Reaction from Pia Dijkstra to the Cass Report – Dutch minster

31 016 Hospital care
No. 372 Letter from the Minister for Medical Care
To the Chairman of the House of Representatives of the States General

The Hague, June 4, 2024

In the procedural meeting of April 11 and April 24 last discussed the Final Report of the Cass Independent Review1
(hereinafter Cass Review) in the United Kingdom. The committee of The Ministry of Health, Welfare and Sport demands a speedy government response to this report asked and its significance for gender care of minors in the Netherlands. Member Van Meijeren (FVD) has also during the arrangement of activities of April 16, 2024, at a response requested. The members also have Diederik van Dijk (SGP)2 and Hertzberger (NSC)3 made the request to the minister for Medical Care to receive a quick response about the implementation of the adopted motions. I respond with this letter your requests.

I will briefly summarize the findings of the Cass Review below explain, then I share the University’s response Medical Centers (UMCs) and conclude with my response. In addition, In this letter I provide information about the evaluation of the Quality Standard Transgender Care Somatic and the research assignment for the Health Council in the field of transgender care with which I implement the motions of the
members Diederik van Dijk (SGP)2 and Herzberger (NSC)3.

Cass Review

The Cass Review is an investigation launched by the National Health Service (NHS) with the aim of providing care to transgender people
young people to improve to ensure that young people with gender dysphoria or young people who have doubts about themselves gender identity receive safe, quality and effective care. The Cass Review took place in response to a interim report that was initiated after criticism of the transgender care in England and the large increase in registrations of young people within transgender care in the United Kingdom (UK). The Review discusses, among other things, access to care, quality of it and the experiences of transgender people in the health care examined.

Based on reviews by the University of York of the existing scientific research, the Cass Review states that there is insufficient scientific substantiation for the sage showing teenagers being treated at the Tavistock clinic. In the review concludes, among other things, that there is significant There are differences between the “Dutch approach” and the working method of the Tavistock clinic. The Tavistock clinic provides multidisciplinary care, attention to psychological comorbidity and long-term follow-up monitoring of children (psychological guidance) abandoned.The researchers argue, among other things, for a reorganization of this concern in the UK.

Some recommendations from the Cass Review include:

1. Improving access to transgender care by reducing wait times for evaluations and
   treatments.
2. Training healthcare professionals to make them aware the needs of transgender people and discrimination to prevent.
3. Creation of specialized transgender health services to improve the quality of care improve.
4. Hormonal treatments only after extensive diagnostics by specialized care providers within a center of expertise
5. Recognition of gender dysphoria as a serious medical one condition that requires appropriate treatment and support.
6. Improving access to psychological and social support for transgender people, both before and after their transition.

These recommendations are intended to improve quality and accessibility, as well as the experiences of transgender people in healthcare in the UK. The recommendations of the report have led to policy changes within the gender care in the UK.

Responses to the Cass Review

The report has led to renewed attention for the protocols and guidelines for treatment of children with gender dysphoria. Reactions to the review varied. In several European countries, such as the UK, Sweden and Finland changes have recently been made to transgender care young people, with more focus on psychological ones support in advance or during a medical intervention. These countries made these changes because of, in their eyes, insufficient evidence for safety and effectiveness of medical treatments at a young age. In these countries people, just as is already done in the Netherlands, provide care to connect research, to get more evidence and to ask questions about for example, side effects of puberty blockers to answer. Another recommendation from the Cass Review is true people in the UK are working on, is that young people during the medical process also extensively supervised psychologically, in accordance with (inter)national guidelines and as is already happening in the Netherlands.

What does the Cass Review mean for gender care minors in the Netherlands?
In this paragraph, at the request of your House, I provide insight into the responses from the UMCs and then I will give my response to the Cass Review and what this means for gender care in the Netherlands.

I have been in contact with the UMCs and the individual individuals below receive responses. In addition, the UMCs also have one joint response drawn up in response to the Cass Review. I have also added this, just like the response from Transgender Network Netherlands at the Cass Review.

Response from UMCs

From the Radboud university medical center (appendix 1) indicates that can find in the recommendations of the Cass Review because they give recommendations that are endorsed in the Netherlands and all are common for a longer period of time. The Cass Review does not advised to ban puberty blockers as in the media is mentioned, but only after careful evaluation, counseling, informed consent and under strict monitoring in one research setting. This is also the case in the Netherlands deployed: this care is only provided in an academic setting with the necessary follow-up is given and data about the treatment is provided collected.

Amsterdam UMC (appendix 2) responds to the Cass Review indicates that they also make recommendations about the design of the care, such as reducing waiting lists, spreading out knowledge and encouraging more research. The centers have focused on sharing in recent years expertise within and outside the Netherlands, training healthcare professionals to provide better care to people with gender dysphoria and shaping regional and national networks of care. Nevertheless, there are still significant obstacles, such as limited access to transgender care and the long waiting lists. The Amsterdam UMC also endorses the recommendations from the report to overcome these obstacles. These recommendations are in line with those implemented in the Netherlands research into the demand and need for gender care.

The joint response from the UMCs has already been met by them shared your room (appendix 3). The UMCs emphasize these children with diagnosed gender dysphoria are entitled to good care. The children can become serious during puberty, develop psychological problems. Medical treatment is possible, this actually helps to reduce complaints. This applies as every step in the process must be carefully tested and supervised. The expertise centers are aware of the increasing heterogeneity group of young people who have a need for care. This is also reason to guidance with the utmost care and expertise offer. The practitioners at Radboudumc, Amsterdam UMC and The UMCG has been conducting scientific research together for years ender care for children and young people scientifically to be set up in a substantiated manner and, if necessary, adapted to new ones insights. With developments in healthcare and social changes, new questions also arise. Because These children and young people deserve good care, they should also finance care and research for people – adults and children – with gender dysphoria are well organized. For ethical questions that are inherent to medical gender care to young people, the centers work closely with ethicists. This ethical one questions are mapped out through research and carefully balanced in the care of young people with gender dysphoria.

