Part 2: Medical
I will not pretend to be an expert about the specifics of trans health. This section is meant to simply bring up some possibilities to consider, and to provide links to other sites that are more qualified to give good health information. (As always, contributions are welcome!)
Contents of Part 2:
Section A: Finding a Good Doctor
Section B: Who the Heck Is Harry Benjamin?
Section C: Your Mental Health
Section D: Hormones, Hormones, Hormones!
Section E: Surgery
Perhaps if you lived in Big City, USA, you could take a stroll down to your local LGBT health center, or maybe the Gender Diversity Center, and sign up for a knowledgeable, experienced, open-minded, non-judgmental physician specializing in transgender patients. In Maine…well, it’s not quite that simple. There are several doctors in the state “experienced” in working with trans patients—though as to how one qualifies as “experienced,” your guess is as good as mine. I personally believe that the number of trans patients a doctor has seen is not as important as his or her willingness to learn about trans issues in order to provide you with the health care you need in a respectful, safe, and professional way. There are a few doctors in Maine who really do have many trans patients, and are very knowledgeable about transgender health issues. (There seem to be various lists of these doctors floating around, but some doctors don't want their information made public...email me if you need some names.) If finding a trans-knowledgeable doctor is not an option in your area, try to find a doctor who seems willing to learn about issues specific to trans patients that he/she might not be familiar with. Especially if you’re medically transitioning with hormones, you need a doctor to whom you can ask questions about your health. If a doctor seems annoyed, is disrespectful, or is too busy to take a few minutes and listen to your concerns, you can probably find a doctor who is a better fit for you. Trust your gut. You deserve respectful medical care. If you don’t feel comfortable with your doctor or nursing/office staff, etc., either talk to them about it to create a change, or find a new doctor.
Now for the insurance question…I’m not an expert in all the intricacies of how insurance plans typically work, and each plan can be different, so I don’t have any answers in this area. But some things to consider are:
The Transsexual Roadmap website has a section with some useful info about insurance issues.
www.trans-health.com is a website with many different articles about various aspects of trans health.
Also, as you probably are already aware, there is a myriad of information online about trans health issues. The internet can be an amazing and useful resource--just be careful to verify any information you find (sometimes websites can be very out-of-date and information has changed, or they might just be plain wrong).
Dr. Harry Benjamin (1885-1986) was one of the first doctors to specialize in treating trans patients. In 1980, the Harry Benjamin International Gender Dysphoria Association (now known as the World Professional Association for Transgender Health, Inc.) published their original "Standard of Care for Gender Identity Disorders," which became the most widely known set of standards used by health professionals who treat trans patients. Before the Standards of Care, there was no widespread consensus among doctors as to the most appropriate medical, psychological, and surgical treatment for trans people. Now in it's sixth edition, the Standards of Care are followed by doctors and health professionals all over the world.
Many members of the trans community criticize WPATH's Standards of Care as being too rigid and not allowing an individual to make informed decisions about his or her own health without having to follow steps that may not be appropriate or possible for that individual. For example, older versions of the SOC used to require a year-long "real life test," where a person had to "live" in their true gender before doctors would prescribe hormones. Of course, without hormones, it was nearly impossible for some people to "pass" as the gender that they wished to be perceived as. A catch-22. Though the SOC are now less rigid, the locus of control still lies with the doctor in determining a person's eligibility and readiness for treatment, not the patient.
The Health Law Project of the International Conference on Transgender Law and Employment Policy, Inc. has published an alternative Standards of Care, which seems to give the patient more freedom to make his or her own medical decisions. However, I'm not sure how widely used these standards are among doctors who treat trans patients.
For those of us falling
under the trans umbrella, life isn't always smooth sailing. Anyone
whose gender identity does not easily fit into the gender role that
most people expected them to fulfill at birth can probably identify
with the internal conflict, difficulties in relationships with family,
partners, coworkers, and friends, and social ostracism that many trans
individuals experience. All this can sometimes feel pretty isolating,
especially in a rural state like Maine where it may be difficult to
find other people with similar experiences. For many people, it can be
helpful to find a therapist knowledgeable in trans issues.
