_Hlk527557282

211 CSO. (2016). Women and Men in Ireland 2016.

212 Ibid.

213 The Yogyakarta Principles. (2006). The Application of International Human Rights Law in Relation to Sexual Orientation and Gender Identity. Retrieved from: http://yogyakartaprinciples.org/wp-content/uploads/2016/08/principles_en.pdf

214 World Professional Association for Transgender Health. (2011). ‘Standards of Care for the Health of Transexual, Transgender, and Gender Nonconforming People, Version 7’. International Journal of Transgenderism. 13(4):165-232

215 Brooks, H., Llewellyn, C.D., Nadarzynski, T., Pelloso, FC., De Souza Guilherme F., Polllard, A., Jones, CJ. (2018) ‘Sexual orientation disclosure in health care: a systematic review’. British Journal of General Practice. 668:e187-e196

216 Heteronormativity: Is a set of beliefs and practices that gender is an absolute and unquestionable binary, therefore describing and reinforcing heterosexuality as a norm. It implies that people’s gender and sex characteristics are by nature and should always be aligned, and therefore heterosexuality is the only conceivable sexuality and the only way of being ‘normal’.

217 Heterosexism is a set of discriminatory attitudes, bias and behaviours relying on gender as a binary to favour heterosexuality and heterosexual relationships

218 Mayock, P., Bryan, A., Carr, N., Kitching, K. (2009). Supporting LGBT Lives: A Study Of the Mental Health and Well-Being of Lesbian, Gay, Bisexual and Transgender People. Dublin: GLEN and BeLong To Youth Service. Retrieved from: https://www.hse.ie/eng/ services/publications/mentalhealth/suporting-lgbt-lives.pdf

219 Minority stress arises where stigma, prejudice and discrimination create a hostile environment where people are subject to stressful social exchange.

220 Victimisation takes place where one person treats another less favourably based on a range of factors such as gender identity, sexual orientation, sex characteristics, sex, disability etc.

221 Institutional discrimination occurs where laws and policies in the public domain sustain inequalities, e.g. the prohibition of same-sex marriage, or where laws do not protect against discrimination based on sexual orientation, gender identity and sex characteristics.

222 Stigma is a perceived negative attribute that causes someone to devalue or think less of the whole person.

223 Health4LGBTI. (2017). State of the Art Synthesis Report (SSR). Retrieved from: https://ec.europa.eu/health/sites/health/files/social_ determinants/docs/stateofart_report_en.pdf

224 Pinto, N. (2014) Consultations with ILAG-Europe’s Members on the needs, priorities, challenges and good practices in the field of health. ILGA- Europe

Women’s Health in Ireland — Evidence Base for the development of the Women’s Health Action Plan

In 2009, the HSE published an overview of health

getting involved in health and access to health

and social service provision and support for

provision include:

LGBTQI+ people in Ireland.225

—Antagonism and lack of cooperation from —

The report highlighted particular health issues

health authorities, organisations and

experienced by lesbian and bisexual women as

professionals, and from governmental

including:

agencies with responsibilities in this field;

—Higher incidences of cardio-vascular disease, —

—Lack of resources; —

polycystic ovarian syndrome, ovarian cancer

—Interrelation with the work of other actors on —

and possibly breast cancer;

health;

—Lower use of gynaecological services; —

—Diversity of issues within LGBTQI+ health, and —

—Low awareness of STIs spread by woman-to- —

specificities of different groups;

woman sex;

—The broad scope of LGBTQI+ health; —

—Barriers to accessing assisted human —

—Lack of involvement of LGBTQI+ communities —

reproduction (AHR) services.

in health activities and difficulties in reaching

The study also found that members of the

out to specific subgroups within LGBTI

transgender community face a lack of essential

community;

health services – surgeons, postoperative care,

endocrinologists, psychiatrists, therapists, and a

Figure from page 54

designated gender specialist – and are more likely

to experience isolation, fear, stigma, physical

violence and family rejection contributing to

depression, anxiety, self-harm, suicide and

substance misuse.

See Table 2.15 for some of the specific health

issues for LGBTQI+ individuals.

