Written by: Aafke Uilhoorn (they/them).
Edited by: Miles Llewellyn (they/them).
The Netherlands was the first country in the world to establish a public gender clinic, the Vrije Universiteit Medical Center Amsterdam (VUmc), in 1975. The location of this clinic in an academic hospital created a convenient setting for long term follow-up studies centering transgender care and the transgender population (1). Dutch research in the field of transitional care has been of international relevance, partly because of the existence of this center.
One particularly relevant example of such research is the introduction of puberty suppression in the early 2000s (2)[1]. Puberty suppression became part of the standard clinical management for transgender adolescents (for those seeking medical intervention) in the Netherlands in 2004 and became an accepted treatment in other countries soon after that (3).
In 2011, the World Professional Association for Transgender Health (WPATH) included ‘The Dutch Approach’ in its Standards of Care (4). Over the last ten years, the number of international publications in the area of transgender healthcare has grown sixteen-fold. Dutch research still currently makes up a significant share of the field: studies conducted by the VUmc Amsterdam account for 5-10% of publications on transgender health worldwide — with approximately 60 to 80 publications per year (5).
Overall, the VUmc Amsterdam gender clinic has had a central role in Dutch transgender healthcare, being the only center offering gender-affirmative care to all age categories with the greatest care capacity. Until some years ago, the center provided care for nearly all (around 90-95%) Dutch transgender patients (6), and currently remains the primary point of care for the majority of transgender individuals in the country. Outside of the VUmc, gender-affirmative care is offered in two other academic hospitals in the Netherlands[2], and national mental healthcare providers specialized in gender dysphoria provide psychological care and diagnoses. The providers themselves are affiliated with hospitals that offer endocrinological and surgical care.
More smaller-scale gender clinics have been established in the Netherlands over the past years. However, this extra capacity of care has not been sufficient to decrease the long wait times until consultation for the vastly increasing numbers of transgender individuals applying for intake: in 2020, over 1,400 treatment requests were registered, a figure four times higher than in 2010 (1).
Almost half of the respondents in a study on the experiences and needs of transgender individuals identified long waiting time for care as a direct contributor to their poor mental health state (8).
For transgender individuals above 18 years old, the waiting time from application until consultation is currently two years (versus only six months in 2016), and for children and adolescents it is around one and a half years (5). These long waiting periods are far above the four weeks maximum acceptable wait time set by Dutch law[3]. In fact, current wait time are so long that they directly impact not only transgender individuals’ physical health, but their mental health as well. Transgender people often experience depression, anxiety, or suicidal thoughts (7), conditions which are only worsened over time as stress piles up. This is not an arbitrary statement:
Fortunately, since 2016, several Dutch patient organizations have raised the alarm concerning the serious physical and mental health-related problems that arise due to these long waiting times[4]. This has led to the analytical organization Zorgvuldig Advies being appointed in 2018 to further investigate the bottlenecks within the transgender care system and develop short- and long-term recommendations for structural change (1).
Besides the growing number of transgender individuals applying for gender-affirmative care, the transgender population itself has also become more diverse. More transgender individuals who identify beyond the normative gender binary are seeking gender-affirmative care. Consequently, the requests and needs of transgender individuals for gender-affirmative care have also changed. This can be seen, for example, in a German study by Koehler and colleagues (2018) which found that non-binary transgender individuals apply for less treatment options (circa 1/3) than binary transgender individuals, and, especially, less genital gender-affirmative surgery (9).
Transgender individuals still experience many barriers in accessing care, as binary transitional trajectories remain the norm (10-13).
Since the beginning of the 2000s, Dutch gender-affirmative care protocols are open for the care of non-binary transgender individuals and gender clinics promote themselves as welcoming to all transgender individuals in order to enable them to express their gender identity. However, transgender individuals still experience many barriers in accessing care, as binary transitional trajectories remain the norm (10-13). There is still a feeling of a “one-size-fits-all” approach, while transgender individuals and advocacy groups demand more autonomy for patients within gender-affirmative care and more room for the individual needs and wishes of transgender patients to be voiced, respected, and acted upon (14).
Besides the critique on the fact that gender-affirmative care is (still) not perceived as adequately tailor-made, there have also been critiques on the lack of de-pathologizing gender dysphoria and gender variance in the Dutch medical system. Currently, the Dutch somatic standard of care still uses a diagnosis of gender dysphoria in accordance with the DSM-5 as one of six necessary criteria to initiate a gender-affirmative care trajectory (15). Even though healthcare professionals may not use this term to describe a pathology, the DSM-5 nonetheless classifies gender dysphoria as a mental health condition.
