Going to the doctor?

I have been asked to write a science book for doctors and other providers to help treat transgender patients. So naturally, I have been studying up on the current state of provider-transpatient encounters. Providers include mental health counselors, primary medical, surgical medical, endocrinology specialists, and nurses. Do not take any of this post as medical advice, but I hope to convey what I think is going on out there and give you my opinions. This post consists of three sections (1) State of provider education, (2) State of healthcare for non-transitioning transgender people (3) State of healthcare for transitioning transgender people.

(1) Provider education is still spotty. In the past, most provider schools provided only a few hours of instruction in the entire LGBT curriculum. That has improved a little but there is still contention over whether it should be provided as one block or distributed over the broader curriculum. Short courses for Continuing Education Credit are now provided by WPATH and other organizations but are still disorganized. I went to a WPATH course here in Atlanta as an APA representative and found that the objectives were vague, the presentations rambling and most of the takeaways could be found online (like how to write a letter in support of transsexual genital plastic surgery.) The notable exceptions were two sessions on endocrinology by Vin Tangpricha who, fortunately, is the WPATH President-elect. I attended this CEU course with several Department of Defense (DOD) providers who were preparing for the Obama implementation of transgender treatment in the military. Since they were accustomed to courses from the DOD which uses the best training methodology available they were generally appalled as I was by the quality of the course. Because of competition with other training providers, I am sure that it is improving.

Left hanging from the WPATH CEU training was the recommendation that providers should “intern” for 6-12 months with an experienced provider of transgender treatment. As far as I can tell, no large-scale program currently exists to accomplish this. It is not something you can apply for when coming out of med school like you can for internal medicine, cardiology, or surgery.

You will not see certificates for transgender specialization on provider walls. Many doctors are “board certified” in, say, internal medicine, OB-GYN, or other specialties which take considerable time and effort. There are no recognized transgender specialties or certifications in any of the provider disciplines, yet. I guess they can hang their WPATH CEU certificate but that is only a 3-4 day course.

Essential point—while the provider schools are trying to catch up with instruction on evidence-based treatment of transgender people, most are not there yet.

(2) Non-transitioning transgender people make up about 90% of us. What should these folks do when they go to see providers? Many still express their transgender behavior in secret because of fear of rejection by family, work, or social contacts. Some are part-timers who go to support groups or just go out occasionally. I am sad to say that some take sex hormones without provider supervision or prescriptions. This is dangerous, but not rare. I recall that Virginia Prince took HT even though she rejected transsexual transition.

First you should know that there are two types of treatment (1) “medically necessary care” such as found in emergency rooms and (2) routine and elective treatments.

There is still a Federal law requiring providers to give “medically necessary” care, although the trend is to gut the ACA provisions requiring a provider to treat transgender people. Many states seek to pass “religious preference” legislation. You cannot be rejected for treatment in an emergency situation. But in the past, many transgender people would not tell the staff in the emergency room or providers that they were transgender out of fear of rejection, embarrassment by the staff, or patient families finding out. And the fears are real. There are numerous horror stories about provider rejection; joking, bantering, and snickering between staff members; and families being told about their loved one being transgender or reading the patient’s chart. And the horror stories are likely to continue with the current encouragement of anti-transgender political leaders. Providers are people too, and they can be ignorant and hold prejudices about transgender folks. I have found no statistics on the frequency of prejudice among providers.

So, the question is, should you tell the providers about being transgender? You must weigh potential exposure versus your survival and well-being. If you think it is relevant to your staying alive or correctly diagnosing your ailment or if they ask, in my non-medical opinion, you probably should tell them. Recent studies indicate that 90% of doctors will not ask, but only 10% of transgender people refuse to tell their doctors.

There is also a new cloud on the horizon termed the transgender broken arm syndrome in which inexperienced providers try to blame all your ailments on your being transgender. You may just need stitches but they will blame everything -– from mental health problems to broken arms on being transgender. Providers are also sometimes over curious and want to retain transgender people longer than necessary to try to understand us and experiment with us. Not being knowledgeable about evidence-based treatment of transgender people, they may try to “cure” you.

In some emergency situations, you may simply have to trust the provider and his adherence to the Hippocratic or the Nightingale pledge (for nurses) or similar ethical rules to help people. I recently picked up an anecdote about a med student who asked what he should do if it was against his religious convictions to treat a transgender person. The instructor’s response was immediate “then, you should find another line of work.”

You might be fortunate and find a provider in emergency situations who knows something about being transgender. Do not be surprised if they ask you if you have attempted or are contemplating suicide. The attempted suicide rate for transpeople is around 40% and those include just the attempts that we know about. Studies have shown that if providers ask about whether you intend to commit suicide it will have no effect on whether you actually follow through. So, the provider is doing the right thing based on evidence-based medicine.

