Neoliberalism versus dysphoria – why gender-affirming care policies do not work?  

Dominika Filipiak

Gender-affirming care in the Netherlands

Gender-affirming care, as delineated by the World Health Organization, encompasses a comprehensive array of social, psychological, behavioural, and medical interventions designed to facilitate individuals in navigating their gender identity within the context of incongruence with the gender assignment they received at birth (Boyle). In the Netherlands, this multifaceted approach typically encompasses a comprehensive set of components, including initial assessments, provision of mental health support, administration of hormone therapy, consideration of surgical options, legal recognition of gender identity, and provision of insurance coverage.

Initiation of this process typically hinges on the receipt of a referral letter from a general practitioner, directing the transgender individual to a specialized gender clinic. At the clinic, a team of healthcare professionals conducts a thorough assessment, culminating in the determination of the individual’s final gender dysphoria diagnosis, mental health status, and medical requirements. Subsequent stages often involve the initiation of hormone replacement therapy, along with gender-affirming surgical procedures, encompassing both chest (top) and genital (bottom) surgeries.

Although insurance coverage extensively supports gender-affirming care, specific situations may arise in which insurance providers decline coverage for these essential treatments. It is essential to scrutinize such scenarios, as they exert a substantial impact on the transgender community. The primary focus of this paper will revolve around an examination of the Health Insurance Act 2.4b policy, with particular emphasis on Paragraph 5: “Treatment of a plastic surgical nature only falls under the purview of care if it serves to correct primary sexual characteristics in cases of established transsexuality” (Health Insurance Act, 2023, para. 5). This analysis will be informed by the “Method for Assessing Treatments of Plastic Surgical Nature” established by the VAGZ (2022).

Navigating through the policy 

Individuals’ lives are undeniably shaped by policy decisions, a notion aptly articulated by Bacchi and Goodwin, who posit that we live in societies “saturated” with policy (5). Komai concurs with this perspective and introduces two critical dimensions of the policy landscape. Firstly, it is imperative to recognize that knowledge itself is inherently political, and thus, all ‘problems’ do not exist independently of outside forces, but only in relation to specific mentalities and models of governance models. Secondly, the phenomena underpinning these ‘problems’ are not fixed per se but rather remain continuously in flux (226).

Consequently, to analyse the mentioned policy, the most suitable seems to be a post-structural approach, particularly What’s the Problem Represented to Be (WPR). The post-structural lens allows for the profound realization that realities are easily influenced and subject to deconstruction. In this vein, policies are viewed as discourses, necessitating a conscientious examination of how policy ensembles or collections of interconnected policies wield authority through the construction of truth and knowledge, as explained by Bacchi and Goodwin (8). WPR serves as a crucial tool within this approach, conceptualizing policy as an enigmatic and intricate social and cultural construct that needs to be unpacked and contextualised if its meanings are to be understood, in alignment with Goodwin’s and Bacchi’s insights. More significantly, it perceives policies not as resolutions to pre-existing problems but as creators of problems, casting them in particular moulds. This perspective empowers critical evaluation and challenges policies that exert damaging effects on marginalized identities (Komai 226).

This essay will concentrate on three fundamental inquiries within this framework. Firstly, we delve into the initial query: “What is the problem represented to be in the chosen case?” Secondly, we navigate the realm of underlying presuppositions and assumptions that form the bedrock of this representation of the ‘problem.’ Lastly, we venture into the uncharted territory of the fourth question: “What aspects remain unproblematic within this representation of the issue?” Where do silences permeate the discourse, and can we envisage an alternative conceptualization of the ‘problem’?

It is imperative to underscore that investigating policies concerning gender-affirming care holds immense significance. Such research is essential for advancing the cause of equitable healthcare access, safeguarding human rights, and enhancing the mental and physical well-being of transgender and gender-diverse individuals. Furthermore, it plays an important role in diminishing stigma and discrimination, nurturing a more inclusive society, and bestowing economic and public health advantages. In essence, this research safeguards that healthcare policies remain grounded in evidence while upholding the principles of fairness and social justice.

Gender-affirming care insurance policy and why it does not work?