Choosing a Therapist
I've heard that Maine has the largest number of therapists (and lawyers) per capita! So finding someone should be easy, right? Hopefully it will be. Here are some things to consider:
Be aware of the different types of therapists out there and what their credentials mean:
licensed clinical counselors - LCPC - master's degree level clinicians who have completed a counseling internship and training/education in many facets of counseling theory and practice. Counseling uses the wellness model, which means that it is a collaborative process in which the emphasis is on the strengths already present within an individual--change occurs by helping a person build on the positive aspects of their life. This is in contrast to the medical/illness model, which views clients as having problems that need to be "fixed" by an "expert."
licensed drug and alcohol counselors - LADC - master's degree level clinicians who have completed a counseling internship in a substance abuse recovery setting - LADCs typically focus on substance abuse issues, but are trained to handle other issues that come up in the course of recovery
social workers - LCSW, possibly MSW - master's degree level - an LCSW has been trained specifically for clinical work, whereas an MSW may not have been. www.answers.com defines social work as "Organized work intended to advance the social conditions of a community, and especially of the disadvantaged, by providing psychological counseling, guidance, and assistance, especially in the form of social services." Social workers look at things from a systemic point of view (i.e. "what's going on in this person's community/culture/family/relationships/job/etc. that may be causing difficulty?") - they often work to connect people with appropriate resources in their community.
psychiatrists - M.D. - medical doctors - they have gone through regular medical school to become a doctor, and have chosen to focus on mental health concerns. Psychiatrists are the only type of mental health professional who can prescribe psychotropic medications. (Other than psychiatric nurse practitioners. Your primary care physician can prescribe as well, but PCPs usually don't have the degree of knowledge and training about psychotropic meds that psychiatrists do.) Because psychiatrists are doctorate level professionals, and are in high demand for medication management, they will most likely be more expensive to see than a master's level clinician, without necessarily having the same degree of training for counseling as master's level clinicians do.
psychologists - Ph.D.s or Psy.D. - doctorate level clinicians - There are many different types of psychologists; you're probably looking for a Clinical Psychologist or a Counseling Psychologist, who have been trained in assessing and treating mental health "disorders." Ph.D.s usually have an extensive background of doing research in graduate school, whereas Psy.D.s have more "hands-on" training in working with mental health consumers.
school counselors - master's level clinicians who specialize in issues specific to school counselors. They usually have many jobs--in one day they could fix students' class schedules, run a group for kids with anger management issues, do crisis intervention, and talk to a class about applying for the SATs. (some school counselors will also have an LCPC, which means they took additional classes in counseling beyond the requirements for becoming a school counselor.
pastoral counselors - state licensed pastoral counselors meet similar requirements to LCPCs and LADCs, master's degree level counselors - counseling tends to incorporate religious principles. Some religious organizations give certification for titles such as "Christian Counselor;" these types of counselors are unregulated by the state, and their training and qualifications vary.
others - To my knowledge, anyone without a criminal history who is willing to pay the application fee can become a "registered counselor." Educational and training requirements are unclear, and can vary person to person. [personal opinion - if a person is claiming to be a "therapist" and does not have at least a master's degree from a reputable institution, I'd be wary of working with them.]
If there is a -c or -cc after a clinician's credentials, this stands for "conditional," which means they've probably received their license in the past few years and haven't yet completed the requirements of becoming fully licensed. (for example, an LCPC-c must complete 3000 hours of counseling-related work in order to receive full licensure)
2. It's ok to "shop around."
There are a huge number of counseling theories that are very different from one another, and a wide variety of personality types in the counseling profession. So, if you end up seeing a therapist who never smiles and keeps making you move plastic dinosaurs around in a sand tray while s/he watches the clock, or makes you do "role plays" week after week even though you hate them, it's ok to try a different therapist. (Obviously, things aren't usually that extreme, but you get the idea.)
It's ok to make appointments for consultations with several therapists to find out more about what they do and get a sense of whether he or she can provide what you're looking for. (Sometimes, therapists don't charge for an initial consultation appointment, but find out before you go!)
If you leave your therapist--even if you've been seeing him or her for months--it doesn't mean that you did anything wrong (or that you think they've done something wrong)--sometimes people just don't work well together for any number of reasons. Remember, you are paying your therapist for his or her services. You are in charge; they are your "employee." If every time you went to McDonalds, they gave you a salad instead of the Happy Meal you ordered, you'd probably stop going, right? This is their job--they shouldn't be personally offended if you leave. [Note from a certain counselor who has been "stood up" many a time: Having said that, it's really annoying when someone makes an appointment and then doesn't show up--unless an emergency is happening. If you're not going to go, whatever the reason may be, just cancel!]
