TRANS HEALTH CARE IN THE NETHERLANDS LEAVES A LOT TO BE DESIRED

Life for trans people is often complicated. The huge amount of gender stress stemming from cis normativity complicates the full development of a trans individual’s sense of self. Changing one’s identity documents to male or female – the only genders recognised in the Netherlands – is relatively straight forward. But in order to get trans specific health care, trans people have to wait for over a year and, once accessed, that health care is often not fit for purpose. This practice costs lives.

Defining trans

It is useful to have a common understanding of what we are talking about when we use the term ‘trans’. This term refers to anyone who feels that their body doesn’t fit comfortably with their gender assigned at birth and wants to make changes, sometimes social, sometimes medical, to alter that discomfort. When taking into consideration the entire trans and gender diverse population, including children and other people who haven’t come forward yet, to seniors who go back into the closet, we estimate that there are about one million people in the Netherlands (1 in 17). Only a small percentage opt for trans-specific health care, but almost all make some change to address the discomfort with their gender. By changing their voice, their hair, wearing makeup (or not), wearing jewellery … many use gender expression to feel more comfortable in themselves. Only a small minority require any form of medical support. Due to discomfort with the norms governing the body, hormones, psychological support and/or surgeries can be used to adapt their body to their needs and thus greatly decrease their gender distress. This distress may never go away fully, as the outside world keeps projecting opinions onto us about our identities and our bodies. This consistently reinforces gender distress upon us, even after accessing trans-specific health care.

Trans inclusivity

There exist good practices of how to design trans inclusive legislation, e.g. Malta in 2014, and the first good practice law, in Argentina in 2012. The same is true for trans health care. This does not mean that the social situation is also trans-inclusive, which is, at best, a couple percent better than in other places. In Argentina, travesticidios (murder of travestis, a regional trans identity) regularly take place, and trans-inclusive health care advances in fits and starts. For Argentina, it took several years after the was law passed to develop the current health care protocol, and Malta is currently in this process. Trans health care in Denmark is better. To start with, being trans is not an illness anymore, and their non-pathologising approach to trans-specific health care is better developed. In general, trans wellbeing is reliant on the following: the more you belong to the demographic ‘mainstream’, i.e. the better your class position, the less issues you face.

A report by TransUnited Amsterdam earlier this year showed that trans-specific health care for trans people of colour is not culturally appropriate. Health care providers often have too little insight into the, often, complicated situation of non-white bi-cultural trans people. This report is focused on Amsterdam, but it is unlikely that other places in the Netherlands are any better.

Lack of respect for trans people in general health care is even more of an issue. Several trans people with in-patient experience in psychiatry state they were not the only trans person in the clinic and that the consistent experience is one of lack of respect, with health care providers assuming that their transness is part of the overall clinical picture, with privacy always being grossly absent. Knowing this, one can only imagine how it is for a non-binary (not male or female identifying) trans person. Furthermore, when that trans person is also a person of colour, all cultural competence of staff disappears completely. In general health care, the “transgender broken arm” syndrome is still prevalent. This term was coined to refers to doctors that refuse to fix your broken arm (for example) because you are trans, so you have to go to the gender clinic (in Amsterdam or Groningen) to have it fixed. This practice is ridiculous, of course, and highlights lack of knowledge and cultural competency. There are still stories of trans people being treated incorrectly by their GPs or by nursing staff. This stems from pure transphobia.

Inadequate health care leads to health care avoidance, something which I do, myself. I have no interest in being patronised by uneducated medical professionals. The last time I went to see an endocrinologist at the VUmc Amsterdam gender team, he hadn’t read my file, misgendered me and assumed I was new, thus ignoring my 20+ years history of attending that clinic (which was clearly demonstrated in my file). Taking into account all the stories and research about trans-specific healthcare that I have accumulated over the years, I went to my GP with this knowledge to ask them to manage my hormone requirements. If I don’t get proper care from those who are supposed to take care of it, I will arrange it myself.

Social rejection

Trans people also experience problems due to poverty. This affects bi-cultural trans people disproportionately. Problems at home, in school, being homeless: all these situations impact upon your health. Trans people, generally, also have a higher likelihood of substance use, caused by stress placed upon them every single day. Multiple research reports indicate a relationship between stress in minority groups and high substance use. This heightened vulnerability often forces them into psychiatric care or sex work. However, sex work is not the most sustainable job in these times of increasingly restrictive regulations.