Each LGBTQI+ group also has particular health

needs. See Table 2.16 for details.

225 HSE LGBT Health sub-committee (2009) LGBT Health: Towards Meeting the Health Care Needs of Lesbian, Gay, Bisexual and Transgender People. Dublin: HSE. Retrieved from: https://www.hse.ie/eng/services/publications/topics/sexual/lgbt-health.pdf

Table 2.15 Health issues for LGBTQI+ individuals
Physical Health	Higher incidences of obesity and eating disorders are to be found among the LGBTQI+ population, raising the risk for diabetes and heart disease, among other weight related ailments. Members of the LGBTQI+ community are typically more likely to be smokers226. The National Drug and Alcohol Strategy 2017 to 2025 identifies LGBTQI+ individuals as a group with complex needs, and the strategy calls for targeted harm-reduction, education and prevention measures for drugs and alcohol abuse that are tailored towards higher risk groups.227
Mental Health	LBTQI+ groups are at significantly higher risk of experiencing mental health problems compared to the heterosexual population. These problems can be linked to the discrimination and marginalisation experienced by LGBTQI+ people, and are not inherent to sexual orientations, gender identities or sex characteristics. 228 LGBTQI+ people have higher rates of risk behaviours (drinking, smoking and drug use) that are linked to discrimination. LGBTQI+ individuals are more likely to report mental health difficulties than the non- LGBTI+ population and are proportionately more likely to access mental health services than heterosexuals229. Nearly one in four LGBTQI+ people have either severe or extremely severe anxiety levels, with one in five LGBTQI+ people suffering from severe or extremely severe depression. Similar trends are found in terms of self-harm230.
Sexual Health	LGBTQI+ Ireland survey respondents identified sexual health promotion as too narrow and heteronormative. The level and quality of sexual health services available around the country varies. Not everyone is aware of the different options open to them (e.g. PrEP and PEP). The costs associated with some of these treatments can also act as a barrier to their use.
Mortality	Lesbian women have greater all-cause mortality than heterosexual people231. LGBTQI+ individuals have a higher risk of certain cancers, are less likely to attend for routine screening and more likely to present with more advanced disease.

226 Higgins, A., Doyle, L., Downes, C., Murphy, R., Sharek, D., DeVries, J., Begley, T., McCann, E., Sheerin, F., Smyth, S. (2016). The LGBT Ireland Report: National Study of the Mental Health and Wellbeing of Lesbian, Gay, Bisexual, Transgender and Intersex People in Ireland. Dublin: GLEN & BeLonG To Youth Service. Retrieved from: http://belongto.org/wp-content/uploads/2018/05/LGBT- Ireland-Full-Reportpdf.pdf

227 Department of Health, Healthy Ireland. (2017). Reducing Harm, Supporting Recovery: A Health-Led Response to Drug and Alcohol Use in Ireland 2017-2025. Retrieved from: https://health.gov.ie/wp-content/uploads/2017/07/Reducing-Harm-Supporting- Recovery-2017-2025.pdf

228 Gonzales, G., Przedworski, J. and Henning-Smith, C. (2016). ‘Comparison of health and health risk factors between lesbian, gay, and bisexual adults and heterosexual adults in the United States’. JAMA Internal Medicine. 176(9):1344-51. Retrieved form: https:// www.ncbi.nlm.nih.gov/pubmed/27367843

229 Fay, V. (2016). Lesbian, Gay, Bisexual and Trans (LGBT) Young People’s Health in the UK: A literature review with a focus on needs, barriers and practice. Proud Trust. Retrieved from: https://www.theproudtrust.org/wp-content/uploads/download-manager-files/LGBT- Young-Peoples-Health-Research(1).pdf

230 Higgins, A., Doyle, L., Downes, C., Murphy, R., Sharek, D., DeVries, J., Begley, T., McCann, E., Sheerin, F., Smyth, S. (2016). The LGBT Ireland Report: National Study of the Mental Health and Wellbeing of Lesbian, Gay, Bisexual, Transgender and Intersex People in Ireland.

