We are not qualified to determine our own gender.

[I Am Paula]

I saw a new Endo (about my thyroid) today. My last one was an oriental man who was very TS positive, and we've shared many great conversations. This new one, as soon as I walked into his office gave me a 'Oh jeez, not another one' kind of look. He looked at my chart and was suprised I was there for my thyroid. After a brief once over he gave me a new scrip. As usual, I brought up hormones, and asked what his protocol was on prescribing them. He said he wanted to see a therapists referral. My pat response to this is "We're not qualified to determine our own gender?'. He said that they are trying to keep powerful drugs out of the hands of the mentally unstable. A therapist must guide us into making these descisions. I mentioned that any surgeon will give me breasts, or FFS, but I'm not qualified to choose pharmaceutical feminization? Then he said 'HRT causes sterility', and that's his main concern.
Okay... You're afraid I'm unstable, but giving me the tools to voluntarily remove myself from the gene pool is a problem! I can walk into ANY Doctors office in N. America and get a vasectomy!
Is this not a doozy of a double standard?-Celeste

[melissaK]

Sweetie, count me in your choir during your sermon!! You are so right. DSM V can't get here soon enough.

[PaulaQ]

Celeste, I'm so sorry - what an annoying combination of arrogance and risk aversion coupled with a total lack of understanding in your new doctor. I take it you are stuck with this one?

[Marleena]

Celeste, yes it does seem odd but in Canada it is very easy to get MTF hormones legally compared to other parts of the world. You need to be monitored once you are on them for any complications. The endos have to have a referral letter (protocol) and of course some endos won't prescribe them to MTF's as part of their practice anyways. My TS group leader gave me the name of an endo that will help TS people once they get the referral. In my case just one visit to a psychiatrist that had helped me wean off Cymbalta that I was on for pain was all that was required. Anyways, he knew me and I brought in pics of me enfemme and in one visit I had my referral. It sounds like your new Endo doesn't care for TS people to begin with.

[celeste26]

The my town there are only two endo offices and neither of them is willing to work with TS patients. The next closest is over 60 miles away.

[Marleena]

@ Celeste I have to travel 100 miles one way for my Endo visits. There is nobody local that deals with TS patients.

[Rianna Humble]

Celeste, if I were in your place, I would complain to his professional body about blatant discrimination. Your endo is not qualified to state that all TS are mentally unstable and as such his remark is unprofessional.

[Kathryn Martin]

It might help to give him this: Endocrine Treatment of Transsexual Persons (http://www.endo-society.org/guidelines/final/upload/endocrine-treatment-of-transsexual-persons.pdf) or the British Columbia Guidelines (http://transhealth.vch.ca/resources/library/tcpdocs/guidelines-endocrine.pdf). The issue is not whether we are qualified to determine our own gender. The issue for your endo is whether there are co-morbidity issues that would militate against prescribing cross sex hormones. The problem is that they need to be assured to do no harm. Part of that determination is the "letter". It confirms that the patient has no co-morbidity issues and is fully aware of the consequences of what they are doing.

Don't rail against clinical guidelines that were developed to protect us. It is not always a slight or a rejection it may just be good medical practice.

Rianna, that is by the account Celeste gave not what he said. He said "we have to keep powerful drugs out the hands of the mentally unstable" which to me makes a lot of sense. If he said "we need to keep these drugs out of your hands because you are mentally unstable" then it would be quite unprofessional and would require censure. But that is not what he said by Celeste's account.

[kellycan27]

You asked ... He answered. Sounds like he follows the SOC, and you might be hard pressed to find a doctor who doesn't. Is your issue really with the doctor or gate keepers in general? The title of your post seems to indicate its more about the gate keepers. You are qualified to determine your own gender, but you are not qualified to prescribe drugs for yourself.. Find a new doctor and move forward.. You can back yourself against a wall and clench your fists, but how will this help your end game? What's more important... Fighting city hall or getting on with transition?

[Anne2345]

You can back yourself against a wall and clench your fists, but how will this help your end game? What's more important... Fighting city hall or getting on with transition?

Exactly. Where there is a will, there is a way. TS resources and support are non-existent where I live, and docs won't take me on because they don't have any experience with this and, I suppose, do not want the "hassle."