Having to wait for health care (currently 60 weeks wait in the Netherlands for trans-specific health care), poverty and lack of acceptance are factors that influence the prevalence of suicide ideation as a last resort. Among trans people, suicide attempts are at least five times higher than among the general population, and suicide ideation is seven times higher. These figures come from the suicide hotline 113Online. In general, statistics are higher again for young people across all social groups. Adult trans women who are not read as cis (a term that refers to people who are not trans), i.e. who do not ‘pass’ enough as cis, have increasingly more problems with gaining mainstream acceptance. This probably coincides with the existence of trans people becoming more well known by mainstream society, leading to greater visibility with an unequal progression in social insight and acceptance of trans communities.

Transphobic health care providers

When we shift our gaze to the population of trans youth, we see that they are realising that they are different earlier than ever and want to start their social transition earlier in life. It is at this that time they face social and legal issues. Social, because a dominant group in society does not care about the rights of the child to be themselves, to be happy (as required by the UN Convention on the Rights of the Child) and because there are no supports in place. Legally one can only change their gender marker at age sixteen, despite the fact that one can be sure of their gender identity at age six. Of course, medical gender transition support is only available from puberty onwards, before which it is not required. From a transphobic viewpoint, trans kids often are seen as gay or autistic, except for those that fit easily into the binary trajectory. A “real” trans person pursues medical transition with hormone treatment and genital surgery (among trans youth, this percentage is worryingly higher, at 95%, far more than trans adults). That a large segment could be gender diverse, rather than strictly binary, is not something these health care providers consider. The Amsterdam team is personally and professionally closely connected to anti-trans pioneer and reparative therapist, former chief of CAMH Toronto, Kenneth J. Zucker (see here at Transavocate [link] or shorter here at Queerty [link]). Such good pals that one starts to wonder how transphobic our great ‘helpers’ really are.

Given the assumptions upon which the Amsterdam team works, the focus on ‘carefulness’ and the cis heteronormativity, I see enough reason to call their working practices structurally transphobic, even when they do good work. For a solution, I would counsel the team to descend from their throne and start taking interest in the humbler social scientific approach. Looking at the attitude of doctors and the Amsterdam gender team especially, we still see an attitude of othering, of seeing trans people as different and unequal. An explicit example of this is dissected in a scientific article by J. R. Latham. These experts continue to argue for a cautious approach, insisting that a psychiatric diagnosis is necessary. This, however is not for our benefit, but for their protection. Informed consent works, that is why it has been introduced into other areas of health care. This is a human rights issue. Up to now, a trans person has never been employed in the gender team.

Needs/Wishes

The trans community has several needs regarding access to health care and the quality thereof. Of course, the needs may differ depending on the specific community, but on the whole we demand, at a minimum: quick, transparent, accessible gender recognition; an end to violence and discrimination; trans-friendly shelters; decent jobs; and adequate trans-specific health care where the health care user is taken seriously. We also demand an end to societal transphobia and the imposition of cisgender norms upon our bodies and our identities.

All of this has a strong connection to health and health care, because those with a decent job get more social respect and are consequently less isolated and lonely. Accessible gender recognition leads to less problems with job applications and with institutions. Working to end societal transphobia by weakening cisgender norms means creating space for everyone who experiences their gender in a different way that of a cisgender, heteronormative ‘man’ or ‘woman,’ or within a different embodiment than expected. All this results in less need for health care as a consequence.

Looking more directly at the health care process itself, diversification of health care provision is required, including provision of more locations where one can access trans-specific health care. Waiting times have reverted to previous lengths of over a year. Many trans people who are currently transitioning know of someone who ended their life because they could not manage any longer. Still, many people hope that the feelings of hopelessness and gender dysphoria will pass when they get married, or work extra hard in a typically ‘masculine’ or ‘feminine’ job. These individuals only report back to the clinic when they really cannot cope anymore. There should be better research on all of this, but there is not. Psychiatrists say that they want to keep the diagnosis in order to encourage research. However, homosexuality was removed from the psychiatric health classification system in the 1990s and research is still booming. Declassification is good for research, as Sam Winter, Ph.D., has demonstrated (research results forthcoming).

Is nothing good, then, in Dutch) trans-specific health care? The default programme (half a year of psychiatric evaluation before access to hormones and surgery) works relatively well, with the exception of the long waiting times. Also, doctors are becoming more aware of gender diversity. The psychiatrists, however – those useless gatekeepers – create a severe obstruction to health care access. Those who live ‘outside the box’ often have to place their life on hold for six months longer than necessary, through the requirement of psychiatric evaluation, before being granted access to medical transition (hormones and/or surgeries).

Quick solutions

The above shows there are quite a lot of issues facing trans people before they can live a decent life. There are, however, a couple of quick solutions that I want to offer, so that we can enjoy our rights and have a better life.

