The National Gender Service and the HSE model of care

How does the HSE treat adults and minors with gender distress, and what is the dispute over the model of care?

Ireland’s public provision for people experiencing gender distress has developed unevenly. Adults can be referred to the National Gender Service, while services for children and adolescents have historically involved GPs, local primary-care services, CAMHS, paediatric endocrinology at Children’s Health Ireland (CHI), and referrals abroad. The result is not a single, published and fully operational national pathway covering every age group.

Background

Ireland’s public provision for people experiencing gender distress has developed unevenly. Adults can be referred to the National Gender Service, while services for children and adolescents have historically involved GPs, local primary-care services, CAMHS, paediatric endocrinology at Children’s Health Ireland (CHI), and referrals abroad. The result is not a single, published and fully operational national pathway covering every age group.

The distinction between legal status and medical care matters. The Gender Recognition Act 2015 introduced legal gender recognition for adults, with a separate and more demanding route for 16- and 17-year-olds. It neither determines a diagnosis nor directs doctors to prescribe medical interventions. There is no Irish court judgment in the public record cited here that establishes a clinical entitlement to puberty blockers, cross-sex hormones or surgery for gender distress. Treatment decisions remain matters of clinical practice, consent, capacity and professional governance.

The policy dispute intensified after the English Cass Review. The HSE’s March 2023 review considered the implications for Ireland of Dr Hilary Cass’s interim findings on the former Tavistock Gender Identity Development Service. In April 2024, the final Cass Review reported substantial weaknesses in the evidence base for paediatric medical interventions and called for a more cautious, holistic and research-led approach. The HSE subsequently said that the final report would be considered alongside other emerging international evidence.

In 2024, the HSE established the National Clinical Programme for Gender Healthcare, led by Dr Karl Neff, to produce an updated Model of Care. This programme is distinct from the NGS: the programme develops a national clinical framework, whereas the NGS delivers adult clinical services.

What the documents say

Adults: the National Gender Service pathway

The NGS describes itself as providing a multidisciplinary and “holistic” pathway. A person may be referred by an Irish Medical Council-registered doctor, commonly a GP. The NGS says neither a pre-existing diagnosis of gender dysphoria nor a prior mental-health referral is required for referral (National Gender Service, 2026).

However, referral is not the same as immediate access to hormones. The service says that initial assessment is part of a full multidisciplinary consultation and normally involves at least two visits. Its published material lists assessment of early development, family and social circumstances, mental health, relationships, sexual health, fertility, work or education, general functioning, gender history and plans for further intervention. The team may include psychiatry, endocrinology, psychology, social work, occupational therapy, nursing and speech and language therapy.

Following assessment, the multidisciplinary team may refer a patient to endocrinology to begin hormones; may first recommend further support for identified needs; or, in a small number of cases, may not recommend endocrine intervention. The NGS explicitly warns that hormones may not improve mental-health symptoms and can in some cases worsen them. It also discusses potential changes to fertility, sexual function and reproductive capacity (National Gender Service, 2026).

The most obvious access problem is delay. The NGS currently states that it is seeing people referred about four and a half years ago. A service designed around thorough assessment can be clinically defensible, but a lengthy wait before first assessment leaves adults without specialist public provision for years. The HSE and Ministers have acknowledged that existing services do not meet the full range of need (Minister for Health, 2025).

Children and adolescents

The HSE’s 2023 review recorded that Ireland had no specialist CAMHS transgender service and that the CHI paediatric endocrinology service had stopped accepting referrals for a year at the time of the report because of capacity constraints. The documented pathway was GP assessment, possible primary-care psychology, CAMHS involvement, paediatric endocrinology where appropriate, and specialist psychological or psychiatric assessment abroad through the Treatment Abroad Scheme.

From November 2022, Tavistock no longer accepted direct Irish referrals. The 2023 HSE review said referrals were triaged for newer NHS services. In October 2024, the Government told the Dáil that children and young people requiring specialist assessment and support were being referred to the UK national referral support service, which could direct them to services in London, Liverpool or Manchester, with CHI involved if endocrine review was needed.

The 2023 review found serious structural problems: fragmented provision, long waits, no clear transfer route from paediatric to adult care, and a risk for young people already receiving hormonal treatment who then joined the adult waiting list. It reported that 72 previous Irish referrals remained on the Tavistock waiting list when the data were last validated. It also recorded incomplete documentation in an administrative review of 18 young people later referred to the adult service: in 10 cases there was no documentary evidence of CAMHS assessment or involvement, although that did not prove assessment had not occurred.

The Minister’s written answer of 24 September 2024 is important because it confirms that puberty blockers had not been universally stopped in Ireland. It said a very small number of CHI patients were receiving them; prescribing was a case-by-case decision by the treating endocrinologist, informed by a multispecialty team and undertaken with the patient and family. That answer did not set out a published national paediatric protocol, numerical total, outcome dataset or long-term follow-up framework.

