Going ‘stealth’ – a term used by those who hide their transgender (trans) history – was never an option for trans activist Noah Halpin, who is also the founder of ‘This Is Me – Transgender Healthcare Campaign’.

Noah describes himself as an “accidental activist” advocating for better healthcare “out of anger” at how trans people are being treated within Ireland’s public health system.

“We’re grass-roots and loud,” says Noah. “We’re shouting about something that needs to change: transgender healthcare,” he adds, referring to several protests that the campaign has held outside Leinster House in recent years.

Despite being assigned female at birth, Noah had known for years that he was male and was desperate to be free of the suffocating compression device he used daily to flatten the appearance of his breasts.

But with long waiting lists typifying access to trans-specific healthcare, and no surgeon willing to provide gender-affirming surgery in Ireland, the 29-year-old from North County Dublin was forced to travel abroad for a life-changing procedure.

He raised the cost of his double mastectomy operation, which he underwent last year at a private clinic in Poland, in just 36 hours on GoFundMe.

Noah’s ‘This Is Me’ campaign, which is made up of trans individuals and activists from across the country, is calling out the Department of Health and Health Service Executive (HSE) over what he describes as an “over-reliance on psychiatric assessment” which is causing “dangerously long waiting lists” at the country’s only gender service clinic.

“Delays accessing treatment, puts a medical transition on hold – which can have a serious impact on a person’s physical and mental health wellbeing,” says Noah.

“The wait is devastating. People who have never experienced any mental health difficulties are now struggling.

“We need to change the ‘psychiatric diagnostic’ model of care to one that is recommended by the World Professional Association for Transgender Health (WPATH).”

Typically, the first port of call for individuals beginning the process of medically transitioning is the National Gender Service (NGS), located in St Columcille’s Hospital in Loughlinstown. The service looks after all trans-specific healthcare for the HSE.

According to Freedom of Information (FOI) data, there are more than 460 patient referrals on a waiting list for a psychiatric assessment at the Dublin-based gender clinic. The minimum waiting time is currently over two years.

Between 2014 and 2019, referral rates to the NGS increased by 400 per cent, from approximately 50 per year to more than 250, according to the FOI.

In Noah’s case, it took three years from disclosing his true gender identity to his GP in 2015, until he had his psychiatric assessment to begin HRT.

“Trans people are waiting for years to start hormones,” says Noah.

“Once they reach the top of the waiting list, they’re put through invasive and inappropriate three-hour-long assessments with a psychiatrist who asks questions that have no relevance to a person’s gender identity,” according to Noah.

He went through this assessment in 2018 and said it was extremely traumatic.

“I was asked to describe the mechanics of how I have sex, whether I experienced abuse in my childhood and even questions about my parent’s relationship – as if any of this information would change the fact that I was born trans,” he says.

Clinicians at the NGS insist that, despite a patient’s preference for hormone treatments or gender-affirming surgery, the service is trying to create the right supports, particularly for those who may be more vulnerable.

“Psychiatric evaluation isn’t just about diagnosing gender dysphoria, but also to detect any co-existing psychological and mental health difficulties that need to be addressed,” says Dr Karl Neff, a Consultant Endocrinologist (hormone specialist) and the Clinical Lead for the NGS.

He is one of just two endocrinologists in Ireland who will prescribe hormone replacement therapy (HRT) to transitioning adults. Both require that trans patients undergo mandatory psychiatric evaluations at the NGS.

Dr Neff remarks that “there’s a misunderstanding that the psychiatric assessment is primarily or solely diagnostic”, stressing that “this is not the case”.  

“Our initial assessment is individualised and focused on social health – home life, work life, interpersonal relationships – and occupational function – the ability to get out and do the things you want or need to do,” he explains.

“While we do talk about people’s gender identity and their goals in terms of gender-affirmation, it is not the emphasis of the assessment.”

The WPATH guidelines, in terms of the provision of HRT and gender-affirming surgery, are internationally accepted as best practice.

