The Future of Transgender Healthcare – Noah Halpin

Thanks, Helen. Thanks for having me on, um, my name is Noah Halpin and I’m the founder of the this is me transgender healthcare campaign. So what we do is we fight for best practice person centered health care for all trans and nonbinary people in Ireland. And we continue to do that every, every single day of the year.

Brilliant. So, okay. Um, what, what do you mean by best practice? What do you mean by person centered and pick those things for us? What does that actually mean in everyday life.

In Ireland, um, the one service that provides healthcare to trans and nonbinary people, they operate off a model of care that was created solely by the clinic themselves. There’s no evidential basis for their model of care. It’s very much a psychiatric model of care. So we strive have international best practice, uh, model of care introduced into Ireland, which would be in our WPATH, the world association for transgender health, um, based on an informed consent model so that people are believed as opposed to having to prove themselves. And so this is, this is what we strive for in Ireland and person centered being that, that the person themselves are, are at the forefront of their own treatment and, and not decisions being made by, uh, like I said, psychiatrist’s opinions of what these people are very, very close to.

Um, I can see you smiling. They’re very, very close to the attitude of GenderGP. Isn’t it? What do these words mean to you? Best practice to monitor them?

Oh, I was going to say, sounds like you’ve been reading the GenderGP script there because that’s what’s going through my mind when he was talking though, was how are you finding effecting change? You know, is it a people open to listening and believing, or are you finding that there’s resistance?

What I find mostly obviously the trans community are very much on board and want change. A lot of families of young trans people are, are similar. I’m finding a very kind of 50/50 split down the middle when it comes to politicians, I work very closely with, uh, with some petitions on someone checks and some absolutely don’t, but at the end of the day in Ireland, it’s not down to politicians and it’s not down to trans people. Um, it’s, it’s down to our health service. Um, so in the UK you would have the, the NHS in Ireland, we would have the HSE, which is the health service executive. It’s just our national public health service. So the end of the day, it is down to them to change things. And, you know, as, as many people involved in trans health care would know there’s a huge amount of politics involved. And, you know, I would say the majority of people in the HSC want change, but there’s a few things that are preventing them from making that change. And, and it’s all very, very much internal politics of individual staffing members.

Yeah, that’s interesting. So you, you, you, you mentioned a couple of stats there, so 50, 50 politicians, you feel one change and then the majority of HSE want change, but there are a small group of people who have real power. And I think we’ve, we’ve talked about that before. Haven’t we, this Marianne, this, this pyramid effect where a single person who has very, very strong views in a position of power can have such an influence on so many policies and protocols and people, um, you know, in the pyramid below them. And it’s, it’s really, it’s really scary and sad, but I have to say, you know, to, to, to hear you say the majority and, and 50/50, I mean, those are, those are actually quite good numbers. Do you think those numbers have changed over the last five years? Is, is there a positive shift or a negative shift, would you say?

Yeah, well, I think there is a positive shift to the model of care that’s currently being used. There was many meetings about this model of care in 14, 15, 16 in Ireland when it was spoken about last time, the model of care that was agreed on didn’t end up being the model of care used. It never filtered down to practice, although it’s still on paper, but what’s used in a bite not being used in practice, but you know, it’s positive knowing I’ve been at the table as you know, national committee level, I’ve been at the table with, uh, our ministers, at the table with our health service, you know, on mostly the people that are dealing with this are, are on side and want change. I’m not quite sure if they know exactly what change they want, but they want to change from, from what we have now, the problem is that, you know, with a lot of things, you know, Ireland is very small and our health services is very small. Everyone knows everybody, you know, the particular problem in trans health care in Ireland, unfortunately, is a problem that has previously won a court case at the workplace commission. So, uh, our national health service are terrified to go anywhere near him. And he’s the person that created this model of care currently being used. So although our health service is onside, our health service, you know, behind closed doors will say to me that they want to make onto anything. You know, he’s won a workplace commission court case once before. And like, they just be like, they can’t touch them.

That’s again, the words that you described that, that lay, you know, terrified and, you know, behind closed doors, you know, it shouldn’t be the way, but we hear, we hear about fear all the time. And again, you know, someone having that power and so interesting that this model of care, which was created so long ago, I mean, I suppose at least you’re having discussions. I, I’m trying to think the last time that a model of care in the UK had any, any kind of near that discussion. I think, you know, the NHS model of care has been in existence for a very long time, and I’m not actually even seeing any, any movement to change. I don’t know about you, Marianne. I mean, you’ve been through the system yourself.

