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.