Overdue Update, on Electrolysis, Surgery, Insurance, and Boobs

"The boob fairy never came for me
No the boob fairy never came for me
Look, I wasn't wanting melons, just a cute curvaceous "B"
But the boob fairy never came for me."

-- Deirdre Flint, The Boob Fairy

I know this is where I'm supposed to make some excuse about why I haven't been updating for the last three months, but I've got nothing. Well, I've got a few things, but they're empty excuses that don't really matter in the long run. It's probably best if we all just move on and pretend that nothing happened. =P

Electrolysis continues. I've now logged just over 8 hours on my face, and 15 down below (and spent about $1,200 on it). I saw my physician for a checkup back in August and finally asked for lidocane/prilocane numbing cream, which she was happy to prescribe. In general, the numbing helps a ton, especially on my upper lip, but there are certain areas I'm not so sure about.

The cream only numbs the top layers of skin, and in a few spots this has the strange effect of removing most of the pain, but not the itching. With the top layers numb, scratching does absolutely nothing, and I end up wanting to crawl out of my skin by the time she's done. At least without the cream, the pain from each successive zap helps relieve some of the itching from the previous stabs.

It helps my mental well-being to think about the time until surgery in terms of how many electrolysis sessions I'll have in the interim. Assuming that I continue with my current schedule of two weeks between sessions, and that I stop around four weeks in advance to allow the skin to fully heal, I only have six more sessions before surgery! Contrasted with the 17 sessions I've already endured, I think I just might make it with my sanity intact.

Yep. Surgery is less than four months away (if I haven't established, I'm definitely waiting for the official date of February 22nd), and once again it's all I can think about. Honestly, damn this wait!

For the longest time I racked my brains over whether or not I even wanted surgery, then whether or not I was ready, whether we could save the money, what surgeon to go to. It seems unfair that the seemingly interminable year-long wait could only happen after these decisions were made. At this point, I check the countdown calendar on the right side of my blog constantly. I'm ready to move on now... please? =P

Still, the year since scheduling is more than two-thirds over. I just hope the days fly by faster as the date approaches, and not slower.

Saving is going well, and I'm pretty sure we have the funds secured, but I've been stressing over money a lot lately. All I can think about is what else we could be spending $20k on, like truly starting our married life together. I've recently been having dreams that insurance pays for it, and suddenly we have enough to put a down payment on a house, buy furniture, take a vacation.

Erin is amazing for taking this all in stride. I also appreciate all my friends for putting up with me repeatedly doling out the same tired excuse: "I want to, but I can't. I'm saving for surgery." If you're sick of hearing it, believe me when I say that I'm sick of saying it, too. I think the fact that I've never had to pretend to be broke for this long is affecting me, though. I'm definitely a child of the consumer age, and I miss spending money on stuff.

On that note, I'm trying really hard not to count any chickens just yet, but it's looking like I probably will be able to get insurance through work that will cover my reassignment surgery. It's insanely exciting, and hopefully I'll have more details soon. Fingers and toes crossed!

Speaking of doctors and insurance, I also saw my endocrinologist not very long ago for a yearly renewal, and to discuss my pre- and post-surgery hormone regimens. Female hormone replacement pills are known for increasing the risk of thromboembolism (traveling blood clots), so most surgeons, including mine, require patients to reduce or stop taking hormones a few weeks before surgery. My endo suggested that I wean myself off slowly, to reduce the inevitable hot flashes and moodiness. Though I'll resume estrogen and progesterone after surgery (and for the rest of my life), I'm definitely looking forward to never needing to take testosterone-blockers again. =D

She also gave me the regular blood work, to check my hormone levels, but apparently she forgot my insurance situation and coded it under "psycho-sexual disorders". My insurance will have none of that, and denied the claim, so I recently got a bill for $400 worth of blood tests. =(

I've talked to the hospital and asked them to change the coding and try again, but I'm nervous that the damage has already been done. A friend of mine recently tried to claim her SRS through the same insurance (SelectHealth), and after denying her, they also decided to start denying anything and everything else that they could claim was related, whether it actually was or not. Hopefully the re-code on my blood work will pass through, and that's the last I'll hear of it, especially since I'm planning to switch insurance ASAP.

Last, but not least, I've been doing a lot of ruminating about possibly getting a breast augmentation. It's something that's been in my head for a long time, but something that, for a few reasons, I haven't really talked about. It's odd to me that I find it fairly easy to disclose all sorts of information about my transition and body, but not so easy to talk about this one thing.

To be honest, I have some self-esteem issues around my body. I still pad my bra, and though I know that's not that strange, I guess I just want to feel like I can have more confidence in my image, without having to think about it daily.

