HRT in Atlanta

[SusanLaine]

Hello girls!

I've posted here before (see my write-up on hair removal) but I'm not very regular at posting - mostly just reading. :-)

I've arrived at a point in my life where I feel very strongly that I want to begin HRT. I'm in my 50s and have been dressing and going out for over 40 years, I have full bloodwork done every month (I get it for free:-) to help track my health and I feel that I know what I'm getting into after a couple years of research.

At this last SCC I heard several presentations from professionals, including a local well known Endo Dr that said the recommendations for HRT have changed and now someone like me (older and consenting) should not need a letter from a therapist.

However, when I called this same Endo Dr. his admin told me that they wouldn't even schedule a consult without a letter from my therapist. So here my dilemma: I don't care to spend a lot of time and $$ on a therapist (not that we can't all use one at times) to cover ground that I don't need covered on this subject. I just want to have a good endo Dr to help me with the HRT.

Can anyone help me find a DR that adheres to the latest guidelines in the Atlanta area or at least the Southeast?

Huggs,
Susan
:sad:

[Angela Campbell]

As far as I know the WPATH SOC still requires a letter from a therapist to begin HRT. There may be some out there who do not ask for it but most will want one.

[stefan37]

If you are that positive you need hrt. Then it would only take a couple sessions with a therapist to get your letter. Thus us a very expensive process and spending a couple hundred on therapy is a drop in the bucket nut to mention funds well spent

[SusanLaine]

Thanks for the fast responses. At SCC I heard a few WPATH "new guidelines" presentations and they were very clear that "informed consent" was the new guideline if you're over 21. If I can get a letter in just a few counseling sessions then I'm fine with that. In fact, a really popular TG therapist has her office just a few miles from mine so that would be convenient.

I'm not concerned about the $ - everyone here already knows how very expensive this life can be :-) I'm really just interested in taking control of my own health. I'll keep looking for a Dr that adheres to the "informed consent" approach but I may go ahead and schedule some counseling sessions as well.

[Jorja]

Ok, so you have to play the game. If you are 100% certain that HRT is what you desire. You understand that HRT will make you impotant and that is fine with you, here is how to handle it. Go to all of your appointments dressed as a woman. Convince the therapist you are what you say you are. Bring out the fact you have done this for 40 years. Tell them right out your goal is to get started on HRT. It should only take one maybe two sessions.

[SusanLaine]

Jorja, very good advice - thank you.
Susan

[Angela Campbell]

Thanks for the fast responses. At SCC I heard a few WPATH "new guidelines" presentations and they were very clear that "informed consent" was the new guideline if you're over 21..

You may be confused on what they mean by "informed consent"

Informed consent is where a therapist has discussed with you the benefits, risks, and application of the hormone therapy and believes you to understand it, thereby being informed you can make the decision to go ahead with hormone therapy. At this point you have been informed and may consent so a letter is provided by the therapist.

Any healthcare provider or MD who follows the WPATH standards will require this letter.

from the WPATH SOC 7

Feminizing/masculinizing hormone therapy may lead to irreversible physical changes. Thus,
hormone therapy should be provided only to those who are legally able to provide informed
consent. This includes people who have been declared by a court to be emancipated minors,
incarcerated people, and cognitively impaired people who are considered competent to participate
in their medical decisions (see also Bockting et al., 2006). Providers should document in the
medical record that comprehensive information has been provided and understood about all
relevant aspects of the hormone therapy, including both possible benefits and risks and the impact on reproductive capacity.

Initiation of hormone therapy may be undertaken after a psychosocial assessment has been
conducted and informed consent has been obtained by a qualified health professional, as outlined
in section VII of the
SOC
. A referral is required from the mental health professional who performed
the assessment, unless the assessment was done by a hormone provider who is also qualified in
this area.

from section VII

Hormone therapy can be initiated with a referral from a qualified mental health professional.
Alternatively, a health professional who is appropriately trained in behavioral health and competent
in the assessment of gender dysphoria may assess eligibility, prepare, and refer the patient for
hormone therapy, particularly in the absence of significant co-existing mental health concerns and
when working in the context of a multidisciplinary specialty team. The referring health professional
provides documentation – in the chart and/or referral letter – of the patient’s personal and treatment
history, progress, and eligibility. Health professionals who recommend hormone therapy share the
ethical and legal responsibility for that decision with the physician who provides the service.

http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf

[Kathryn Martin]

Every medical procedure requires informed consent. What if you woke up from surgery and the surgeon had just grafted a nose on your ass. It's like that with hormones. First the psychologists assesses you to determine whether you are not mentally and therefore have the capacity to provide informed consent, then she will discuss with you all of the potential consequences of taking hormones, so you can provide informed consent. Noses on asses are ungainly and you would certainly sue the surgeon, the endo and your psychologist if that happened.

