issues were referred by the HSE to the Tavistock GIDS service between 2015 and 2022. The Tavistock GIDS service was shut down for new referrals in 2022 following reviews by the UK Care Quality Commission (CQC) and after the Cass Independent review of gender identity services for children and young people revealed unsatisfactory levels of care at GIDS.

The NGS doctors’ complaint also relates to the HSE writing to the families of 101 children on the waiting list for issues related to gender identity following the closure of the Tavistock GIDS service to new patients. The HSE wrote to the families advising them of a gender clinic in Belgium as a possible treatment option. In a statement to Prime Time, the HSE said that the quality of care at the Belgian clinic was not assessed and that it does not recommend or formally refer patients there, it simply informed patients of the availability of the service.

The NGS complaint is the latest development in an ongoing public battle between NGS doctors and other clinicians/senior managers within the HSE over the safety of the model of care for children and adolescents with gender identity issues. The current Minister for Health, Stephen Donnelly has acknowledged the fundamental disagreement between the NGS and another clinical team in the HSE and he has said that he wants “an agreed model of care for Ireland”.

Four days after the Prime Time show was broadcast it was reported that Dr Karl Neff of the NGS is to be appointed as the HSE’s new clinical lead for transgender services in Ireland. An HSE spokesperson said the clinical lead “will be responsible for developing and launching an integrated model of care and implementation plan for transgender services within two years of the start date” of the role. Minister Donnelly stated that he wants the new clinical lead to “listen carefully to both groups” and to “take on board the new evidence”.

Transgender Equality Network Ireland (TENI)’s involvement

Transgender Equality Network Ireland (TENI) is the largest transgender activist group in Ireland. TENI receive public funding from the HSE and other government sources. In recent years HSE funding to TENI had to be suspended temporarily due to financial governance issues in TENI. It was reported that concerns have been raised by HSE managers over some social media posts by TENI staff that were considered abusive to staff at the NGS.

When the HSE advertised the post for a new clinical lead for transgender services, TENI signed an open letter written by Trans Healthcare Action critical of the HSE for following NHS England and the Cass review interim report, and for not following the World Professional Association for Transgender Health Standard (WPATH) Standards of Care 8. WPATH Standards of Care 8 have themselves been criticised for removing lower age limits for medical and surgical interventions and removing a chapter on ethics. 

A former TENI employee, Dr Vanessa Lacey PhD was instrumental in winning a bid to host the European Professional Association for Transgender Health (EPATH) medical conference in Ireland in 2023 (EPATH is a sister organisation to WPATH). The Prime Time programme revealed that TENI asked EPATH not to invite NGS clinicians to speak at a public session at the conference and EPATH agreed. Dr Lacey resigned from the board of EPATH in protest and neither Dr Lacey nor NGS clinicians attended the conference. TENI issued a statement justifying the request to EPATH not to invite NGS clinicians to speak, stating that the conference “aimed to highlight and celebrate best practices for EPATH colleagues across Europe. Having recently seen Ireland’s “gender-affirming healthcare” rated as the worst in Europe, we did not feel that there was anything to celebrate about the Irish service”. Celebrating best practice is not mentioned anywhere within the 49-page EPATH conference programme booklet. The booklet includes a welcome address from the chair of TENI that states the theme of the conference is “Strengthening the standards: communities and research”. The NGS clinicians are key members of the gender healthcare community in Ireland and have co-authored recent peer-reviewed academic research relevant to strengthening standards in healthcare for those presenting with gender distress. Requesting that the two most experienced clinicians involved in “transgender healthcare” in Ireland not be invited to speak at a conference on the topic being hosted in Ireland directly conflicts with the stated theme of the conference.

Informed consent: the traditional medical model vs “gender affirmation“

During the Prime Time programme, Professor O’Shea described concerns the NGS doctors have about the “gender-affirming” Model of Care promoted by transgender activists that is based on the concept of informed consent.

Niamh Ní Féineadh, a spokesperson for Trans Healthcare Action appeared on the Prime Time programme and said “The patient-centred gender-affirming model means that doctors, patients and their parents should work together as a team. They should have a trust relationship. They should understand the patient’s needs at any one given moment … The doctors should then present the treatment options and information to the patient … The patient should be supported in whatever decision that they make. It’s kind of like supporting a child who wants to learn a language or an instrument”. Under this model, according to Ms Ní Féineadh, the patient would decide on treatment even when the clinician is recommending against it.

