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Mining for Gold: Developing Medical Resources From Scratch

When Sam began his transition, we were frankly dismayed by the lack of medical resources in our locality. Granted, we don’t live in the Big Apple or anywhere near the Land of the Golden Gate, but we still expected to find something here in River City. Our city has around 670,000 people. We have a major teaching hospital along with a Level I Regional Trauma Center. We have five major hospitals in the metropolitan are with more on the way. When we began a local search for transgender care services, the obvious lack of available health care was appalling: one lone therapist who had questionable credentials, and a physician who worked with her who obviously knew little or nothing about transgender care and who lacked basic board certification in his own specialty. As it dawned on us that we were about to begin paddling our own canoe, I called on my experience in community health and used some very basic skills to navigate and maximize the resources we already had.

The first thing we did was schedule a visit with our family doctor. He is a wonderful young man who, when we first went to him, was fresh out of his residency in Internal Medicine. At the time, I was quite ill and was not satisfied with the care I was receiving from my internist. Sam had needed to find a new doc for a while, and we thought we’d try going to the same office as a matter of convenience. This was three years before he began his transition, so Sam tended to be a bit doctor-shy at times. I think that is pretty common with FTMs from what I have observed. The younger ones are especially leery, it seems. Our doctor (let’s just call him Dr. H for now) was very accepting of our relationship and seemed to understand Sam’s body image/privacy needs without having to be told. How amazing is that? When Dr. H passed inspection with me as well, we were firmly in place as his regular patients. I have many health problems, and as my primary care physician, Dr. H directs my care much as a coach runs a team. He may not do all the maneuvers, but he is the one calling the shots (with input from me regarding certain preferences). In other words, he manages my care. He does the same for Sam and did so before the word “transition” was ever uttered in his office. That seems to be a real issue with younger FTMs… the need for a doctor just doesn’t seem real to them. That is true of most young people, in fact, not just FTMs. As anyone can tell you who got sick before they had a regular physician, it’s a whole lot easier to get one when you don’t need one than to wait until the need is urgent or worse. So, if you look around in your area and find, as we did, that there aren’t many medical resources for transfolks, consider becoming the patient of a reasonable physician. If you already know that transition may be in your future, you might want to bring it up at the first visit.

CAUTION: Do not expect to walk into a strange doctor’s office, ask for a prescription for testosterone and get it. It just doesn’t work that way.

Here’s what we did: we discussed Sam’s need for someone to oversee the medical aspects of his transition. We did not propose this as something that was optional, but rather as something we were going to do. We asked our physician if he would help us find an endocrinologist in the area who would be willing to manage Sam’s Hormone Replacement Therapy (HRT). He explained to us a previous referral (given to us by a not-very-well-qualified counselor who had previously given Sam his GID letter for name-change purposes) was to a physician who was not board certified in his specialty which, after all, was internal medicine… the same specialty as our family doctor. He agreed to try to help us locate an endocrinologist in the area. I gave him a floppy disc copy of the most current version of the Harry Benjamin standards. He took it graciously and promised to look at it. We scheduled another appointment for a week later to discuss the results of Sam’s testosterone level, liver panel, and lipid profile and to get the referral to an endocrinologist.

On the suggestion of an FTM who has been through this entire process, I would like to point out that there are several different specialties that might be appropriate for an FTM to utilize for HRT. First of all, there is really no such thing as a general practitioner (GP) any more. Two types of specialists meet the medical needs that they met in the past. Those two are the Internal Medicine specialist and the Family Practice specialist. A physician board certified in these specialties practices the general kind of medicine that most people think of when they speak of a “GP”. An endocrinologist is a physician who is board-certified in endocrinology, the specialized practice of medicine involving hormones of various sorts.

