IT took Lydia Foy 21 years to win her legal battle with the Irish government. In 1993, this transgender woman asked for a birth certificate which would recognise her preferred gender. When she was refused, she took legal action which resulted in the High Court ruling that the absence of Irish legislation recognising transgender people breached the European Convention on Human Rights.

Last week, the government finally announced it would enact this legislation early next year. It also paid Dr Foy, a retired dentist, compensation (about €50,000) for its failure to do so to date.

This reluctance to act has sent a negative message to people with gender dysphoria (the medical term for those born into the wrong gender) for the past two decades. Vulnerable people, especially teenagers who are coming to terms with what being transgender means for them, have officially been ignored.

There are no reliable statistics for the number of transgender people in Ireland but the main treatment centre, in St Columcille’s Hospital in Dublin, is dealing with an increasing number of patients. A report called ‘Gender Dysphoria: Prevalence and Co-Morbidities in an Irish Adult Population’, published in June found that 218 transgender patients had attended its endocrinology department from 2005 to 2013, growing from six in 2005 to 55 in 2013.

US actress Laverne Cox has long been in the headlines and is the first transgender person to receive an Emmy nomination. But how accpeting is Irish society about transgender people? The lack of shock expressed when boxing promoter Frank (now Kellie) Maloney came out as a transgender woman this summer appeared to suggest we might be. However, VanessaLacey, a transgender woman and Health and Education Officer with the Transgender Equality Network Ireland (TENI) is not so sure.

“Just look at the media,” she says. “Cher’s son Chaz Bono is one of the few transgender people presented in a positive way. The over- the-top coverage given to Kellie Maloney proved we’re not dealing with this properly yet.”

A HSE report supports Lacey’s view that more needs to be done.

Speaking from the Margins: Trans Mental Health and Wellbeing in Ireland was published last December. It found that 78% of the 210 transgender people interviewed had considered suicide and 40% had tried at least once.

Transphobia had driven them to despair; 6% had been raped, 16% sexually assaulted and 36% sexually harassed. 83% avoided public spaces for fear of further attack.

Lack of understanding is part of the problem, according to Dr Lisa Brinkmann, a clinical psychologist specialising in gender issues from clinics in Clonakilty and Dublin. “I’ve worked in this field in Ireland and Germany for 15 years and transgender issues are ten years behind, here,” she says. “There will be less shame as soon as we start talking about it. It was the same with homosexuality: we started to talk and now we are open towards that.”

Like homosexuality, Dr Brinkmann believes people are born transgender, not raised to become so. “It exists in all cultures and even in animals,” she says. “It’s part of who these people are. They were born that way.”

Her clinical experiences back this up. “Children are aware something is wrong but don’t have the words or concepts to express it,” she says. “Often it’s only once their cognitive ability develops and especially when hormones kick in that they realise what it is.”

Vanessa Lacey has personal experience of this. “My earliest memories are of knowing something was wrong but not being able to say what it was,” she says.

The findings of the gender dysphoria report are in line with this too. Of the 218 patients surveyed, 61.9% self diagnosed as children while another 14.7% did so as adolescents. Typically, children’s worries simmer under the surface until puberty.

“As soon as they start to show signs of the gender they don’t want to be, children feel betrayed by their bodies,” says Dr Brinkmann. “They feel angry and disgusted.”

Most families engage with the issue at this point. They go to their GP who puts them in touch with psychologists, endocrinologists and support groups such as TENI.

But this is not always the case. Some parents remain in denial and their children may not get help until they are adults.

Even those with supportive families are not guaranteed a positive response from the HSE. The Speaking from the Margins report found 26% were discouraged by healthcare workers from exploring their gender while 19% were told they weren’t really transgender.

The best outcome for transgender teens is to be given the psychological help they need to access hormone treatment. “Young children don’t need treatment yet,” explains Lacey. “They can make a social transition at home and at school. But older children may need hormone suppressors to delay puberty for a while. This gives them and their families breathing space to decide what’s best for the future.”

Hormone suppressors ((known as anti-androgens) delay the development of breasts, facial hair and other secondary sex characteristics. Males who identify as female take anti-androgens to block testosterone while females identifying as male take anti-androgens to block oestrogen.

“These suppressors are 100% reversible,” says Lacey. “Young people resume puberty if they stop taking them.”

However, transgender teens must have seen a psychologist or psychiatrist and have been diagnosed with gender dysphoria before they can start taking them.

Dr Donal O’Shea, a consultant endocrinologist at St Columcille’s, stresses how vital this is.

