Friday, February 5, 2010

The Standard Process and Substandard Care

"One pill makes you larger,
And one pill makes you small,
And the ones that Mother gives you,
Don't do anything at all."
-- Jefferson Airplane, White Rabbit

I've been on hormones for a bit over six months now (wooh-hooh!), and you aren't taking them away from me. Ever. Unless I run out, and my dumb doctor and pharmacy can't coordinate to save their lives. Ugh.

For those that don't know the process, maybe I should start with the basics. Transsexualism is interesting in that it has both psychological and physical sides to it, maybe we'll get in to that more at another time. Decades ago, many tried "curing" it psychologically, which usually turned out badly. Nowadays, it's generally accepted that it's much more healthy to treat the body to match the mind, rather than the other way 'round. Sure, you run a few minor health risks, but a lot less people are killing themselves.

Eventually, the medical community adopted a semi-standard set of treatment guidelines, which are called the WPATH-SOC (World Professional Association for Transgender Heath - Standards of Care), formerly the HBIGDA-SOC (Harry Benjamin International Gender Dysphoria Association - Standards of Care, after a German doctor who did a lot of work to help transsexuals in San Francisco in the 50s and 60s).

The SOC has a lot of good information in it, but the main effect it has is to limit most physical treatment to those who have gone through psychological counseling and received a letter of recommendation for treatment. For hormones, usually a therapist will require three months of counseling before giving you "the letter," and for major surgeries, a year of being "full time" (living as your preferred gender socially, usually including work and/or school).

This makes sense on some levels, because it limits treatment to those who are serious and ready, but it also causes a lot of problems. Some people don't have money for therapy, especially since most insurance companies have specific exclusions for Gender Identity Disorder in their policies. Some people are perfectly well adjusted, and feel they shouldn't be forced to undergo mental therapy for something they've already figured out. Finally, some therapists are just bad, and either ignore the SOC completely, or get a gatekeeper complex and go on power trips, withholding letters and making trans people jump through unnecessary hoops.

Without the SOC, support from the medical community would probably be a lot harder to find, so I think of the Standards as a necessary evil, though it would be great for us to work out a more ideal solution some day.

Personally, I didn't mind starting with some therapy. The cost thing sucks, but my therapist is awesome. Since I am relatively well adjusted, I only went in every couple of weeks until the three month marker, when she gave me the hormones letter, and now once a month.

I took the letter to the endocrinologist she recommended, who first requested blood tests to make sure giving me hormones was safe. She then gave me a prescription for six months, with a plan to do follow up work before renewing at six months.

A couple of weeks before the six month marker, I had an appointment with my doctor, who gave me instructions to:
1. - Get new blood work done.
B. - Leave a message on her answering machine, telling her when to call me so that we could discuss the results.
Three. - Have my pharmacy fax a prescription refill request to her.

By the way, she also mistook me for a FtM at first, asked if I'd had a pap smear done, and received confused looks in response. I'm still not sure what to take away from this one besides a good laugh.

I went to IHC to get my labs done, so that I could at least have that covered by insurance. The next week, I left a message giving the doc a few days of wide open time in which to call back. No call.

I asked my pharmacy to send the refill request, and I left another message with another wide open time frame. No call.

I ran out of pills, so I called my pharmacy to check on the status of the request, to which they replied, "She declined it, because she wants to discuss your labs." SO DO I!

I left a third message, and a few days later she finally called me back, but I missed the call because I'd gotten sick. She leaves a message that says "Have the pharmacy fax over another request, and here's my pager number."

I have the pharmacy send it again, and leave a message on the pager. Two days later, on Saturday of all days, she calls me again. "Your labs look fine, I'll approve the fax request, but I haven't received it." Ok, ok, ok, I know you probably couldn't tell me about the labs in a message because of patient confidentiality and all that, but couldn't you approve the request, and then mail the results to me? That is, if you can't be bothered to do your job and call me.

And what's this about not receiving the fax? I confirm with the pharmacy that they have the right number, they send it a third time, and finally get a response. My spiro is renewed for five months, and my estradiol for one month. Wait, what!? The pharmacy says they'll call the doc to work it out. "Good luck with that!" I say, but by some miracle, they fixed it that evening, and both are now for five months.

I'm still confused as to why five, instead of six, but I don't care anymore. Once this is up, I'm likely finding a new doctor anyway.


  1. You really should find a new doctor.

    -- Eric Sophie Gingell

  2. Sending a hello your way and definitely digging the blog. :]

    With your doc, that sounds obnoxious, but maybe (s)he's just trying to be careful and making absolutely sure your lab results are in before proceeding? Hopefully?

    With the standards of care, I agree with you that not having them would be a big problem. Before they came along, it was hard to find a country that offered any safe or legal medical options for trans people. A lot of places even outright criminalized cross-gender behavior.

    BUT, I'd personally prefer if the standards of care would upgrade with the times more quickly. The requirements are way too strict and not applicable to a lot of trans-people, especially those who are genderqueer.

    Or that "real-life experience" shindig, where you're supposed to live in the "role" of "man" or "woman" (wtf?)? It often ends up being both mentally harmful and physically dangerous for people. :(

  3. Hi again, and thanks! You too. =)

    RLE has always confused me as well. Being a man, woman, or in-between is interpreted differently by everyone, cis or trans, so what defines "living as my chosen gender"? Is it the clothes I wear? The way I talk and act? Asking everyone to use a new name and pronouns?

    How does a therapist measure if my combination of traits is satisfactory to them, when the point is for me to be satisfied with myself? It seems so arbitrary.

    /rant =P