So I go out of state almost 200 miles away to visit my HRT doc. And because he is out of state, he is out of my insurance network. But my insurance has denied my claims regardless (a TS exclusion), so I pay completely out of pocket.

It's far from ideal, but it is much, much better than the alternative, which is not doing it at all.

[ReineD]

He said he wanted to see a therapists referral ...

He said that they are trying to keep powerful drugs out of the hands of the mentally unstable ...

Then he said 'HRT causes sterility', and that's his main concern.

Maybe I'm missing something, but I looked at the Endocrine Society's Clinical Guidelines that Kathryn posted. On page 4 it states:


1.0. DIAGNOSTIC PROCEDURE

1.1. We recommend that the diagnosis of gender identity disorder (GID) be made by a mental health professional (MHP). For children and adolescents the MHP should also have training in child and adolescent developmental psychopathology.

1.2. Given the high rate of remission of GID after the onset of puberty, we recommend against a complete social role change and hormone treatment in prepubertal children with GID.

1.3. We recommend that physicians evaluate and ensure that applicants understand the reversible and irreversible effects of hormone suppression (e.g., GnRH analogue treatment) and cross-sex hormone treatment before they start hormone treatment.

1.4. We recommend that all transsexual individuals be informed and counseled regarding options for fertility prior to initiation of puberty suppression in adolescents and prior to treatment with sex hormones of the desired sex in both adolescents and adults.

I've heard others mention these procedures before, as a safety precaution to rule out people who may want to transition for reasons other than gender dysphoria. In all fairness to this new doc, he doesn't know you and so he's just following procedure?

Edited to add:
You mention that you saw a new endo. If you've gone through all these procedures with your last endo, is there any way that he or she can write a letter to your new endo, or perhaps you can have the medical records forwarded?

[Lorileah]

I always thought the MD referred you to a therapist...it's the other way around?
"It will make you sterile" So? I already am (been that way for 25 years, had to fight that fight at 32...same thing "What if you want children later??" ......).

"...drugs out of the hands of the mentally unstable..." OK...don't you try and prescribe to help those people? This could be a therapeutic treatment.

My favorite is "you won't like it." Well I don't like the antidepressants either.....and yet....

Luckily there are a lot of MDs out there. Not saying you should seek one that will just roll over but they could have at least discussed with you why you want the drugs. Oh yeah...7.5 minutes per patient on most HMOs....

[Kathryn Martin]

"...drugs out of the hands of the mentally unstable..." OK...don't you try and prescribe to help those people? This could be a therapeutic treatment.

Lorilea, but not by an endocrinologist. Endocrinologists do not perscribe drugs for people who are mentally unstable. Endos only deal with human endocrine physiology not mental disorders.

[kellycan27]

They tell you one thing to satisfy you and get you to go away. The real reason they do it the way they do is because of the malpractice insurance. They are trying to keep it and not get sued. Things are so messed up a Dr. Cannot really practice medicine he just follows a script.

In this case its more the doctor not telling the patient what they want to hear... And the "script" the doctor is following seems to be the SOC... Just saying.

[LeaP]

It's not necessary to see an endocrinologist. Any competent physician who will monitor blood levels will do. I would take a GP or internist who had HRT experience over an endo without such experience.

Thankfully, my doctor is in the town next to home.

[Marleena]

In this case its more the doctor not telling the patient what they want to hear... And the "script" the doctor is following seems to be the SOC... Just saying.

Yes, I think Celeste was venting because she was disappointed by the the new Endo who appears to be going strictly by the book. It sounds like her first Endo would at least discuss hormones with her and was TG/TS friendly. If it came to actual treatment I think her first Endo would still need the referral though.

Oh and Lorileah you were correct. The common method to obtain HRT is to see your M.D. and discuss, then a referral to a gender therapist to make sure HRT is the correct option for you. Once it is decided that you are thinking clearly and understand the ramifications of HRT there will be a referral to the Endo.

[EnglishRose]

The common method to obtain HRT is to see your M.D. and discuss, then a referral to a gender therapist to make sure HRT is the correct option for you. Once it is decided that you are thinking clearly and understand the ramifications of HRT there will be a referral to the Endo.