Comparatively, the 11th version of the World Health Organization’s International Classification of Diseases (ICD) removed gender incongruence from the “Mental and behavioral disorders” category, instead opting to add it to the “Conditions related to sexual health” chapter. Because of this, European countries including Denmark, Sweden, and Belgium switched from the DSM-5 classification on gender dysphoria to that of the ICD-11 (5). However, this movement for the de-pathologizing of gender variance and gender dysphoria is not currently supported by the VUmc Amsterdam gender clinic.
This theme was introduced to Dutch politics at the beginning of 2021, when a motion was adopted to pay more attention to the de-pathologizing of gender variance in the upcoming evaluation of the Dutch somatic standard[5] (16). Further, the aforementioned Zorgvuldig Advies suggested leaving the six diagnostic criteria behind in favour of a concise indication based on strong informed consent (5), thereby transforming the care pathway from its current multi-criteria process to one hinging on strong informed consent[6] as the sole criterion required for treatment.
Demands in the manifesto include, among other things, the right to bodily self-determination and autonomy, as well as a commitment from gender clinics to strive towards informed consent-based practices (17).
Within the activist scene, transgender individuals who are currently or were previously seen at the VUmc have recently started to speak up about their experiences with the gender clinic through the initiative “VU Gender (Mis)Treatment” (12). Based on the stories that were shared, a manifesto with action points for better gender-affirmative care was drafted, and could be signed via a petition. The demands in the manifesto include, among other things, the right to bodily self-determination and autonomy, as well as a commitment from gender clinics to strive towards informed consent-based practices (17).
The rise of the VU Gender (Mis)Treatment experiences has led to the rise of more activism: over the last few months multiple protests have taken place all around the Netherlands. The organizers, an activist group called Trans Zorg Nu (which translates as ”Transgender Care Now”), demand an end to the long waiting lists, the abolishment of the gender dysphoria diagnosis, the decentralization of gender-affirmative care, and the hiring of transgender individuals as staff members and volunteers within gender-affirmative care organizations (18). The slogan “Summer of Trans Rage” has been used to describe this ongoing activist movement.
It is positive to see that multiple actors (patient organizations, activist groups, civil society organizations, policy makers, and politicians) have started to express the need of revising the current system. Together these actors created a larger movement for rethinking the current Dutch gender-affirmative care system. Although many of these points for improvement of gender-affirmative care are not new, there currently seems to be more societal support and a collective perception of the urgency of these reforms. This shift is of great importance, because whereas the Netherlands may still be perceived as one of the more progressive countries in the area of gender-affirmative care, it is certainly not perfect. There remains a lot of work to be done, and it is important to keep critically examining the policy structures that inform our care systems, and their direct, tangible impacts on patients.
There remains a lot of work to be done, and it is important to keep critically examining the policy structures that inform our care systems, and their direct, tangible impacts on patients.
The need for the revision of gender-affirmative care practices is clear. Many sources (policy research, advocacy and activism, and politics, among others) point to the same windows of possibility and intervention. However, proper qualitative data on the care-needs of the diverse group of Dutch transgender individuals within gender-affirmative care is lacking.
This creates a gap in knowledge which needs to be addressed in order to innovate clinical practice and adjust healthcare standards for gender-affirmative care, here in the Netherlands, and elsewhere. Still, this gap should not be seen as any reason to relent in the pursuit of personalized care for transgender patients, and instead should be taken for what it is: a call to action. Change — especially systemic change — cannot happen overnight, but the conditions are present right now to push for the appropriate research to be done, for the crucial legislative conversations to be had, and for the first important steps in this reform process to be taken.
Footnote:
[1] Also known as puberty blockers, puberty suppression is a method that aims to ‘buy time’ for gender dysphoric adolescents to find out whether they want to continue further medical transition, without having to deal with the developments of secondary sex characteristics.
[2] These are the UMC in Groningen (for adults), and the Radboud UMC Nijmegen (for children and adolescents).
[3] Called Treeknorm.
[4] Including a petition was established and statements were published, that were picked-up by the government.
[5] This standard was published in 2019 and provides the guidelines for somatic gender-affirmative care in the Netherlands. It is written in line with the international Standard of Care by the WPATH.
[6] This would mean that healthcare professionals focus on making sure that the individual understands the consequences of the specific gender-affirmative treatment, and is declared mentally competent to make a decision.ers, puberty suppression is a method that aims to ‘buy time’ for gender dysphoric adolescents to find out whether they want to continue further medical transition, without having to deal with the developments of secondary sex characteristics.
References:
1. Bakker A. Een Halve Eeuw Transgenderzorg aan de VU: Boom 2021.
2. Cohen-Kettenis PT, Van Goozen SH. Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent. Eur Child Adolesc Psychiatry. 1998;7(4):246-8.
3. Arnoldussen M, Steensma TD, Popma A, Van der Miesen AIR, Twisk JWR, De Vries ALC. Re-evaluation of the Dutch approach: are recently referred transgender youth different compared to earlier referrals? . European Child & Adolescent Psychiatry 2020;29:803-11.
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