One more thing: board certification means that the physician completed a residency and passed a board exam that verified s/he had a certain amount of knowledge in a given area. Be sure to ask your physician if they are board certified in their specialty. It they are ethical, they will answer you without question. If they don’t want to answer, there is some reason for that. Only you can decide if the reason is a good one.1

We kept our appointment, and Dr. H had to break the bad news to Sam that there was no endocrinologist in the East Tennessee area who would agree to do HRT for a transsexual. That was no great surprise to me. I had fully expected we might have to go to Atlanta to get the prescription. That is a four-hour drive from our house…and an overnight stay if you’re as old as we are. But instead of helping us make plans for an Atlanta referral, I heard Dr. H saying something that was so wonderful I could hardly believe my ears. What he was saying is that if we would cooperate by having Sam there routinely for the proper lab work and exams, he would manage his HRT right here in Knoxville. I was elated. I looked over at Sam who was sitting in a heap looking dejected. I knew he didn’t comprehend what we had just been told. It was understandable. Waiting 30 years to transition makes it seem like a dream that will never come true. I nudged him and said, “Honey, did you hear what he said?” He stared at me blankly. When I point blank stated the facts to Sam, his face turned bright red… he looked ecstatic… and incredulous all at the same time. I was so very happy for him. That was his birthday in the Spring of 2001.

We went that very day to fill the prescription. I bought it for him as a very special birthday present. What a gift to me to get to give him his first shot that day. I can cry just thinking about it right now… and every time I remember my throat starts to close up and the butterflies return to nest in the pit of my stomach. I was truly honored to be able to help Sam get something that he had wanted all of his adult life – since the age of 15 when he first realized that he was transgendered. What a long, hard road!

We are both still seeing Dr. H. He manages my high blood pressure and various other common complaints that people see doctors for every day. He also manages Sam’s HRT. It’s just another one of our health concerns, and that is the way he treats it – as just another subject on the agenda for discussion in a perfectly normal physician office visit. He is a wonderful, caring and talented physician. We are fortunate to have him here in Knoxville. But we still wouldn’t have a wonderful doctor that would do these very necessary services for Sam if we hadn’t done one very simple thing – ask. It is sometimes just that simple. If you are anxious and afraid of being treated badly in a face-to-face situation, my suggestion is this: call first… and be honest. I did this very thing once for a friend. Just call the office of the physician that you choose. Make sure they are accepting new patients and that your insurance is accepted by their practice. Once you clear those hurdles, explain that you need an initial exam, but have some questions that you would prefer to discuss with the doctor’s nurse before you commit to an appointment. Remember, the person who answers the phone is rarely a nurse – s/he is probably not even a medical assistant. S/he will press you for details as s/he has been instructed to do. If you feel comfortable, tell her matter-of-factly that the patient who wishes to make an appointment is a female-to-male transsexual and ask her if the doctor feels comfortable seeing a person with Gender Identity Disorder (GID). Using clinical, medical terminology is very important. GID is a medical condition. No doctor should refuse to see you because you have a given medical condition. While I realize that not everyone is comfortable with describing himself or herself as having a “disorder”. I respect that. Just keep in mind that in the medical world, the condition is seen as a medical reason to see a patient for treatment. I agree with those who feel that gender dysphoria is not a disorder, but it can certainly be described as a condition. A good analogy might be pregnancy. It is hardly an illness or disorder, but is certainly cause to seek medical treatment. Now, whether or not the medical professional you contact feels competent to treat that condition is another matter entirely, but your first goal is to find a physician with whom you feel comfortable to be your family doctor. If you approach the whole thing in that way, you are probably going to succeed in obtaining medical services. If you go looking for a prescription for testosterone, you are probably not going to succeed, at least not with a quality medical practice. You don’t want second-rate health care. You want good services delivered in an adequate facility by qualified people who treat you with respect. We have that. You can, too. You may not succeed with your first attempt, but don’t give up – keep trying. If you get discouraged, I am here to help you in any way I can. Black market testosterone kills people. You need a doctor to oversee your HRT who knows what they are doing. Don’t settle for less.

1. I would like to give credit to my friend, Jon, for his helpful critique of my article. His insights as both an FTM and a layperson were valuable.

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