In Dutch trans healthcare, there seems to be little room for the personal input of trans care recipients. On paper, it is reasonably well organised, but in practice it is often more difficult. Many trans care recipients experience medical treatment mainly as ‘a series of hoops’ that you have to ‘jump through’ in order to receive the health care you so desperately need. In this article, you can read how you can take control of your treatment (a little) more into your own hands.
On this page:
- Body Mass Index (BMI)
- Discrimination
- Hormones & self-medication
- Mental stability
- Smoking, drinking, substance use
- Waiting times & waiting list mediation
Rights: know your patient rights!
The Dutch Patients Federation has good information about your rights as a care recipient. Make sure you know to what you are entitled, and to what not! Then you can claim your rights, if necessary.
Body Mass Index (BMI)
Many gender teams have strict requirements for your BMI before you can start taking hormones and/or undergo surgery. That is actually very strange, because the BMI is a statistical tool for groups and therefore is unsuitable for individual diagnosis. A well-known example is trans health care recipients who do a lot of sports (and therefore have a lot of muscle mass). They often score ’too high’ in terms of BMI and then have to lose weight first, before the gender team wants to operate. That is of course an idiotic situation.
If you get stuck because of the BMI requirement, tell your health care provider that BMI says little about individual health. (The following articles, among others, provide more information: article 1, article 2, article 3, article 4 and article 5.) Suggest that your doctor looks at other characteristics that tell more about your physical capacity, such as your condition and your muscularity.
You can also refer to the ‘Kwaliteitsstandaard Transgenderzorg – Somatisch’ (‘Quality Standard Transgender Care – Somatic’, 2018), which states the following for genital surgery:
“Smoking and a BMI of less than 18 or more than 30 significantly increase the risk of complications and are a contraindication for genital surgery. [This is advice – P17] No gender confirmation surgery will be performed for a BMI of more than 35. [This is a condition – P17]”
With the following explanation in a footnote:
“The transgender experiences setting additional conditions as very restrictive and these are therefore limited to only medically essential aspects or aspects resulting from the international WPATH standard. Therefore, the aspects mentioned in the Advice column are not interpreted as de facto conditions.” (page 17)
None of the other components of transition health care mention BMI, neither as a condition nor as advice!
For some comparable procedures for cisgender care recipients, different BMI requirements or even no BMI requirements apply. It may help to refer to this and ask your health care provider why a different BMI requirement applies to you as a trans care recipient. Your health care provider will not be able to explain this, so they will say something like ‘it’s just protocol’. You do not have to accept that answer.
Discrimination
It is sad to have to conclude, but also in trans health care some practitioners discriminate. (Apart from the fact that trans health care systematically discriminates against trans care recipients, as we explain in our Alternative Vision on Trans Health Care.) Are you a person of colour, non-binary or neurodivergent? Do you have a disability or chronic illness? Or do you not meet the Dutch standard? Then expect that you will have more difficulty accessing trans health care and that your process will be delayed.
It may help to bring someone you trust with you to consultations. You don’t need permission for this, because you are always allowed to bring someone! It is highly recommended if you feel like you are not being taken (entirely) seriously, or if you have to answer strange or irrelevant questions. After all, extra eyes make practitioners less discriminating. Even if that person doesn’t say anything at all: their presence is enough. That extra person can also ensure that conversations will discuss what they should.
[We are currently compiling more information. We expect to be able to put this online at the end of February 2025.]
Hormones & self-medication
For some trans people, the waiting times are too long. They cannot wait 5 to 6 years before they are ‘allowed’ to start their medical treatment. In that case, it is good to know that other ways are available. About 300 Dutch general practitioners have followed a training course by Trans In Eigen Hand on prescribing hormones to trans care recipients. In the Netherlands are several Do-It-Yourself groups, or DIY groups for short, active as well.
» Click here for more detailed information about hormones and self-medication.
Mental stability
Gender teams often require you to be mentally stable before you can start trans health care. This may be a problem for trans care recipients with a mental vulnerability. Their trajectory can therefore take much longer.
A tip is to have the therapists from your mental health care and from your trans health care consult with each other. Together they can ensure that treatments or support are well coordinated, so that you can still start the treatment.
If you have the idea that your gender dysphoria leads to psychological problems, you can also explain this to your health care provider. It is known that gender dysphoria might lead to psychological instability. In extreme cases, it can even lead to psychoses – or increase the predisposition for psychoses.
It may help to bring someone you trust with you to consultations. You don’t need permission for this, because you are always allowed to bring someone! It is highly recommended if you feel like you are not being taken (entirely) seriously, or if you have to answer strange or irrelevant questions. After all, extra eyes make practitioners less discriminating. Even if that person doesn’t say anything at all: their presence is enough. That extra person can also ensure that conversations will discuss what they should.
Smoking, drinking, substance use
Many gender teams require stopping or strongly reducing smoking, drinking or other substance use as a condition for surgery and sometimes even for hormone treatment. This strict requirement does not take into account the personal situation of the individual care recipient. Many trans people experience a lot of stress (if only because of the years of waiting) and smoking, drinking or other substance use is often a coping strategy, a way of ‘self-medication’ to be able to cope with the situation.
You could ask your health care provider for a nuanced approach that suits your personal situation. Sometimes cutting down is an option, but stopping entirely not (yet). Sometimes hormones and/or operations are needed first to give you the space to be able to cut down or stop.
If you are unable to quit on your own, you can ask for a referral to a smoking cessation support worker who has trans competence (who therefore knows which specific problems trans people have) or to a trans therapist who also has knowledge about smoking cessation. If you have a good relationship with your GP, they may be able to help you. Or maybe you can contact the practice nurse.
If a lot is going on in your life and your situation is complex, Jellinek may be able to help. They have expertise and know that to successfully quit, you have to look at the entire context of someone’s life.
You can also refer to the ‘Quality Standard Transgender Care – Somatic’ (2018), which states on page 34:
“It is better if the transgender does not smoke, because smoking around the time of the operation increases the risk of wound infections, it slows down wound healing and increases the risk of (part of) the tissue dying. […] Smoking is a contraindication for genital surgery. Other medical contraindications are assessed by the person responsible who also sets the indication.”
In short, not smoking is only a condition for genital surgery, but in principle not for other procedures!
Waiting times & waiting list mediation
The ‘Quality Standard Transgender Care – Somatic’ (2018) describes the following “generally acceptable standards for waiting times”:
Waiting time for indication
An appointment for indication is made within 6 weeks; also if a second opinion is required.Waiting time for hormone therapy
An appointment is made for the start of hormone therapy within 6 weeks after indication (Treeknormen GGZ, December 2016).Waiting time for surgery
When it has been determined that the transgender meets the conditions for surgery (of which waiting time/reflection period is a part), they will be seen pre-operatively within 6 weeks. From the pre-operative consultation, the waiting time for surgery is a maximum of 8 weeks.
The actual waiting times for trans health care are extremely much longer! That is why it is advisable to ask your health insurer for waiting list mediation. If you do that, your health insurer will contact all gender teams with which they have a contract and they will look for where the waiting time is the shortest. (Also read the information from the Consumers’ Association about waiting list mediation.) If you are lucky, your health insurer will find a provider for you where the waiting time is shorter.
Regardless of the outcome, you are sending an important signal to your health insurer. You are indicating there is a problem. If your health insurer cannot help you, they have purchased too little health care. In that case, they would do well to improve that as of next year!
Geef een reactie