JUSTIN, A 21-YEAR-OLD transgender man from Dublin, has been taking testosterone for nine months as part of his transition. He said it has made him feel better in most aspects of his life.

“I feel more confident in work, I feel more confident socialising… as I’m being perceived more and more as male, I feel like I can finally live my life, get on with my life in a way that I never have before.”

Justin* began seeking a referral almost three years ago from his college psychiatrist to see an endocrinologist in St Columcille’s Hospital, Loughlinstown, who specialises in transgender healthcare. She wrote the referral almost two and a half years later in June 2018.

Accessing transgender healthcare in Ireland was such a long process for Justin that he eventually sought it privately in England. The process of contacting the service, having psychological evaluation and receiving his hormone replacement therapy took two appointments over six months.

He has since transferred his hormone replacement therapy care to a private clinic in Belfast.

Long waits

A psychiatrist’s referral to a gender endocrinologist was vital for Justin, as he could not legally access hormones in Ireland without first seeing an endocrinologist. There are currently three endocrinologists in Ireland who will prescribe hormone replacement therapy to adults.

All three require patients to undergo psychiatric evaluation, with a diagnosis of gender dysphoria, before they will treat them.

Justin said that while seeking the referral, the waiting list for Prof Donal O’Shea, a

Loughlinstown-based endocrinologist, increased from about 14 months to about three and a half years.

A HSE representative said that the waiting list is currently 13 months long, but there are “some patients who have been waiting longer than this due to a number of factors, including capacity constraints”.

The HSE hope to have seen everyone on the “legacy list” by the end of the third quarter of 2020, they said, and aim to “have reduced our waiting times substantially by Q4 2020″.

Long waiting lists for hormone replacement therapy and gender-related surgery is one of the greatest issues facing transgender people in Ireland today. O’Shea agrees that it is a problem.

“When the level of distress is high, waiting times are potentially dangerous… The distress can lead to self-harm, suicide,” O’Shea said. “It can also lead to online accessing of treatment and overseas accessing of surgery.”

“For some people that’s the right thing to do because the level of distress and dysphoria is immediately reprieved… and then for others who do that, the outcome is disastrous,” he said.

O’Shea said that for some who access treatment elsewhere, there is no improvement to their dysphoria, distress and mental health problems. “So our job is to make sure that the people who [transition] be truly better through transitioning.”

Taking matters into their own hands

Feeling the need to access hormone replacement therapy online illegally is a reality for many transgender people in Ireland.

Amber*, a 24-year-old transgender woman, lived in Galway for almost four years and accessed her hormones this way for over a year before recently returning home to the US.

While living in Ireland she was on an endocrinologist’s waiting list for 18 months, and she said she would have continued waiting if she stayed here.

“I began with DIY [hormone replacement therapy] because my dysphoria had gotten so bad that I needed to transition to stop myself from becoming suicidal,” she said. She saw someone online say they were “taking matters into their own hands”.

Through forums, Amber learned about how to access hormones and did extensive research into how much she needed to take. She spent approximately €140 for a three month supply of hormones.

While she finds the DIY online community helpful, she takes their advice with a “large grain of salt”.

Some recommended performing surgery on themselves. While she knows how bad dysphoria can get, she finds it “wrong and dangerous and irresponsible” to advise surgery like this.

While administering her own hormone replacement therapy, her levels of prolactin reached excess levels – a situation that can cause anaemia, decreased energy and even osteoporosis if untreated.

Amber also said that the testosterone blocker she was taking caused her depression to “get out of control”.

Despite initial issues Amber continued successfully with hormone replacement therapy, with the help of her doctor. “My GP knew and he helped monitor my bloods to make sure I was healthy,” she said.

John Keenan, a Roscommon-based GP, said that while he would ultimately help patients who were buying their hormones online, he would do so reluctantly. Keenan has never had a patient who got hormones this way before, but has treated three transgender patients. “Most GPs will only have had one or two trans patients,” he said.

He said that if someone approached him administering their own hormone replacement therapy ”we can’t not help them out”.

“It wouldn’t be that we’d be against them going through it, but we’d be trying to get them to do it properly.”