Policy response

It is primarily up to science and the healthcare field itself to work on knowledge and expertise development. I have every confidence that healthcare professionals will work with the utmost care when offering transgender care. Find in the field (inter)national cooperation takes place in the field of knowledge and expertise development. It is then up to the field parties jointly, in quality standards and guidelines (both part of the professional standard). the question of what good transgender care is and what healthcare providers should do to offer this as for all forms of care in the Netherlands, on the basis of the Healthcare Quality, Complaints and Disputes Act (Wkkgz) Article 2 applies. This is the state of care for transgender people described in the Somatic Transgender Care Quality Standard.6 This arises from scientific research, medical practical experience, patient input and international guidelines.

Transgender care is relatively new care that is rapidly developing. This means that the current quality standard from the beginning
has had a provisional character and that distribution of care, increase in experience among a broader group of healthcare providers or new research can lead to different insights or opportunities for improving the quality of care. It Knowledge Institute of the Federation of Medical Specialists (KIMS). commissioned by ZonMw and with a subsidy from the Ministry of VWS the process surrounding the evaluation of the existing Transgender Care Quality Standard Performed somatically. In the exploratory (literature) search carried out for this purpose is also looked at guidelines/protocols from other countries. This guidelines and scientific literature have been included timeliness of the current quality standard. Also the situation in the UK is included. I value it to point out that the situation in the UK is not one-to-one comparison with the situation in the Netherlands.

I presented this evaluation to your House on April 5 last sent. As my offer letter shows, the evaluation shows indicates that the current Transgender Care Quality Standard Somatic is no longer completely up to date in certain areas. Since the publication of the current Quality Standard there are new developments and there are relevant new scientific literature and international guidelines published. This new literature and developments form the basis for the revision of the directive. Important this includes the Standards of Care (SOC) guideline for the Health of Transgender and Gender Diverse People version 8. In the valuation is recommended to include the modules on treatment of children and adolescents, hormone treatment, surgery, fertility preservation and pregnancy in the revision to the Dutch situation to be adapted, if possible.

Parallel to the evaluation of the Transgender Care Quality Standard is Somatic by the Dutch Internists Association with support from the Knowledge Institute has submitted an application for review. Of this revision of the guideline started on December 1, 2023. This allows immediate follow-up results of this evaluation. Also the conclusions of the Cass Review will, where relevant to the Dutch context, be included herein are taken along. In addition, it has been agreed that the adjusted guideline will be submitted to the Register in due course Healthcare Institute of the Netherlands. Pending this, the professional groups work in accordance with the latest guidelines. About the I have already promised you the progress of the revision to your House to be further informed in due course.

Health Council advice

Your House recently adopted two motions regarding: transgender care, which require more research and/or independence advice on transgender care, namely: the motion Diederik van Dijk (SGP) who asks the government for advice ask the Health Council to what extent the current approach of gender-affirming treatments for minors complies with the applicable health law framework (Parliamentary document 36410 XVI, no. 89) and the Hertzberger motion (NSC) that the government requests that physical and mental examination be carried out health outcomes after treatment with the ‘Dutch protocol’ methodology and compare it with cohorts of patients in others European countries, with a different standard of care (Parliamentary document 31 016, no. 370).

In my appreciation of these motions I have already indicated that the government does not interfere substantively with the manner in which this is done healthcare providers describe good care when it concerns medical care substantive considerations. At the same time, I also see the dilemmas associated with transgender care for minors and close I would greatly appreciate advice from the Health Council on this. The primary importance is that the care provided does justice to the stakeholders, such as transgender and non-binary people themselves and theirs healthcare providers.

I have therefore asked the Health Council to assist me advise on the elements mentioned in the motions, such as use of the ‘Dutch protocol’ methodology. As expected the Health Council will start the advisory process this year. By submitting the request for advice, I am implementing the above-mentioned motions.

Closing

I think it is important to continue to emphasize, also towards you Chamber, that a climate of acceptance and recognition is essential
for transgender people. It concerns a group of people who are already extremely vulnerable due to stigmatization and discrimination. Figures show that transgender people have worse overall health outcomes and mental health than cisgender people. Transgender people are 5 to 10 times more likely to attempt suicide and… think about suicide 7 times more often compared to cisgender people persons. There is also a group of transgender young people who self-medicate or are considering doing so, with all consequences. Medical care may sometimes be urgently necessary and it is important that the conditions for this care.

Partly in view of the questions raised about this life, the Ministry of Health, Welfare and Sport has had in recent years initiated various investigations: such as an order for evaluation of the Somatic Transgender Care Quality Standard, which describes what good transgender care is. Insights from others countries, the hormone treatment, and whether the other group that now presents itself needs a different approach part of this evaluation.

I think that in the Netherlands we do not leave transgender young people out in the cold should be left alone and that we cannot ignore it (mental) well-being of this vulnerable group and the fear among them this group for losing their access to care. Therefore I also think it is important to point out that via www.genderpraatjes.nl young people can chat, call and email with all kinds of questions surrounding gender and gender identity. There can there are many questions about gender identity and gender talk the opportunity to talk to someone about it. Also parents You can contact us here with questions. Finally, I agree with the call from the UMCs in the Netherlands to conduct the debate around transgender care for young people with nuance and care, especially with a view to and in the interest of this vulnerable group. Therefore, with the same are and nuance, care has already been given to this group in the Netherlands.

The Minister for Medical Care,
P.A. Dijkstra

 

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