The Banality of Dutch (Western) Trans Health Care
October 6th, 2016
I wake at 3 am each day this week. This morning it is with the intuition that I’ll never wake up with the same bodily chemistry set again. The thought has shaken me over the past 36 hours but done little to change my resolve. With what can only be described as the essential oil extract of nervousness pumping like jet fuel through my brain, I head for my appointment at the “English” gender clinic in Gangnam.
I arrive early and take a deep breath. After locating the building and the floor the clinic is on I settle on some Starbucks as I have 40 minutes to wait. Later, and one scone fatter, I check with the guards in the lobby of the KLB building and they confirm my clever detective work — this is the correct place. I alight from the elevator to a row of well-signed clinics. I walk down the hall and back not discovering the one I want. I circle back and at the front of the right-angled hallway is a clinic without a sign. There is no receptionist and the peeling wallpaper looks like a former occupant had vacated the premise some time ago. The wall-sized Klimt print of The Kiss clashes with the blue granite wallpaper, especially the flecks of holographic space foil running through the fake quartz veins. This can’t be right. I confirm in the next clinic that this was indeed the place I wanted: “gender-uh clinic-uh,” pointing. It was.
I sit down in a chair back in the clinic. Fear is pulsing through me at this point. Some straight-faced transmen come in, sit down, and stare unblinkingly towards the perpendicular wall. A male nurse, tall and in blue, comes out, frowns at me and calls one of the boys up in Korean. One, two, three, they all go.
I am inducted in a small office collapsing under the weight of a thousand files hanging like avalanches on two shelves. The only decoration in the office is a diagram of a phalloplasty. A cheap cigar lays wrapped on the desk and the masked nurse asks me to wait for the doctor: he is “busy.”
Dr. Kim greets me, a large man with a cough, and leads me congenially into his office. He half slides the door shut. He asks for my “paper” and shuffles through the seven-page document (my psych report I attained three weeks earlier). He smiles and asks for me to point out the conclusion. I do so and he reads a single sentence — the part that says I am gender dysphoric — and smiles. “That’s all we need.” He asks how much the report had cost and chuckling at my response says, “100 dollars for each page!”
He looks at my diagnosis of OCD and tells me we all have “obsessions;” he air quotes — or at least it seems like he should. From the smell of his heavy breathing, smoking was one of his. He says that it was normal for someone who suppresses their personality to have OCD. He then levels with me that he doesn’t really care for this aspect of his job. He’d prefer to “cut people up.” I assume he means people’s genitals and then he makes a comment about thousands of dollars that I don’t understand. I assume it is a cost of surgery joke. As this consultation costs about 30 dollars (30k won), I can see his point: this part of his job doesn’t make him any money.
I ask him about the trans community in Seoul and he tangentially quips that he is doing a scientific service, he cites some statistics and says that “this” is not a cultural sickness. He ignores my question, or maybe we just don’t understand each other—his English is marginal and my Korean is almost non-existent. Then he mentions that he sees mostly transmen as most transwomen go to Thailand as they also want top surgery and he can’t provide that. I smile as best I can as at this point, as I fell like the acid I didn’t drop on the way in is kicking in. The room elongates and seems to breathe. I fell lightheaded. I can feel the holographic veins of space foil coursing through the wall.
He gives me five months supply of hormones after describing how I should inject a needle into myself. He asks if I understand and I nod emphatically, I can do that. He actually asked what kind of HRT I wanted, as if I knew. Antiandrogens, why not? Have whatever you need, just don’t come back too often.
I go into the next room to pay. The nurse gives me my first injection and then I am sent to the pharmacy. I am still too shocked to ask about blood tests or where to get laser hair removal. The nurse calls out, “next time, cash-ee on-lee.” In the pharmacy, I can see that my face is flush in a mirror. The women behind the counter talk for a while and tell me to come back tomorrow as they don’t have enough medicine. I wander back out onto the street to absorb what has just happened.
In Seoul, my diagnosis to my first estrogen injection took six weeks. It took twice that long to figure out where to go. Finding the only psychiatrist that could diagnose me in English was a stroke of luck. But I am sure it wouldn’t have been difficult if I spoke Korean.
Today (April 2018)
It wasn’t supposed to be like this. When I think back to that initial doctor’s office visit, before I found an endo at 순천향대학교서울병원, the recklessness of my treatment seemed almost criminal in its negligence. The ease of access to care was great, but the actual care seemed absent. Korean healthcare is, in a word, efficient. I consumed a lot of health services during my five years in Seoul. From life-saving treatments which required week-long hospital stays, to weekly sessions to remove a wart(s). And though everything was always slick and shiny, there was always a sense of carelessness to treatment: bloody tissue sitting in the open in the dermatology clinic, a pool of blood left in the triage ward, or antibiotics issued without a test. I longed for the more controlled and regulated Western model of medicine. Where I knew my transition would be overseen by professionals with experience and guidelines. Girl, was that a misplaced sentiment. This misguided optimism for Western medicine was shared by my therapist, who also commented a few months ago that my move to the Netherlands was supposed to improve my access to healthcare. It didn’t.
I was waitlisted for an induction appointment at the VUmc’s gender clinic in Amsterdam virtually within a few weeks of my arrival here in August 2017. As of this morning, my friend informed me — she was there for a checkup — that the waitlist is 75 weeks for an initial meeting followed by another 25 to see the psychiatric assessment team to be eligible for treatment. I guess I get a second round of gatekeeping for moving countries? Another trans femme friend, after waiting for a year, finally gave up and went to an outreach centre for sex workers to see an independent doctor — she is not a sex worker, but after waiting a year, she just couldn’t wait any longer. If demand is this high, then another clinic is clearly called for. And yet, the VUmc seems to be very centralized and powerful. They are very guarded with their information, unlike other clinics in the UK, Canada, and US which at least publish their standards of care guides. I’ve heard anecdotally that the VUmc has shut down other providers historically and refused to share information. Though because of demand, they will consult with my GP in a situation where someone like me is already 18+ months on HRT.