“Endocrinologists cannot make that diagnosis so collaboration with psychologists and psychiatrists is essential,” he says. “A wrong diagnosis could lead an individual down a path of gender reassignment they might regret.

“International best practice shows that once the diagnosis is clear-cut, early intervention is best for the future wellbeing of the patient,” he says.

Young people are urged to socially transition while taking hormone suppressors. Essentially, this means living in their preferred gender, changing clothes, hairstyles and even names.

They often encounter problems at this stage, especially at school.

Common issues include being forced to wear a gendered school uniform, teachers refusing to use new names and bullying.

Lacey works with schools and organisations to overcome these prejudices. “A successful social transition is vital for these teenagers to move on with their lives,” she says. “Everyone has to try to make it work.”

A successful transition is also necessary to take the next step on the transgender journey. This involves taking cross-sex hormones to develop the physical characteristics of the preferred gender.

Those who want to develop as female are prescribed estrogen and progesterone while those who want to develop as male are prescribed testosterone.

Prescribing cross-sex hormones is taken more seriously than hormone blockers. Teenagers must have socially transitioned and be aged over 16 to qualify.

“We have to be sure it’s the right thing to do,” explains Dr Brinkmann. “Cross-sex hormones have irreversible effects on fertility. There’s no going back.”

Being supported through each stage of this journey makes a huge difference to transgender men and women. The ‘From the Margins’ report found suicide rates plummeted once supports were in place.

“This is a positive finding,” says Broden Giambrone, chief executive of TENI. “When appropriate healthcare is provided, we make a tangible improvement in the lives of transgender people and their families.”

But there is a way to go before Irish transgender teens are assured of these supports. The HSE has no clear guidelines for staff working with transgender people; access to its services is unequal.

Dr Brinkmann is one of only two specialists working in gender dysphoria in Ireland and both work on an exclusively private basis.

TENI is working with the HSE to train more psychologists but in the meantime there are long waiting lists for psychologists in the public system.

“The mental health component is vital because you need a diagnosis before you can see an endocrinologist,” says Lacey. “It can’t be done fast enough and as a result; many are paying for it privately.”

Treatment is expensive. Those on a medical card may be prescribed hormone suppressors and cross-sex hormones for free but others will pay up to €5,000 a year.

Outside of the health system, the Department of Education has no guidelines for schools dealing with transgender students. And despite Lydia Foy’s decades of struggle, we are still the only country in the EU that does not legally recognise transgender men and women.

Young people are suffering in the absence of legal guidelines. “We are failing them,” says Lacey. “If there were laws in place, everyone would know what they had to do and there would be less stress for the young people involved.”

Dr Brinkmann is more emphatic.“Legislation would send a message that we recognise and protect transgender people,” she says. “We’re not doing that at the moment.”

As long as I didn’t open my mouth, I passed as a man

Benji sounds so happy. Yet until last year, this 19-year-old transgender man had constant issues with his female body.

“I never liked it and didn’t know why,” he says. “I used to think I needed to lose weight, change my hairstyle or look prettier. Then when I started to like girls as a teenager, I thought I was gay.”

He first encountered gender dysphoria on the internet. “I didn’t even know it was a thing before that,” he laughs.

He decided to explore it further when he started university in Dublin last year. He cut his hair, started to bind his chest and wear masculine clothing.

“I could go out in Dublin and, as long as I didn’t open my mouth, I passed as a man,” says Benji. “I was shocked at how comfortable I felt. I realised then that my problem was never with how my body looked; it was with what my body was. I’d been looking at it from the wrong angle all along.”

Embracing his new identity further, he changed his name to Benji and told his close friends.

“Everyone I’ve told so far has been fantastic,” he says. “I’m so grateful to them.”

He has yet to tell his parents but hopes to do so soon. His reservations about doing so are complicated.

“I think they have started to cop on already,” he says. “When that boxing manager came out, they were asking me all sorts of questions about it. I think my dad’s side of the family will be fine.

But my mum’s family have strange relationships. I wouldn’t want them to hurt my mum and for it to be because of me.”

Although he is only one year into his transgender journey, Benji is already looking to the future. “I’m thinking about surgery,” he says. “I’d love not to have to bind anymore but it [surgery] costs money so I’ll wait until after college. I might start taking hormones but again that requires money too.”

In the meantime, he is thankful for the support available to him.

“TENI, BeLonGTo and the Irish Trans Student Alliance are so helpful,” he says. “I’d urge anyone to reach out and talk to them. I know the HSE isn’t as helpful because of their long waiting lists.”

The best advice he has for people who think they may be transgender is to try it out. “See how it makes you feel. That’s what worked for me. It wasn’t until I presented as a man that I finally started to feel like myself.”