[DebbieL]

You probably don't need "A Lifetime of Therapy", but you do need to be evaluated to determine whether you have considered the possible consequences in YOUR life (each of us has different consequences). Are there any consequences that you would be unwilling to accept if you were to transition. I aborted transition in 1993 when my ex-wife threatened to have my visitation completely revoked or supervised. I would have still had to pay child support for children I would never see again.

Before my dad died, he told me "Be yourself, even if that's Debbie", and after he finally spent 4 days with Debbie, he was amazed at how much he liked her. Sadly I lost his ability to communicate the next day and died the day after that. Watching him die the way he did made me realize there is no "nice" way to die. I started transition and almost freaked when my wife told me "I'm not OK with this". We talked a bit more, and she made it clear that she was upset that I hadn't included her in the discussions, and she wanted to make sure that I didn't pull away from her because I was keeping secrets. She has gone to therapy with me as well.

It only takes about 3 sessions to know that you are a transsexual. In my case, I'm "type 6" - someone who becomes suicidal when it appears that transition is not an option. Even in my late 50s I'm not immune from that terrible thought that "Spending the rest of my life in my male body" is synonymous with "Life in solitary confinement with no possibility of parole".

My therapists have all been ready to do the letters, though they did want me to get as much Real Life Experience as I could before starting hormones. You need to make sure that you will remain a responsible, productive member of society and be healthy and happy after transition. The therapist will help you with that.

[NCAmazon]

Contrary to popular belief you don't need to go to a therapist to get informed consent. The doctor or health care provider can serve as the person who evaluates if your mentally prepared for hrt. This can happen in one session and you sign the informed consent form. These providers and docs are out there and you can find them.

This is to discourage people that can't afford therapy and would then get hrt from the black market.

[Angela Campbell]

That is true but with stipulations:

"Alternatively, a health professional who is appropriately trained in behavioral health and competent
in the assessment of gender dysphoria may assess eligibility, prepare, and refer the patient for
hormone therapy, particularly in the absence of significant co-existing mental health concerns and
when working in the context of a multidisciplinary specialty team"

And yes there are likely a few who do this. I have not heard of any specifically though.

[LeaP]

Contrary to popular belief you don't need to go to a therapist to get informed consent. The doctor or health care provider can serve as the person who evaluates if your mentally prepared for hrt. This can happen in one session and you sign the informed consent form. These providers and docs are out there and you can find them.
...
This is to discourage people that can't afford therapy and would then get hrt from the black market.

That's not what informed consent is about and not the audience it's intended for.

As Kathryn said, it applies to all medical procedures and therapies (the non-trivial ones, anyway). It isn't a substitute or shortcut for evaluation!

Think of it this way:

A physician may do anything for which he is licensed - trained or not, competent or not. Standards of care and informed consent be hanged (except in the few instances where procedures are written into law and enforceable rules). The system is meant to work this way, the purpose being to allow a physician to respond appropriately to individual circumstances. People really need to understand the expectations for what appropriate means in this context, though!

There are constraints to physician freedom in practice. Procedures done in hospitals have to conform to the hospital's oversight and rules. Procedures billed to insurance must follow insurance company procedure and rules. Medical specialty boards, professional association (membership in which is sometime required), and state boards require you to adhere to professional standards. Etc., etc., etc.

There are really two primary kinds of professional medical standards. Ethical standards and formal standards of care. An example of the former is the oft-heard "do no harm." Examples of the latter are found by the hundreds and thousands in every area of medicine. There can be more than one standard of care for any given condition or treatment. No problem there at all. Sometimes that's due to overlaps in different specialties. Sometimes it's because there are competing standards.

The WPATH SOC is the most widely-followed standard for transsexual and gender variant care by far, at least in the US. But it is not the only such. Nonetheless, when something goes awry with a patient, one of the first things that will be examined is whether the physician followed any professionally recognized standard of care in the treatment plan.

A physician who did not and had good reason to deviate from normal standards of care is just fine. Woe be to the doctor who did not follow standards of care and who encountered an issue which a standard was designed to address! He will get his rear end sued six ways to Sunday. Negligence. Malpractice. Perhaps of criminal charges filed. Beyond any malpractice insurance considerations, all kinds of sanctions exist, from losing hospital admitting rights to loss of board certification to loss of license.

The informed consent process is never – ever – to pass responsibility away from the physician or other provider. Rather, it is to enforce the physician's diligence and to enforce patient knowledge and education.