3. It's ok to ask questions.
If you ever get confused or don't understand something (from a technique a therapist is using to his or her billing plan), don't be afraid to ask! You have the right to understand what you're getting into. If you're taking about your huge fear of spiders one week, and the next week your therapist brings in a tank of big fury tarantulas, it'll probably be helpful to find out his or her reasoning behind that decision! You and your therapist should be partners in working towards your goals--if you often suspect that s/he is "hiding" things from you, or not letting you in on what s/he is doing, this is more like having a boss and lesser-ranked worker relationship. [Note: Counselors (and other types of therapists, I think) are required to have a "disclosure statement," which is a document explaining what their credentials are and how they do their work. It should also have information about payment and billing, and other info that would be good to know. If you have questions, and don't remember getting a disclosure statement, or have lost it, just ask for another one--it could be useful!]
In therapy, confidentially is of utmost importance. If you ever feel like your therapist might be breaking confidentiality in any way, ask what's going on! Sometimes it's difficult to question people who seem like "experts." But remember, nothing will change unless you talk about it.
Looking for a counselor?
I can provide referrals to therapists in Maine who have had at least one training on transgender issues, and/or have some experience working with transgender clients. Email me.
I also happen to be an LCPC-c, and you can find more info about me on my personal counseling page.
Getting "The Letter"
Although the Harry Benjamin Standards of Care no longer absolutely require psychotherapy before starting hormone treatment, the SOC's eligibility and readiness criteria make it difficult to proceed without having a letter from a qualified mental health professional. For example, part of the eligibility criteria are either receiving therapy, or documenting a "real-life experience of at least three months." But how exactly do you show this "documented real-life experience" without having someone to do the documenting? Furthermore, readiness criteria include: "(1) The patient has had further consolidation of gender identity during the real-life experience or psychotherapy; (2) The patient has made some progress in mastering other identified problems leading to improving or continuing stable mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis and suicidality; (3) The patient is likely to take hormones in a responsible manner." Of course, you could try telling the doctor that you are consolidated, sane, and responsible, but many doctors require a letter from a therapist that supports these statements. [see the Standards of Care in its entirety here. Follow the appropriate link at the bottom of the page.]
In the past (and probably still in the present), some transgender folks see this letter as an unnecessary hoop to jump through (therapy costs money; why can't a person and his or her doctor decide the appropriate course of treatment without the opinion of some mental health worker; and isn't this more of a hurdle for the sake of protecting the doctor from liability rather than actual concern for the patient?). These are all good questions, and doctors vary in how closely they follow the Harry Benjamin Standards, and whether or not they require therapy. However, if you have to document three months or so of seeing a therapist, this is not necessarily a bad thing. First, make sure you talk with the therapist to find out what exactly you need to accomplish or demonstrate before they'll write the letter, so you don't get any sudden surprises when you're expecting your letter. After you've confident that the therapist will help you, why not make the best of your time? As a mental health counselor, I'm probably biased, but I think that practically everyone could benefit from being in therapy. We all have certain aspects of our lives that could be improved, whether it's learning to decrease negative thinking, dealing with relationship or family issues, increasing self-esteem, or even something like learning to reduce your anxiety while taking tests. If an issue has anything to do with interpersonal relationships, or the way you think and perceive, chances are your therapist can help you find ways to work on it. I think it's too bad that many people are embarrassed to "be in counseling," or think that only crazy people see a therapist. It's sort of like if you had a knee injury, you could probably look online for physical therapy exercises and handle the whole thing yourself, or try to ignore the pain and hope it goes away eventually, OR, you could see a physical therapist, who has dealt with knee injuries before, and can help you decide what options are best for your particular situation. You probably wouldn't think you're being "weak" or showing lack of will power by consulting a physical therapist. You don't NEED to; you could live without seeing a physical therapist, but if you could, why not? It's the same with psychotherapy. Throughout our early years, most people develop thinking patterns that are unproductive to achieving a sense of wellbeing in our lives. Having a nonjudgmental objective person to help you rearrange the way you perceive yourself and/or your circumstances can be tremendously helpful.