During the Prime Time programme, Professor O’Shea voiced his concerns about this model of care. “It is driven by the patient … They use the term ‘informed consent,’ which is the patient has informed themselves and consents to the treatment … That’s not the informed consent model that works in medicine, that we’re obliged by the Medical Council to adhere to, where we inform the patient in detail of the risks and benefits, and then make a joint decision.”

Informed consent is part of the traditional medical model of care. The traditional medical model involves a patient and a medical doctor who has completed extensive specialised education and training, is regulated by a Medical Council and has taken the Hippocratic Oath to “First Do No Harm”.

A typical clinical scenario under this traditional model would go something like this:

1. A patient visits their doctor and states their health concern or symptoms.

2. Based upon a combination of information from the patient, results of medical tests/examination and training and experience, a doctor will complete an assessment, diagnose the health condition that they believe to be causing the patient’s symptoms and then propose medical interventions/treatment options.

3. Doctors help patients understand the diagnosis, prognosis, nature and purpose of the treatment, and discuss alternative treatments, risks, and benefits to enable the patient to provide informed consent to proceed with the treatment/intervention. Obtaining informed consent is a fundamental principle of medical law in most countries. 

For example, a woman finds a lump in her breast and goes to her doctor who examines her and refers her for medical tests in a specialist clinic for example; a mammogram, an ultrasound, a biopsy etc. If a clinical diagnosis of breast cancer is determined based upon the results of the tests, then an oncologist (cancer doctor) would discuss a treatment plan with the woman including the risks and benefits of each aspect of the proposed treatment as part of the informed consent process.

The “gender-affirming” informed consent model that transgender activist groups, including TENI, are campaigning for is a fundamentally different model of informed consent.

Under the “gender-affirming” informed consent model steps 1, 2 and 3 of the traditional medical model where a medical diagnosis leads to informed consent for treatment, are replaced with two different steps:

1. A person with gender identity issues states their physical, medical or psychological needs to a doctor (for example, someone who is biologically female identifies as non-binary or as a transgender man and states that they need to masculinise their chest to better align with their gender identity).

2. The doctor then provides information to the patient regarding all treatment options to be able to make an informed decision (based upon the person’s stated need rather than a clinical diagnosis) including all treatment possibilities and consequences and effects of each. For example, surgical removal of breast tissue (a mastectomy) would be a treatment option for someone who stated that they need to masculinise their chest.

In the traditional medical model of informed consent, a doctor diagnoses a condition based upon diagnostic measures and then proposes appropriate medical options available to treat that condition—in the “gender-affirming” informed consent model, there is no diagnosis—a patient states their need and the doctor provides information about available medical treatment options to meet that stated need.

Diagnosis is an important part of medical treatment because certain treatments are explicitly not recommended for certain conditions. For example, Body Dysmorphic Disorder, a psychiatric disorder characterised by a preoccupation with an imagined defect in physical appearance or a distorted perception of one’s body image is a contraindication for cosmetic surgery due to ethical, safety and legal considerations.

Activist groups are campaigning for the “gender-affirming” informed consent model to be followed not just for adults but for young children, too. TGEU (a network of 200 transgender activist groups across Europe and Africa that includes TENI) claim that “Prejudice and lack of information regarding trans children include thinking that they can’t know who they are or what they need. All children—trans and cis—from the age of 2-3 years old may become aware of their gender identity and start verbalising it.”

Activist groups campaigning for the “gender-affirming” informed consent model, including WPATH, quote very low levels of regret—(1% – 1.5%) among adults who medically transitioned in the past—as evidence that people who identify as transgender, including children, “know who they are and what they need”.

Regret rates of 1% came from studies on adults who medically transitioned under the traditional medical informed consent model and not under the new “gender-affirming” informed consent model. Emerging evidence on rates of regret and detransition among people who medically transitioned more recently range from 6%  to 25%. Reliable data on regret are difficult to capture while so much is changing: the number of young people being referred for gender distress has increased dramatically in the past decade (4,000% increase in UK Tavistock GIDS clinic); the profile of those experiencing gender-related distress has shifted from predominantly older males to predominantly younger females; the model of care people are receiving is changing in response to activist pressure for “gender-affirming” informed consent; and regret and detransition often do not manifest until at least 5 years after completion of medical transition.  

In 2019, Professor O’Shea said that he believed the “gender-affirming” informed consent model is “dangerous for 50% of patients, particularly children”. Professor Stephen Levine Clinical Professor of Psychiatry has been providing clinical care since 1973 and has written 23 publications on gender dysphoria. In 2022 Professor Levine co-authored a peer-reviewed article highlighting deficiencies in the “gender-affirming” informed consent model for transgender-identified youth.

