As you have seen in the practical examples, we believe in transgender people and in their abilities. These abilities are comparable with those of all other people in the Netherlands. There are clever transgender people and stupid ones and many, many in between. There are people who are capable of doing everything by themselves and people who always need help from others to make progress and many, many variants in between. There are people who overestimate themselves and people who can do much more than they think they can and many variants between them.
But if people have to be subjected to compulsory mental care, there must be something very wrong with them. In the Netherlands compulsory mental care is a last resort, which is used very sparingly. Except... for transgender people.
What we would like, is that if a transgender person requests hormones, this request has to be judged by his general practitioner or (only in more complicated cases) by a specialized endocrinologist. And if a transgender person requests an operation we think a surgeon should make the decision whether to perform the surgery. Neither for hormone treatments nor for operations should one or more referral letters from a psychologist be needed.
The criteria for such treatment should be no different from those for other kinds of medication or operations. Over the past decades, the psychologists who decide on treatments for transgender people have grown into a role we do not agree with. Unfortunately the doctors who provide care still fear people would think they are careless if not 100% of the treatments for transgender people are backed by a screening by one or more psychologists.
This way of working has already existed for decades in the US, and the Standards of Care also support this way of thinking. This can be found in the Dutch language version on page 36 and in the English language version on page 41 (Informed Consent).
We hope that Dutch general practitioners will also stick their necks out soon. There are general practitioners like Helen Webberley MD (https://www.GenderGP.co.uk) who already provide hormones. She does her consultations by video link, by mail and also via (recorded) sessions in her practice. Blood samples can be sent by mail if people live too far away. Because consultations can be done via email less time is needed than in face to face meetings. And because all interaction with the patients is archived she has full support from the authorities in the UK.
Webberley proves that good care doesn’t have to be centralized, that it doesn’t require a minimum of 4-6 sessions, that good transgender care doesn’t need to have a very high threshold, and that it isn’t necessary to go see a gender team.
Unfortunately we have not yet reached this situation in the Netherlands. The Netherlands were pioneers in transgender care in the past, but now this is working against us: because the VU took the lead in gender treatments, many general practitioners know about the existence of the gender team in Amsterdam. And because Amsterdam is near the center of the Netherlands (or Groningen or Ghent are near), general practitioners prefer giving referrals to prescribing hormones themselves. They are backed in this decision by the Dutch gender teams, who claim help for transgender people is “specialized help”, for which "very careful" screening with a minimum of 4-6 consultations needs to be done before hormones or operations can be offered. This suggests that general practitioners should not provide this kind of help.
The situation in other countries is very different. At the most recent WPATH, general practitioners from Canada told us they had no problem with prescribing hormones: “Transgender people are not a risky group to work with. We take more risks in prescribing anti-depressants than in prescribing hormones: with anti-depressants it is difficult to say what dosage of which medicine is best for an individual patient. We have so far treated dozens of transgender people and we have yet to see the first case of someone who had regrets.”
We hope general practitioners in the Netherlands stop listening to the gender teams and contact their colleagues in foreign countries instead. General practitioners in foreign countries usually do 1 or 2 consultations before supplying hormones. Good transgender care is not specialized, not difficult, and not risky. Or, as a general practitioner said, “I have a can-do mentality. At first I thought I could provide care for adults only, until an 18-year-old came into my practice. I could handle that. Then a 16-year-old came in. And I could handle that as well. And so it went on. Nowadays I get 3-year-olds. And I can handle that too.” If you have an open mind and use your brains, nobody can scare you and you can handle everything.
Transgender people in the Netherlands mainly see the disadvantages of multi-disciplinary teams, because in these teams the need for treatment of the transgender person gets snowed under by the rules, protocols, and "prudence" of the therapists. At the moment, decisions in multi-disciplinary teams are made by consensus, i.e. the most conservative care provider can always block everything. That is why we would like to see that only one care provider takes responsibility for the treatment (and that should be the care provider who actually does the treatment).
We would also like to see that the multi-disciplinary teams abolished the requirement that diagnosis, hormone therapy, and gender operation all must be done in the same hospital. Or, if lateral entry is allowed, that we still always get mandatory "care" from the psychologist of the same hospital. Please treat us like adults, give us the freedom to make our own choices in our own process.
We already know the multi-disciplinary teams will not be able to handle the demand for care in the future: research shows that on average 0,6% of the population need hormones and/or operations. In the Netherlands that is about 100,000 people. If all diagnosis, all hormone treatments and all operations have to be provided by the two current gender teams, unacceptable waiting times will be the result. And if we know this is coming, it is better to start building a broad network of general practitioners now.
Gender identity, gender expression, gender role and body parts
We do not believe in the assumptions that are currently in the Standards of Care, the DSM and the ICD: the ideal world is not one with only people whose gender identity, gender expression, gender role, and body parts are all exactly aligned with each other. And that does not apply to queer gender identities only. We know people who are born as a man, have a binary male gender identity, have a male gender expression, have a male gender role, and yet need a vagina. These people can only be treated in Thailand at the moment, because hospitals in Western Europe will not, or only after prolonged investigation, help these people, because of the rules in the Standards of Care and the DSM.
In our ideal world all couplings between gender identity, gender expression, gender role, and needed changes in body parts are abolished. This means that:
- In the DSM only the A3-criterion (absence of necessary body parts) and/or a slightly altered variant of this criterion (body parts that should be removed) would be enough to help people with hormones or operations related to their gender incongruence. (The problem with the A2-criterion is the "due to"-coupling with gender identity or gender expression).
- From the Standards of Care all obligations for seeing psychologists and the obligation of a Real Life Experience should be removed. Real Life Experience can be an advice given by an (only) curing psychologist, not by a gatekeeper. The transgender person should be free to decide if, and when, a social transition can begin.
The requirement of feeling a dysphoria before a transgender fits in a diagnosis is also very strange. That is why we want to remove the B-criterion from the DSM. Unfortunately, there are psychologists who wait until they can see a transgender person suffers from a dysphoria before they give them a referral for hormones or operations. Try to imagine what would happen if the same thing would be done in case of diabetes: "yes, we are indeed convinced that you have diabetes (A-criterion), but you aren’t emotional/depressive enough about your diabetes (B-criterion), therefore we will wait with prescribing insulin until we know for sure whether or not you need a treatment: please come back next month, then we will look at your situation again". A doctor or a psychologist who says this about diabetes will get negative reactions from colleagues because the patient’s body may be damaged if diabetes is not treated in time. Why don’t psychologists get negative reactions when they aggravate the mental impact of our transgender process by demanding a visible dysphoria before starting a transgender treatment with hormones or operations?
Current versions of these protocols:
* WPATH Standards of Care: Dutch / English