'I'm not looking up someone's skirt': Pharmacists reject deciding who's eligible for free HRT

PHARMACISTS ARE PUSHING back on the Department of Health’s suggestion that they should determine who is eligible for the free Hormone Replacement Therapy (HRT) scheme, amid continuing confusion surrounding the eligibility of trans people.

HRT has been free in Ireland since June, but there are questions within the healthcare system over who qualifies, and whether a person’s reason for taking it affects their eligibility.

The issue stems from some HRT medications, used to relieve symptoms of menopause, perimenopause and postmenopause, having other uses, such as for IVF, some cancer treatments and as part of gender-affirming healthcare for transgender people.

Pharmacists have raised concerns over how they are supposed to determine eligibility for the free HRT scheme, saying they won’t ask patients personal questions to do so.

Trans people argue that they can experience the same menopausal symptoms if they stop taking HRT as their hormone levels will decrease substantially.

They also say that as they have prescriptions for the same medicines as on the prescribed list, they should be entitled to access free HRT under the scheme.

The Minister for Health, Jennifer Carroll MacNeill, has maintained that the legislation enacted limits eligibility to the treatment of menopause, which appears to suggest trans people would not be eligible for the scheme.

But internal records raise significant questions about the practicalities of this.

Records released under Freedom of Information and seen by The Journal show that in May this year, the Irish Pharmacy Union (IPU) questioned whether prescribers would be required to indicate on the prescription that the product is for menopause treatment.

This would have differentiated between the different uses of HRT medication, but was rejected by the Primary Care Reimbursement Service (PCRS), a HSE service that reimburses healthcare professionals for the free or reduced-cost services they provide to the public.

The PCRS stated that “pharmacists in the course of their professional duties, including counselling the patient, will be aware of the intention for prescribing the product”.

The Journal has previously reported that trans women are experiencing inconsistent approaches from pharmacies, with some granted free HRT under the scheme, while others are denied.

Footage seen by The Journal of a pharmacist calling the PCRS to check whether a patient is eligible appears to show the PCRS instructing the pharmacist to deny free HRT to trans people – even when they are listed as female on the system.

A spokesperson for the Department of Health told The Journal, “officials from the Department and the Health Service Executive will continue to work closely with pharmacy representatives to ensure that communications relating to the scheme are clear, accurate, and fully reflective of pharmacists’ responsibilities.”

Pharmacists refusing to determine eligibility

Pharmacists who spoke to The Journal rejected any attempt to pass the responsibility on to them in determining eligibility under the scheme.

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Mark Jordan, a community pharmacist based in Mayo, told The Journal that nobody entering a pharmacy should expect to be questioned or examined as to whether they are transgender or not.

He said that the “counselling” referred to by the PCRS in its response to the IPU “happens after we dispense the drug” and is to do with the proper application of the medication.

Jordan, who runs a forum for Irish pharmacists with over 1,000 members, said that when the scheme was introduced and this issue was raised, “the overwhelming response was we just won’t be dealing with this”.

“We will not be putting anybody in a position where they will have to answer to their previous self, for lack of a better description.”

Ashleigh Bennett, a pharmacist in Dublin, said, “We don’t sit anyone else down and ask them to prove they’re male or female when they come in for items.” She added:

I’m not looking up someone’s skirt to see whether they are or are not.

Jordan said the free HRT scheme creates “a tiered system” that is “completely inequitable and unfair”.

Another pharmacist and IPU member who spoke on the condition of anonymity told The Journal that they believe the scheme was “rushed through”, “poorly thought out” and “sloppy”.

‘A gross misinterpretation of the role of a pharmacist’

Some politicians, including Social Democrats’ Pádraig Rice, have questioned the Minister for Health how pharmacists are expected to know the reason a prescription was made.

The Minister, citing principles from the Pharmaceutical Society of Ireland (PSI) code of conduct, responded that pharmacists must consider “not only the legal validity of the prescription, but also whether the continued supply of the medicine is clinically appropriate”.

Jordan, an elected member of the PSI Council, but who stressed that he was speaking in a personal capacity, said the principles cited by the Minister are “a gross misinterpretation of the role of a pharmacist, and indeed, the code of conduct.”

Jordan said these principles have “nothing to do with the eligibility of an individual relative to a scheme” and are instead “entirely associated with the safe and effective use of the drug”.

The PSI code of conduct also expects pharmacists to “respect patients’ rights to privacy and confidentiality…except where disclosure is legally required”.

Jordan said expecting pharmacists to ask whether the people before them are transgender is “ridiculous” and “is not within the remit of a professional pharmacist, nor do we want it to be”.

A spokesperson for the Department of Health said, “Pharmacists play an essential role in delivering safe access to medicines, and the Minister remains committed to ongoing engagement with the profession.”

No clinical information required

While the Department of Health argues that the intention of the scheme is for the treatment of menopause, internal records show that there are few practical methods of limiting eligibility.

The free HRT scheme is administered through the Drugs Payment Scheme (DPS), with those accessing the free HRT required to produce their card when collecting the prescription from a pharmacy.

This was decided, records show, as it didn’t require a separate portal to be created, and crucially, “will not require women to provide any clinical information”.

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Trans women facing confusion over their eligibility under the free HRT scheme

Further records released by the PCRS show that the DPS database does not categorise those accessing the free HRT scheme separately or collect any information on women’s menopause status.

“That would be a data protection nightmare”, the Assistant National Director of the PCRS told colleagues in an email.

Luna Liboni, a senior policy officer at the Irish Council for Civil Liberties (ICCL), told The Journal that clarity should be provided to pharmacists. They added:

ICCL’s perspective would be that trans and non-binary people should be in a position to access general health care and gender affirming services with no differential treatment.

Out of step with the UK

The potential exclusion of trans people from the scheme also appears to be out of step with a similar scheme in the UK.

The NHS HRT Prescription Prepayment Certificate (PPC) – which requires an upfront cost of £20 (€23) – “covers an unlimited number of certain HRT medicines for 12 months, regardless of why they are prescribed”.

Much like the Irish scheme, this scheme is limited to licensed medicines for the treatment of menopause.

But the UK Department of Health & Social Care stated that while the policy intention was to apply to treatments for menopausal symptoms, “anyone who is prescribed qualifying HRT medicines for any reason, not just menopause symptoms,” can benefit from it.

This is because “prescriptions do not contain information about why a treatment has been prescribed.”

As a result, trans people with prescriptions for the same HRT medication covered by the scheme are fully entitled to avail of it.

A spokesperson for the HSE said the scheme expressly “limits eligibility to those whose healthcare provider has prescribed HRT to alleviate the symptoms of menopause”, but didn’t respond to specific questions on how pharmacists are supposed to determine eligibility.

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Conor O’Carroll is an investigative reporter with The Journal Investigates.

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