Is Ireland’s healthcare for those with gender distress the “worst in Europe”?

TENI’s statement to Prime Time stated that Ireland has “the worst gender-affirming healthcare in the whole of Europe”. This claim came from a survey run by TGEU (a network of 200 transgender activist groups across Europe and Africa that includes TENI).

The TGEU  ‘Trans Health Map’ survey rating Ireland as the “worst in Europe” was quoted verbatim in Irish media including the Irish Times, Irish Examiner, RTE, and Virgin Media. The media reports did not mention that the TGEU survey scoring was weighted against countries that exercise caution regarding access for young people to puberty blockers and hormones, a measure that recent polling shows is supported by a majority of the Irish public. None of the media outlets reported that the rating of Ireland as the “worst in Europe” did not come from objective independent research, it came from a survey carried out by a transgender activist group, with all the survey responses completed by other transgender activist groups. 

The TGEU survey responses were based upon a tiny sample: 1 to 3 respondents from transgender activist groups within the TGEU network in each of the 27 countries compiled their countries’ responses.

Just one person compiled the TGEU survey responses for Ireland—Noah Halpin TENI’s Healthcare Officer. Halpin has publicly campaigned for an “informed consent model” for transgender people in Ireland in recent years. In 2019, Halpin contacted Florida-based Irish gender surgeon Dr Sidhbh Gallagher, and they both then met with the then Minister for Health Simon Harris and attended an HSE steering committee to improve services for people with gender identity issues set up by the Minister. Dr Gallagher said that Minister Harris welcomed her offer to teach or carry out “gender affirmation” surgery in Ireland.

Dr Gallagher advertises surgeries for people with gender issues on TikTok where her account has over 200k followers. TikTok is a social media platform used mostly by younger people, the largest age group using TikTok is 10-19 years of age. In one TikTok video, Dr Gallagher says “Most folks say their top surgery is easier than wisdom teeth removal”. “Top surgery” is a euphemism for a double mastectomy which is the removal of all breast tissue. In another video, Dr Gallagher makes a disturbed face alongside the words “When a hospital tells me I can’t do gender-affirming surgeries there for ‘ethical reasons’”. Since meeting Minister Harris in 2019, Dr Gallagher has been reported to the Federal Trade Commission (FTC) for alleged false promotion of services to under-18s.

TENI describes the informed consent model for “transgender healthcare” as a healthcare professional offering “the objective and necessary information about the different possibilities and refrains from making assumptions about a person’s needs based on their gender or trans status during the process, so that the trans person can make free and informed decisions.” TENI lobby to “progress beyond pathologization” and believe in “a human rights approach rather than a medicalized approach”. TGEU have very similar “transgender healthcare” aims, campaigning for “principles of bodily integrity, bodily autonomy and informed consent”.

The TGEU survey scores were based on the following six measures:

1. Type of “transgender healthcare” and coverage available in the country

2. Requirement for a psychiatric diagnosis before hormonal treatment or surgery

3. Waiting time for a first appointment with a “trans healthcare” professional

4. Groups excluded or made to wait longer to access “trans-specific healthcare”

5. Youngest age for puberty blockers, and

6. Youngest age for hormones.

Countries could score a maximum of 12 points. Ireland scored 1 point.

The Irish scores were as follows:

1. Type of “trans healthcare” and coverage available in the country: Ireland scored 1 point (out of a possible 2 points) because although some transgender treatments and surgeries are available in Ireland others are not. Treatments available in Ireland include hormones (Oestrogen and Testosterone), mastectomy, hysterectomy (removal of womb), oophorectomy (removal of ovaries) and voice training. Unavailable treatments in Ireland include orchiectomy (removal of testicles), facial feminisation surgery (a broad range of procedures to change the shape of a male face to look more feminine) and tracheal shaving (reduction of a male’s Adam’s apple to look more feminine).

2. Requirement for a psychiatric diagnosis before hormonal treatment or surgery: Ireland scored 0 points (out of a possible 2 points) because the NGS’ clinical approach requires patients—particularly young adults with gender issues (many of whom have very complex clinical needs including complex family histories or been exposed to major trauma and psychiatric conditions including depression, anxiety, ADHD and Autism at much higher rates than the general population)—to go through a holistic assessment before treatment.