Maybe in Canada, but family practice doctors in the US tend to know nothing about this. You'd begin with the therapist.

My own doctor utterly refused to prescribe (even with a referral) and none of the endocrinologists she worked with would either. I have an endocrinologist not far though who already had experience and she required my referral letter also.

[EnglishRose]

So how do you go about finding a therapist in your area who is experienced in gender issues? Most I have looked up on the internet either barely mention TS issues or they do not list it at all.

Try here:

http://www.t-vox.org/index.php?title=Therapists_in_the_South_Atlantic_S tates

I found my own excellent therapist on that site.

[Marleena]

Maybe in Canada, but family practice doctors in the US tend to know nothing about this. You'd begin with the therapist.


True, in Canada you can skip the family doctor if you can book a gender therapist without a referral. My TS support group helped me find the endo I went to as many do not deal with TS people. The endo won't give you the time of day without a referral. This was my own experience and the steps I was told I needed to take.

[I Am Paula]

Thanks girls
To a large degree I was talking about a system that has very little trust in our own judgement.

It was a secondary observation that the Dr. really had little interest in gender medicine.

My old Dr. who I will be going back to (he's 80km. away) has told me any Dr. CAN prescribe hrt. There is a recommended protocol most follow, but a few enlightened ones base things on their own observations. There is an element of liability involved.

Using sterility as an issue is just a cop out to avoid further discussion.

I don't think the Dr. was calling me or ts patients mentally unstable, he was referring to wanting to make sure that a patient is genuinely gender dyphoric, and not suffering some mental problem that hrt will not help.

My opinion is that the medical system as a whole always wants to play it safe. Let someone else make the diagnosis, let someone else establish the treatment protocol, let someone else be responsable for liability. No one likes to deal with anything vaguely controvercial. We're going on fifty years of transgender care, and tho' medical technology has improved greatly, the way we are treated by the medical community is still in the stone ages. If teenage suicide rates were the same as tg suicide rates, we would see an OVERNIGHT change in the system.-Celeste

[Marleena]

I'm glad you've cleared that up Celeste, we were guessing a bit. Canada uses a system comparable to the U.S. using WPATH and their SOC. The guidelines and criteria are there in Kathryn's link. We can tell a doctor we are anything but they need proof (diagnosis) before treating us. Since treatment is different for CD/TG/TS they must know where you fit in, that's why a gender therapist gets involved. HRT is usually only used on a TS patient experiencing GD.

I wouldn't recommend skipping a family doctor in the process since they need to know what meds you're on. He helped me with a referral. In my case my endo did not need to contact my doctor about the HRT. I felt I needed to tell him myself. No doctor in my area deal with trans patients on any level. I'm the only trans patient my doctor has.

*disclaimer* My knowledge on this stuff is limited feel free to correct me if needed.

[Nicole Erin]

The act that he wanted a letter - understandable. but he was acting like a prick with his "oh no, not another one" demeanor - piss on him.

I wonder if he would have been hesitant if you were there wanting whatever designer drug the docs are pushing this season for whatever fake illness? He'da been all over that

[Marleena]

@ Erin, his bedside manner sucks! Kinda cliche I know but not uncommon.

[kellycan27]

Did the doctors bedside manner suck or was he just too busy to answer questions that were irrelevant to what he was seeing the patient for to begin with. Did the OP's obvious dislike of gate keepers and not getting the answer they were looking for have anything to do with how they perceived the doctor's " attitude"?

[josee]

You make a good point, Nicole. My family doctor had no problem prescribing an amphetamine for ADD on my word alone but refused to even discuss HRT. Luckily after much searching I found an Internist who had experience with HRT for MtF transsexuals.
As a side note I don't take the amphetamine any longer.

The act that he wanted a letter - understandable. but he was acting like a prick with his "oh no, not another one" demeanor - piss on him.