Luckily, because of Dr. Kim and my trippy experience in Korea, I am in okay shape. I’m transitioning. But what if I had come here first for HRT? I almost chose to do that. I wouldn’t have survived the 100 months wait. It’s already hard to survive even though I am at least getting basic care. But that care is basic. I need to walk my GP through this process, he’s willing, but utterly without experience. I’ve not actually been seen by a professional who can communicate in my language and is educated in trans healthcare. That’s scary. And I have to live with things, like my testicles, that give me potent gender dysphoria. I don’t want to wait another year plus to deal with them. Our community’s suicide rates are astronomical, and a recent study done in Ontario* reveals that those rates are highest while we wait for health care and other medical interventions.
Trans lives apparently don’t matter. These types of institutions are complicit in our deaths through gatekeeping: year-long real-life trials without hormones and 100 week long wait times. The federal and provincial governments, like Ontario’s, which illegally ignore their own human rights laws and deny birth certificate and name changes, are just as culpable. It’s the same for the Dutch government which is equally unwilling to help or make access to resources easy. We are being pushed to the margins and in these gutters, we die ignominiously or forgotten. And this blood is on their hands — the invisible hands of clinicians and ministers. I mentioned to my mother, only half joking that I wanted to go into the VUmc and cut my testicles off in bloody protest. She told me not to say things like that, it hurt her to think about me in pain. Apparently, no one wants to acknowledge how much this hurts. I feel disenfranchisement and totally lacking agency. I want to punch someone. And this is the problem, there is no one to punch, bureaucracy is my enemy.
I am reminded of Arendt’s depiction of Eichmann (a Nazi on trial in Israel and a major organizer of the Holocaust), not as an evil Nazi, but a stupid career man pushing paper to further the goals of a larger mechanism. Which is not to say that some Nazis weren’t evil—yes there was plenty of gratuitous acts of evil—but rather, sometimes the outcome of a complex system is harmful and the parts of that system aren’t always to blame. I’m sure no one at the VUmc deserves to be punched in the face, but the facelessness of my oppressor somehow makes the situation seem bleaker, like there is no action I can take, it’s a systemic issue: i.e. the system is “evil.”
I return to my Korea experience. I think it is a point of contrast for Western trans healthcare. Somehow, despite the lack of LGBTQ+ rights and medicalization of trans people, Korea makes their system more efficient. It is not perfect, there is a lack of social support and a high demand for normative conformity—and probably a lower demand for services, but hey, they don’t make people wait for any type of treatment. In contrast, the supposedly more homo/trans friendly West is bogged down in endless red tape. And red tape costs lives (40%+ of American trans people have attempted suicide, National Centre for Transgender Equality survey data). Clearly, looking at an alternative model, at least medically, to the centralized gender clinics we have in the West seems advised.
Personally, I can’t wait, I can’t handle the precarity. And, I shouldn’t have to wait. Cis people are not subjected to tedious pathologizing medical and legal bureaucracy in order to just be themselves. It’s time for radical change to the trans medical model. And these institutions, which determine who lives and dies, need to be held accountable for the lives they snuff out. We also need faster action on gender self-determination and easier access to changing our documents. I am not the only trans immigrant and our numbers will only increase. The stakes are too high for trans people. Trans suicide is a euphemism for institutional murder. The seemingly endless array of obstacles laid out before me are instruments of my destruction. There is no one source of my peril, but many perilous systems of bureaucracy that would make Kafka’s head spin.
At the end of the day I am not saying that the doctors at the VUmc are Nazis. But like Eichmann, they are “just doing their job” working in a system that oppresses trans people. I am sure they are nice people, even think they are helping trans people. But that doesn’t mean that their actions and conduct through their profession don’t enforce and replicate harmful systems of power. This January I told my doctor that if I didn’t fix my hormone levels after switching to the patch — they tanked — I’d kill myself. The VUmc took a week to reply. I was serious. Luckily I had a backup supply of injections. How do you rationalize making a suicidal person wait for treatment? “Oh, we are to busy; too much demand.” Can we distill people’s lives down to this form of utilitarianism, especially when we could easily expand the system to accommodate more trans people? Arendt wouldn’t have bought this reasoning, she saw the potential for people to choose moral action even under a totalitarian regime—which this is not. Maybe this is why my friend was able to see a VUmc trained doctor working outside of the system. But still, the most common interpretation of Arendt’s work suggests that ordinary people can participate in “evil” given the right incentives and structures. No one at the trial thought Eichmann was a psychopathic killer. (Ordinary Men: Reserve Police Battalion 101 and the Final Solution in Poland by Christopher Browning is an interesting exploration of this idea.) Trans health care isn’t the Final Solution, we can make better decisions, it’s just a matter of resources and access. But those resources don’t seem to be materialising and the stakes are high for our community. We experience astronomically high rates of suicide and marginalization. I am sick of this passing the buck by governments, and gatekeeping by medical practitioners.
So, until I am treated like my life matters, I am going to fucking compare this system to Nazis, okay. I don’t accept that this is just the way to treat me. I don’t belong on a 100-week waitlist. I don’t need another psych evaluation or real-life trial time. I need recognition and support. I am just a simple 33-year-old aspiring trans scholar who wants to be able to work and have her testicles removed.
*Bauer, Greta, et al. (2013), ‘Suicidality among trans people in Ontario: Implications for social work and social justice’, Service Social, 59:1, pp. 35–62.