Bloody hell, just reading the articles that were in the Sindo yesterday, the amount of young trans people with autism that the HSE is seeing has gone from 20% to 90%
www.independent.ie/irish-news/health/unquestioned-unproven-unsafe-hse-must-learn-from-britains-tavistock-gender-clinic-debacle-says-expert-41894871.html
Unquestioned, unproven, unsafe
Lessons must be learned from UK gender clinic debacle, says expert HSE's preferred model is still 'rushed' treatment despite discrediting of Tavistock centre's methods, doctor tells Mark Tighe
In 2009, the HSE began referring Irish children seeking treatment for gender issues to the Gender Identity Development Service (GIDS) run by the Tavistock NHS clinic in London. The numbers were small, but growing. Between 2011 and 2021, 234 Irish children, two as young as five, were referred to the clinic for treatment.
Irish children had to fly to London for appointments at first, but from 2014 Tavistock began holding satellite clinics in Crumlin children's hospital. The project was supported by Dr Philip Crowley, the HSE's head of quality improvement. However, the standard of care given to patients by Tavistock was soon called into question by doctors working in the National Gender Service (NGS) in Loughlinstown in south Dublin where adults and teenagers over 16 are treated.
In early 2019, senior clinicians in the NGS warned the HSE and Crumlin that Tavistock's Irish operation was "unsafe" and should be immediately shut down. Despite this, the HSE continued to use Tavistock even as alarm about its practices grew in the UK.
An interim report last March by Dr Hillary Cass, a consultant paediatrician commissioned by the UK government to examine Tavistock, found serious failings in how it assessed children and decided which were placed on puberty blockers.
Even though Tavistock is to close next year because of the fallout, the HSE has continued to use the service. "The Irish healthcare system has still been referring to GIDS in the financial year 2022/23," a Tavistock spokesman said.
The Cass report found children attending Tavistock faced a "clinician lottery". They either would be assessed for a range of psychological and social issues or instead would get a doctor who would see gender incongruence as "immutable", with the prescription of puberty blockers and hormones the only solution.
Staff felt pressurised to adopt an "unquestioning affirmative approach" to gender — at odds with standard clinical assessment requirements. A lack of documented assessments meant there was missing evidence justifying transition regimes that children were placed on.
This was all flagged in writing in 2019 by Dr Paul Moran, a consultant psychiatrist with the NGS in St Colmcille's hospital, who along with Donal O'Shea, a consultant endocrinologist, tried to shout "stop".
Dr Moran fears there is an ideological desire in the HSE to continue the Tavistock-type model of care. After years of unsuccessfully trying to recruit a consultant to start a Crumlin-led service for gender-questioning children in Ireland, Dr Moran has been told the HSE is now assessing a children's clinic in Belgium for Irish patients.
Having treated former child patients of the Tavistock Irish satellite in the NGS, Dr Moran is predicting significant numbers of patients will regret transitioning or have other adverse outcomes because they were "rushed" on to puberty blockers and hormones.
"We have good evidence from the patients we have seen that it is the wrong approach for most likely the majority," Dr Moran said. "There are some children who seem to do well, but at the moment there is no way of predicting at the start of treatment who will do well or badly.
"In cases where we've seen them and they've been left in a heap we've put resources in to try and fix their mental health, their social problems, try and get them back into college, et cetera."
Dr Moran believes the Tavistock service in Crumlin was set up without proper clinical governance or a service level agreement. Instead of Tavistock supervising care given by local Child and Adolescent Mental Health Services (CAMHS), Dr Moran said the satellite service which operated in Crumlin for six years had no proper supervision of its work.
Dr Moran and Dr O'Shea attended a meeting with Crumlin hospital management on March 20, 2019, to discuss how patients would graduate from the Tavistock service to the NGS. "We asked basic questions about the service, such as 'how many patients attended' and 'how many letters of referral there were'," Dr Moran said. Crumlin management said they had no knowledge about the service. 'Who approved it?' They had no idea."
As more patients aged out of Tavistock's care and into the NGS age cohort, Dr Moran and his colleagues became aware of the "very poor clinical service for children".
"We were coming across children who were clearly unwell and who had none of their underlying mental health problems addressed," Dr Moran said. "Many of them were not suitable or ready yet to be on hormone treatment. The endocrinologists working in Crumlin recognised that, too.
"They had basically gone over to Tavistock in distress, dropped out of school and started self-harming. They were rushed on to hormones but left sitting at home, not being schooled. Mental health issues were not addressed.
