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Medical Gatekeeping
April 2, 2013 4:42 PM   Subscribe

A Trip to the Clinic

or, What if other medical problems were treated the way transgender medical problems are?

Inspired by the relatively recent #TransDocFail hashtag.
posted by ArmyOfKittens (41 comments total) 29 users marked this as a favorite

 
Wow, that was very helpful, and extremely frustrating.
posted by roomthreeseventeen at 4:47 PM on April 2, 2013


I love this.
posted by liketitanic at 5:08 PM on April 2, 2013


I think this is a useful tool for people who have no experience with the gatekeeping that goes on trying to access medical transition services to gain some sense of it, and I appreciate the post.

What it isn't able to capture is the frustrating way that medical practitioners continuously raise one's status as trans* (or as intersex) when people are visiting for some totally unrelated matter, like an injury, which is what I thought might come up when things started with arm pain. Or the way transphobia negatively impacts routine medical care provision. Still, it's a useful simulation of the intrusiveness of the gatekeeping process, and the strange postures it forces people into in order to access services.
posted by DrMew at 5:16 PM on April 2, 2013 [2 favorites]


DrMew: "What it isn't able to capture is the frustrating way that medical practitioners continuously raise one's status as trans* (or as intersex) when people are visiting for some totally unrelated matter, like an injury, which is what I thought might come up when things started with arm pain."

If I had a penny for every time a doctor tried to refer me to a specialist with a waiting list measured in months for a trivial medical problem I could have eaten my weight in Mars Bars by now.
posted by ArmyOfKittens at 5:20 PM on April 2, 2013


I wonder if this game has a "Good End". Probably would defeat the purpose, I guess.

Also I totally avoided any initial gatekeeping by self-medicating hormones to begin with :D
posted by yeoz at 5:34 PM on April 2, 2013


... Oh, hey, there is a "Good End". Neat.
posted by yeoz at 5:38 PM on April 2, 2013


I don't actually understand what the problem is that they're parodying here -- is it that it's hard for trans people to access medical services in general? Or that it's hard for trans people to receive surgery on request? I thought it was the latter, until I got to the end and the doctor declared he didn't understand the difference between types of fractures, and then I kind of got confused. Wouldn't a doctor who does transition surgery at least know what it is?

I guess this is more targeted at people who have some idea what the issues are, to give them a better sense of the frustration, rather than at people who are pretty oblivious to the whole problem, to introduce them to the concepts. Or maybe the whole process actually is that confusing.
posted by jacquilynne at 5:48 PM on April 2, 2013 [1 favorite]


This needs some more context because I'm honestly confused. Is this expressing frustration with the fact that doctors insist on a psychiatric evaluation before performing transition surgery or prescribing hormones? That doesn't seem at all unreasonable to me, in the same way that I'd expect a doctor to ask me relevant background questions before prescribing me antidepressants (say).

If one insists on analogizing to a broken arm, isn't the right analogy to an arm x-ray?

Or is this making a point about access to trans-specific healthcare more broadly? And if so, what is that point? Good faith question.
posted by eugenen at 5:49 PM on April 2, 2013


jacquilynne: "I don't actually understand what the problem is that they're parodying here -- is it that it's hard for trans people to access medical services in general? Or that it's hard for trans people to receive surgery on request? I thought it was the latter, until I got to the end and the doctor declared he didn't understand the difference between types of fractures, and then I kind of got confused. Wouldn't a doctor who does transition surgery at least know what it is?"

I suppose the context is (and I'm going to be brief because I've injured my hand):

1. There is a specific narrative that trans people are often expected to conform to while seeking treatment. It goes: "know" you're transgender from your earliest memories and express it visibly; experience severe dysphoria from puberty onwards; hate your penis/breasts and be turned off from sex or forming relationships because of your body; desire surgery; be gender normative. If you differ from this, and many do, you will often have trouble accessing even the most basic medical treatment; you don't have the "right kind" of broken arm. Even those of us who conform to this narrative are judged extremely harshly against it.

2. Further, many clinics require trans people to live "in role" without any kind of treatment, which is horrendously damaging in many cases: you are required to act as if you are receiving treatment, and then be evaluated on how well you pretend to receive treatment, in order to receive treatment!

3. Doctors don't take us at our word: I feel I should tell you now that, in my notes, I've been writing "pain" in inverted commas.

4. Treatment is often unnecessarily time-consuming. Trans people can wait years before being prescribed hormones; this while many suffer from intense depression and suicidal ideation.

