I know I have readers from around the world. This entry primarily focuses on medical care in America but I hope some of this info may be useful for anyone, anywhere, be they trans or not.
I am fortunate to have an amazing General Practitioner, who knows which way the wind blows when it comes to trans patients. Some are not as fortunate as I am. In fact, if I ever move, I may have to in some ways, start all over.
My doctor practices what is known as Informed Consent, which means I told him I was trans and that I have known I am trans for more than thirty years. I explained that I am ready to begin transition. He asked me a few questions, pulled out some paperwork and had me sign it, and then sent me to get my blood tested. A week later, he reviewed the test results, gave me a shot in the ass (full of estrogen) and a prescription for Spironolactone to stop my body’s ability to absorb testosterone. It was that simple.
A doctor who practices Informed Consent (IC) often knows what they are doing. Otherwise, they would likely want you to get a second opinion from a psychologist to confirm you are trans. How a psychologist can determine whether or not I am trans better than I can is beyond me. Still, it is common practice.
An even older method, which is surprisingly still widely in use, requires a trans patient to see a therapist for at least three months before the therapist decides if the patient is trans enough to start hormone replacement therapy (HRT). Thankfully, this faulty method is going the way of the dodo. To be fair, some people seek therapy to find out if they are trans or not, but again, how can somebody else make that decision for them? If you do not know you are trans, do not transition.
Why is the three months of therapy method faulty? There are many reasons. Let me see, um, therapists can be as inexperienced in trans issues as anyone. I have two therapists a psychologist who I see weekly and a psychiatrist who I see every two months, mostly to see if I need to keep taking my low dose of anti depressants (I may not need them much longer). Neither therapist has much, if any, experience dealing with trans patients. I find them both helpful in their own way, but I would be concerned if they were supposed to determine for my doctor that I truly am trans.
In the trans community, there are some who call their therapists, “Gatekeepers”. This is in reference to a therapist who wishes to string their trans patient(s) along for all they are worth, with the promise of some day, giving approval to their doctor to begin transition. This is especially common in rural areas and red states.
Perhaps a therapist is just biased, and refuses to give you permission ever. Then the patient must start all over with a new therapist.
Transition, to this day, is rarely covered by American insurers, and that goes doubly for trans therapy. So, every visit to a shrink, every blood test, every doctor’s visit, every prescription, every surgery is typically out of pocket. Transition, is treated as a vanity thing, like a face lift. Even though the suicide rate of trans people is like, 30x higher than cisgendered (non trans) folks.
Lucky for me, I not only have a doctor who practices IC, I was suicidal! YAY!!! That means my therapy is covered! I get, “Treated” for suicidal depression even though 90% of what we talk about is how happy I am, and other trans related experiences like coming out, presenting in public, and shoes!!! OMG! Shoes! I love shoes!
So, I am lucky. I was suicidal. Many trans folk are not so fortunate. They are required by their doctor to get a therapist to sign off for them and they have no serious mental conditions that would allow their insurance policy to cover them.
Then there are doctors. It may come as a shock to some, to learn that doctors often consult guidebooks to see what the current standards of care are for any given issue they are supposed to treat. You know when the doctor leaves the room for ten minutes and then returns? They are probably just looking up your symptoms and studying the preferred courses of treatment for the most likely ailments. Most doctors treat trans patients exactly the same way. They never had a trans patient before, so they consult their material, and do exactly what it says. Sometimes the material is outdated and tells the doctor to send their patient to three months of therapy. Sometimes a doctor remembers how they treated their last trans patient twenty years ago so they do not consult their reference material to look for updates, they just continue doing things the old way.
These issues are particularly troublesome for trans people who live in rural areas, and do not have many options for their medical and mental care. If their doctor and/or therapist is not up to snuff, who else should they turn to?
This is where I implore people who are considering transition to study up. Know your rights. Learn the most current methods of treatment. Learn the standards of care, past and present, so you know if your treatment is up to date.