Under such a model, trans individuals make their own decisions around medical treatments without requiring psychiatric approval.

The guidelines also state that general practitioners (GPs) should be empowered to dispense hormone treatments to trans patients, as they are qualified to do so.

“HRT is provided to cisgender people – that’s anybody whose birth sex and gender identity matches – every day by GPs,” says Noah, referring to the medication prescribed to treat menopausal symptoms.

“It’s a very simple, straightforward treatment, but if you’re trans, you need psychiatric approval.”

Concerning the role of GPs, Dr Neff explains that the standard practice at the NGS is to initiate and establish gender-affirming hormone therapy, and then discharge people to their GPs for longer-term care.

“GPs are usually more than happy to accept the care of people for long-term hormone prescription and monitoring once we have established that therapy, and given them advice and guidance on long-term monitoring,” says Dr Neff.

Perhaps not surprisingly, people with gender dysphoria, – particularly those waiting years for access to medical treatments, like hormones and gender-affirming surgery – experience stress, isolation, anxiety, depression and poor self-esteem.

For transmen, like Noah, the ways that gender dysphoria affects day-to-day life can include – on a really surface level – wearing a chest binder, for example.

“Imagine a corset for your chest made out of unyielding fabric,” explains Noah, referring to the daily torture he endured for years, before surgery.

“When you’re binding, it squeezes around your chest, spine and ribcage – the worst thing about it is pain, all the time.”

It’s recommended not to bind for longer than eight hours a day, but often Noah would start work early and go to an event afterwards, in which case he was binding for up to 18 hours.

“I’ve experienced bruised ribs, heat exhaustion and breathing problems.”

There is also the emotional aspect of waiting for treatment.

For those who feel that they don’t necessarily ‘pass’, it’s the day-to-day invalidation of being associated with a gender that isn’t who they are, which causes the most distress and an overwhelming need to transition medically.

While the HSE does cover gender-affirming procedures as part of the public health system, there are long waiting lists to access surgeries under the EU Treatment Abroad Scheme and further psychiatric assessments.

“If you ‘go private’, you’re paying about €12k for ‘top surgery’ in London, for example, but it’s a lot cheaper in central Europe,” says Noah.

Many ask friends, family, colleagues, or even strangers online to donate to fundraising campaigns to help them raise the money.

“My GoFundMe funding was highly unusual,” remarks Noah. “The majority of trans people don’t get their target in such a short space of time. I had a great network of supporters.”

Although objectively speaking, binding did its job well – Noah looked flat-chested, and no one seemed to notice the binder – by the time he booked his surgery he was worn down physically and mentally by the constant effort to be partially hidden, from himself as much as other people.

He’s now free from pain, overheating, friction and breathlessness, and every other form of physical and mental distress that manifests while binding.

Discussions about trans healthcare mainly dwell on its problems: waiting lists, lack of access, uneven quality, and little consideration for a better future.

Noah explains that because of the number of agencies involved in the delivery of care to the trans population in Ireland, the Department of Health and the HSE established a steering committee in 2019 to develop a seamless healthcare service for those with gender identity issues.

Members of this committee are mostly leading HSE clinicians and Department of Health officials, except for Noah, who is a patient advocate and the former Health Minister Simon Harris’ appointment.

Noah believes that sharing his experiences is helping to shift the conversation to something different – something positive and enriching.

“There have been many happy moments since having surgery,” remarks Noah.

“They can be the tiniest things for some people, like wearing a white t-shirt for the first time – I could never wear one because my binder would be visible underneath.

“The first time I could wear a white t-shirt after surgery was a moment that I’ll never forget, I still get emotional. It’s just a white t-shirt, a plain white t-shirt. I didn’t buy it. My friend Holly bought it for me as a gift after my surgery.”

He’s even getting used to the etiquette and nuances of being topless in public.

“Recently, and for the first time, while in the park with a male friend, I was able to take my top off while lying on the grass, and not have to worry,” he says.

“Little moments like that are huge for trans people.”