231 Cochran, S., Bjorkenstam, C., and Mays, V. (2016). ‘Sexual orientation and all-cause mortality among US adults aged 18 to 59 years, 2001-2011.’ Am J Public Health. 106: 918– 920.

Women’s Health in Ireland — Evidence Base for the development of the Women’s Health Action Plan

Table 2.16 Health issues for specific LBTQI+ groups of women232
Lesbian women	Specific health needs include sexual and cervical health, reproductive health, mental health, substance use, weight discrepancies etc.
Bisexual women	Specific health needs include aspects of general/physical health (cancer), mental health, and substance (mis) use including stress with limited research specifically focusing on health issue relating to bi-sexual people.
Trans women	Specific health needs include general health, mental health, depression, suicidal ideation and suicide attempts, substance mis-use, as well as the impact of transitioning on mental health. Specific barrier facing transgender individuals include inappropriate or prejudicial treatment from healthcare staff. This treatment includes using inappropriate pronouns, using and displaying old names in front of other patients, offering inappropriate services, providing inaccurate advice and refusing service provision233.
Intersex individuals	Specific health needs include assigned sex, impact of surgery, ethical accountability, mental health, and accessing specialist services.

female prisons regularly run above capacity with

2.7.7 Women who offend

an average female population of 152 in custody

Women who commit crime comprise a relatively

in 2012.

small yet increasing group within the criminal

justice system in Ireland. International research

Most women who offend pose a low risk to society; however they generally have high support and health needs235.

suggests that women offenders are likely to

be poor, have limited education and are either

unemployed or in low skilled employment. Many

experience accommodation problems234, often

resulting in homelessness, and serious problems

of addiction and/or mental health often feature.

In 2013, the Probation Service worked on a daily

Figure from page 56

basis with almost 1,300 women offenders in the

community, either assessing or supervising them

on a range of probation type orders, community

service or post release supervision. In 2013, 14%

or 1 in 7 new referrals to the Probation Service are

for women offenders (1,206 new referrals). On any

day there are around 150 women in custody. 2,151

women were committed to prison in 2012 which is

almost 15% of all committals. In comparison 2,326

women were committed to prison in 2013 which

accounted for 18% of all committals. While there

are currently 133 spaces for female prisoners, both

232 Health4LGBTI. (2017). State of the Art Synthesis Report (SSR).

233 Santiago McBride, R. (2011). Healthcare Issues for Transgender People Living in Northern Ireland. Institute for Conflict Research. Retrieved from: http://www.hscbusiness.hscni.net/pdf/Healthcare_Issues_for_Transgender_People_in_Northern_ Ireland_-Ex_Summary-_JULY_2011.pdf

234 Mayock, P. and Sheridan, S. (2012) Women’s ‘Journeys’ to Homelessness: Key Findings from a Biographical Study of Homeless Women in Ireland. Women and Homelessness in Ireland, Research Paper 1. Dublin: School of Social Work and Social Policy and Children’s Research Centre, Trinity College Dublin.

235 Irish Prison Service and the Probation Service. (2014). Joint Probation Service – Irish Prison Service Strategy 2014 – 2016: An Effective Response to Women Who Offend. Retrieved from: http://www.irishprisons.ie/images/pdf/women_strat_2014.pdf

needing to be hypervigilant about their safety238.

2.7.8 Women involved in prostitution

Women in prostitution may also have other chronic

The profile and associated health needs of women

health problems linked to complex socioeconomic

involved in prostitution has changed significantly

backgrounds and lifestyle factors239 that may have

over the last 10-15 years (Sweeney, 2015)236. Those

initially led them into prostitution240.

health services which were provided for women

in prostitution traditionally centred on sexual

Women in prostitution in 2019 are alsoprimarily

health and addiction. However, women working

a highly mobile group, involved in largely indoor

in prostitution are not a homogenous group and

focused activity that involves foreign nationals

how women in prostitution will interact with

and touring populations (with far smaller

health services may differ depending on their

numbers involved in on-street prostitution in

context, for example whether they are a victim

larger cities)241. Among some of the most recent

of trafficking, a migrant woman or a transgender

data available is the Immigrant Council of Ireland

woman.