To begin, it is essential to gain a comprehensive understanding of the underlying problem that this policy seeks to address. This policy confronts several issues, but paramount among them is the concern of “passibility.” The concept of passibility, as articulated in the VAGZ’s documentation, arises when “a male-female transsexual is not acknowledged as a woman due to persisting male facial features, consequently prompting startled reactions, unusual behaviour, or disrespectful treatment from others” (33). In accordance with this definition, insurance providers may opt to withhold coverage for certain procedures, such as facial feminization surgery, the expenses associated with hair removal (perceived as easily concealable with makeup and clothing), or the treatment of baldness (as it can ostensibly be rectified with a wig or hairpiece). As an individual wishes to undergo such procedures, they are obligated to substantiate that their predicament qualifies as a form of mutilation, and to clarify the extent to which it contributes to the passibility problem, substantiated through photographic or video evidence, in conjunction with a request from their general practitioner.

Another dimension of concern within this context pertains to the reactions of strangers. The evaluation of whether one successfully passes as their chosen gender is contingent solely upon the perspective of bystanders, rather than the individual’s own perception of themselves. If an individual’s outward appearance invites negative comments or elicits disrespect, it becomes a critical point of focus. However, the policy seems to remain indifferent to an individual’s personal self-perception and the extent to which they feel comfortable in their own body.

Thirdly, the overarching objective of this policy is to advance equality between cisgender and transgender individuals. It explicitly articulates its mission, stating, “Similar to cisgender women, alternative treatments like waxing, plucking, bleaching, and shaving are available. The entitlement to compensation ceases when the passability problem no longer persists. The treatment’s goal is to achieve a satisfactory outcome, and both transgender and cisgender women are ineligible for reimbursement for the permanent and complete removal of facial hair.” (VAGZ 34). In essence, the policy strives to ensure equal access to treatments for both cisgender and transgender individuals while maintaining a focus on achieving acceptable results rather than absolute hair removal.

To fully grasp the policy’s essence, it’s crucial to explore the fundamental beliefs that underlie the issues it addresses. The policy primarily focuses on how people react to transgender individuals and their ability to blend into society (passibility). This suggests that the policy assumes that how society views and accepts individuals greatly affects their well-being, especially when it comes to gender identity, which refers to how someone sees themselves concerning traditional ideas about male and female roles and expressions.

Additionally, the policy implies that there are existing disparities between transgender and cisgender individuals. It acknowledges that these differences need to be addressed through policy to create a more inclusive and fair healthcare system for everyone. In essence, the policy’s core principles revolve around the importance of societal attitudes and the need to reduce inequalities, all in an effort to ensure fair and inclusive healthcare for transgender individuals.

Lastly, it’s imperative to recognize the notable omissions within this policy. Firstly, it’s essential to acknowledge that this policy was formulated within a neoliberal framework. Neoliberalism places significant emphasis on individuals taking personal responsibility by investing in their own skills and capabilities to become less reliant on society as a whole, or else face stricter disciplinary measures (Schram 308). Thus, concerning care, including gender-affirming care, it categorises it in three distinct ways: as a matter of personal responsibility, a concern for the free market to address, and, lastly, as a responsibility that often falls upon the family, as Tronto elucidates (29-30). It suggests individuals should care for themselves by acting rationally and responsibly; if they have care needs they cannot meet alone, they should seek market solutions. When those are unaffordable or not preferred, they should turn to family, friends, or charities to fulfil their caregiving needs.

However, this neoliberal perspective doesn’t neatly align with the intricacies of the gender-affirming care process and how policies function in this context. Transgender individuals often have limited agency and cannot independently care for themselves in a manner conducive to their well-being. The alternative solution of relying on family as the primary source of care also frequently falls short, as many transgender individuals face familial rejection and dire circumstances such as homelessness after coming out. Lewis argues that the family’s fundamental nature lies in privatizing care, a process in which all forms of families inadvertently partake. Thus, it is untenable to view the family as the sole or central source of care, as neoliberalism suggests, given that families exhibit a combined and unequal pattern of thriving, denied to some, while simultaneously representing a combined and unequal mechanism of violence, consolidating power in the hands of others. There’s no plausible strategy that can be safely chosen, as Lewis posits, that would be adequate to confront the vast complexities inherent in the family dynamic. One cannot see family as main source of care, as seen in neoliberal ideas since family is a combined-and-uneven form of thriving, denied to some while being a combined-and-uneven mechanism of violence, concentrating power in the hands of others, it is foolish to imagine that there is an interpellative strategy we could “safely” choose that would also be adequate to the magnitude of the problem that is the family (Lewis 30).

