Petition: Structural expansion of transgender health care is highly necessary!
Principle 17 is deeply concerned about the again dramatically accumulated waiting times in transgender health care. That is why this collective has started the petition "Structural expansion of transgender health care is essential!". Below you can read the extended version of the petition, with a detailed explanation of all the points mentioned. If necessary, read our answers to the most frequently asked questions (see FAQ).
Almost a 1.5 years ago, Principe 17 started a petition because of the threat of a reduction in trans health care. We were very worried because of the rigid way in which health care for transgenders ("trans health care") is provided in the Netherlands, ánd because of the monopolisation of the trans health care.
At the time, the petition was presented to the Standing Committee of Health, Welfare and Sport together with the report ’Trans health care in the Netherlands’. Minister Schippers responded with concern, but had confidence in the changes that were introduced within the trans health care. We were more skeptical.
There have been positive developments in the past year: a care standard for mental health care has been put together, and a somatic care standard is in the completion phase. And the capacity of trans health care has been expanded.
But these changes are insufficient, because the waiting times have risen dramatically, again. The waiting times at the UMC Amsterdam (new name for the AMC and VUmc cooperation) for the intake alone have increased to more than 2 years (for adults) and more than 1.5 years (for children and young people).
This is the umpteenth time that patch-ups have been used to ‘tackle’ the structural problems in trans health care. This must and can be done differently!!
The number of registrations of transgender care recipients increases by 40% each year, but the capacity of the gender teams grows disproportionately by 20% (figures UMC Amsterdam, May 2018). This situation can only get out of hand, and that is exactly what is happening now, again (!).
In addition, the trans health care is still not working according to the model of informed consent, where this is common practice for all other health care recipients. That’s why trans health care recipients are forced to undergo a psychological evaluation (the so-called ‘diagnostic phase’), in which a psychologist determines whether the person is trans enough to be allowed to be trans. This is not only a violation of patient rights, but also of human rights.
Those psychologists too often lack the necessary gender sensitivity (also called ‘cultural competence’). As a result, transgender health care recipients too often are dependent on the personal views of an individual therapist. Because the diagnosis by the psychologist is not a treatment and is not voluntary, we speak of an ‘assessment psychologist’.
That is why Principle 17 starts another petition, because it is about time that these problems are finally solved structurally! Below you can read the extended version of the petition, with a further explanation of all the points mentioned.
Full petition with explanation
The undersigned note:
- The expansion at the KZcG of the UMC Amsterdam (20% annually) is seriously behind the increase in the number of applications (40% annually).
So, these figures mean that the demand for trans health care grows twice as fast as the supply! As long as the supply does not grow proportionately with the demand, the trans health care continues to lag behind more and more, and therefore there is no question of ‘solving’ the problem. That is now again painfully clear, because the KZcG of the UMC Amsterdam has a waiting list of 1,000 people at the end of May 2018! (See the UMC Amsterdam website and the KZcG UMC Amsterdam letter dated 28 May 2018.)
- The status of the intended expansion of the UMCG (‘doubling’) is unclear, and because of the small capacity it will be of little significance anyway. The intention of the Genderteam South Netherlands to expand their offer with medical care has not yet been realised.
Intents and intentions are good and necessary, but are not yet a reality. Transgender health care recipients who need health care at this moment are therefore not helped by this!
- The Genderteam Stepwork trans health care does provide medical care, but can only serve a limited number of people.
What Stepwork trans health care provides, is invaluable to transgender health care recipients. But at national level they can not offer more than the proverbial drop on a glowing plate.
- Psycho Informa Institutions has recently gone bankrupt and adequate supervision of the 130 clients is still very difficult.
In the event of a bankruptcy, it is more often difficult to ensure adequate follow-up, because a lot of legal sorting has to be done. Especially in the case of psychological health care. But in this case the problem is bigger, because clients can not easily be referred to a colleague. In various Facebook groups there are already many experiences to read from desperate transgender health care recipients, who have been told that they can start all over again at the KZcG of the UMC Amsterdam, and have to queue in the back of the waiting row. This is unacceptable!
- In the discussions about trans health care, people often talk about ‘careful handling’, whereby only possible dangers of (medical) interventions are taken into account, but the risks of NONE or (TOO) LATE (medical) interventions usually remain unspoken.
An important argument in all discussions about trans health care always is the importance of careful interventions. Obviously, Principle 17 fully agrees with this.
That is why we think it is all the more astonishing that ‘careful intervention’ only refers to the risk of so-called ‘regret optants’. (People who have entered into a gender-confirming medical treatment and come back to this later.) Experience shows, and research confirms this, that the number of regret optants actually is lower with an informed consent construction than with the gatekeeper construction used in the Netherlands!
Furthermore, the risk of (too) late or none medical interventions of transgender health care recipients is ignored completely. Everyone in the transgender community knows the stories of desperate health care recipients who register with a gender team and are told that they have to wait 1 to 2 years for the intake alone. Health care recipients are desperate! This not only causes additional traumatisation, but literally costs human lives. Unfortunately, statistics will never show these are transgender health care recipients, because these problems occur before the diagnosis of gender dysphoria could be made.
