At the beginning of 2020, the rainbow flag will be displayed at the main entrance of Radboudumc. The Nijmegen hospital opens the third academic center for transgender care, a gender outpatient clinic. The waiting lists for this care have now risen to almost two years and the Ministry of Health, Welfare and Sport (VWS) had asked hospitals if they could help. At the festive opening there will be cakes in the colors of the trans flag.
But now, two years later, the waiting lists have all but shrunk. Someone who registers at the Radboud gender outpatient clinic has to wait two to three years for an intake interview with a psychologist. “So instead of solving a problem, that problem only got bigger,” says Chris Verhaak, clinical psychologist at Radboudumc, throwing her hands in the air.
She is in the office of Enny Das, professor of communication and influence at Radboud University. Verhaak and Das are investigating the cause of the increasing demand for transgender care on behalf of the ministry. This care includes: psychological help, and possibly hormone treatments and operations. The study should be completed by the end of this year. But they already have something to say to them: they think that too often when dealing with the waiting lists, only healthcare is considered.
“We are regularly asked by the ministry how much capacity we have and whether we can do more,” says Verhaak. This gives her and her colleagues a feeling of ‘uneasiness’. “It’s not enough just to open a can of psychologists, because we don’t understand enough where the increase is coming from.”
Double capacity
The supply of transgender care has grown enormously in recent years. The capacity for psychological treatments more than doubled between 2019 and 2022, from 2,220 to 4,822 places. The number of places for hormone treatments even increased fivefold (from 770 to 3,855).
But the demand is growing even faster. This could be because the awareness and acceptance of transgender people has increased and care has improved. But whether that is really the case is unknown. “We know very little about how gender identity develops,” says Verhaak. “That is special, because we have been doing treatments with that group for a long time.”
Last autumn, the Ministry of Health, Welfare and Sport decided to have an investigation into the cause of the increased demand for transgender care. This is carried out by the Platform Diversity in Gender and Gender of Radboudumc and Radboud University. The platform was set up at the same time as the Nijmegen gender clinic to conduct research into gender and gender from various disciplines. Verhaak and Das are part of the team of about ten researchers, some of whom are transgender and non-binary themselves.
A literature study has already shown that many factors are at play, says Das: “Such as cultural views, legal aspects, discrimination. That is actually at odds with the biomedical model, in which an individual presents a care question that the doctor has to solve.” A major US population survey last week found that the number of people who identify as transgender varies a lot by stateprobably due to differences in social acceptance.
Also read: ‘When I came out as transgender, I lost everyone’
There are concerns that young people are infecting each other with their gender struggle via social media.
Verhaak: “Yes, the contagion hypothesis. That is also taken. We can already say that it has many sides: social media can also offer a lot of positive recognition and self-confidence.”
But also arouse transgender feelings?
Verhaak: “Never only because of social media. That always happens in context.”
Das: “In this discussion, a causal conclusion is quickly drawn. You’ve been on Instagram three times and gender has suddenly become fluid. But that media influences people one-on-one has long been disproved. We know, of course, that you can find recognition among like-minded people if you are searching for your identity.”
This touches on the main concern of some that the many applications for transgender care are the result of hype. Can you answer that at the end of the year?
Verhaak: “It’s too complex a question for that. What I see in the literature and in my consulting room is that there is now much more openness about identity questions.
“But the question is whether the answers lie in medical care. With an important group yes, but with another group you can wonder whether this will help people in the long term. Whether we should not look much broader, especially at the acceptance of people.
“That does not mean that the gender incongruity is incorrect or has been ‘contaminated’ by friends, no, it is very authentic. I myself sometimes struggle with the question: if we have an ideal society in which we accept all kinds of gender expression, how much gender care do we need?”
You mean some of the people on the gender outpatient waiting list don’t belong there?
Das: “The care demand is very clear. But it is not only the gender treatment that solves this issue. Children should feel safe in schools, discrimination should be addressed. If the GP says that he finds questions about gender too complicated, if society pushes the gender issue away, then it is not surprising that the funnel at the specialist centers is clogged.”
