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!

Praktische oplossingen voor patiëntenstop VUmc

Sinds januari neemt het VUmc geen nieuwe trans*-patiënten meer aan, want daar hebben ze geen geld voor. De regering heeft de Nederlandse Zorgautoriteit (NZa) ingeschakeld voor een analyse van de situatie. Continue reading

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Daags na de aanname van de wijzigingen voor artikel 1:28 BW, de wet op de geslachtsregistratie, kwam het VUmc met de melding: “We hebben miljoenen extra nodig want we kunnen de zorg niet financieren”. En vandaag kwam de pers met een update. Het ligt uiteraard weer heel anders. Hier in het kort de problemen en de doodsimpele oplossing.
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Spanish trans activists start hunger strike

From midnight tonight six trans* activists In Andalusia, Spain will start a permanent hunger strike until either the bill for better trans legislation that is stuck, will be really introduced in Parliament or until they die.
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Entanglements

This post highlights some nasty details hiding in the shades of the current Dutch transgender bill, as imposed upon Dutch trans people by obscure deliberations between the Justice ministry and the gender teams. Where informed consent on the one hand is the only criterion for LGR, the gender teams through a back door still have their say who is credible and who is not, who will be recognised and who will be scrutinised.

In many countries medical interventions are required in order to be able to change your gender registration on birth certificate and/or passports. Think France, Spain, US, Scandinavia, Poland, Chile, Brazil Japan, Philippines … From a human rights perspective requiring medical intervention for legal change constitutes a violation of the right to be exempt form medical maltreatment. And recently the UN Special Rapporteur in Torture classified obligatory medical interventions as such. He explicitly mentioned infant genital mutilation and forcible trans genital surgery to equal torture. And then there are countries that do not require it to be so, but do expect it. Even if they say to rely on the informed consent of the applicant. As it stands, the new Dutch law presupposes the wish to medical intervention. Also there are some countries that do not require any medical intervention. Examples are Argentina of course, the UK, Hungary, Portugal …

With the recently adapted legislation for legal gender recognition the Netherlands now opts for a strange hybrid that has some devils hiding in the details. The formal construction to be is that anyone (with a legal registration in the Netherlands) of sixteen years or older can request a confirmation letter of their long term and/or deeply seated feeling of not belonging to the sex/gender they are registered under. The only requirement is they have to understand what they are engaging upon. But as stated: the devil hides in the details. For the professionals allowed to issue such a letter of understanding, are the doctors and psychologists of the gender teams. Which is surprising. If the applicant is not by definition suffering from a mental disorder, then why have them screened by a psychologist? If going down that way, one might expect obstructive co-morbidities. These are given in the explanation of the law: the legislator fears for applications by people suffering from psychoses or other delusions. Not that there have been many reports of misuse. Most psychoses or delusions of people that apply for trans health care interventions, concern trans people with mental coping problems, trans people with co-morbidities. Not madmen playing trans. Nor villains wanting to abuse the system. And anyway, if this might be the case sometimes, the statistics are really low and the harm done is only to themselves. So the legislator is confused, fearful or influenced by the medical establishment.

Brain

The second and related problem lies in how the gender teams will react. How they will perform their task. Here word on the street is not really positive either. What is to be expected is a conflation of tasks. On the one hand psychologists still have to inform prospective patients on the medical gender reassignment protocols and procedures. On the other hand they get a new task, to screen if the applicant understands what this change of legal gender entails. When the setting is mostly assisting people with coping with their cross gender feelings, filtering out who is eligible for gender reaffirming treatment, then this is not an illogical step. But the legal requirement is different. The psychologists however – from professional pride? – insist on not just checking the measure of informed consent, but already inform and check the client’s readiness for medical treatment. This does injustice also to the current population of people that come to the gender team. Not all those rejected are not transgender (enough). Also applicants for medical assistance that are not ready for medical treatment – in the current setting or not ready at all – are being turned away.

Up to now everyone passes through a psychological diagnosis of gender dysphoria. If you just want acknowledgement of your identity, partial treatment, the whole package or maybe counselling. No discrimination this way. That starts behind the first gate. It very    much looks like the amount of people requesting a consult will grow, potentially a lot, and next there will be quick and a slow path/trajectory. The fast route is for who only wants legal gender recognition. They get in principle one talk and are free to go then. Until they want medical treatment. Group two wants immediately medical assistance. It is not clear now if they will get the offer to first change their gender marker. Or will be side lined with longer waiting times until there is more capacity. Or the other way round: if you only need a certificate, you can wait. This approach is plain wrong. Not from a medical/psychological point of view. Then it is logical to first do a thorough anamnesis. But these people do not come for a medical anamnesis, they want their gender marker changed in order to easier decide how to continue with life. In order to find out how to make sense of their gender difference. Now the processes of gender change have the chance to be more separated, it also could become more clear that there is a need for more counselling. The psychologists at the gender teams only check if you conform enough to the diagnostic criteria for (full) medical treatment. And then they only take your pulse during transition. Which leaves trans people in limbo again for the most important element of health care: support.

So, the applicant for legal gender change who does not want or need (any more) medical assistance inquires at the civil registry for the conditions to change their gender marker and then hears they have to go and see a psychologist or psychiatrist from the gender team. That means the state considers the requester to be mentally incapacitated for an autonomous decision regarding their gender.

Transgender Network Netherlands asked the secretary of Justice for clarification, since he is making a mess of it. I am very curious what he will come up with, but something tells me we still have to wait some years before we will get real informed consent.