The proposed Model of Care

The HSE says the new Model of Care will be based on two strands: an evidence base and an experience base. The evidence work asks what clinical needs are present among people seeking gender healthcare and what the clinical outcomes of medical transition are. The HSE registered two systematic-review protocols and says the results will inform the Model of Care once published.

The experience strand seeks views from service users, prospective service users, families, carers, GPs and other clinicians. The HSE’s stakeholder-design group included representatives from TENI, Belong To, LGBT Ireland and Gendercare. Its own summary records that some participants were concerned about the role of psychiatry and sought stronger representation for people with lived experience. The working group is accountable through the National Clinical Lead, the HSE steering structure and ultimately the Chief Clinical Officer; it is also advised by a Clinical Advisory Group convened through the Royal College of Physicians of Ireland.

The positions

Trans advocacy organisations and many service users argue that Ireland’s principal failure is denial through delay. From this perspective, a single under-resourced adult service, detailed psychiatric-style assessment and long waits are intrusive barriers which drive people towards private, overseas or unregulated routes. They favour timely, decentralised and patient-centred care, with adults having substantial authority over their own treatment decisions.

The HSE’s stated position is that gender-diverse people should be respected, that some people need psychological, medical or social support, and that benefits and risks must be addressed through safe and effective care. It has not committed the forthcoming Model of Care to any single international guideline, report or study. In May 2025, the Minister said the Model would consider all available information, including but not limited to evidence on hormones and surgery.

Gender-critical clinicians and campaigners argue that gender distress in young people should not be treated as proof that medical transition is the appropriate solution. They support the Cass Review’s emphasis on developmental assessment, mental health, neurodevelopmental conditions, family context, diagnostic caution, clinical accountability and long-term outcome data. They also argue that the medical consequences of puberty suppression and cross-sex hormones require a higher evidential threshold in minors.

Critics of Cass, including some clinicians, trans advocates and politicians, dispute aspects of its methodology and fear that its recommendations will restrict care or legitimise stigma. During a Dáil debate in October 2024, Deputy Neasa Hourigan called the report “bad science” and asked the HSE to pause its consideration. That disagreement is real. It does not remove the HSE’s duty to examine evidence critically, publish its reasoning and explain how it will safeguard children.

Interpretation

Beyond Gender’s reading is that the Irish State has two simultaneous problems: inadequate access to supportive public services, and inadequate public clarity about what medical interventions are being offered, to whom, on what evidence and with what follow-up. These problems should not be confused. A long waiting list is not evidence that every requested intervention is clinically indicated; equally, concern about evidence is not a justification for leaving distressed people and families without competent support.

The NGS adult pathway is notable for resisting a purely demand-led model. Its published approach considers mental health, function, relationships, fertility and wider life circumstances before endocrine treatment. That is broadly consistent with ordinary medical practice where interventions can have substantial and sometimes irreversible consequences. The weakness is capacity: a four-and-a-half-year wait makes meaningful assessment inaccessible when it is needed.

For minors, the case for caution is stronger. The HSE’s own 2023 review acknowledged fragmented services, uncertain transfer arrangements and limited evidence. It documented a pathway dependent on overseas assessment and an absence of a dedicated domestic specialist CAMHS service. The existence of a small number of public prescriptions in 2024 does not answer the central questions of eligibility, consent, monitoring, outcomes or discontinuation.

A credible Irish model should provide prompt local support for distress without treating social or medical transition as the default endpoint. It should distinguish clearly between respectful care, exploratory psychological support, treatment of co-occurring difficulties and interventions intended to alter pubertal or adult sex characteristics. Those distinctions protect patients, parents and clinicians alike.

Open questions

As of 2026, the public still needs a final, published Model of Care setting out age-specific pathways, referral thresholds, responsibility for prescribing, multidisciplinary membership, safeguarding procedures, arrangements for fertility counselling and preservation, and transition from paediatric to adult services.

The HSE should also publish outcome measures. These should include referrals, waiting times, diagnoses and co-occurring conditions, interventions offered and declined, adverse events, discontinuation, detransition where reported, physical outcomes, mental-health outcomes and long-term follow-up. Aggregate data must protect privacy, but absence of public outcome reporting prevents serious evaluation.

Parents and clinicians need clarity on the present interim position. Which written policy governs CHI prescribing for minors? How are overseas referrals audited? What information is provided on uncertainty, fertility, sexual function, bone health and the possibility that distress may change over time? What support is available to young people who do not pursue medical transition, stop treatment or regret it?

The Oireachtas should scrutinise these questions as health-service governance questions, not merely as slogans in a culture-war dispute. The final Model of Care should be published in full, consulted upon transparently and evaluated against outcomes rather than intentions.

On the Irish timeline

Episodes on this subject

Inside Europe's Transgender Medicine System with Róisín Michaux