I'm sure other people can provide more, as my hand is very tired! You might also check out the #transdocfail link in the FPP.
posted by ArmyOfKittens at 6:07 PM on April 2, 2013 [10 favorites]


Yes, absolutely. It is difficult to find doctors who will oversee an HRT regimen, and typically they're following old WPATH guidelines and require a letter saying that you are who and what you say you are from a therapist that you have seen for at least three months (this costs money, remember). They will ask you a lot of prying questions, even though, presumably, providing the letter from a therapist means that someone more qualified to ask prying questions has already asked you prying questions. At checkups, they expect you to endorse stereotypes and conform to their specific view of how trans people feel and who they are. Some doctors expect their patients to come dressed in certain kinds of clothing. This usually isn't covered by insurance, and if it is, you have to jump through your insurance company's separate set of hoops.

Things are improving, and more doctors are operating on an informed consent model, which allows you to sign something saying that you understand the risks of HRT and still wish to undergo it without so much busywork and burning through so much money. But clinics like these aren't available everywhere.

Most of the trans women in my local support group see the same doctor (mine), because there simply aren't that many in town who are willing to work with us. My last visit, when I asked my doctor about my dosage and requested that he measure my estrogen levels and not just my testosterone levels (I had already badgered his office a half dozen times before this visit, and had talked with him about it previously, unsuccessfully), he said that he didn't use estrogen levels (?) and instead prefer to adjust dosage based on how feminine his patients are feeling. He asked how often I was crying, and said that if it wasn't much more than previously "that might be a problem." It felt to me like he would question my transness (and thus my right to my medication) if I did not answer in a way he wanted to hear. He said he would include the estrogen test on my next bloodwork order, but he said that last time too and then didn't. This is my doctor, and he is considered to be one of the best in the area.
posted by Corinth at 6:08 PM on April 2, 2013 [13 favorites]


In sort of related news (barriers to care), a Brooklyn family filed suit today in the wrongful death of a trans woman who died after EMS allegedly refused to treat her.
posted by roomthreeseventeen at 6:09 PM on April 2, 2013 [1 favorite]


The comparison is twofold. First, the doctor doesn't believe that the arm is a problem now because (in my version of the game), the individual hadn't had arm problems in childhood or puberty, and the individual stated that getting through the day meant getting onto the bus though it was very painful. The arm problem began last week. And the appointment was made as soon as the problem was apparent to the sufferer.

Some trans people realize they are trans at a later time in life, but are forced to adopt a narrative of "always having felt this way." Most/Many transpeople exerience "getting by even though it is difficult" but must create a narrative of being "completely unable to function" in the body they have.

So if the feelings developed over time, and/or you can still "function" you are not a candidate for treatment, except maybe the mental illness kind of therapy.


There's so much more, but on preview, ArmyOfKittens has responded way better than I could ever hope to.

(side note: I was expecting this to be about racial/socioeconomic gatekeeping in health care, which I absolutely experience. Any time I have any pain and can get to see a doctor I am taken absolutely seriously. Being a white lady means lots and lots of suggestions that maybe they could give me some percocet. The downside, whether I accepted or refused the meds is that finding the source of my pain was not a priority. But I was never considered to be a drug seeker or a Fakey Fakerpants. Not once. And it pissed me off every fucking time. Health Insurance Gatekeeping is another thing altogether and makes me just as grary.)
posted by bilabial at 6:14 PM on April 2, 2013 [3 favorites]


That doesn't seem at all unreasonable to me, in the same way that I'd expect a doctor to ask me relevant background questions before prescribing me antidepressants (say).

Unless you're troubled by the assumption that non-normative gender identities are a mental illness.
posted by liketitanic at 6:23 PM on April 2, 2013 [1 favorite]


Unless you're troubled by the assumption that non-normative gender identities are a mental illness.

Right, so the crap part of our medical system is that you need a diagnosis of GID (or gender dysphoria later this spring) in order for insurance companies to code some of this stuff.
posted by roomthreeseventeen at 6:39 PM on April 2, 2013


[A couple comments removed, please consider not jumping into a difficult topic with "yes but what if x was y instead of x" analogies.]
posted by cortex at 6:57 PM on April 2, 2013


This was an informative game. As a student doc I'm always saddened to hear about this kind of frustration. It's bad enough to be sick, but to be both sick and treated by a tone-deaf doctor is, I'm sure, doubly frustrating. I also feel, though, that some of the #TransDocFail criticism fails to appreciate just how rare the condition is, and how prevalence affects a doctor's clinical knowledge and practice.

Just to provide some context, estimates of transgender prevalence are in the 30 per 100,000 range for MtF folks and 4 per 100,000 range for FtM folks, though earlier research suggested it was more rare and the trans community argues that it is more common*. These prevalence numbers are on par with those for other rare conditions, conditions for which med students/residents would have to know maybe two or three facts in order to pass their licensing exams.

