On March 20, 2019, members of the National Gender Service (NGS) met with senior members of Children’s Health Ireland (CHI) at Crumlin and the Ireland East Hospital Group in Crumlin hospital’s boardroom to discuss the hospital’s care for transgender children who were referred to the Tavistock clinic in London.
Sharon Hayden, Crumlin hospital’s director of operational services, later sent out minutes of the meeting to the attendees but missed out on Dr Paul Moran, psychiatrist with the NGS. When Dr Moran was forwarded the minutes by his colleague Dr Donal O’Shea, who was also at the meeting, he was not happy.
His email on April 25, 2019, was copied to everyone at the meeting and put on the record his extensive concerns about the Tavistock arrangement. Complaining that the minutes did not reflect what took place, he said the “main focus of the meeting was the current unsafe service at Crumlin, and how this could be remedied”.
He said there “appears to be no documentary record of assessments for most patients being treated at Crumlin hospital. The full extent of this deficit remains to be confirmed. Requests to the Tavistock Clinic for assessment records have been met with ambiguous and obstructive responses.”
When Tavistock documents were present, they were inadequate for the purpose of treatment, he said. “Limited specific history regarding gender identity development, paltry assessment of mental health or social circumstances. Psychosexual issues generally not addressed. Most reports have no clear conclusions or treatment records.” He said Dr Susan O’Connell, a Crumlin endocrinologist, had told the meeting she had concerns “some patients on treatment did not appear to be suitable or ready”.
Dr Moran said other concerns were raised about Tavistock’s Irish clinic, including the absence of psychiatry — “making it incapable of providing a safe pre-treatment assessment”. He said a clear view put by himself, Dr O’Shea and Dr Ian Schneider, a fellow NGS psychiatrist, was that the Tavistock service funded by the Treatment Abroad Scheme “should be terminated with immediate effect”.
He said the HSE administrators present discussed “difficulties with proposing this”, including the challenge of providing alternative care and uncertainty about who was commissioning the current service. Dr Moran said it was a very important meeting in terms of clinicians and administrators acknowledging “the current situation and risks and the urgent need to address these”. It was “unfortunate” an inaccurate record was disseminated with most of the important points omitted.
Dr Moran received a response from Dr Paul Oslizlok, clinical director of Crumlin hospital, which was copied to all the other attendees.
Dr Oslizlok, who was not at the meeting, said Ms Hayden was on leave and he apologised for an administrative error that meant the minutes were not circulated to Dr Moran or Dr Schneider. He said the main concern of Dr O’Connell was the safe transition of patients to an adult transgender service and that was what Crumlin thought would be the main issue discussed at the March meeting.
He understood neither Dr O’Connell nor her colleagues regarded the Tavistock service in Crumlin as “unsafe” and would dispute other points Dr Moran made. He said most other major paediatric hospitals had a similar approach to Crumlin. Dr Oslizlok said he brought Dr Moran’s concerns to the group clinical director at CHI and he was happy to meet him.
Dr Moran responded that he would like an integrated national gender service for both children and adults. While the adult service was developed with psychiatry as a central component, the HSE’s Quality Improvement Division [led by Philip Crowley] “favoured a non-psychiatry model WPATH (World Professional Association of Transgender Health)”.
Dr Moran said this reflected “HSE/Department of Health deference to political pressure from lay advocate organisations”.
He warned the HSE this was a “mistake” and said the difficulties they now faced stemmed from a 2015 decision “taken by the Quality Improvement Division to separate the development of the Paediatric Gender Service from the Adult Service”.
“The service currently in place in Crumlin is unsafe and sub-standard,” he wrote. He said the English clinic’s lack of documentation and inadequate assessments reflected deeper problems. “We need to terminate the Tavistock assessment referrals to stop the legacy growing,” he said. For those already treated by Tavistock, Moran said an unknown percentage “are not suitable or ready for treatment of blockers/hormones” but they were hard to identify because of the poor documentation.
He said the legacy from this group of children was more problematic than that encountered by the adult service previously, when dealing with adults who had not been properly assessed before treatment.
He said adults were less likely to revert to their previous genders and they had informed consent about life-changing treatments. “It is likely we will encounter significant levels of regret and other adverse outcomes in the Crumlin legacy group over the years to come which will be difficult to defend,” he warned.
On March 22 this year, following the publication of the Dr Hillary Cass report, Dr Moran wrote to Dr Amir Niazi, HSE group lead for mental health, that this was a “watershed moment”.
While the world was following the “Dutch model” of prescribing puberty blockers to prepubescent children, he had met the Dutch paediatric service in 2015 and they told him they believed 15 years old was a more appropriate age to intervene.
He said the growing evidence was that the Dutch model was “not clinically sound”. Hoped-for benefits of reduced dysphoria and improved mental health did not happen. He said the idea of providing a breathing space was “a fallacy”. Evidence of harmful side-effects on brain and bone development were emerging.
He noted the “exponential increase” in children with autism, or who had been abused, being referred to gender clinics. “It became clear that gender dysphoria reported or observed in pre-pubertal children is not stable to base medical treatment on,” he said. With the Cass report, Dr Moran said he believed they could no longer “support the idea of a children’s gender service based in Crumlin hospital”.
He said it was “fortuitous that we were unable to fill the consultant psychiatry post” as it made it easier to wind up the service and look at developing a more appropriate service for adolescents. He appreciated this was “a challenge” for Dr Niazi as he had undertaken to develop a children’s service under a model that was previously best practice.
“Our job is to firstly re-educate senior stakeholders (HSE and Department of Health) that continuing to develop a specialist service at Crumlin would be indefensible following the Cass report,” he said.