Somatic Transgender Healthcare Quality Standard

On 25 November 2019, the Somatic Transgender Healthcare Quality Standard was published. For the first time, this gave the Netherlands a national standard for the physical aspects of transgender healthcare: hormones, surgery, and care for children and young people.

Who developed the standard

The standard was developed over two and a half years by a committee comprising internists, paediatricians, psychiatrists, psychologists, plastic surgeons, gynaecologists and GPs, together with the patient organisation Transvisie. The Ministry of Health, Welfare and Sport funded its development. The standard complements the 2017 quality standard for psychological transgender healthcare; an overview is available in the Dutch guidelines for transgender healthcare.

What it covers

The standard describes when someone is eligible for treatment, how hormone treatment and surgery are carried out, and how fertility can be preserved. A separate module covers children and young people. It follows the structure of the Dutch Protocol, with puberty blockers after the onset of puberty.

Why it was developed

The number of people seeking transgender healthcare had risen sharply, and waiting times were increasing. At the same time, more and more providers outside the university medical centres began offering this care. A national standard was intended to ensure that the quality of care was consistent everywhere.

What a quality standard is

A quality standard describes what good care looks like for a particular condition. Healthcare professionals, patients and health insurers develop it together. Once a standard has been established, it serves as a benchmark: healthcare providers are expected to follow it, insurers use it when purchasing care, and the inspectorate uses it for supervision. Deviating from it is allowed, but only with good reason. A standard is therefore not a law, but carries considerable weight in practice. Until 2019, Dutch centres worked with their own protocols and with the international guidelines of WPATH and the Endocrine Society.

The standard and the evidence

The authors themselves state that this is relatively new healthcare that is still evolving, and that the standard therefore needs to be regularly reviewed for currency. For many recommendations, little comparative research was available; they were based in part on clinicians’ experience and patients’ preferences. The module on young people is based primarily on research from Amsterdam; see the 2014 follow-up study. An evaluation was planned for two years after the standard was adopted.

Waiting lists

That same year, the ministry and health insurers appointed a coordinator to tackle the long waiting times. The coordinator mapped how many people were waiting for an initial consultation and tried to expand capacity, including by involving new providers. Nevertheless, waiting times continued to grow. More information is available on the page about waiting times and the care pathway.

Significance

The standard gave the treatment of young people in the Netherlands a formal, national basis for the first time. Until then, the Dutch Protocol had been the approach used by one centre, documented in scientific articles. It now became the standard that every provider must follow and on which insurers base their reimbursement. This has two sides. It protects young people from providers who offer treatment without thorough diagnostic assessment, as has happened in some other countries. But it also means that changing course is no longer solely a matter for clinicians in Amsterdam: the standard must be revised, in consultation between professional groups, patients and insurers.

The standard is the benchmark followed by Dutch healthcare providers and health insurers. It was published shortly before Finland, Sweden and the United Kingdom revised their policies for young people. In 2024, the House of Representatives called for these international developments towards greater caution to be taken into account in further development; see the House of Representatives calls for an investigation.