"There was this total focus on blockers and hormones, but the bigger problems that were pressing in their lives were ignored. By the time they got to us they were often a couple of years sitting in their rooms self-harming.
"There were some individuals who were practically mute who had started on hormone treatment. In contrast, Dr Moran said the NGS had a recent case of an adult woman who never had a job or felt comfortable in social settings who also had "a clear gender issue". After 15 months with the NGS this woman now has her first car, first job and is starting a third-level course.
"If at an early point you look after these things, people are more likely to do well," Dr Moran said. "That's why you need a multi-disciplinary team. We've got speech and language, occupational therapy, psychology, social work, nurs- ing, psychiatry and endocrinology. These people have a broader range of problems than just difficulty with their body.
"Tavistock had a very narrow approach, because they didn't have the clinical skill or the mix of professions, they become a very ideologically driven service. If you ignore the other problems and proceed with medical treatment, it doesn't just leave problems unaddressed, it generally worsens. A person who's really having difficulty engaging with life now, when they're on hormones, unprepared, that can worsen."
After the Keira Bell case emerged in 2020, where the young woman took a London High Court case alleging that she was improperly prescribed puberty blockers at age 16 by Tavistock, Dr Moran thought the HSE would reassess its relationship with Tavistock. Bell won her case in December 2020, but it was overturned on appeal in the summer 2021.
After the High Court ruling in the Bell case in late 2020, the HSE wrote a letter of comfort for Crumlin hospital over its use of Tavistock. The hospital said it stopped using Tavistock after the Bell case but Irish patients have continued to be referred to Tavistock.
Dr Moran said there needs to be clarity abut how Tavistock was set up in Ireland.
"There were a large number of meetings, but we haven't been able to find any minutes or record of them," he said. The key point is the shift from Tavistock psychologists working in their own hospital where they're employed, insured and supervised to working in a different country where they are not registered, with no supervision, no governance, no audit. It was a completely irregular thing."
Dr Moran believes the Cass report is a watershed moment. "The international consensus is rolling back against specialist hormone treatment for children before puberty," he said. While puberty blockers were previously described as "reversible", he said the emerging evidence is that administering them to children hitting puberty can have detrimental effects on bone growth and brain development.
"They're supposed to pause puberty to give time to grow up and to think about things so people can choose which way they wanted to go," he said. "But as time moved forward, the problems emerged. It seems that instead of providing a pause, it actually provided an acceleration. As soon as the children were started on blockers, the pressure on everybody to progress to sex hormones grew.
"It reversed the trend that previously about 80pc to 90pc of gender non-conforming kids became gender conforming after puberty. With this treatment, about 80 to 90pc of the kids who start with blockers remain gender non-conforming and move on to cross-gender hormones. That became alarming.
"Are we having an impact on not just the bone, not just the brain, on the whole social trajectory of what's happening? We've done a huge intervention."
Dr Moran said it is "really hard for a kid to say 'stop' when there's been such massive investment in what they want, by their family, by their doctor, by their school, by their peers". He said the idea of regret or people changing their minds is seen as "taboo" by some transgender activist groups. Patients tell him they are made feel unwelcome if they bring it up.
"There's such cultural taboo about regret that people feel shame if they say they're not happy because they're left out of the community," he said.
He also voices concern that some HSE-funded groups have coached patients to "get their stories straight" before being assessed so they have the best chance of being prescribed hormones.
"They are being told to deny mental health problems and particularly any history of suicide attempts when they come for assessments," Dr Moran said.
The NGS itself has more than 1,000 patients on a waiting list, with the newest patients facing a wait of up to five years unless capacity is increased. Dr Moran and his colleagues have proposed it could take on children in their mid-teens and this could be extended to lower ages in future years. He advocates for community services to provide services to gender-questioning children in the meantime.
Much of the surge has been caused by a huge increase in autistic people presenting. Dr Moran said while roughly 20pc of their cases involved autistic people five years ago, it is now approaching 90pc. These cases generally take far longer to process because of their complexity.
Dr Moran is now concerned the HSE will repeat the mistakes of its Tavistock alliance. "We have become aware that the HSE has been exploring moving gender care of Irish children to a clinic in Belgium," he said. "We have explained that this is a bad idea, for all the same reasons the Cass Report identified. The HSE seems wedded to this idea of specialist, hormone-based care for children, which is unsafe. It may be developed safely in the future, but right now, as we don't have evidence for the safety of these treatments."