Consequently, the fate of transgender individuals often hinges on third-party entities, notably, market-driven solutions. This includes general practitioners, who provide referral letters, gender clinics (offering hormones, surgical procedures, and often lengthy waiting lists), and insurance companies. Insurance companies, as argued in this article, advocate for equality between transgender and cisgender individuals, asserting that they have similar access to treatments such as hair removal, and hence, such procedures may not be covered by insurance. These treatments are frequently expensive and not universally affordable. The crisis and the burden of addressing it, as Hall contends, disproportionately fall upon the working population and adversely affect vulnerable and marginalised groups (10). Additionally, another conspicuous silence arises in the differentiation between transgender and cisgender individuals, particularly concerning body and gender dysphoria. As Kirkland et al. highlighted, for a health insurer to authorize treatment, they must determine the procedure, drug, or service is “medically necessary” as opposed to excluded as “cosmetic, experimental or investigational.” (541). Insurers decide what is medically necessary based on a mixture of medical diagnosis, established standards of care, value judgments, and business calculations while in the same time terms like “medically necessary” and “cosmetic” are socially constructed and contested in the transgender health context in bureaucratic actions led by both trans people and allied professionals, ignoring deeper issues with gender dysphoria.

Gender dysphoria is a complex and often distressing psychological experience resulting from the profound incongruence between one’s assigned sex at birth and their deeply held gender identity. While gender dysphoria is frequently recognized in childhood, it can manifest at any point in an individual’s life, even well into adulthood (What Is Gender Dysphoria?). Its effects ripple throughout various aspects of daily life, significantly influencing an individual’s engagement in everyday activities, whether it be attending school or participating in the workforce. Left untreated, gender dysphoria has the potential to inflict a cascade of severe consequences, including anxiety, depression, self-harm, eating disorders, substance abuse, and various other mental health challenges. In the most extreme circumstances, it may tragically lead to suicide attempts. Therefore, it is imperative to provide unwavering support to transgender individuals and grant them access to gender-affirming treatments that can help them harmonize their external appearance with their deeply felt sense of self.

The importance of addressing “primary sex characteristics,” as stipulated in some policies, should not be understated, as it serves as a pivotal cornerstone for many individuals in their journey towards self-acceptance and well-being. However, the applicability of this approach varies considerably, especially for those who have already undergone puberty before embarking on their gender-affirming path. Such individuals often require supplementary treatments like facial surgeries or hair removal to align their external presentation with their true gender identity. These treatments hold immense significance and can significantly improve an individual’s overall quality of life, underscoring the inadequacy of policies aimed at merely achieving equality between cisgender and transgender individuals. As Linander et. al. argued Passing and stealth can be important to live liveable lives;  however,  the  concepts  have  also  been  problematised  from  a  critical  perspective  arguing that they are based on cisnormative assumptions in which the gender presentation has to be linear for subjects to be recognisable (25)

The term “equality” falls short of encapsulating the complex issues at the heart of gender dysphoria. Unlike their cisgender counterparts, transgender individuals grapple with unique experiences and challenges, making it essential to pivot from a strict equality perspective to a more encompassing focus on “equity” in policy-making. This shift acknowledges the need for tailored, context-specific solutions that take into account the distinctive needs and experiences of transgender individuals. Equity recognizes that different situations necessitate different approaches, and rather than imposing a uniform policy on all, it encourages a deeper understanding of the individualized nature of gender-affirming care.

