Assessment psychologist remains a bottleneck

On Friday 10 January, the daily newspaper NRC reported that Amsterdam UMC is closing its doors to new patients: feel free to register, but do not expect a call in the coming years. Amsterdam UMC and Transvisie qualified this message, but Principle 17 points out the cause and provides alternatives.

Trans health care has been under pressure for decades. Previously, psychiatrisation and medicalisation limited the number of trans and gender diverse people who sought medical support for their gender incongruence. But since the sterilisation requirement has been abolished in 2014, waiting times for an intake have increased even further. The waiting times for gender health care are alarming: at Amsterdam UMC, the largest gender team, the waiting time for an intake is “at least” 4 years and 5 months as of January 1, 2025. At Radboud UMC in Nijmegen, the waiting time is “approximately 3 years” as of January 13, 2025. After the intake, you are put on a waiting list for consultations with a psychologist: another 1 year and 7 months to wait in Amsterdam. Nijmegen does not provide any information about this. That makes six years before you can start.

Indication statement

According to Principle 17, the core of the problem lies in how trans health care is still organised in the Netherlands. Advocacy group Transgender Europe (TGEU) and professional organisation World Professional Association for Transgender Health (WPATH) are clear: every person has the right to good gender-affirming health care. The World Health Organization WHO explicitly states that trans health care recipients are no crazier than cisgender health care recipients. Nevertheless, Dutch health care continues to stubbornly adhere to an extensive psychiatric indication. This makes trans health care recipients the only patient group in the Netherlands who need a psychiatric diagnosis in order to receive physical health care.

There are objections to this course of events in principle and in practice. An important objection in principle is the fact that being transgender is considered a psychiatric disorder by the Dutch health care protocol. A practical objection is that this practice itself is the cause of the enormous backlog in trans health care.

Stigmatising

The assumption that there is something mentally wrong with being trans (psychopathologisation) is of course nonsense. The situation is comparable to homosexuality: for a long time this was also – wrongly – thought to be a psychiatric illness. It is not without reason that the WHO removed the diagnosis ‘gender incongruence’ from the psychiatric section of the ICD. Dutch health care would do well to follow this trend: for physical health care you use the ICD, and not the psychiatric DSM!

This would solve the entire problem of trans health care in one go: trans people would no longer receive a stigmatising psychiatric diagnosis, all unnecessary sssessment psychologists could do what they were trained for: providing actual mental health care to trans and gender diverse people. Stopping this imposed indication would prevent a lot of unnecessary health care costs, and the waiting times for gender-affirming health care would be reduced by 3 to 4 years in one go! That does not mean that those who use the process to gain more clarity about themselves can no longer go anywhere; that is simply health care.

New: triage

Good news: in 2023, a motion was passed to accelerate access to trans health care using triage. This means that a trans health care recipient makes clear what their health care needs are in an initial consultation with a doctor or nurse. The doctor or nurse can refer the vast majority to an endocrinologist immediately after the consultation. Trans health care recipients who have questions or are not (yet) sure what they want, can visit a gender psychologist themselves. Incidentally, self-help groups also play an important role in this, even now.

This ’triage’ is a first step towards the model for trans health care that Principle 17 has been promoting for years: simple where possible, specialised where necessary. In short, do an intake with a nurse or doctor to discuss what the trans health care recipient wants. General practitioners can do hormone care, but specialists are needed for surgery.

Advice: collaborate more

In 2023, a working group of consultancy firm KPMG, commissioned by the Ministry of Health, Welfare and Sport, concluded that trans health care should be more coordinated. Much trans health care can easily be transferred to zero and primary health care. Unfortunately, in practice, all attention is focused on setting up more clinics, which continue to operate in the current manner. This actually contributes to the current long waiting times and makes trans health care unnecessarily expensive.

Like the House of Representatives and KPMG, Principle 17 sees more benefit in other solutions. In solutions that do justice to the needs and rights of trans health care recipients. Assess trans health care recipients via triage and thereby significantly reduce the lead time of trans health care. Focus on broad further training of primary health care, so that GPs who are willing also feel able to provide health care. And abolish the assessment psychologist as gatekeeper of trans health care. This is an archaic obstacle to better, faster and cheaper trans health care.