Take Neurofibromatosis type 1, for instance. Its prevalence (25:100,000) is on par with MtF, and most docs would be able to tell you that it's an autosomal dominant disease with a gene locus on the long arm of chromosome 17 that presents as "cafe au lait spots". They wouldn't know much more than that, and they certainly wouldn't try treating it-- they'd probably refer out to the nearest academic neurologist.

Compare this to more common medical conditions that primary care docs are used to treating (Diabetes, 8,300:100,000; Asthma, 8,400:100,000; Bone Fracture, 2,800 per 100,000 people per year). We spend weeks and weeks learning about diabetes endocrinology, asthma autonomic pathophysiology, and the process of bone remodeling. During clerkships and residency, we'll see hundreds if not thousands of patients with these conditions. Most of us would be lucky to see more than one transperson during our training. In this light, I feel that a lot of #TransDocFail is the result of trans patients being the first of their kind to seek treatment from a given doctor who may or may not know about three things related to trans health.

Don't get me wrong-- I've certainly worked with docs who are transphobic and wouldn't think twice about denying treatment based on prejudice, but I've also worked with well-intentioned docs who would feel more comfortable referring transfolk looking for HRT to a regional specialist, simply because they've never treated a transperson before and prefer to practice only in areas where they've received training. My med school is great-- they co-sponsored a talk by a gender reassignment surgeon that was exceedingly informative. I came away from it knowing enough to not look like a fool in front of my first trans patient who I saw a few months later, but I don't think I knew nearly enough to help her make informed treatment decisions about anything trans-specific like HRT.

I live in a major metropolitan center, so I'm more likely to have a small but appreciable number of trans patients when I get out there and start practicing. Because of this, I'm going to do my best to be on top of the literature in the same way that I'd be on top of MSUD (15:100,000) literature if I practiced out in Lancaster. Again, though, this will all be in the context of a practice where diabetes, obesity, heart disease, and violence are all more prevalent conditions, so I'm sure that my relative unfamiliarity will lead to missteps and flubbed pronouns. I hope that my patients, trans and otherwise, will bear with me as I try my best to serve them with the few talents I possess.
posted by The White Hat at 7:32 PM on April 2, 2013 [7 favorites]


This link is brilliant. Thanks.

I feel that a lot of #TransDocFail is the result of trans patients being the first of their kind to seek treatment from a given doctor who may or may not know about three things related to trans health.

Actually, many of the experiences being described here are the experiences of trans people interacting with doctors who are specialists in treating trans patients. That's why it's so disturbing.
posted by medusa at 8:03 PM on April 2, 2013 [8 favorites]


How do I attack the doctor?
posted by homunculus at 8:38 PM on April 2, 2013 [3 favorites]


Unless you're troubled by the assumption that non-normative gender identities are a mental illness.

I thought about this before asking my question. I totally get this, but it seems like if what you're after are prescription drugs and surgery from a medical professional, that medical professional should ensure that his dispensation of same is medically responsible in the same way that he would if you were seeking treatment for an illness. No?

Anyway, the explanations above are super-helpful, thank you.
posted by eugenen at 8:39 PM on April 2, 2013


I dived in without any context and without reading comments first; it started to feel to me like the type of treatment some rape victims get. "You weren't really raped, were you, you did stuff afterwards, you didn't cry out in pain enough..." ?
posted by mrbill at 9:19 PM on April 2, 2013 [3 favorites]


And also - as a non-gender-conforming (and I observe also being a person of color, or disabled, or very young or very old) person EVERY medical encounter takes place through the lens of one's non-conformance.

Rotator cuff injury? Must be from being trans - what did trans thing did the patient do to bring this on, and really, why would a NGCP need two working arms, anyway?
Cancer? It's due to one's gender-non-compliance. Patient must present more "normally" and stop taking hormones in order to access any other treatment (wish I was making this one up!). And not for a reproductive cancer, either.
Seizures? It's because all queer/gender-non-conforming people are drug addicts, specifically of drugs that cause seizures. Stop taking the recreational drugs (that one is not taking, and have never had a positive lab test for), we don't need to treat your seizures. Also a true story.

So, yes, this is exactly what most medical encounters are like for non-gender-conforming people.
posted by Dreidl at 9:35 PM on April 2, 2013 [7 favorites]


I don't actually understand what the problem is that they're parodying here -- is it that it's hard for trans people to access medical services in general? Or that it's hard for trans people to receive surgery on request? I thought it was the latter, until I got to the end and the doctor declared he didn't understand the difference between types of fractures, and then I kind of got confused. Wouldn't a doctor who does transition surgery at least know what it is?

Not all trans healthcare is surgery. A lot of trans people choose never have any kind of transition-related surgery at all, in fact.