My understanding is that the, um, CPD that clinicians go through is all within the NHS in the UK. They don’t look outside of the UK. So, like you say, know about the WPATH guidelines, why is the NHS or the HSE not adopt, and then why would they not adopt them guidelines? Um, and I think, you know, at least you’re having a discussion about it in Ireland, in the UK. I don’t know about, but like Helen said, I’m not hearing that there’s the discussion. Is there any discussion next to keep it a mental health issue, which clearly it isn’t, you know, being transgendered in and of itself is not a mental health issue. That’s what they seem to want to do. How did you get involved? How have you got so deeply rooted in this to get so far? Are you from a health service background? If you don’t mind me asking?

I love this question because my answer back same in that I’m an absolutely completely 100% accidental activist when it comes to trans health care. You know, when I started this in Ireland, I never wanted to be north house. I would ever be the poster boy for trans health care. And it’s, it’s quite an interesting story as to how that started. And it involves two bottles of wine and being very angry. You know, I was on the waiting list for the national gender service here in Ireland for three years. Um, before I got a phone call to say that my referral had been lost for a third time, um, in that three years, and I got off the phone, I went to, I bought two bottles of wine and I just sat at home and I got drunk and I decided in my angry drunk trans man state to organize a protest on Facebook. And I’ve never done it in my life. I didn’t even know how to go on a protest. And I woke up the next day, hung over and embarrassed and saying, oh God, I better go and delete this. And when I clicked into the event, there was 400 attendees already ready to go. So, you know, I figured that this is something that’s needed. Went ahead with the protest, got about 400 attendees at that. And then I said, this can’t be a protest. This has to be a campaign, keep going. It’s too important.

And so you talk about the person centered, but do they have any trans in the service as service providers, you know, doctors, nurses, counselors, anything?

No. No. So, um, recently, so I was, uh, the Irish government minister for health appointee on the national transgender health care steering committee. More most recently, the committee concluded, uh, in January, 2020. And part of that report recommended that a service user joins the governance committee and of the national gender service they’ve recently met. And TENI, the transgender equality network Ireland have been given the seat on that, despite the people given a seat, not being in the circle, going through the service. So they, they don’t have any influence from any services there’s whatsoever in the national agenda service in Ireland.

No, and that’s something, I mean, since I started in this field, you know, five, six years ago, that’s I it’s a recurring theme is stop letting cis-gender people make all these decisions. And, you know, if we took the system to people out then that all those things that you talked about in terms of them having to prove yourself as being trans, having to prove that it’s the right thing to prove that you’re going to be a trans person for the rest of your life, prove, prove, prove it’s like, no, just listen to me. I’m telling you, I am telling you I’m trans right. Okay. Let’s, let’s move on from that. Um, and I, I think it’s really important that the trans people’s voice is what is heard and not locked behind closed doors. As, as you were talking about.

This is what I’m saying, Helen, you know, this model of care, that’s not evidential base that was created by one psychiatrist, individual at the national gender service, you know, a lot of the assessments at the psychiatric assessments questions. And in Ireland, you must have standard go through two psychiatric assessments before even being considered to be put forward to endocrinology here. Most people are given more than that, but, uh, those questions that you’re asked are very, hyper-sexualized, it’s very, a lot of trans people, not only would say voyeuristic often asked about what kind of porn you watch, um, about who you’ve had sex with, what sex acts you perform, um, on are performed on you and how you feel about what’s happening to you. You know, all these things that are absolutely nothing to do with your gender identity whatsoever, you know, whatever porn. And I, I decide to watch it on, on my computer has no relevance to my gender identity, whatever sexual acts I perform with my partner has no relevance to my gender identity, as well as being questions, you know, to describe your life from birth to date, you know, take them back to any traumas, abuses, things like that. You know, as if my parents separating when I was 14, has anything to do with the fact that I just happened to be transgender, you know, it, it, it’s really irrelevant to, and, and it’s only getting worse, you know, as they say, comorbid conditions, anything at all, that’s admitted such as if someone happens to have autism or borderline personality disorder or ADHD, they’re being delayed treatments for further assessment. And we both know it’s not mutually exclusive. You can be autistic and be trans at the same time. You can have borderline personality disorder and be trans at the same time. Whereas as being something that influences your transness, which of course, isn’t the word, that’s what we’re doing with our psychiatric service at the national gender service.

The questions are making me shudder. Um, quite a lot. I have to say, are they published anywhere? Has anyone ever said, right, I’ve been to the clinic. And this is the list of questions that I was asked. Has anyone done that? There’s no list, but I personally have, I, I believe I’m the only person in the country who has a recording of someone else’s psychiactric assessment and a trans woman that I know decided to record that secretly her session. Um, I’ve had it for the past year. So I’m still deciding what I’m going to do with it. What’s the best way to use it and how to protect her herself. So I believe I might be the only person in the country that does have a recording of one of these assessments.