Here's the key as it pertains to things like hormones approval: A physician may not reasonably substitute the patient's consent for his own diligence when the normal diligence is not even his role! A physician who does not also happen to be a psychiatrist, psychologist, licensed social worker, etc. who administers hormones on the basis of his patient signing an informed consent form with him alone is improperly bypassing a psychological evaluation. The physician informed consent form is properly limited to the education and knowledge concerns of his patient as it applies (in this case) to such things as physical effects and risks of the hormone treatment. Were an underlying psychological issue to come up with that patient as a result of taking hormones, that physician would have his head cut off in court (and whomever had other kinds of oversight jurisdiction as well) and rightfully so.

[Angela Campbell]

You must also understand that the drugs used for HRT are being used "off label"...that is not according to the use indicated by the manufacturer. This alone is cause for some physicians to be concerned about liability issues. Failure to follow a standard of care and off label use of a drug would be a very risky thing for a Dr. to do.

Yes some may, but probably not many.

[NCAmazon]

Ok,

I all I know is There are well known popular centers where you can make an appointment, do a 30 minute interview, then blood test, and get hrt the next week. Whatever rules they follow who cares, Some are even government funded.

[Rianna Humble]

This sounds like typical tabloid scare-mongering. It may be true that in isolated cases where the medical history justified it, a patient could be prescribed Hormone Therapy without going through extended evaluations, but that does not make it standard practice.

In general, the sort of thing that you have generalised might apply to someone who has already been self-medicating (as was the case with one of our members) but that does not absolve the doctors from their responsibility, in fact it heightens their responsibility because they need to be able to demonstrate why they went outside standard practice.

This has nothing at all to do with the false dichotomy created by opposing informed consent to standards of care.

[Angela Campbell]

I imagine so. There have been several threads about the roles of gatekeepers on here, and my opinion of them is they are just as much to protect the medical community from liability as they are to protect you from yourself. This is why Susan is having a difficult time finding a Dr. who is willing to bypass the SOC.

To the best of my knowledge the SOC 7 is the latest standard, and the vast majority of healthcare providers will want to follow this.

[LeaP]

Standards of care are assumed in the informed consent model in many places. In English law, a rule titled the "Bolam Test" is applied when assessing negligence.

See:

http://www.oxfordreference.com/view/10.1093/oi/authority.20110803095515879


In the US, it varies by jurisdiction as to whether the point of view taken as to sufficiency and materiality of knowledge is from the physician's or patient's point of view. This is an excellent presentation of how complex it gets when the "subjective patient" point of view is taken.

http://www.aans.org/Education%20and%20Meetings/CME/~/media/Files/Education%20and%20Meetingf/Ethics%20Module/13InformedConsentModuleWTC35.ashx

Away from legalities, the following is a very detailed discussion of the ethics surrounding informed consent.

http://plato.stanford.edu/entries/informed-consent/#Cog

[SusanLaine]

Actually, I'm not having any difficulty finding a DR who will let me sign an informed consent doc and then proceed with HRT. I read the guidelines and spoke directly to a number of TG medical professionals. The notion that we must have therapy in order to treat our bodies is not only old fashioned but outdated and just plain ridiculous.

[Angela Campbell]

I hope it works out well for you! :)

[LeaP]

I'm incredulous at your dismissing the depth of information in this thread's responses with subjective terms like "old fashioned," "outdated," and "ridiculous."

Do let us know when you're prepared to have an exchange based on facts.

[SusanLaine]

sorry, unless there were TS/TG knowledgeable doctors or other medical professionals WITH hard facts on this thread then we're all just voicing our opinions aren't we? I see many of these "old fashioned" rules and regulations as little more than CYA on the part of many doctors - not all of course - but many. I can make my own decisions about my own body thank you very much.

Anyway, I found plenty of HRT informed consent doctors who don't need any letters and so I''m on my way, thank you for all the advice and comments - agree or disagree - I love a lively discussion. :-)

[Angela Campbell]

I am sure you can find a doctor who does not follow the internationally accepted and current up to date standards of care. I certainly wouldn't trust my health to one, but good luck to you.

And all the "opinions" I stated are from files and links provided to me from two Dr's. One a clinical psychologist and the other a medical Dr. The information I provided is not old fashioned it is the currently used standards that those who follow the APA and WPATH standards follow.

Your original post inquired about Dr.'s who follow the latest guidelines. We provided information on what the latest guidelines are and you seem to reject them.

Have you asked any of the Dr's you approached if they are familiar with WPATH? Do you intend to transition and get SRS? I do not think there are any reputable Doctors who will do that without letters and assurances the standards have been met.

There is a lot more to it than HRT.

[Cheryl123]

Some of the disagreements here seem to come from not being clear about the Informed Consent Model as opposed to the Standards of Care Model advocated by WPATH. WPATH favors SOC but they also recognize the validity of the Informed Consent Model.