Even though putting it that way makes perfect sense to me, I still feel guilt around the subject. I suppose I view SRS as simply necessary, but implants have been socially drilled in to my brain as being purely superficial. Well, sure, they are superficial, but we live in a superficial world, and if that's what it takes to make me feel comfortable in my own skin, then I should probably stop feeling guilty and do it.

Updates on Electrolysis, Surgery Prep, and the HRC CEI

"Easy now, hush, love, hush;
Don't distress yourself, what's your rush?
Keep your thoughts nice and lush;
Wait.
Hush, love, hush, think it through;
Once it bubbles, then, what's to do?
Watch it close, let it brew;
Wait."

-- Wait, Helena Bonham Carter as Mrs. Lovett (Stephen Sondheim's Sweeney Todd)

The updates are slow(er than usual), because life is simple and relatively routine. That's probably a good thing.

Another two hours of electrolysis down. I've started doing sessions every two weeks, instead of one, to allow some time for the dormant hair to cycle back in. We're still doing about 30m at the beginning of each session to re-clear my face, and the rest of the time on the lower area. So far I've logged just under 5 hours on my face, and about 6 hours down below. My electrologist still leaves the room while I change in to the towel skirt thingy, but it seems like a silly ritual at this point. All other pretense is gone, and she doesn't even pretend to keep me covered any more. =P

My insurance won't cover a physician checkup until August, so I'm still managing the pain with just an Ibuprofen or two, but I'm considering calling to ask if my doc will prescribe some EMLA (numbing cream) over the phone. Some electrolysis sessions, I feel like I can take about anything, and I almost fall asleep while she's working. Other days, the pain consumes me, and I start getting visions of that one Fight Club scene ("I tried not to think of the words 'searing', and 'flesh'." "Stop it! This is your pain."). =P

Speaking of surgery prep, I've still got a lot to do in the next few months. Besides electrolysis, I need a psychological evaluation and two letters of recommendation from therapists (one being a PhD/MD), I need to get HIV testing, and I need to work with my endocrinologist regarding my pre- and post-op changes to my hormone regimen.

The most pressing of these is probably the letters. My primary therapist has agreed to write the first, but I'm having a hard time finding someone with a degree and familiarity with GID to write the second letter. I've been calling various people suggested by trans friends, with no luck so far. I'm sure I'll find someone to write it; it's just another thing I want to get out of the way. =)

As I mentioned before, my set SRS date is in February 2012, but I'm on a cancellation list for November. When I scheduled, there were a lot of personal advantages to having my surgery done in November, but those pros are slowly being overwhelmed by the possible advantages of waiting until the scheduled date in February.

The Human Rights Campaign (HRC), a major organization focused on the advocacy of BLTG rights (you've probably seen their bumper sticker logo: a blue square with a yellow "=" sign), releases a Corporate Equality Index each year. Basically, companies volunteer to send in a survey and information about their TGBL-related policies, and HRC scores each company on a 100-point scale. My employer has consistently gotten 100 points each year that they've participated (2009, 2010, and 2011).

As of 2012 however, HRC is changing the criteria by assigning 10 points for having trans-inclusive benefits-- health insurance that covers GID therapy, hormones, surgery, etc. Since my company seems pretty proud of their CEI rating, I've informed the powers-that-be that we are in danger of losing our 100, unless they add an inclusive insurance option by the end of this year. They definitely listened, but I probably won't find out what they've decided until around November. It's an off-chance, which is why we've been saving and planning for paying for it ourselves. But as the date approaches, waiting three more months for even a small possibility of saving twenty-thousand dollars is sounding more and more worthwhile.

We've also found out that Erin isn't eligible for family medical leave through her work until she's been there for a year, which will occur in January. She gets 40 hours of PTO a year, and at the moment, she has to save every minute of it to be able to go to Cali with me in November, which really isn't fair to her. Finally, waiting until February means the date is no longer uncertain, and gives us that much more time to settle the funds.

I was really looking forward to November, but logic dictates otherwise, and I think (hope) I can deal with waiting just a little longer.

By the way, if you want to see the CEI ratings, here are the 2011 results (ratings start on page 38):
http://www.hrc.org/documents/HRC-CEI-2011-Final.pdf

And a few previous years:
http://www.hrc.org/documents/HRC_Corporate_Equality_Index_2010.pdf
http://www.hrc.org/documents/HRC_Corporate_Equality_Index_2009.pdf
http://www.hrc.org/documents/HRC_Corporate_Equality_Index_2008.pdf

Does your company participate? What's their rating?