2009 study242, it estimated that at that time

there was a minimum of 1,000 women involved

If health services are to meet the different health

in indoor prostitution in Ireland (representing 51

needs of women, working indoors and working on

different nationalities and ranging in age from 18

the street then health services must consider and

to 58 years (with evidence that girls as young as 16

understand the differences between the needs of

years are involved).

these groups of women237.

This study estimated that just 3-13% of the women

Prostitution impacts negatively on the physical,

involved in indoor prostitution were Irish, while the

sexual and reproductive and emotional and

majority were migrant women. It also estimated at

mental health of women. Health risks can include

that time that, 41% were ‘touring escorts’ moving

frequent viral illness, STDs, vaginal infections,

and/or being moved by criminal gangs around

back aches, sleeplessness, depression, general

Ireland and internationally. The profile of clients

physical conditions including headache and

attending the HSE Women’s Health Project (WHP) 243

stomach ache, eating disorders, cervical cancer,

in 2017 supports this overview, although it does only

infertility, hepatitis, rape and sexual assault with

reflect those women accessing its service. (See Table

related injuries such as fissures; traumatic brain

2.17 for details).

injury from physical assaults; symptoms of post-

traumatic stress disorder and suicidal ideation.

Women in prostitution are also known to be at far

higher risk of violence and murder compared to

the general population, with women continually

236 Sweeney, L-A. (2015). The psychosocial experiences of women involved in prostitution: an exploratory study. PhD in Health Promotion, National University of Ireland, Galway. Retrieved from: https://aran.library.nuigalway.ie/xmlui/bitstream/handle/10379/4970/ Leigh-Ann%20Sweeney%20PhD.pdf?sequence=1

237 Jeal N, Salisbury C. (2007). ‘Health needs and service use of parlour-based prostitutes compared with street-based prostitutes: a cross-sectional survey.’ BJOG. 114:875–881.

238 Farley, M. (2004) ‘“Bad for the Body, Bad for the Heart” Prostitution Harms Women Even if Legalized or Decriminalized’. Violence Against Women, 10 (10):1087-1125.

239 Mastrocola E. L., Taylor A. K., & Chew-Graham, C. (2015). Access to healthcare for long-term conditions in women involved in street-based prostitution: a qualitative study. BMC Family Practice 16:118. Retrieved from: https://bmcfampract.biomedcentral. com/articles/10.1186/s12875-015-0331-9

240 Kurtz, S.P., Surratt, H.L., Kiley, M.C., Inciardi, J.A. (2005) ‘Barriers to health and social services for street-based sex workers’. J Health Care Poor Underserved. 16(2):345-61. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/15937397

241 In 2017 20% of the individual supported by Ruhama were involved is on-street prostitution in Dublin. Ruhama. (2017). Ruhama Annual Report 2017. Retrieved from: https://www.ruhama.ie/assets/Press-Releases/Ruhama-2017-Annual-Report

242 Kelleher Associates, O’Connor, M., and Pillinger, J. (2009) Globalisation, Sex Trafficking and Prostitution: The Experiences of Migrant Women in Ireland. Immigrant Council of Ireland. Dublin 2. Retrieved from: https://www.immigrantcouncil.ie/sites/default/ files/2017-09/AT%202009%20Globalisation%2C%20Sex%20trafficking%20%26%20Prostitution%20Report%20SUMMARY.pdf

243 The WHP (HSE) was established in 1991 to respond to the health needs and the harm experienced by women in prostitution. Since 2003, it has worked with trafficked women Current clinic time are Tuesday 2-4pm by appointment, Wednesday 2-4pm and Thursday 6-8pm.

