Trans In Eigen Hand - Vision on Transgender Care

GPs play a pivotal role in humane care for transgender people

Dr. Sam Röttjers on behalf of Trans In Eigen Hand

April 2022

Gender-affirming care is a necessity for a large group of transgender people, yet it is nearly impossible to find. Rising demand, an already overburdened system, and the unnecessary pathologization of transgender people mean that waiting times for an intake now exceed 1 year at most providers [Zorgvuldig Advies, 2021]. Furthermore, not all providers are accepting new patients. In practice, this means many individuals must wait at least 2 years before they can actually start gender-affirming treatment [Langman and Lugt, 2021]. Given that the risk of suicide for transgender people appears to be highest while they are on the waiting list, these delays cause unnecessary and severe suffering [Bauer et al., 2013]. GPs can take on an important role in reducing this distress during such a vulnerable period.

Psychological care, specifically the screening for gender dysphoria, is the primary driver of these extremely long waiting times. Currently, more than 6,000 people are waiting for this care; from 2018 to 2021, this was an increase of 211%, a trend that does not yet seem to have stabilized [Langman and Lugt, 2021]. Because the psychological track is the first step to accessing gender-affirming care, this patient group suffers from very limited access to appropriate care for long periods. The source of this unsustainable trajectory lies in the recommendations of the World Professional Association for Transgender Health (WPATH). According to WPATH, a leading authority in the field of gender-affirming care, it is necessary to establish gender dysphoria, potentially diagnose it, and assess the patient's resilience [Coleman et al., 2012]. Additionally, it must be determined whether there are other mental health issues, such as depression or anxiety disorders [Coleman et al., 2012]. In the Netherlands, these issues are not treated at gender clinics, but within primary and secondary GGZ (mental healthcare). GPs can support their patients by providing timely referrals to GGZ providers if there are signs that this aligns with the patient's needs. This means the screening recommended by WPATH is primarily used to confirm gender dysphoria.

Not all providers of gender-affirming care recognize the necessity of establishing gender dysphoria through a diagnosis [Cavanaugh et al., 2016]. According to the informed consent model of gender-affirming care, transgender people are themselves capable of determining which treatment options would benefit their health. When establishing a care plan within this model, the doctor's role is limited to explaining and discussing treatment options and risks. Provided they are mentally competent, transgender people can assess for themselves whether they can undergo a medical transition in their current life situation. This care model respects the autonomy of transgender people and uses their self-knowledge to reach an appropriate treatment. In this context, psychological care is a tool during transition rather than a requirement to undergo transition, thereby avoiding the stigmatization and pathologization of gender diversity. While this model could theoretically lead to individuals undergoing treatment that isn't actually necessary, this rarely proves to be the case; in a study of multiple clinics using the informed consent model, only 17 out of 1,994 people regretted their choices [Deutsch, 2012]. This stands in stark contrast to the distress caused by withholding care [Lipshie-Williams, 2020].

Although GPs cannot offer all forms of gender-affirming care, they can make a significant difference for transgender people within the informed consent model by providing hormone therapy. For many, this therapy is a first step in their transition, where desired outcomes can take years to manifest. Therefore, being able to start therapy sooner can make a world of difference for transgender people. In their publication on hormone therapy for transgender people, the International Medical Advisory Panel (IMAP) states that hormone therapy can be performed by primary care professionals such as GPs. Despite often not having specific training, they are qualified to prescribe hormone therapy to transgender people [IPFF, 2015]. By doing so, they prevent transgender people from seeking other, more dangerous options to obtain gender-affirming care. Gardner & Safer [2013] also confirm that GPs are capable of providing this care. These and other sources can be consulted for
guidelines regarding the implementation of this care [IPFF, 2015; Deutsch, 2016;
Gardner and Safer, 2013]. Given the increasing demand for care from transgender people, it is inevitable that non-specialists will also increasingly encounter this request for care [T’Sjoen and Defreyne, 2021].

The state of gender-affirming care in the Netherlands is unacceptable. The current care model is based on a lack of trust in the self-knowledge and autonomy of transgender people. Unfortunately, healthcare providers are often seen as barriers withholding life-saving care. Consequently, the healthcare system fosters distrust from this patient group toward providers and contributes to extreme waiting times, resulting in very distressing situations. GPs can take a leading role in the shift toward a system that puts human dignity and trust at its center.

References

G. Bauer, J. Pyne, M. Francino, and R. Hammond. Suicidality among trans
people in Ontario: implications for social work and social justice. Service
social, 59(1):35–62, 2013.

T. Cavanaugh, R. Hopwood, and C. Lambert. Informed consent in the medical
care of transgender and gender-nonconforming patients. AMA journal of
ethics, 18(11):1147–1155, 2016.

E. Coleman, W. Bockting, M. Botzer, P. Cohen-Kettenis, G. DeCuypere,
J. Feldman, L. Fraser, J. Green, G. Knudson, W. J. Meyer, et al. Standards
of care for the health of transsexual, transgender, and gender-nonconforming
people, version 7. International journal of transgenderism, 13(4):165–232,
2012.

M. B. Deutsch. Use of the informed consent model in the provision of cross-sex
hormone therapy: a survey of the practices of selected clinics. International
Journal of Transgenderism, 13(3):140–146, 2012.

M. B. Deutsch. Guidelines for the primary and gender-affirming care of transgender
and gender nonbinary people. 2016. [Online; accessed 25-March-2022].

I. H. Gardner and J. D. Safer. Progress on the road to better medical care
for transgender patients. Current Opinion in Endocrinology, Diabetes and
Obesity, 20(6):553–558, 2013.

IPFF. IMAP statement on hormone therapy for transgender people. 2015. [Online;
accessed 25-March-2022].

M. Langman and M. Lugt. Rapport wachttijden genderzorg. 2021.
URL . [Online; accessed 25-March-
2022].

M. Lipshie-Williams. The peculiar case of the standards of care: Ethical ramifications
of deviating from informed consent in transgender-specific healthcare.
Ethics, Medicine and Public Health, 13:100470, 2020.

G. T’Sjoen and J. Defreyne. Transgender health care, what you missed during
your training, 2021.

Zorgvuldig Advies. Voortgangsbrief kwartiermaker transgenderzorg.
2021.
[Online; accessed 25-March-2022].