Finally, it is important to look at the practice abroad. In various countries GPs take on a large part of trans health care. At the WPATH symposium in 2017, it became clear that many international colleagues were more than surprised about the Dutch practice with regard to the (assessment) psychologist. The consensus in international trans health care increasingly is that one to a few conversations are sufficient to start with a hormone treatment. This approach has not yet been implemented on a larger scale, but it has already been implemented in various LGBT health care centers.
- When it comes to requests for waiting list mediation health care insurers can only help very limited, because they can not find enough (medical) expertise to refer to.
There simply is too little supply for the demand for trans health care! Approx. 4% of the population is transgender and a large proportion of these people seek medical assistance. It is therefore a potential patient population of 680,000 people!
Even the (outdated) figures from 2006 [Sexual health in the Netherlands 2006, Rutgers Nisso Group], which are based on 0.5% ‘transsexuals’, result in a patient population of 81,670. Also that number of transgender health care recipients we can not handle.
Strangely enough, health care insurers have been refering health care recipients in similar situations to treatment providers abroad for years, and also reimburse them. But not when it comes to transgender health care recipients.
- In short, that distressing problem of the unacceptably long waiting times in the trans health care (rising up to 2 years and more) that took place in 2017 now - a year later - again is relevant and therefore far from being resolved.
Let's be transparent: this problem of exceptionally long waiting lists has never been solved in 2017. This situation is destroying human lives! This must and can be different. And the solution is much simpler one thinks.
and demand the following:
A structural solution for the unacceptably long waiting times in the trans health care sector.
The current situation unequivocally shows that there is an urgent and sustainable great need for the expansion of trans health care. In order to be able to guarantee the health care in the longer term, there is a need for investment in jobs and training.
In 2014, health insurers made the reopening of the KZcG of the UMC Amsterdam possible for new health care recipients (according to the UMC Amsterdam, dated 23 May 2014). Also in the years before, there were already structural problems with the waiting times.
In 2017, the access is again silted up: the waiting times on all parts are far beyond the standard norms of 6 to 8 weeks (see the Treek standards).
Now in 2018, the waiting times in the trans health care again are excessive. For the intake alone, the KZcG at the UMC Amsterdam has a waiting period of more than 2 years (for adults) and more than 1.5 years (for children and adolescents).
In our opinion, two fundamental changes are necessary for the structural solution of this distressing situation:
- Introduction of the principle of self-diagnosis (also known as informed consent)
A practitioner informs the transgender health care recipient about the advantages and disadvantages, and consequences of possible treatments, so that they themselves can make an informed decision in consultation with the doctor. Abolition of the mandatory psychological consultations.
All health somatic care is arranged without a psychologist or psychiatrist as gatekeeper, with the exception of health care to transgender people. They would be ‘special’ because this care would be ‘complex’. All health care recipients are equal, but transgender health care recipients apparently are more equal.
This practice is contrary to human rights as captured in Yogyakarta Beginsel 18, which emphasizes the safeguard from unnecessary treatment.
A practical elaboration of self-diagnosis is the threefold approach:
- Intake with a standard anamnesis for every transgender health care recipient.
During this interview you will be asked about your health care demand, the experienced complaints and any medical and psychiatric history that may be present. During the interview, the practitioner makes an assessment of whether the health care recipient in question has sufficient insight into the consequences of a treatment. After this the health care recipient can start the treatment, unless the practitioner has indications that this would be irresponsible.
- One or a few additional interviews in case of questions.
- If a transgender health care recipient still has questions, then one or a few additional interviews can follow, in order to answer these questions.
- Also if the practitioner has doubts about the insight of the transgender health care recipient, some interviews might follow, so that the practitioner can determine better whether the health care recipient has sufficient understanding of the consequences of the treatment.
- Referral in case of complex issues.
- If a transgender health care recipient has serious doubts about a medical treatment or can not make a choice about which treatment to do or not to do, referral to a regular gender therapist is indicated. The gender therapist can support the health care recipient in the further search.
- If complex psychiatric problem is present, referral to regular mental health care is indicated. It is of vital importance that the practitioner of the gender team and the regular mental health care keep in touch with each other for a healthy aligning. For gender dysphoria could be so strong that it manifests itself as a psychiatric problem. It could also strengthen existing psychiatric problems. A multidisciplinary approach is necessary in these cases, because both disorders can not be treated separately from each other.
- Trans health care = normal health care
We can not repeat it often enough: trans health care is normal health care. The prescription and monitoring of hormone delivery is a simple medical procedure, that every competent gp or other doctor can perform. Also for transgender health care recipients this should be a possibility. In special cases, a practitioner can refer to a specialist, as is common practice for other health care recipients.
Here is an important informing task for the KZcG of the UMC Amsterdam, which as a knowledge center has the task of informing gps and other doctors who contact them, about the special attention points at transgender health care recipients. Nowadays it often happens that they advise practitioners to forward their health care recipients to the KZcG. That is unnecessary.
The Standards Of Care of the WPATH, the internationally recognised guidelines for trans health care, expressly allow this approach. And in international trans health care it has increasingly been practice for a long time.