3. Waiting time for a first appointment with a “trans healthcare” professional: Ireland scored 0 points (out of a possible 2 points) due to long waiting lists at the NGS. In response to a question raised in a parliamentary debate about Ireland’s ranking in the TGEU report, the current Irish Minister for Health Stephen Donnelly stated that waiting lists in many areas of Irish public healthcare are unacceptable, not just for people with gender identity issues. Waiting lists are notoriously bad across the entire Irish public health system from emergency departments to spinal surgeries for children with scoliosis and spina bifida to mental health services for children. Ireland has a population of 5 million and in May 2023 it was reported that more than more than 830,000 patients were on hospital waiting lists.

4. Groups excluded or made to wait longer to access “trans-specific healthcare”: Ireland scored 0 points (out of a possible 2 points) because certain groups, including those with high Body Mass Index (BMI) (classified as clinically obese), individuals with Autism and individuals with disabilities have to wait longer before receiving interventions (e.g. cross-sex hormones). The National Gender Service (NGS) has estimated that as many as 90 per cent of the people who used its service in 2022 may be Autistic and have said the HSE must make resources available so that it can hire staff who specialise in Autism. The NGS clinicians have said that being autistic does not mean that a person cannot go on to start hormones or have surgery, just that it is important to understand a person’s Autism as part of a broader clinical assessment that includes assessment of social and occupational function, mental health and communication needs.

5. Youngest age for puberty blockers and

6. Youngest age for hormones: Ireland scored 0 points (out of a possible 4 points) for both these measures as public services for under 18s with gender identity issues are in abeyance following the closure of the Tavistock GIDS clinic where Irish children were being referred and the ongoing civil war over gender services in the Irish Health Service Executive.  

A Sunday Independent/Ireland Thinks poll in August 2022 found that the majority of Irish people polled (64%) are not in favour of children under the age of 16 being able to access puberty-blockers/hormones with parental consent, 16% were unsure only 20% were in favour.

Research from the Health Promotion Research Centre, National University of Ireland Galway, commissioned and published by the Department for Children, Equality, Disability, Integration and Youth (DCDEIY) in 2021 reported that “Evidence on medical interventions to assist gender transitioning of trans young people, especially that on pubertal blocking and administration of cross-sex hormones, is very scarce, and the long-term impact on cognitive and physical development, fertility or on other outcomes remains largely unknown.”

Independent evidence reviews of treatment for young people with gender dysphoria carried out by national health boards in Finland, Sweden, the UK, Florida and France have all concluded that psychological support should be the first line of support and recommend increased caution regarding the use of medical interventions including puberty blockers, cross-sex hormones and surgery.

Dr Laura Edwards-Leeper, Chair of the Child/Adolescent Committee on the World Professional Association for Transgender Health (WPATH), has noted: “we do not currently have medical or psychological means to predict an individual child’s future course. Thus, there will undoubtedly be ‘false positives’ who transition early and later are faced with the challenge of transitioning back to their assigned gender.”

Criticism of the RTÉ Prime Time programme

Following the airing of the Prime Time programme, RTÉ were criticised for not providing a balanced perspective and for not engaging with LGBTQI+ service providers. TENI are the largest transgender service provider in Ireland. Prime Time requested an interview with TENI but TENI declined and suggested that Prime Time speak with Trans Healthcare Action. A representative from Trans Healthcare Action was interviewed on the Prime Time programme. Dr Aiden Kelly—a clinical psychologist who worked at the Tavistock GIDS service for 5 years and currently provides a private “gender healthcare” service, Gender Plus, serving the UK and Ireland care that is guided by WPATH—was also interviewed on the Prime Time programme.

Further criticism of RTÉ Prime Time alleged that the “voices of trans people have rarely been heard in national discourse” and that Prime Time did not “include the perspectives of those who feel their lives have been positively changed by gender-affirming healthcare”. The Prime Time programme included the perspective of Niamh Ní Féineadh, a transgender person who supports “gender-affirming healthcare.” RTÉ are members of the National LGBTI+ Inclusion Strategy Committee and report annually on the proactive measures taken by the broadcaster to deliver against the goal to “Develop and implement further actions to support the positive portrayal and representation of LGBTI+ identities in broadcast media.” There are numerous examples of positive representation of those who feel their lives have been positively changed by “gender-affirming healthcare” on RTÉ television, radio and online media in recent years including: here, here, here, here, here, here, here, here, here, here, here, here and here.

Speaking after the broadcast of the Prime Time programme the Tánaiste (deputy Prime Minister) Micheál Martin said: “There needs to be an informed, balanced debate on transgender policy and treatment in Ireland.”

Those of us living in Ireland who know people with gender dysphoria and who want the best possible outcomes for them couldn’t agree more.