  1. Abolish psychiatric evaluation and engage in an informed consent process where the health care user has an active role and the final say in their own healthcare. This is demonstrated at Callen Lorde Community Health Centre in New York City. Eisfeld and Radix write extensively about this in the German Zeitschrift für Sexualforschung (Vol.27; 31-43).
  2. Establish more facilities for trans-specific health care in the country, with culturally competent providers, so that good experiences are not limited only to white trans people.
  3. Better management of existing facilities. A year waiting time is outrageous. Look forward, go off the beaten path, and work collaboratively with trans communities.
  4. Create a curriculum for general health care based on social scientific research around transgender communities with a focus on practical issues. Make use of experiences in relation to homosexuality or bi-culturality and health care needs. Teach providers to think differently.
  5. Encourage students and providers to choose trans-specific health care as a career path. Do not leave it to spontaneous initiative. Transness is too stigmatised for that.
  6. Improve the position of trans people on all fronts and create a health care budget for this.
This piece discusses the Dutch context where trans-specific health care is only available in an institutionalised context from two clinics. This version is updated from the original Dutch language piece that appeared on Dec 14, 2017 on Tijdschrift Lover website.

Thanks to Naomhán O’Connor for proofreading!

The evil of psychiatrisation of trans people: just two bad examples?

In this article I present two cases of trans* women in the Netherlands with their story that indicates thoroughly the transphobia and preoccupation with a mental health model of Dutch trans* health care professionals in the Amsterdam gender clinic.

Amsterdam Free University Medical Centre (VUmc) Knowledge and Care Centre for Gender Dysphoria (KZcG) is the biggest in the country with over 200 clients a year. That they have to bear the brunt of complaints is only logical in a restrictive transition supporting health care model. Some 80% of clients are seen at the VUmc KZcG, 10 to 15 at the northern UMCG and the remainder at private practices of mental health care providers; only a tiny percentage finds their way into medical assistance outside of VUmc and UMCG. This has to do with health care providers realising not having the cultural to medical competence to help health care users, plus the clinics discouraging providers to get educated in the field and demanding the client to go to their facilities in Amsterdam or Groningen.

The societal, medical and psychiatric tendency is to view transgender persons as having an identity issue or even identity disorder. This way trans* people entered psychiatric classifications (1978 and 1980) and have since never left. The general audience thinks trans* people to be freaks of nature that through medical treatment can be helped, involving genital surgery. With genitals being a topic of interest for people in general and for the cis supremacy, the SRS trope lives on even in progressive press. General practitioners or other (para)medical personnel generally do not have any cultural competence in dealing with trans* people. No official training apart from on the job when working explicitly with trans* people, is given.

International development through human rights interventions has led to the development that in all probability the next edition of the authoritative International Classification of Diseases of the World Health Organisation (WHO) will no longer list gender identity as a mental health issue, an identity disorder. All changes have been pushed for by the trans movement and taken up by among others the EU and the Council of Europe. Analogous to the struggle of homosexuals for their rights and for depathologisation, the trans movements have taken this up with considerate success.

The clinics however are only dimly aware of this and up to now arguing with human rights and patients rights does not have the success it should have, neither with the ministry of Health, health authorities and insurance companies (that play a strong role in the Dutch system) nor within the medical sector.

First do no harm

I contend that lack of consideration for a patient who indicates severe emotional/physical problems strongly related to her gender transition/gender identity, or not securely checking on a patient who indicates health issues with the medication, amount to cisgenderism. To a relative blindness for what lies outside of the expected realities, outside of ramifications of what might reasonably happen. In fact these two people and most probably several or even many others are withheld access to appropriate health care. Protocols and expectations count over individual lives while the decisions and lack thereof could have led to suicide or even death by medical neglect.

A doctor who puts protocol before patient and values strict enforcement of the treatment procedure over the wellbeing of their health care users, might need to think twice if they are in the right place. It is seriously debatable if such a situation is compliant with primum non nocere, first do no harm. Patient B had to go to her GP for the first instance of allergy and ended up at the Emergency Care for acute issues with the second anti-androgen. Due to hitherto unknown medical condition she showed lupus like reactions to medication and strong immunodeficiency reactions.

As other healthcare users report in interviews and talk among each other, and as the Principle 17 report shows, there is large discomfort with the care providers who are experienced as culturally incompetent.

Health care users regularly debate the medical stance that co-existing issues must be fixed before medical transition can start. In their experience it is exactly the “gender dysphoria” that causes or stimulates those other problems. Starting their medical transition causes a significant relief and makes several of the problems go into remission. Providers are advised strongly to listen more closely to the needs of their clients.

