The press release of the Amsterdam gender team they sent out on Wednesday December 18, stating they cannot treat all the people who applied in recent times constitutes a brilliant opportunity to stop diagnosing trans people with gender dysphoria and start an informed consent based treatment process.
The day after the glorious victory of the passing of a strongly improved gender recognition law in the Netherlands, the Amsterdam Gender team that treats 85% of Dutch trans people who need a bodily and/or legal gender change, published a press realease saying they may stop accepting new patients within half a year. Where there is an increase of 500% of applications in recent times, they do not get enough extra money to help them.
Of course this a bad development. When health care cannot be delivered people lose their right to health on certain points. On the other hand, with the attention because of the adoption of the new law, this is a form of blackmail. A way to hopefully get government and insurance companies around the table. Completely legitimate.
But as usual there is a back story to this. Dutch government designated the VUmc team as the Expert Centre on transgender Health in the Netherlands. And persistent rumours have it they use this position to create an oligopoly, having only the UMCG in Groningen that caters for the northern provinces, as their collegial competition. A small department at LUMC in Leyden treats trans* children.
VUmc actively discourages surgeons or endocrinologists working elsewhere to treat trans* people. When psychologists elsewhere want to diagnose trans* people so they can have their bodily and legal changes, these are also discouraged.
I do no tell this to badmouth the work they do. This means to explain part of the origin of the problem. And probably from their point of view it is completely legitimate. So they need a good solution. Well, that is easy. Tell the psychologists to stop diagnosing their “patients”. That will save millions of euros.
Alternatively a better way of spending the money they got and the money they still need, lies in helping trans* people cope with the transphobia they experience. And with their internalised transphobia they develop from all the bad reactions. Psychologists are good at helping people get rid of many complaints and otherwise learn them cope with other issues. Transphobia (society’s reaction to people who do not fall within the accepted limits of male/female) causes depression and anxiety and more. Suicidal tendencies. That needs to be helped. But diagnosing trans people with gender dysphoria (DSM-5) or gender identity disorder (ICD-10) or gender incongruence (ICD-11, proposal) does not work. I imagine these psychologists would be far more proud of their work also, would feel more qualified ease these complaints than diagnose people with a non existing disorder. Additionally it will still be cheaper since not everybody needs this help.
A very dangerous sideeffect of the new law that states surgery is nog longer needed (which is great!) is that the treatment centres that do this surgery can start shifting attention form improving surgical practice for gender reassignment to psychological services. This might be good for some but in the end the people who do desire surgery as the preferred solution in their lives might very well end up in the cold. That risk runs higher when there is a lack of validated surgeons (which there is) and when there’s only one centre (with two sidecars), which is also the case.
So the VUMC action is politically driven, using the momentum of a new law to pressure the government and insurance companies to push the budget up, otherwise… Although understandable and legitimate from their perspective it is highly unethical to fight budget battles abusing the vulnerable position of patients. Then again, the VUMC has a recent history of unethical behavior.
This calls for restructuring. Dismantling the nationwide responsibility of the VUMC and turn that group into some sort of knowledge centre while organizing new treatment teams on a regional basis improving distribution of care equally over the country. Why not have Maastricht, Nijmegen and Vlissingen hospitals installed as gender treatment hubs with the assistance of the VUMC? Vlissingen might even (or better) be an annex to the UZ Gent in Belgium which is already is for a lot of other medical treatments in the south. VUMC might still be the treatment centre for the northwest is such a model. But on a very different basis.
Most economists will underline that with the number of patients out there regional services are certainly possible on an economically solid basis.
Legal sex recognition BEFORE treatment, rather than AFTER treatment allows a shift in medical process from a use of F65.0 diagnosis (transmen and transwomen alike) to a use of N62 diagnosis (transmen) and Q50.0 diagnosis (transwomen). And so on, Q55.0, Q55.5, Q52.0 as appropriate.
Which will result is a huge diversion of resources away from mental health towards endocrinology and surgery thus solving, at a stroke, the resource problems of which VUmc complains.
Of course, there will always be some transpeople who are in need of BOTH somatic sex change and who also have mental illness. VUmc can focus its relative small resources on this much smaller group. What VUmc needs is not more resources but a smaller charter that is focussed on areas in which more traditional psychiatry is found to be helpful (depression etc).
Henry, the tendency at WHO is to move away from the F. codes. Most probably is placement in a chapter on sexal health and dsorders. F.6x is out of the question most probably. How to then place the physical adaptations remains a challenge.
An interesting and accurate analysis with sensible proposals. I wish we had a similar situation in the UK, which is unfortunately still based on psychiatric diagnosis of dysphoria.
It’s indeed time that there will be more genderteams, where some of them can implement a 100% informed consent-procedure. This means that psychologists are only needed when a transgender needs them. Let’s see what happens. I suppose the number of regretters will be lower in the 100% informed consent group than in the current-treatment-group: when it’s clear that there is just one person who can decide about having treatment (or not) it’s also cristal clear who is responsible when one regrets.
It’s not bad to have psychologists. It’s bad to have mandatory diagnostic-psychologists who think that any transgender needs them. There are many people who don’t and who are now forced to stick to rules that are not appropriate for their individual transgender-processes.