Keenan questions the need for psychiatric evaluation prior to a medical transition.

“It’s one area where people are told, ‘you don’t know what you’re talking about, you need to see a psychiatrist,’” he said. “I think it’s very insulting to people, to the trans person, to tell them that they need to see a psychiatrist.”

Keen said such a requirement should be “dropped” and instead “let the GP who’s doing the referrals in the first place decide if they need to see a psychiatrist”.

He knows some of these transgender patients may need to see a psychiatrist for issues like depression, but “that would be to treat their problem, rather than do an assessment”.

O’Shea feels that the role of the psychiatrist in a transgender person’s transition is

important, as psychiatric evaluation leads to the detection of more co-existing psychological and psychiatric conditions than a psychologist’s evaluation alone.

Protesters gather at the trans pride march in 2018. Source: Leah Farrell/RollingNews.ie

He said that a psychologist’s evaluation generally reveals that 8% to 10% of patients

experience a co-existing mental condition, and with a psychiatrist’s involvement that figure rises to around 60%.

Felix, a 23-year-old transgender man from Dublin, began hormone replacement therapy in June 2015. He attempted suicide in 2016. He said that the reasons for his attempt were unrelated to his taking testosterone being “family-related”.

After recovering he met with his psychiatrist multiple times, to “try and assure him” that going back on hormones would not make him suicidal. He felt that being on hormones meant he was “doing better in many ways” because he could see progress.

“Throughout these interviews he would refer to the attempt as ‘the hanging’, despite the fact that that was not a term that I was using.”

While still recovering in hospital he also asked if he could get his testosterone injection, which was due at the time. He was refused it, and was put on hormone blockers, blocking his oestrogen.

“That was super bad for my mental health, especially in a recovery period,” he said. “If all of your hormones are blocked you’re more likely to experience reduced energy, and depression is connected.”

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Informed consent

The informed consent model of transgender healthcare is advocated by transgender individuals and activists across Ireland. Under this model patients would make their own decisions around hormone replacement therapy, with full awareness of potential risks, without psychiatric evaluation.

O’Shea does not support informed consent because of the amount of people who want to de-transition under the model elsewhere. “The informed consent model is leading to a surge in reversal surgeries… and when you’ve got a surge in presentation of any condition you’ve got to look at being even more careful.”

Felix said many people opposed to models like informed consent argue that “if people can access hormones really easily, people will do it at a snap decision”.

He thinks that long waiting lists and model of healthcare in Ireland “pens people in”.

“The fact that the wait times are so long means that people often try and get on the waiting list as early as possible because they know it will be a couple of years before they get seen by anyone.”

During this period people can realise that transitioning would not be right for them.

“But they’ve already been on this waiting list for a year and it feels like a waste,” he said.

“You’ve got to have a multidisciplinary team of your psychiatrist, your psychologist, your social worker, your speech and language therapist. You can’t do this in isolation,” O’Shea says.

He adds that patients he sees today are “different to the individuals we were seeing 15 years ago”.

We were seeing mainly truly cross-gendered people, now there is a lot of fluidity and non-binary

He has seen an increase in non-binary identifying patients, sometimes stopping their

testosterone treatment after having top surgery. This is something that O’Shea thinks needs to be looked at in greater detail, as it is a “new phenomenon.”

“We need to get our heads around that. We need to see what the international experience with surgery for non-binary is.”

Felix feels that the Irish transgender healthcare model has too much control over patients.

“There’s a lot of scaremongering amongst people who want to keep medical systems… under this incredibly constrictive gatekeeping, who say, ‘if we allow people to make decisions for themselves they’ll start transitioning willy-nilly and then regret it.’”

“It’s certainly undermining people’s own agency.”

According to Felix, de-transitioning can happen for many reasons that are often ignored. “A lot of de-transitioning cases that are trotted out by people who say, ‘look at all these examples,’ are not necessarily people who don’t identify as trans.”

He cites financial instability, family issues and the difficulty of being a transgender woman in society as other reasons for de-transitioning.

“It’s a big old world. Statistically speaking there are going to be people who have a bad

experience. But overwhelmingly the majority of trans people who do undergo transition are happier for it.”

*Names have been changed to protect identities.