Women’s Health in Ireland — Evidence Base for the development of the Women’s Health Action Plan

For women who are controlled and held in

Table 2.17 Profile of Clients attending the HSE WHP Clinic in 2017
Total attendees		205
New Attendees (including 63 new internationals)		64
Nationalities	Irish	11
	UK	3
	International	191
Opiate dependent		3
On/off street	Indoor	192
	Outdoor	2
	N/A as Victim of Trafficking	11
Source: Latham, L . (2018). Presentation on Anti-Human Trafficking Team & Women’s Health Service in Ireland. Given at the 18th Alliance OSCE Conference against Trafficking in Persons conference entitled Everyone Has a Role: How to Make a Difference Together, in Vienna, 23-24 April 2018. Retrieved from: https://www.osce.org/secretariat/382177?download=true

prostitution by criminal gangs, they are likely

to have no control over where they stay, or

opportunity to link with local services. For those

women who are independent – a minority of

those in prostitution – lack of reliable income

and vigilance about attacks by buyers or criminal

gangs means they may have to continue to work

while ill.

Currently, only one HSE facility, the Women’s

Health Project situated in Dublin is available

to women involved in prostitution. Other

organisations supporting women in prostitution

include Ruhama and the Immigrant Council of

Ireland both of which are also Dublin-based. In

other parts of the country, AIDs West, Cork Sexual

Health Service, Cork Sexual Violence Centre,

GOSSH (Limerick) and Doras Luimní work with

women in prostitution in a health capacity. Key

health needs244 for women in prostitution have

been identified as including:

The current diverse, dispersed and highly mobile

nature of prostitution means that for many

1. The provision of basic health and support

women involved in prostitution their health needs

services available nationwide to include

are increasingly determined by their psychosocial

specialised sexual health clinic in all major

experiences and location.

cities (as provided by the WHP (HSE) for the

greater Dublin area).

Among the key barriers identified by Sweeney

2. Culturally appropriate training for health

(2015) in relation to women in prostitution in

care practitioners give them the skills to

Ireland accessing health services, included: a

identify the health needs of women from other

fear of being identified due to concern about

countries in prostitution in Ireland.

the reaction of traffickers/pimps and the fear

of experiencing stigma from service providers;

3. Research on the long-term impact of

limited information on where they could go due to

prostitution on women’s mental and physical

their constant movement around the country; and

health and the mortality rate of women in

the limited nature of services available to them,

prostitution

given that many local agencies do not provide a

service for women involved in prostitution.

244 Kelleher Associates, O’Connor, M., and Pillinger, J. (2009) Globalisation, Sex Trafficking and Prostitution: The Experiences of Migrant Women in Ireland.

Team (AHTT) deliver an individual care plan

2.7.9 Women and trafficking

for each victim of human trafficking under the

Prostitution and trafficking are not the same

national action plan. The HSE team then assesses

but are inherently intertwined as women are

and plans care with the individual according to

trafficked primarily for the purpose of sexual

their particular needs and within the limitation

exploitation. The clandestine nature of human

of the existing policies. Ruhama 248 also provides

trafficking makes it difficult to measure

education and training support, housing support,

accurately. The Department of Justice and

counselling, outreach, advocacy and specialist

Equality’s Anti-Human Trafficking Unit (AHTU)

casework support to victims of sex trafficking.

gathers information from a number of sources

to create two distinct datasets of a) potential

The health problems affecting victims of

victims245 and b) suspected victims246. The data

trafficking are a result of number of factors

that is available, relates to suspected victims of

including stress, deprivation of food and sleep,

trafficking only, see Table 2.18 for details.

hazards related to being trafficked to various

locations and across borders, physical violence

Table 2.18 Total suspected adult trafficking (including for labour and sex trafficking) victims by year and gender
Year	Age	Female	Male	Trans	Total
2013	Adult	26	2	-	28
2014	Adult	26	8	-	34
2015	Adult	35	19	1	55
2016	Adult	38	36	-	74
2017	Adult	42	30	-	72 (includes 31 sex trafficking victims)
Totals		167	95	1	263
Source: Dept of Justice and Equality (2018) Trafficking in Human Beings in Ireland, Annual Report 2017 p 5.

and sexual violence249. It is also the case that

because women who are trafficked generally

do not have access to health care, by the time

they reach a clinician it is likely that health

problems are well advanced250. These women are

at particularly high risk for acquiring multiple

sexually transmitted infections and the sequelae

of multiple forced and unsafe abortions251.

