The 31st March is the International Transgender Day of Visibility: a day dedicated to the celebration of transgender people and raising awareness of the barriers and issues they still encounter and which should be dealt with. It’s therefore a good opportunity to talk about an issue that transgender people, a group of the Queer community with the lowest life satisfaction, struggle with: access to trans healthcare. What’s it like going to a doctor as a trans* [1] person in Europe? How easy or difficult is it to access and afford gender-affirming surgeries and/or hormones in EU countries? And how does the country of residence impact a trans person’s accessibility to healthcare and the overall quality of life?
Before diving into the specifics, let us clarify the terms general healthcare and trans specific healthcare. General healthcare is all healthcare that is unrelated to being trans, for example, dentists, cardiologists, etc. Trans specific healthcare is a kind of healthcare trans people seek to better align their bodies with their gender identity. This includes everything from facial feminisation, hair removal or hormonal and psychological therapy to surgeries, such as vaginoplasty, mastectomy or breast augmentation.
The rules
The 2004/113/EC directive on goods & services mandates that the public has the right to access goods and services notwithstanding their sex. Health services, such as health insurance and healthcare, are also covered by this directive. This means that nobody, including trans people, should be prevented from accessing and using these services.
However, the reality is often different. According to the 2014 survey by the European Union Agency for Fundamental Rights, on average 22% of trans people in the EU felt discriminated against in the last 12 months when accessing healthcare. There are various additional kinds of discrimination trans people experience in terms of healthcare access.
Legal discrimination
Trans specific healthcare is often connected to legal documents, such as passports and IDs. For a country to legally recognise someone’s gender change (by changing the markers in their documents), some European countries require a person undergoes medical procedures, be it physical or mental.
There are only 10 countries in Europe that don’t require trans people to undergo a mental evaluation and get a diagnosis before being able to change their gender in official documents. Iceland, Ireland, Norway, Denmark, Greece, Portugal, France, Belgium, Luxembourg, and Malta base this change on self-determination. In other words, there is no need for a diagnosis - the individual person can determine their gender identity. Ireland and Malta are also the only two EU countries that allow children over 16 to access gender confirmation surgery; the threshold in the rest of the countries is 18.
More concerningly, the condition for legally changing gender in Finland, Latvia, Czechia, Slovakia, Romania, Bosnia & Herzegovina, Kosovo, Montenegro, or Turkey, is sterilisation. This practice has been condemned by the United Nations, the Council of Europe, and the European Court of Human Rights, but it still persists in Europe.
The price of health
Once a trans person is able to access trans specific healthcare, how much does it cost? And who pays for it? The answer differs from country to country, based on the public health insurance system in a given country. Even though many countries require trans people to obtain a diagnosis before being legally recognised, the necessary medical procedures are often not fully covered by public health insurance. Transgender EU (TGEU) mentions the situation in Poland where, although the diagnosis is covered by public insurance, the waiting times are so long that most people just pay for it out of pocket. This, according to TGEU, amounts to “financ[ing] their own human rights violations”.
The public insurance systems in some countries often arbitrarily distinguish between procedures that are for medical purposes (and are covered by the insurance) and those they consider aesthetic, which aren’t covered. A trans person in the Czech Republic or Belgium could get a mastectomy covered by public insurance, but if they wished to augment their breasts, they would not be able to rely on public insurance. This is slightly better in Germany and France, where breast augmentation can be covered if the person has begun their transition. In Luxembourg or Italy, procedures such as facial feminisation or hair removal would also be outside of the public coverage.
TGEU’s report also notes that the situation is even direr with private insurance companies, many of which do not include trans healthcare in their service offers, again arguing that these are ‘cosmetic’.
There are, of course, also more progressive initiatives and approaches, such as the Institute for Equality Between Women and Men in Belgium. This organisation offers help and guidance to trans people in legal matters, including claiming insurance money.
Access to health
But even when one successfully navigates the often confusing environment of laws and public insurance, it is not certain that they can access the procedures they need. One of the reasons is the long waiting times before procedures. The Netherlands, for example, has only two gender clinics and a limited number of clinicians specialising in trans healthcare outside of these clinics. This makes waiting times for hormone therapy as long as 2 years, which is slightly better than France, where people can wait up to 4 years for the public insurance system to simply get diagnosed.
As frustrating as they are, long waiting times at least imply the possibility of getting treatment. However, some countries do not even offer any trans healthcare. Clinics in Luxembourg, Spain, the Czech Republic, or Italy do not offer some specific surgeries and procedures or lack doctors who can perform them. So trans people who need these, have to seek them in other countries, where there is a higher risk of having to pay for the procedures on their own instead of relying on public insurance.
The good news is that several countries (the Czech Republic, Slovakia, Spain, Italy, and San Marino) have agreements allowing trans people to get the needed procedure in a different country/region and still get reimbursed for it.
At the doctor’s
The issue of trans healthcare access also encompasses the lived experience and attitudes of transgender people towards healthcare providers. The data on this issue is scarce, but it exists. TGEU published a survey titled “Overdiagnosed but Underserved” in 2017 which maps out attitudes of trans people in Georgia, Poland, Serbia, Spain, and Sweden.
Concerning general healthcare, the trans respondents mentioned the staff’s lack of knowledge on trans issues, not being addressed by the right pronoun, and inappropriate curiosity as the most common experiences. And more than half of TGEU’s trans respondents have delayed a doctor’s visit due to their gender identity, with the most common reason being their fear of being treated badly. The country with the largest number of respondents delaying their doctor appointments due to gender identity was Serbia.
Work in progress
Although there has been some progress in improving trans people’s access to trans healthcare, the battle is far from over. Luckily, there are many organisations working towards improving the situation. Some Europe-wide examples include the advocacy group International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA-Europe) and a network of organisations called Transgender Europe (TGEU). These two regularly monitor the situation of trans and LGBTI people in and outside of Europe. At the same time, they also collect and publish valuable data on the situation of the queer community. There is also Trans United, a European activist organisation advocating for BPOC trans people. But there are even more organisations and groups on the national level, all working with trans rights, such as Trans*parent in the Czech Republic, Transgender Infopunt in Belgium, or Movimento Italiano Trans in Italy.
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