Isn’t there a lot of attention in schools and in the media for people who don’t fit into the boxes?
Verhaak: „Not everywhere yet, or only with Purple Friday. But we don’t yet know what the effect of that attention is on healthcare. We still know so little.”
Can you say that because we know so little, young people may be treated too quickly?
Verhaak: “The whole diagnosis is done very carefully. But we do have discussions about that in our team: should we offer treatments quickly or wait, what they are doing now, for example in England, because they are afraid that children will regret it?”
At the end of 2020 judged a British judge that young people under the age of sixteen should no longer be given puberty inhibitors, because they would not be able to foresee the consequences. A study by the Amsterdam UMC concluded last autumn that young people that can indeed†
In England and Sweden they say: little is known, so let’s not treat young people for the time being. Isn’t that what you say?
Verhaak: “You have to monitor the care carefully and children have to be cared for well outside the specialist centers. It cannot be the case that children with complex problems have to wait years. That is unacceptable.”
Verhaak notices that there is still a lot of ‘shyness to act’ outside the specialist centers. “Colleagues in mental health care do not know how to deal with the gender question. But at a time when so many people struggle with their gender, this must be part of the expertise of all health care psychologists.
“Many of the young people who register with our gender outpatient clinic, at least half, have significantly different problems. Problems at home, autism, trauma. The gender questions are sent to us in isolation. But you really have to see it in the context of other questions. If a child cannot find a connection, this can be partly due to autism, partly due to a difficult home situation and also partly due to gender. If you can treat that in an integrated way, you don’t have to leave it to specialized centers.”
How is it possible that half of the young people at the gender clinic also have other problems?
Verhaak: “We don’t know. There are hypotheses about that. Not feeling at home in your body can cause behavioral problems. Or: children with autism find it difficult to deal with a body that is entering puberty. That is not to say that you deny the gender issue, but that you have to see it in context.”
The number of girls born who register at the gender outpatient clinic has in recent years been much higher than the number of boys born. Are you going to investigate that too?
Verhaak: „We take that with us, but we have few ideas about why that is. At our outpatient clinic, three quarters are also born girls. They are also more often searching. Perhaps that gender role feels a bit more compelling for girls at the beginning of puberty than for boys.”
As a healthcare provider, do you ever wonder if you are doing the right thing?
Verhaak: “I sometimes wonder that, yes.”
And what is the answer to that?
Verhaak: “It is very clear with a group of children. But with another group, it’s somewhere in between. You’re doing quite a bit when you start inhibiting puberty. Then you wonder: is this the best choice for this child at the moment? That is the unease I feel as a practitioner: we just don’t know, but we have to act.”
You can’t trade, can you?
Verhaak: “Even if you don’t act, you do something: a trans girl will have a beard in the throat, or a trans boy will have breasts. That has a negative impact.”
What do you need as a healthcare provider?
Verhaak: “More research. Towards the short- and long-term effects of treatments. To the different ways of gender expression and how young people in different age categories deal with it.
Das: “I would like to link that to social factors: family life, social media use. That you can follow such a group for a long time.”
Can it be investigated? There are so many factors.
Verhaak: “That’s the tricky part with identity development. This is a process of decades, and by that time healthcare has completely changed again. In the end you will not find the truth.”
Also read: Gender Confirmed: How Appearance and Identity Can Match
So at the end of the year there is a study with the message: it is a complex story.
Das: “As a society, we are very untolerant of complexity and uncertainty. We want a simple solution to the gender issue, but many people fall short. We often put on those medical glasses. At Covid? More beds in the ICU! Waiting list? More doctors!
“Complexity may be a less appealing story, but that’s what I believe in. Selling cheap, one-dimensional truths, I hope we’re pretty much past that stage in the transgender debate.”
A version of this article also appeared in the newspaper of June 24, 2022
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