Physical abuse and torture also often occur, while

psychological violence results in high rates of

posttraumatic stress disorder, depression, suicidal

ideation, drug addiction, etc252.

Importantly, health care providers are often the

only professionals to interact with individuals

who have been trafficked, or who are still under

the control of traffickers, pimps or criminal

gangs, as women may attend for STI testing,

pregnancy and/or abortion services. Health

Nationally, three dedicated State units247 focus

care providers must therefore be aware of this

directly on human trafficking supported by

possibility and prepared to identify, treat, and

2016 Second National Action Plan to Prevent and

assist such individuals as part of their regular

Combat Human Trafficking in Ireland. From a health

clinical practice. One study found that 28% of

perspective the HSE Anti-Human Trafficking

245 A “potential victim” refers to a person encountered by non-State groups, who they believe may be a victim of trafficking. These persons may, or may not, be referred to An Garda Síochána for identification and entry to the system of State supports known as the National Referral Mechanism (NRM).

246 A “suspected victim” refers to a person that meets a reasonable grounds threshold and is therefore considered a victim of human trafficking by An Garda Síochána.

247 The Department of Justice and Equality’s Anti-Human Trafficking Unit (AHTU), the Human Trafficking Investigation & Co- Ordination Unit (HTICU) which is part of the Garda National Protective Services Bureau (GNPSB) and the HSE Anti-Human Trafficking Team (AHTT).

248 In 2017, Ruhama provided support to 109 victims of sex trafficking, originating from 26 different nations. Ruhama. (2017). Ruhama Annual Report 2017.

249 Dovydaitis, T. (2010). ‘Human Trafficking: The Role of the Health Care Provider’. J Midwifery Women’s Health. 55(5): 462–467. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3125713/

250 Barrows, J., Finger, R. (2008). ‘Human trafficking and the healthcare professional’. South Med J. 101:521–4.

251 Cwikel, J., Chudakov, B., Paikin, M., Agmon, K., Belmaker, RH. (2004) ‘Trafficked female sex workers awaiting deportation: Comparison with brothel workers’. Arch Womens Ment Health. 7:243– 9.

252 Dovydaitis, T. (2010). ‘Human Trafficking: The Role of the Health Care Provider’.

Women’s Health in Ireland — Evidence Base for the development of the Women’s Health Action Plan

trafficked women saw a health care professional

while still in control of traffickers253. This

represents a serious missed opportunity for

intervention.

Women who are trafficked clearly have multiple

needs which demands a complex response

involving multiple agencies including medical and

health care, welfare, sexual health services, rape

crisis centres, and in many cases, interpreting

services. Concerns also particularly exist

regarding the lack of appropriate accommodation

for particularly traumatised victims of sexual

Figure from page 60

abuse. Currently, potential or suspected victims

of trafficking – who have specific safety needs

(from their traffickers) and health needs – are

provided with the same accommodation and

ancillary services as those provided to newly

arrived asylum seekers, namely direct provision

reception centres, arranged by the Reception and

Integration Agency.

Concerns exist in relation to the appropriateness

of this accommodation for particularly

traumatised victims of sexual abuse/trafficking254.

2.7.10 Other groups

Other groups of women whose health needs need

to be explored and addressed within the WHAP

include female lone parent families, women

involved in substance misuse as well as women

working in health care. As is the case for all

these priority groups of women (including those

discussed in section 2.7 above), there is a need for

further research to identify their health needs,

health outcomes and engagement with health

services. Within the health services there are

a number of programmes designed to support

women (e.g. Women in Leadership) that could be

explored and built upon within the WHAP.

253 Ibid.

254 Kelleher Associates, O’Connor, M., and Pillinger, J. (2009) Globalisation, Sex Trafficking and Prostitution: The Experiences of Migrant Women in Ireland.

Figure from page 61

Section 3 – Women’s Engagement with the Health Service

of gender as a genuine health determinant; and

3.1 Overview of national and international literature on women’s engagement with health services (service use, service needs)

the third, final wave in this political process of

creating true gender policies included the Beijing

Conference held in 1995, together with the work of

the WHO’s Commission on Social Determinants of

Health, with gender now recognised as one of the