Outside of emergencies, many transgender people report negative provider encounters including rejection, physical assault, misgendered, or sexual assault. In the past, 65% report that transgender people had to teach providers about being transgender. Providers may have the right to reject serving you if you are transgender, citing religious or moral grounds depending on the law. But if it is not an emergency, why would you want this type of provider to treat you, anyway? If you can, take your business elsewhere and make sure that provider’s reputation is not clean. You can complain to licensing boards, hospitals, and clinics. Better yet, check with local support groups to see which providers are trans-friendly or trans-hostile before you make an appointment.

When I first got to Atlanta in 1999, I did not know anyone in the local LGBT community but did know that I needed a mental health counselor to deal with potential, and later, real transphobia. I was okay with my wife — she knew all about me being trans but also knew that the hoity-toity of Atlanta would not approve. So, I went counselor shopping. I first went to a pure Freudian who never said a thing. She just listened, or at least I thought she was listening! I called her the “Ice Maiden” and I continued shopping for counselors. Next was a cognitive therapist who told me that my crossdressing was because I missed my mother and wanted feminine clothing to cling to, like the blanket Linus carries. He wanted to teach me cognitive behavior techniques and I wanted to get out of there ASAP. I found the next provider by joining an Atlanta transgender Yahoo discussion group. This one was a winner. She was the first counselor that I found that actually knew something about being transgender and we worked together for several years until she retired. I still keep in touch.

(3) What about transgender people who are transitioning? They should definitely find trans-friendly and trans-knowledgeable providers (mental health, MD, endo, surgeons). Again, local support groups and PFLAG are your best bets for provider references (but also such things as where best to change name and sex markers.) One group I belong to has a “double secret” (homage to Animal House) website with listing of providers who have been vetted. Providers should have training and specific experience with transgender people including WPATH CEU training (such as it is). If they have done an internship with an experienced transgender provider, that is a plus. But many providers are willing to treat you without training or experience about being transgender and you should avoid them.

The providers you need may not be in your local area. There is an increasing capability to use secure teleconferencing to communicate remotely with providers. One typically has to see the provider at first in person, which may mean traveling the first time. But after that, a lot of work can be done over the Internet. After my counselor retired we did this cross-country for several months when she was in Washington State and I was in Atlanta. A pioneer in this area is Dr. Isabel Lowell in Atlanta who runs a very good gender clinic with connections to the providers many need. Izzy’s clinic and use of telemedicine for trans treatment was recently featured in NPR for its innovation.

Although some transgender transitioners are still secretive, the ability to use stealth after transition got increasingly difficult after 911 when identification papers rules tightened. Many are now proud of their transition and wear it on their sleeve. If you are on HT and you have to go to the emergency room, in my non-medical opinion, you should provide information on all your meds. HT medications may have interactions with other meds or may conflict with diagnosis. For example, if you are taking spironolactone, a doctor may need to investigate dehydration or too much potassium because spiro as well as being a testosterone suppressor is a potassium-sparing diuretic. I had a bout with dehydration from spiro and my doctor decreased my dosage. He said it is common as we get older. Transsexual women need to be on guard for blood clots although since providers changed to prescribing estradiol valerate (from the previous ethinyl estradiol), this problem has been significantly reduced. Transsexual men on testosterone may have elevated red blood cell count which might be due to taking testosterone. Red blood count should be routinely monitored and can be easily treated if elevated but it may screw up diagnoses.

I must admit that on one occasion when I was in an ER for a minor cut that I did not tell the providers that I had just started HT. I did not want that on the hospital computer system because too many family “friends” had access. They fixed me up with some medical superglue and I was out of there without a problem. It probably did not make a difference but who knows, there might have been complications. That was several years ago. I would do things differently now.

Some transitioning transgender people include plastic surgeries in their plans. Here I am guided by the old saying “in matters of art the best is not good enough.” And plastic surgery is an art. Recently there have been lots of plastic surgeons popping up who claim they know all about dealing with transgender patients but many do not really. So, beware, find someone with real experience in dealing with such things as facial feminization surgery, tracheal shave, and breast implants. People will see the results. The same popups are going on with transsexual genital plastic surgery (TGPS). Although the surgical model is “see one, do one, teach one” that does not apply to complicated operations like TGPS. One needs months, if not years of experience.

So, think over what you might experience in the future during provider-transpatient encounters. I want you all to be free to express your transgender behavior as much as you like but I also want you to be alive and happy.

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Tags: featured, health care, Transgender

Category: Transgender Body & Soul