Coming back to, uh, you know, person centered approach the reality is the person is the, the patient is the expert in their own with their own experience, the trouble that we, and again, this might seem controversial, but having a lot of CIS people trying to work out, whether we are worthy of treatment or not, or everything you said, there sounds like CIS people trying to protect CIS people from making a mistake that not actually being person centered and trying to listen to the person that’s in front of them, look at them, talk to them, get to know them a little bit. And actually I do, you know, do they understand who they are? Are they worthy of treatment because this is who they are. And it doesn’t have to be complicated. There’s nothing that you’re going to find that is going to be definitive. It’s, uh, the clinicians are looking after the CIS population. That’s how it feels to me. I don’t know how you feel about that, Helen.

We’ve always we’ve said that, secondly, you know, it’s, it’s just not worth sacrificing one. Person’s, uh, what we know one cis person’s life, who’s making a terrible mistake by pretending to be trans. It’s just not worth risking that that person’s voice breaking or breasts growing. And, and of course, I’m not saying this is not how I feel. This is how I, how it’s perceived sometimes. And I think it’s a terrible, terrible way that time and time again, we hear it. Um, it being portrayed and I feel embarrassed by any cis people who feel that their life is more precious than, than, than any other person’s life. Um, you know, put that on the record completely. So what’s the future Noah? Let’s. If we were to pull down those people who are, who have this power and cause harm, uh, and we rewrite the rule book, what does it mean? So, you know, let’s, let’s, let’s get okay on rewrite that the healthcare rule book written by a trans person who an accidental ally and advocate in the trans health care, what’s the future.

In my opinion, the future is informed consent. And I’m not saying to pick mental health or psychiatry out of the field, I’m repurposing them. I’m putting them in a support role. And I’m not as a gatekeeping. I don’t want psychiatry and trans people don’t want psychiatry to be playing God with our health care. You know, there is a place for psychiatry when it comes to trans health care, but that’s in a supportive role. That’s in a role that can support trans people as we go on our journey because you know, transition is difficult. It’s, you know, although it, you know, studies would show it overall improves our mental health through our parts, with the difficult, some people’s headspace changes on hormones going through surgeries is, is hard. So there is a place for psychiatry, but the place for it is not gatekeeping the place where, it is not deciding whether I am trans or whether I am not it’s in a supportive role. And, you know, I, the way forward, as I said is it is informed consent. It’s taking trans healthcare out of a hospital setting. It’s putting it into the community. We’re not sick people. We don’t need to be in the hospital. Our GP can provide care. If my GP provides hormone replacement therapy to my mother, going through the menopause, he can provide it to me. It’s not much different. Care can be in the community because we’re not sick. You know, it doesn’t have to be centralized to one clinic where people from the entire country have to travel to. Even if they live six hours away, our blood tests can be done by nurses in our GP clinics. It doesn’t have to be done. And, you know, we want to be believed. We don’t want to have to prove ourselves. We don’t want to have to explain our sex lives and our sexual partners to people just be given the hormones that we need. And lastly, I’d say that in Ireland, we have no surgery options. We have zero surgery options for trans people. So any trans person that wants surgery must travel abroad and most have to pay for it. So it would be, you know, surgery options in Ireland for trans people. For me, total mastectomy, which I had year and a half ago, I think in Poland, double mastectomies are carried out every single day in this country by chest surgeons, plastic surgeons on cisgender people, but they won’t perform it on transgender people. So that’s another thing I would change. I don’t want to have to travel abroad for major invasive surgeries and not being entitled to any aftercare. When I get home, I took my own stitches out of my nipples when I returned from Poland and that’s not good enough. It’s not good enough for anybody.