So, if you're "required" to get some therapy before pursuing hormone treatment, try to look at it as an opportunity rather than a hurdle. You've waited this long in your life to start transitioning--another three months can seem like forever when you're waiting, but using those months to start working on any loose ends that need tying up could be very beneficial in the long run.
Disclosure: The previous paragraphs are the slightly biased opinions of a counselor who would have to find a new job if everyone decided psychotherapy is useless. :-)
The GID Diagnosis Dilemma
Gender Identity Disorder has been somewhat of a controversial diagnosis from its initial inclusion in the DSM III (Diagnostic and Statistical Manual of Mental Disorders- the "Bible" of diagnosis for mental health professionals) in 1980 to its current incarnation in the DSM IV-TR (Diagnostic and Statistical Manual, 4th edition, text revision). For a variety of reasons, critics say that GID should be changed, or removed completely, from the next edition of the DSM. They argue that the diagnosis is used to pathologize difference, and often leads to stigmatization and harmful “treatments” that aim to make individuals conform to a rigid socially constructed binary gender system. However, there are practitioners and researchers specializing in GID who believe that the diagnosis should remain and that the opposition’s criticisms are largely unfounded. Many individuals diagnosed with GID are also in favor of keeping the diagnosis, asserting that it would be far more difficult for many people to obtain services if the DSM diagnosis did not exist.
For more info on this matter, here is a paper on GID in the DSM that I wrote. (This is a Word document.)
The best way to get information about hormones (or anything medical) is to talk to a doctor experienced in treating trans patients. The internet is no substitute for expert medical advice! Keeping this in mind, there are several excellent websites containing comprehensive information about hormone treatment, including the following:
Before beginning any medical treatment, it may be helpful to be informed about WPATH's Standards of Care. Even if you disagree with the concept of having "experts" regulating your healthcare, these are the guidelines that many (and perhaps most?) doctors will follow when administering hormone treatment.
A FAQ about hormone treatment in general - http://www.sexuality.org/l/transgen/hormone.html
More information about the function of hormones - http://www.transgendercare.com/medical/hormonal/hormone-tx_assch_gooren.htm
"Hudson's FTM Resource Guide" has a lot of info on the basics of testosterone therapy and its effects on the body, the different ways testosterone can be administered, potential side effects and T-related health issues, and some common misconceptions about taking testosterone. Kudos to Hudson for putting together this excellent site!
Another excellent resource is the free 98-page book, Medical Therapy and Health Maintenance for Transgender Men: A Guide for Health Care Providers, by Nick Gorton, MD, Jamie Buth, MD, and Dean Spade, Esq. As the title suggests, this could really be a useful resource for health providers learning about treating transmen.
For transwomen: (Note: I am not as familiar with MTF health issues--though the following sites appear to be useful, if you know of any significant useful websites I am missing, please let me know.)
"Female Hormones and Transsexual Women" is a site containing basic information about hormone treatment, how hormones work, their effects, and the potential risks involved.
The yahoo group "TsDoItYourselfHormones" is a 12,000+ member group of transpeople sharing information and experiences related to hormone use. (Just remember, medical information that you read on the internet is no substitute for talking to a doctor! Yes, medical treatment can be expensive, but your health and safety should be your highest priority! </soapbox>)
Once again, Hudson's FTM Resource Guide has some great FTM surgery-related information, addressing chest reconstruction surgeries, hysterectomy and oophorectomy options, and genital reconstruction surgeries. Transster.com is a "photo repository" of FTM surgery results, which can be very useful if you are researching possible surgeons to use. The yahoo group FTM Surgery Info is a group with 3000+ members sharing surgery experiences and information. This group has been around a long time and chances are that you can find just about anything by searching the archives.
The Transsexual Roadmap has an excellent list
of MTF SRS resources,
including descriptions of surgery, reproductive options, sexual
function, post-op care, etc., and an extensive
list of experienced SRS surgeons from around the world.
It also has information and resources related to facial feminization
Misc. Health Notes
Transwomen: Be aware of the dangers of injecting silicone for cosmetic purposes. Bottom line: Don't do it.
Transmen who have had chest surgery: It is still possible to develop breast cancer - be sure to do self-examinations to stay on the safe side! Discuss any concerns with your doctor!
If you have the means to do this, there is a large conference on trans health in Philadelphia every year that I have heard good things about. There is a day designated for health care providers and another day for community members.
(c)Maine Transgender Network, Inc., 2009