It is quite likely, your medical professionals will know less about being transgender than you do. I do not think a trans person needs a doctorate in endocrinology, nor do I advocate self medication, I just think you should know what you are talking about, and hopefully know what your doctor is talking about as well.
My grandpa, who had a life full of serious medical issues always used to say, “Remember, doctors work for YOU.” This is a simple truth that I fear not enough people really understand. Insured or not, your visits are what pay your doctor. You have every right to question their approach, seek a second opinion and/or suggest different types of treatment. You are the customer, your doctor provides a service. If you do not like what your doctor provides, or you find they are stuck in the past, try and get them to change. If that fails, you may have to go elsewhere but, you may be surprised how flexible a medical professional may be, when they suspect they are at risk of losing your business.
Some doctors and therapists are biased against trans people. Many more just do not have experience treating them. Being a doctor’s guinea pig is not always the preferred place to be, but I know from experience, being trans can really engage a doctor or a therapist. They are not used to dealing with people like us, so they may actually become passionate about your treatment just because it is new and interesting. That is not a bad thing. Remember, doctors usually just follow their reference materials anyway, no matter what they are treating. Often enough, being treated according to the current standards of practice is the best anyone can hope for, no matter what their medical issues happen to be.
Being trans is not a mental illness. Many people do not need therapy for being trans, no matter what a doctor tells them. Granted, being trans can lead to mental issues, especially if it has been repressed, closeted and hidden. Also, switching hormones is not for the feint of heart. A good therapist is helpful for almost anyone, trans or not, but therapy is no longer a requirement.
Medicare may change its rules for trans treatment soon. This primarily has to do with, “The operation”, often know as a sex change or, gender reassignment surgery (GRS) which is the most commonly used term now. This would be huge. For over thirty years, GRS has been considered experimental. Now, for male to female (MTF) trans folk like me, it is just an expensive, two hour, $20,000 operation. This change in policy would be even more monumental for female to male (FTM) trans folk, since their bottom surgery costs them around five times as much as it does for a MTF.
“Medicare, no big deal.” you may think. Wrong. As Medicare goes, so goes American insurance in general. If Medicare changes their policy on trans treatment, other insurers will follow.
The main issue here, as I see it, is, GRS is not for every trans person. I hear people say things like, “I just don’t understand why someone would want to chop their dick off!” Well, not every trans person wants to do that. It is a very invasive surgery and it could come with complications, some quite serious. The risk of going numb down there is fairly common. Recovery time is lengthy. A MTF, would have to insert dilators (small dildos) for a half hour at a time, multiple times a day just to keep their new vagina from sealing up. Over time, the frequency of dilation would be reduced, as the size of the dilator would increase. Eventually, it sounds like it would become quite fun… ahem… but not at first and not for a good while.
For ages, GRS and hormone replacement therapy (HRT) have been considered cosmetic treatments. An insurer is not obligated to cure you if you are born ugly. At long last, GRS may become covered by insurance plans. HRT however, is not yet being considered. The funny thing about this? A trans person is required to be on HRT for at least a year before they are eligible for GRS. Also, after GRS, a trans person is legally considered to be their new sex. So, continued HRT would be covered. Legally, after GRS, a trans person like me would be no different from any other woman without a reproductive system, like say, any cis woman who has had a full hysterectomy.
So, I am rather shocked that the first proven treatment for trans folk, HRT, is still considered to be akin to a nose job, but I am thrilled to see potential advancement in covering gender reassignment.
In any case, transition is a commitment to a permanent need for medical care. It is not cheap. Not without universal insurance coverage. Quite frankly it is a risk for many reasons one may not consider from a cis (non trans) perspective. What if being trans was outlawed? What happens to people like me who are mid transition? Humans need either estrogen or testosterone in order to maintain healthy bones. This is why women get brittle bones post menopause.
It is vitally important for trans folk to understand medicine and the medical system, in order to use it to their advantage. Otherwise, we will be at its mercy.