New Doc, New Meds, New Prescription Madness

"You kn-kn-know what I want!
Gimme more. Gimme more.
Pretty please, a prescription!"
-- Mindless Self Indulgence, Prescription

I usually avoid talking very specifically about my body, but this is pretty limiting in a transition blog. Physical changes are a huge part of my transition, and if any place should be safe to talk about them, it should be here... I just worry that I'll make other people uncomfortable. Since I've really got to stop worrying so much about other people, I'm just gonna give you a heads up: I will talk about my boobs. There, I've said it. Whether you know me or not, if you think you might be uncomfortable with me talking about anatomy, nobody will blame you for ducking out. =P

As usual, I've waited far too long to talk about what's going on in my life, and I've got quite a backlog, so let's catch up on hormones. =)

My first endocrinologist sucked, so about four months ago, a month before my hormone prescription ran out, I decided to look for a new doc. I had three goals in mind: find someone who cares, is in my insurance, and prescribes *progesterone. I got a big list of endos and ratings of said endos from various trans friends, then narrowed it down by insurance, and started making calls. The only one within my plan that was taking new patients however, was only accepting referrals from a primary care physician. The good news was that there was a PCP in the same office that works closely with the endo. The bad news? The physician was booked about a month out, and the endo three months. =/

*(Progesterone is a primarily female hormone often prescribed as part of both post-menopausal and transsexual hormone replacement, but many docs are afraid of it, because some synthetics have been known for nasty side-effects, and its full effects on development aren't well known. Progesterone is key in breast development, among other things, but there is still a lot of disagreement as to how much is gained, and which meds, if any, benefit trans-women the most. Part of the problem is that most of the data comes from post-menopausal women, and broad testing with trans-women is virtually non-existent.)

Since I wouldn't see the new endo for a while, I called my old doc to ask for an extension on my prescription, and she told me that she would grant it, but never followed up. Fortunately, my appointment with the new PCP was just a few days after my prescription expired.

The new physician was awesome! She listened, she answered, she genuinely cared. I know, weird, right? She even chatted with me excitedly about my (then) upcoming wedding, and gave me a three month extension to last until I could see the endo. About a month later, when I went through my legal name/gender change, she was also nice enough to write up a letter of recommendation for me to present to the judge.

When I finally saw my new endocrinologist, she was just as cool. She was extremely enthusiastic in getting to know me and explaining things to me in detail. Before I could even bring up the progesterone, she asked, "How's your breast growth?" I explained that I'd had some growth spurts in the beginning, but nothing much since then, and she immediately followed up with "We should get you on progesterone!" =D

Of course, there's always a hitch. To save myself from having to go in at different times for different prescriptions, I waited for my other two to run out before filling the progesterone. When I did, the pharmacy informed me that I could now get three months of the spironolactone and estradiol, but that my insurance would only let me get one month to start on the progesterone. That seemed reasonable, but when I got home, I realized that they only gave me half my normal dose of spiro. It turned out that the new endo had accidentally prescribed it wrong. =/

Unlike with my old endo though, I was actually able to get a hold of one of the new doctor's staff, and they immediately sent a correction. The pharmacy then told me that I should just take the spiro at the correct dosage, and that they'd get it corrected at the 45-day marker when my supply is gone.

Last night, I called in a refill on the progesterone, but when I picked it up, they said they only had enough for 5 days, and that they'll call me in the next few days when the rest is available. I also asked them about the spiro, and they told me that they'll probably just refill for three more months when I run out.

So now, even though I'm getting meds for three months at a time, I had to go in yesterday for the progesterone, I'll have to go back in a few days for more progesterone, then back in two weeks for the spiro, again 45 days later for the estradiol, and repeat. Despite my efforts, my three prescriptions will never be on the same schedule again. *sigh*

Anywho, I've now been on progesterone for one month, and I've definitely noticed a few effects. Like with my first hormone post, I'll just present the evidence, and let you decide what's unrelated/psychosomatic and what's not. =P

• My breasts have been tender and itchy almost constantly for the last month, which indicates growth to me. This is basically what it felt like off-and-on when I first started hormones. Their shape has also rounded out a bit, and they look more natural.
• I've noticed some skin changes, and the weirdest thing, the tattoo on my back sometimes "raises", and I can feel bumps where the lines are; when this happens, it's also itchy.
• My skin is a little more oily, and I've gotten a few more zits than usual.
• My anxiety is back, which is odd, because progesterone is supposed to be calming. Of course, this could easily be due to a lot of other things going on, too. =P

I really haven't experienced any extreme side effects so far; the acne is a little annoying, but hopefully that will fade after a few months, as it did when I first started on hormones. Otherwise, med-related things are going pretty hunky-dory, and still far better than when I had to deal with my old endo. =)

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.