Wow. There you go. I mean, again, GenderGP written in a patient centered way and actually, no, I think one of the things we often talk about what you’ve said, caring, the community care provided by general practice. That’s what your mother or your father going through the menopause because men have menopause too. Their hormones drop off. They will be treated in the GP surgery. They’ll have the blood tests to check the in the GP surgery and then they will get their hormones from the GP surgery. And it’s a bit tricky. Then we will ask the local hospital to help out, you know, if it’s a bit tricky, but a hundred percent, this kind of care should be provided in general practice. And all it needs is a little bit of education and acceptance and belief, belief that it’s important and the same with the surgery now, you know, so I don’t think that someone who’s used to doing female chest breast surgery can tomorrow use that technique on male chest surgery, but they can learn. And there’s no reason why there shouldn’t be some funding there for that education and learning to get that up and running. So we’ve got to, we’ve got to have that education in that GPS surgeons a hundred percent and dressing around, pick that bit about psychiatry, actually just from the medical point of view, because psychiatry is the, this is the discipline that deals with, with mental ill health. So things like depression or suicide or schizophrenia, bipolar disease, you know, those kinds of mental health disorders conditions. And I think really what you may be we’re talking about more is, is what Marianne’s type of role is the support for someone’s transition and their journey and the difficult ups and downs that all, that, all that fantastic ups and downs that might be in front of them, um, and a hundred percent agree with you on that support role, um, whether it has to be given by psychiatry or whether it was best to give, like to begin by psychology and counseling services. I would kind of challenge that really, you know, a trans person would need a referral to a psychiatrist in the same way that a CIS person would need a referral to a psychiatrist if they had a severe mental health problem that the GP couldn’t handle. If you know what I mean.

I think, um, when we talk about GenderGP, people come to us for care. When they’re asking us about the, the, the model of care, the one thing I always say to them is you’ve got to make sure that this is the right model of care for you. And I wouldn’t argue that person centered approach would suit everybody in terms of, if somebody is so damaged that they’re having a psychosis or they’ve got other, you know, uh, addictions or whatever, and it’s gotta be done as a joined up approach. So it shouldn’t be a, your trans therefore you need to see a psychiatrist. It’s actually what you need help with. But the reality is overwhelmingly, even though, you know, I agree completely what you say going through transition in and of itself is really difficult. You know, we shouldn’t minimize it. You know what the level of support that people need is different and it can be done in the community. It doesn’t need to be a referral to a psychiatrist. So I would, I would argue that’s what we were doing.

I think it needs to be a holistic approach to people’s health care. So, you know, your mind, your body, everything, but you know, here in Ireland, the national dentist service, you know, claim to take this holistic approach. But I don’t think they even understand the meaning of what the word means, because it’s just, you know, if you present as a trans person with autism, you’re not getting treatment. Um, if you present as a trans person who might have a history of self-harming, you’re not getting treatment, you know, it’s, it’s not holistic. Whereas, you know, if you present with any of those issues, the holistic approach would be to treat you at the same time as taking care of your other mental health issues, which is what we all would expect to on,  what should be happening. And not a point blank refusal, or point blank, blank delay. I was recently refused, not refused an offer for a surgery. Referral was retracted for me only last week, something to do with mental health. When I, I never stated I’ve any mental health issues, which I don’t or happens all the time, but it’s all about corruption. It’s all about the work I do. And there’s nothing I can do to change that because there’s only one surgeon or there’s any one clinic in the country. So, you know, what do we do when we get to their bedside? We can do nothing.

Yeah. You remind me when we were talking to Freddy O’Connell on one of our live broadcast. And he was saying that he was a perfect patient. Absolutely. From the beginning to the end, he was your perfect transmasculine patient. He ticked all the boxes. He was a good boy. He didn’t smoke. He didn’t do any of those bad things. And everything was really smooth until the time he said, I want a baby. And then it was like, oh my goodness, everyone throw everything out of the pram and discharge them. So it’s the same kind of thing. Isn’t it? So, you know, perfect patients in you, but, oh, hang on a minute. Have you heard what he does? Have you heard the festival because you the trouble, right. Okay. How can we punish you? It’s really, it’s terrible. But I think, you know, what can we do? And I think what we definitely need to do is just not hold these things to ourselves. If people feel that they have been given poor medical care, nursing care, psychiatric care, if they think they’ve been harmed more than abused and abused, more than hoped, then there should be avenues. And each doctor, nurse, counselor psychiatrist is regulated by their own regulatory body. And they have a code of conduct with which they have to adhere to. So sometimes, you know, and I don’t want to be the one that says that escalate, escalate, take things further, but the courts are there to protect us. Regulators are there to protect us. And actually what we need to do is share our knowledge of these things, um, to help people get the care that they need. And then of course, there’s people that you know, who do an amazing job, um, understanding both sides of it because, you know, it takes somebody with it, with a flag and some, a couple of bottles of wine and 400 people of protest behind them to, to start them up it, which is, which is clearly what you’ve done. And from what I hear, you’ve achieved a lot since you started your support group.

I always say it’s, it’s not just me. It’s the entire trans community. I might’ve said a word, but I have an entire community behind me.

