Neasa Hourigan (Dublin Central, Green Party)
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In 2020, the United Kingdom's National Health Service commissioned a report to optimise healthcare for transgender adolescents but it instead produced the Cass review. For some inexplicable reason, the HSE in Ireland is, by all accounts, undertaking its own review of this report. The report is highly politicised, junk science. It is driven by the UK's culture wars and should be allowed nowhere near policymaking in Ireland.

At a time when our health service is moving towards care that is rooted in the person and their rights, the Cass review actively undermines the legal competence of both children and adults to access choice-based medical treatment. It dismisses almost all existing clinical evidence on trans people's healthcare by applying evidence standards which, if applied to other medicines, would effectively invalidate more than three quarters of the existing treatments currently used in paediatric care.

The ways in which the report is flawed, bogus or methodologically compromised include but are not limited to the following: the Cass review does not follow established standards for evaluating evidence or evidence quality; the review casually discusses evidence quality but does not define it; it contravenes standard practice in scientific evaluations of medical research; and the review uses misleading and subjective terminology and misuses technical language regarding evidence quality. In any other field of medicine, this practice would be deemed unacceptable and harmful to patients.

An independent review of the evidence evaluation of the Cass report has described it as pseudo-scientific and subjective. It does not follow best practice or even standard practice in its fields. For example, the review conducted a series of focus groups with healthcare workers of varying backgrounds. It is not clear what expertise these individuals had but 34% of them admitted that their understanding of gender-questioning children came from the media.

The Cass review misinterprets and misrepresents its own data. There are too many instances to recount today but as an example, the review states without evidence that practitioners have abandoned normal clinical approaches to holistic assessment and that puberty pausing medications are available in routine clinical practice. However, the review's own data shows that only 178 young people in the UK with gender dysphoria, as the review describes it, currently receive medications that pause puberty under its definition. It is difficult to see how a medication is routine but also only applies to 0.0024% of the adolescent population.

The Cass review levies unsupported assertions about gender identity, gender dysphoria, standard practice and the safety of gender affirming medical treatments. It also repeats claims that have been disproved by sound evidence. This is where we truly see the political agenda laid bare in the Cass review. While the review places a high value on evidence quality and certainty, its recommendations frequently emanate from insufficiently supported assertions that have been disproven by scientific evidence. For example, the review continually highlights the concept of desistance - I hope I am saying that correctly - in a completely unproven way. Studies in the 1980s demonstrated that most gender non-conforming children would not meet the criteria for gender dysphoria after progression through puberty for a variety of reasons. This is not the same as a loss of transgender identity. Studies that claim high rates of desistance in children rely on data collected before there was a formal definition of gender dysphoria. At the time, children's behaviours were classified as non-gender conforming if they did not adhere to gender stereotypes, such as not wearing enough pink or not playing football.

More concerning is that despite stating opposition to so-called conversion therapy, the review favourably cites literature proposing methods which claim to suppress transgender identity in children and uses the desistance data from this literature unquestioningly. This is a terrifying vista for children, parents and families who are dealing with this - a health service that is willing to suppress you but not meet your needs.

The HSE has to uphold its good name and its commitment to evidence-based policy. It should not go anywhere near junk science or the Cass review.

Emer Higgins (Dublin Mid West, Fine Gael)
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I thank Deputy Hourigan for raising this important issue and for her passion, knowledge and commitment to the subject. I am taking this Topical Issue on behalf of the Minister for Health, Deputy Stephen Donnelly, who has spoken previously on the topic of gender healthcare. He has acknowledged this is a small and vulnerable group of people who need to have access to proper, appropriate and integrated care, including acute care and community care. He has also acknowledged that they do not currently have access to that in Ireland and he is determined to change that.

The HSE has appointed a new clinical lead who is overseeing a new clinical programme for gender healthcare. Over the next two years, an updated clinical model and implementation plan for gender healthcare services will be developed. Separate from that, following the publication of the interim Cass report in February 2021, the HSE’s chief clinical officer, Dr. Colm Henry, requested the HSE’s national quality and patient safety directorate to review the interim Cass report and how it applies to clinical pathways from Ireland. This HSE review of the implications of the Cass report for the provision of gender identity services for children and young people in Ireland was published in March 2023 and is available online.

Following the publication of the final report of the Cass review in April this year, Dr. Henry asked that an expert clinical group be convened within the HSE to consider the clinical implications of this final report, if any. The membership of the HSE Cass review group was convened based on their expertise and clinical leadership. It expects to complete its work shortly.