This is how WPATH compares the two:

"The difference between the Informed Consent Model and SOC, Version 7, is that the SOC puts greater emphasis on the important role that mental health professionals can play in alleviating gender dysphoria and facilitating changes in gender role and psychosocial adjustment. This may include a comprehensive mental health assessment and psychotherapy, when indicated. In the Informed Consent Model, the focus is on obtaining informed consent as the threshold for the initiation of hormone therapy in a multidisciplinary, harm-reduction environment. Less emphasis is placed on the provision of mental health care until the patient requests it, unless significant mental health concerns are identified that would need to be addressed before hormone prescription."

The Informed Consent Model does not involve going to some shady doctor who issues a prescription on the spot. Again WPATH explains the process:

"Screening for and addressing acute or current mental health concerns is an important part of the informed consent process. This may be done by a mental health professional or by an appropriately trained prescribing provider (see section VII of the SOC). The same provider or another appropriately trained member of the health care team (e.g., a nurse) can address the psychosocial implications of taking hormones when necessary (e.g., the impact of masculinization/feminization on how one is perceived and its potential impact on relationships with family, friends, and coworkers). If indicated, these providers will make referrals for psychotherapy and for the assessment and treatment of coexisting mental health concerns such as anxiety or depression. "

There are scores, perhaps a hundred or more, transgender clinics and doctors specializing in transgender care in the US who follow the Informed Consent Model. Some (such as Callen Lorde in New York ) are recognized as leading authorities in providing care for the transgender community.

The model is less rigid than SOC. For example it allows social workers to become advocates for clients as opposed to having therapists acting as gatekeepers. It's also less expensive for clinics to implement and tends to reach a greater number of those in need of care. The Informed Consent Model has become more popular with clinics (but maybe it is unfair to call SOC old fashioned!)

[LeaP]

This is a difference in emphasis. What is being left out is the training and qualifications needed by those doing the screening. It may indeed be a nurse or doctor, but the guidelines call for the following (the section VII referred to in your SOC cite). I have little doubt that a clinic like Callen Lorde has scads of qualified staff. The average doctor, however, has NONE of these.




"1. A master’s degree or its equivalent in a clinical behavioral science field. This degree, or a more advanced one, should be granted by an institution accredited by the appropriate national or regional accrediting board. The mental health professional should have documented credentials from a relevant licensing board or equivalent for that country."

"2. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Diseases for diagnostic purposes."

"3. Ability to recognize and diagnose coexisting mental health concerns and to distinguish these from gender dysphoria."

"4. Documented supervised training and competence in psychotherapy or counseling."

"5. Knowledgeable about gender-nonconforming identities and expressions, and the assessment and treatment of gender dysphoria."

"6. Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.

"In addition to the minimum credentials above, it is recommended that mental health professionals develop and maintain cultural competence to facilitate their work with transsexual, transgender, and gender-nonconforming clients. This may involve, for example, becoming knowledgeable about current community, advocacy, and public policy issues relevant to these clients and their families. Additionally, knowledge about sexuality, sexual health concerns, and the assessment and treatment of sexual disorders is preferred."

[Angela Campbell]

Again WPATH explains the process:

"Screening for and addressing acute or current mental health concerns is an important part of the informed consent process. This may be done by a mental health professional or by an appropriately trained prescribing provider (see section VII of the SOC). The same provider or another appropriately trained member of the health care team (e.g., a nurse) can address the psychosocial implications of taking hormones when necessary (e.g., the impact of masculinization/feminization on how one is perceived and its potential impact on relationships with family, friends, and coworkers). If indicated, these providers will make referrals for psychotherapy and for the assessment and treatment of coexisting mental health concerns such as anxiety or depression. "



Pretty much sounds like the WPATH SOC to me.

[LeaP]

It IS in the SOC V7 document. All the cites are.

My point is that informed consent doesn't replace screening. That screening should only be performed by someone trained and qualified to do it. There is NO intent to eliminate it. The SOC changes do change the former gates around letters and time under assessment, but not in favor of letting unqualified people making the assessment, and, moreover, the cites apply only to hormones administration.

Surgeries still require full-on assessment and documentation, 2 referrals, 12 months minimum HRT, and RLE. "Conventional" informed consent as to understanding risk still applies, but:


"Genital and breast/chest surgical treatments for gender dysphoria are not merely another set of elective procedures. Typical elective procedures involve only a private mutually consenting contract between a patient and a surgeon. Genital and breast/chest surgeries as medically necessary treatments for gender dysphoria are to be undertaken only after assessment of the patient by qualified mental health professionals, as outlined in section VII of the SOC. These surgeries may be performed once there is written documentation that this assessment has occurred and that the person has met the criteria for a specific surgical treatment. By following this procedure, mental health professionals, surgeons, and patients share responsibility for the decision to make irreversible changes to the body."