And I feel sorry Marianne as well. Um, but you know, no saying that Ireland is very small. And so I guess that privacy, it’s difficult, you know, to be able to be in stealth or to be just quiet and just get on with your own trans life. It must be very, very difficult, particularly if you need the force of numbers behind you to affect change. And what have you didn’t want to be one of those of those, what if you would just want it to be one of the ones that just, you know, melded into life easily. It must be very difficult Marianne to have that extra.

Is that, do you know, we just talked before about the strains of transition and then just talking, you know, and we know it at GenderGP, how difficult it’s made and the fact that we’re having to come pain and we’re having to beg for change. And that we have to, not only do we have to prove our gender, then we have to prove the we’re being marginalized or, you know, despite all the evidence. So I just think that continual drip feeding of point, you know, if it’s not a psychiatrist, that’s a gatekeeper, it’s politicians or it’s your GP. Do you know what I mean? It’s just that every step of the way, it’s like, society’s trying to make it hard. And I, for one, cause I’m not an activist after saying in any stretch of the word, I work in my own way. And I like to think that I bring something to the community, but my God do I admire the people like yourselves Noah because it’s hard enough without all of that.

Sometimes I just absolutely wish that I know I don’t have to be trans. No, I can just be Noah, Noah Halpin. I don’t have to be the person that, you know, when the newspapers writing about J K Rowling, that I’m the one contacted. I wish that I didn’t have to be known as the trans guy. I sometimes just wish I could live as just Noah. And no one knew and my life would just be so much easier. You know, last night, for example, I had a meeting with a police station in Ireland. Don’t worry. I’m not in trouble. Um, it was all work and I was waiting the, in the public gallery of the police station. And um, someone said to me, oh Noah, how are you? Um, I didn’t know the person. I don’t, I didn’t know them. And at that moment I kind of said, do you know what if I was in trouble, I would hate the fact that I am standing in this police station and people know me. I know it. You know, and even getting into the meeting with the, with the inspector of the station, you know, it was about, uh, trans people in, in policing and things like that. And he said, are you trans? I said, yes. And he goes, oh, well, if it’s any consolation, I wouldn’t be able to tell. And I was like, I hate that now for the rest of this conversation, I am not Noah who is meeting you about policing when it comes to trans people. I am now Noah the trans person meeting you about trans people. Yeah.

Yes.

Well, no, I’m not going to let you disappear just yet. I think, you know, we, we need to, we, and maybe give it, let’s give it a few years and maybe you’ll get your best to, to just subside back out and be nowhere, nowhere, the man, rather than they were the trans man. But the work that you do I think is too valuable. And I think that’d be a protest if he left. So, um, and I might lead it. So you’re not, we’re not like we’re not letting you go yet. But what I do want to say is that we talked about the WPATH a little bit, um, and just, I just want to close on the fact that the WPATH are writing best their version, eight of the standards of care. And I’m so, so, so excited for it. I hope that the voice of all the people that have put in the suggestions and committees, um, and the trans representation on those committees, making dicing the chapters are going to be listened to. I shouldn’t be terribly sad if they are terrified into not doing best practice person centered health care, I’d be really sad if behind closed doors, they write the things that we didn’t want to see. And, but this time, this time of writing, we do have trans representation. We do have more evidence and, um, I’m going to remain very, very, very positive and excited about the WPATH certain standards of care version eight, which we’re waiting for. And I hope that it will give us that evidence-based I know that you’ve been talking about to take to our GPs and our primary and secondary care, not this tertiary care specialist center, but our primary and our secondary care. And say, here you go. Here’s the rule book. This is how I’d like to be treated. This is what I need, please. Could you help me? And please don’t please don’t judge me for being trans. And that is going to be the future when it will be. I’m not quite sure, but that will be the future. I don’t know whether you’d agree on that.

I hope so, Helen, you know, one thing I’d say is if I can be my own doctor, having never gone to medical school, and if I can read my own bloods, if I can read my LFTs and my hormone levels and all that, I’m sure my GP can do this. You know, if my GP can do it for every other CIS person in the world, it’s the treatment. It’s, you know, the same reading of bloods, if I can do it for myself, you know, every doctor in the country. And as you said earlier on, unless there’s, you know, when you usual changes or problems that arise, it doesn’t need.

Education and, and belief that it’s their job and their role and their duty as a doctor to provide that care for you. And that’s, that’s the little bit of ticks or that’s missing at the moment. And I think maybe in our campaigning, we should be fighting for, for those doctors and nurses and psychologists and counselors, but we do need to be accountable for their own decisions and the decisions when they say no, how will they be held to account for saying, no.