The cases1

Person A called upon the Amsterdam gender team some nine years ago for needing medical assistance to align her body with her felt female gender identity. During the process she reported an ever increasing dysphoria with her body and feeling excruciating pains whenever she passed a cisgender woman in the streets. She reports this was related with on the one hand the endocrinologist not willing to accept her for diabetes that did not all interfere with her gender affirming treatment (not even to him) and on the other the psychologist who did not advance. She developed strong depression related problems around the rejection, the waiting times, the insecurity with a second opinion that might have had grave consequences.

Person B is as a young trans woman and had initially no problems. Shortly after going on anti-androgens she reported severe allergic reactions to them2. Long time she had all kinds of complaints, and never was taken seriously by the doctors or the psychologists. Then, as she decided to search a non-clinic plastic surgeon, she got a letter by the hospital threatening to stop her transition health care there and leaving her thus in limbo. Just for exercising her freedom of choice for a medical provider now that was a realistic option (contrary to changing transition providing centre). This issue is reported more frequently though it does not surface explicitly in the most recent Dutch research. Only after filing a formal complaint things got better. Now her transition is finished but due to non-gender related medical problems she is a very frequent visitor of clinic for treatment and for some finishing surgeries. Most doctors now treat her as an ordinary medical patient with not so ordinary medical issues. Apart from one surgeon at the gender department of VUmc, who behaves as arrogantly to her as probably to all other gender patients.

In my eyes this not only points to reproachable behaviour and questionable estimates, but also of an inherent transphobia. It is very questionable if a cis person would not have been believed. This is even more questionable for an academic hospital.

Gender dysphoria and being transgender is not considered an issue that may require medical assistance to relieve a societal problem, but in the core it still considered a mental health issue: there is something essentially weird/wrong with trans people. Gender dysphoria is still considered a psychiatric issue, as it is listed in the DSM-5.

Both examples serve to indicate a inherent transphobic and psychiatric attitude with the involved clinic. This patient is being read more and more as female and her self confidence has grown so she hardly perceives any transphobia anymore in the hospital (being read as the correct gender works miracles) except for this gender team surgeon who approaches her with arrogance and medical authority.

Both persons got no mental health care at the clinic, while person A actually just needed a less presumptuous MD and no psychologist; or a psychologist that really helped. Person B has her own therapist and in the clinic even had an extra psychologist who insisted in making clear that to her person B had not finished her transition and thus was not ready for surgery.

Action

In a reaction to the Principle 17 report on the state of trans health care in the Netherlands from December 2016 that measured 43% complaints in the interviewed population, the director of the gender team suggested it was all word of mouth and an over representation of complaints. In the meantime the report and a petition will be handed to the Parliamentary Committee on Public Health, together with over a thousand supporting signatures gathered in four days time. It is election time now and that offers interesting opportunities to see what we can get.

1The stories of person A and B are based on their own orally or written shared experience. My summary has been approved by them as accurate.

Zorg zonder poortwachters

De discussie over een betere transzorg lijdt onder onzekerheid over hoe een niet-pathologiserende zorg er dan uitziet. Dit stuk legt uit waar we vandaan komen en werpt een blik in de toekomst door een paar alternatieve scenario’s te schetsen.

De gendertransitiezorg (kortweg transzorg) in Nederland heeft een sterk poortwachterselement in zich. Wie de ‘keuringspsycholoog’ niet kan overtuigen is praktisch uitgesloten van deze zorg. En dan moet je hormoonvervangende therapie goedkeuring hebben van het hele team (consensus) en voor chirurgie is weer een deskundigenbrief nodig of teamovereenstemming. Dit model wordt nationaal en internationaal zwaar gekritiseerd en en er wordt flink aan de poten ervan gezaagd. Dat leidt tot onrust in verschillende betrokken geledingen. Bij psychiaters, psychologen en medici die bij de transzorg betrokken zijn. En ook bij transactivisten die het (nog weer) anders willen, en bij de transgender zorgvragers die zich afvragen of en hoe hun zorg toekomstig gefinancierd gaat worden. Dat vraagt om uitleg, en vooral om een visioen hoe het eruit kan komen te zien. Continue reading

Depathologisation through legislation

In the Netherlands legal gender recognition is half depathologised. State, medical services and public opinion still have a long way to go. Continue reading

Depathologisering via de wet

In Nederland is de zorg half gedepathologiseerd. Staat, medische hulp en publieke opinie moeten nog een lang eind afleggen voor we zijn waar we willen.

Continue reading