In conclusion, the treatment of gender dysphoria is a complex and multifaceted endeavour, requiring careful consideration of the individual’s unique circumstances and needs. Policies aimed at promoting equity rather than mere equality can provide a more comprehensive framework for addressing the challenges faced by transgender individuals, ultimately facilitating their access to the essential care that improves their overall well-being and quality of life.

Moreover, a critical issue within the purview of policies is the perpetuation of a binary model of gender, which inadequately represents the intricate tapestry of gender identities. Linander et al. illuminate this matter, coining the term “cisnormativity” to denote the societal narratives and practices that presume alignment between an individual’s physical attributes and their gender identity. Cisnormativity, in essence, engenders the portrayal of transgender experiences as enigmatic and may inadvertently reinforce institutional narratives that pathologize these individuals, framing them as necessitating correction (Linander et al., 24).

Policies, regrettably, tend to centre their focus on individuals transitioning from female to male (FTM) or male to female (MTF), inadvertently sidelining non-binary transgender individuals. Gieles et al. astutely argue that the clinical classification of ‘male’ and ‘female’ as straightforward, binary, and mutually exclusive constructs, coupled with the assumption that gender identity can be straightforwardly inferred from an individual’s assigned sex at birth, exerts a significant impact on how healthcare practitioners and policymakers perceive and address non-binary experiences, bodies, and care needs (13). This unswerving adherence to a binary gender paradigm leads to the unintentional negation of the diverse spectrum of non-binary, gender-non-conforming, embodied, and sexual identities and experiences (Gieles et al 12).

A poignant consequence of this exclusion is the complete oversight of the “passibility problem” experienced by non-binary individuals. Some non-binary individuals may indeed experience gender dysphoria due to specific aspects of their appearance; yet, they do not wish to conform to the entirely opposite gender because it does not correspond with their self-identification. Consequently, their aspiration is not to conform strictly to either the female or male category; rather, they seek adjustments to specific characteristics that align with their self-concept. This nuanced, non-binary perspective poses a significant challenge for the existing policy framework, which remains tethered to the constraints of a binary gender system.

In conclusion, this binary perspective leaves non-binary individuals without comprehensive support, exacerbating the hurdles they encounter when seeking gender-affirming care. Policies should evolve to acknowledge the full spectrum of gender identities and strive to provide equitable access to gender-affirming care, irrespective of where an individual falls on the gender continuum. This shift towards inclusivity is not only a matter of fairness but also a recognition of the complex and diverse landscape of gender identities, which demands a more nuanced approach to healthcare policy and access.

Conclusion

In conclusion, the intricacies of gender-affirming care reveal the inadequacies of a neoliberal framework in addressing the multifaceted needs of transgender individuals. Neoliberalism’s emphasis on individual responsibility, market-driven solutions, and reliance on family as sources of care does not align with the complexities of gender dysphoria and the unique requirements of gender-affirming care. Moreover, the financial barriers and inequalities perpetuated by neoliberal policies pose significant challenges for transgender individuals seeking essential treatments.

Gender-affirming care is not a one-size-fits-all market commodity but a personalised and multifaceted journey that encompasses medical procedures, mental health support, and social acceptance. It requires a holistic and nuanced approach that acknowledges the diverse needs and experiences of transgender individuals. Neoliberalism’s disconnect with the complex realities of gender-affirming care underscores the importance of reevaluating healthcare policies to better support and inclusively serve transgender individuals.

The binary model of gender further compounds the issue within policies, sidelining non-binary transgender individuals and exacerbating the hurdles they face when seeking gender-affirming care. Policies must evolve to acknowledge the full spectrum of gender identities and provide equitable access to care, irrespective of where individuals fall on the gender continuum. This shift towards inclusivity is not only a matter of fairness but also a recognition of the complex and diverse landscape of gender identities, which demands a more nuanced approach to healthcare policy and access.

In light of these challenges, it becomes clear that gender-affirming care requires a framework that prioritizes the well-being, mental health, and individuality of transgender individuals. A more inclusive approach that focuses on equity rather than strict equality is essential in accommodating the unique experiences of transgender individuals. Such a shift in policy and healthcare practice would not only promote equitable access to care but also contribute to a more just and compassionate society for all, regardless of their gender identity.

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