The work of the expert clinical group is specific and defined. It is independent of the HSE’s planned update of the clinical model of care for gender healthcare by the new HSE national clinical programme for gender healthcare. It is that model of care that will ultimately make recommendations on the delivery of gender healthcare services in the HSE for both adults and young people.

The development of the model of care will be informed by the best evidence-based clinical care for individuals who express gender incongruence or dysphoria. As well as reviewing the best clinical evidence available, the HSE will also incorporate input from healthcare professionals, patient advocates and those with lived experience. Stakeholder engagement will be a key element of this work and will ensure that people with lived experience will have input into the design of services and can advise on the delivery and evaluation of services. That is the message the Minister has asked me to convey today. He wishes to get across the crucial part of the development of this model of care, namely, the consultation with relevant stakeholders. The Minister is strongly of the view that we cannot have a situation where a model of care is being developed for a group of people who are not involved and whose voices are not heard. I can assure Deputy Hourigan that both the Minister and the HSE are anxious to ensure that all stakeholders are heard as part of this process.

While the model of care is being developed, people will continue to receive healthcare in the community and under the endocrinology service in the adult and paediatric centres in Ireland East Hospital Group and Children’s Health Ireland, CHI. Regarding current services, children and young people who require specialist psychological or psychiatric assessment and support are now referred to the children and young people gender national referral support service in the UK, which will triage these referrals to one of the newly developed services in London, Liverpool and Manchester. This service will work with CHI if an endocrine review is required. The adult gender service, which is based in St. Columcille’s Hospital, Loughlinstown, provides services for people over the age of 16 years. I assure the Deputy that it will be the model of care that will be making policy recommendations on the delivery of gender healthcare in the HSE.

Neasa Hourigan (Dublin Central, Green Party)
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I thank the Minister of State for the response. I acknowledge that the Minister has spoken to me about his commitment to ensuring that while we currently have no service for children and adults who are transgender, he is very committed to having one and I have no reason to disbelieve him. I absolutely agree on that. It is important, however, that we pause that review, the reason being that concerns about the Cass report are such that it is now under investigation by the British Medical Association, BMA. Members of the BMA's council recently voted in favour of a motion asking the association to review the Cass report after doctors and academics in several countries, including the UK, voiced concern about weaknesses in the methodology used in the review. We should not be reviewing something so questionable that it is being questioned in the territory in which it was produced.

We also know from a 2021 EU Tip of the Iceberg report that a significant amount of the political activity we saw in the UK around this issue is funded by foreign entities, including Russia. The intention is to do exactly what the Cass review is helping to do, which is create a culture war rallying point rooted in fear and marginalising vulnerable groups. I hope the HSE will recognise that questioning of the Cass review. If the BMA is undertaking an evaluation of the review and pausing to look at it, we should do the same.

Ireland has a very sad and difficult history in trying to control people's choice around their bodies and policing their sexuality. Nowhere in all of this is the person often heard. It is a top down attempt at politicising people's lived experience. The Cass review is bad science and I hope the HSE will undertake to pause its review.

Emer Higgins (Dublin Mid West, Fine Gael)
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I thank Deputy Hourigan. She made some valid and interesting points, which I take on board. I will refer them to the Minister, Deputy Donnelly, and ask that he take them on board as well. The Minister wants to ensure that members of the transgender community are given the proper, appropriate and integrated care and support they need to live authentic, fulfilling lives. The new model of care aims to do just that and it will be at the heart of it. The development of the new model of care for gender healthcare services is expected to be a complex process and the HSE and the Department of Health will work closely to support the process, ensure transparency and keep the patient at the centre of everything.

As I said, consultation with stakeholders will be a crucial part of this work. However, as the Deputy said, it is important that the HSE is given time to develop a model of care based on the best clinical evidence that will deliver the best outcomes for the person with gender dysphoria. As I said, the expert clinical group's review of the Cass report is specific. It is a defined piece of work that is independent of the HSE but I take on board the concerns raised by the Deputy and will bring them to the Minister. It is not possible to pre-empt the outcome of the review, but it is possible to say that-----

Neasa Hourigan (Dublin Central, Green Party)
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It is a model.

Emer Higgins (Dublin Mid West, Fine Gael)
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-----the model of care will be our policy decision on this.

The long-term aim is to provide a wide range of services for all people with gender dysphoria, from care locally in the community to more specialised and complex care. The Minister and the HSE are dedicated to building a service based on experience, clinical evidence, respect, inclusiveness and compassion. I know the Minister is committed to the development of a well-governed and patient-centred healthcare service for members of the transgender community. I thank the Deputy for her input on this issue, on which she is a fantastic advocate.