I wonder if he would have been hesitant if you were there wanting whatever designer drug the docs are pushing this season for whatever fake illness? He'da been all over that

[kellycan27]

There is no physical test to diagnose ADD so yes the doctor would have to take your word for the symptoms that you are experiencing... And use his best judgement in treating you. Doctors also tend to treat patients in their field of expertise and refer those who aren't. Why would your family doctor discuss HRT with you if hormone therapy was not in his field of expertise? And furthermore, and more importantly.... Why on earth would you want him to?
Speaking for myself... I care about my physical well being and on an issue as important as HRT I wanted to get the best info I could from the most experienced person I could find.

[josee]

At the time I was getting desperate after calling every endo office in the city and finding no one who would work with transsexuals, so I thought I try the route LeaP mentioned that any MD could prescribe hormone therapy and monitor blood work.

My main point I was trying to make was that controlled substances were no problem, but life saving hormones were very difficult to go about getting access to going through the proper channels. I could see why some turn to self-medicating. Eventually I did find my Internist whom I love.

[kellycan27]

LeaP is technically correct... any doctor probably can prescribe hormones, but I am pretty sure you'd be pretty hard pressed to find one who would without a proper diagnosis by a qualified medical professional. And I am pretty sure you'd be hard pressed to find a doctor who doesn't specialize who would make that diagnosis. As apparently you have discovered.

[Aprilrain]

Its worth noting that Amphetamines and methylphenidate (Ritalin) as a class are some of the most studied drugs for the purpose of treating ADD/ADHD. Their efficacy and safety in persons with ADD/ADHD is well established. They get a bad rep because of Meth. There is a prescription version of methamphetamine (trade name desoxyn) which almost no doctor will prescribe. It's also worth noting that as a class female hormones, namely Progestins and Estrogens are NOT well studied even in genetic females and are basically unstudied in MTF TS patients. Here in the US the typical protocol for obtaining treatment for ADD/ADHD is to see ones family physician where as the typical protocol for obtaining hormones for the purpose of cross sex HRT is to find a therapist who deals with TG clients and get a referral letter from her/him to an endocrinologist.

Comparing the two is like comparing Apples to Oranges.

[I Am Paula]

LeaP is technically correct... any doctor probably can prescribe hormones, but I am pretty sure you'd be pretty hard pressed to find one who would without a proper diagnosis by a qualified medical professional. And I am pretty sure you'd be hard pressed to find a doctor who doesn't specialize who would make that diagnosis. As apparently you have discovered.

I was obviously wrong. There are those here that feel we are not qualified to determine our own gender. I've known mine since I was about 8 yrs. old.
He's a perfect catch 22, if you feel you need professional help to determine your gender, than perhaps you don't have an issue with it.

[Kathryn Martin]

Celeste,

You really don't get it do you. This is not about what you determine or not. If you went to a doctor and said I am a diabetic I want insulin, he would get a blood test done to confirm. Anything else would be professional negligence. The same is true for hormone treatment in transsexuals. Since there is no blood test for transsexuals they need the diagnosis from a qualified practitioner.

If I went to a surgeon and said I want a new hip the first question would be, what's the diagnosis. So you would need an MRI to make sure you actually need one.

You're looking at the wrong thing. No one disputes your claim, but before significant medical intervention is warranted you need to be diagnosed.

[LeaP]

... any doctor probably can prescribe hormones, but I am pretty sure you'd be pretty hard pressed to find one who would without a proper diagnosis ...

Yes. I didn't mean to imply that one could go directly to a doctor without a therapist's referral letter, just that an endo wasn't a necessity.



You're looking at the wrong thing. No one disputes your claim, but before significant medical intervention is warranted you need to be diagnosed.

Exactly right. On top of that, it's still mostly a self-diagnosis even with a therapist. The therapist's role isn't so much to confirm the gender situation as it is to ensure it isn't another condition presenting as a gender issue. They also are supposed to ensure readiness to start hormones.

[Kaitlyn Michele]

you are really stretching to create the catch 22...

first off, tons of people struggle with it, and end up getting a "Diagnosis" and start HRT...many of them were just hoping to be validated, others give up fighting..etc..
second, if you don't "need" a diagnosis..you go to a therapist, you tell them you are ts and they give you a letter...

i'm not saying i like the gatekeeping mentality that sometimes creeps in, but its frankly very easy to get a letter if you want it...

the doctore in the op was a jerk, but the system (at least in US) works without much fuss