I also feel, though, that some of the #TransDocFail criticism fails to appreciate just how rare the condition is, and how prevalence affects a doctor's clinical knowledge and practice.

Anecdote: a friend of mine was at an NHS conference fairly recently, where she learned that the number of Gender Identity Clinic referrals in the UK has risen by roughly 10% year-on-year for the last decade, except the last three years, where it's been between 20% and 25%. The current medical literature almost certainly underestimates the prevalence of transgender identities.
posted by Dysk at 10:34 PM on April 2, 2013 [2 favorites]


Oh my god. I am not trans, but I actually had a doctor who basically said this:
"Have you tried living with your arm as it is, without any medical intervention? Perhaps just avoiding any use of it?"

I had gone in because I had extreme pain whenever I put pressure on my middle finger of my right hand. It came up in the course of the appointment that they only times I put pressure there in my everyday life were when playing sports: rock climbing, weight lifting, push ups, pull ups, rowing, and throwing balls. The doctor suggested I just avoid all those sorts of activities, and she didn't think intensive sports were all that appropriate for women, anyway.

I flipped the fuck out. I cried then and there, I wrote a letter of complaint to the doctor's surgery, and I told everyone I knew the story for weeks and weeks.

It is only just now, seeing this link, that I realise how lucky I am that as a Cis-gendered person this was my only experience like this with medical people, and that everyone I told about it automatically sympathized and agreed the doctor was terrible. If I were trans, I guess a lot of people would think that sort of reaction was perfectly okay.
posted by lollusc at 10:40 PM on April 2, 2013 [8 favorites]


I got to the end and the doctor declared he didn't understand the difference between types of fractures, and then I kind of got confused. Wouldn't a doctor who does transition surgery at least know what it is?

A little more broadly, wouldn't a doctor who provides transition-related medical treatment at least know about the differences between and nuances of various trans identities? All signs point to 'no'. An incredibly regressive view of gender (and gender roles in particular) is incredibly commonplace, as is a dogmatic adherence to the One True Way to be trans, and an insistence that anyone who doesn't fit that particular model must be faking it or mentally unstable or whatever - certainly not a candidate for treatment - and definitely not a problem with the model. A lot of people have referenced this in the thread already - the notion that you must obviously have always known, the notion that you must perform your maleness/femaleness in certain ways (gruff and 'laddish', certainly not camp/skirts and acquiescence, definitely not tomboy or trousers), the notion that you must have a certain sexuality (seriously - in Denmark for example, the only medical institution that offers any trans-related treatment - Sexologisk Klinik - doesn't believe that gay/lesbian or bisexual trans people exist. 'Oh, you slept with/sleep with women? You must be a man.' and vice versa) to be a 'proper' trans person, and to qualify for any sort of treatment. This is not the exception. It's true in countries with comparatively progressive trans healthcare and legislation/policy in general, too (such as the UK - I know several people who have been denied treatment). This is the norm.
posted by Dysk at 11:00 PM on April 2, 2013 [3 favorites]


> (and I'm going to be brief because I've injured my hand):

Wow, you really got into role-playing this game!


OK, serious now: Thanks for this post. This is a sort of ongoing, daily discrimination that I have no exposure to, even as an observer, and it communicates the idea fairly powerfully, if somewhat vaguely. Like others, I don't quite understand the specifics of what interactions are being analogized here, but I get the drift.

Maybe some specific examples from some of our cis-Mefites would help us, if anyone would volunteer them...?
posted by IAmBroom at 11:25 PM on April 2, 2013


Going to share a couple of anecdotes about my experience with trans health care:

I transitioned back in 2000/2001 -- roughly around the time I started reading mefi, coincidentally -- and did it pretty much outside the regular NHS process. I went to a private doctor in London who gave me an HRT prescription after an in-depth, soul-searching interview ("So you've paid £150 to come see me? You must be pretty serious about this! Are you transsexual?" "Yeah, I'm pretty sure I am." "Okay, take these. If you hate the effects, stop taking them." "Righto. Incidentally, can I borrow this book of yours and never give it back?"). My local GP was kind enough to convert it to an NHS prescription, monitor my bloods, and refer me for speech therapy.

I did it this way specifically to bypass the "experts" at Charing Cross in London, who at the time were requiring trans women to live "as women" for at least three months -- but often much longer -- without any kind of HRT or really any support whatsoever. Given that I was already suicidal I didn't want to add daily harassment and threats to my list of things to cope with; I was an attractive enough boy but not someone who could look sufficiently like a cis woman to avoid setting off "I must abuse this person" alarms in people's heads.

I was lucky that my GP was willing to convert the prescription and monitor my bloods. Other trans people had to pay privately for their pills. Today, thanks to the internet, self-medicating is much easier and many trans people bypass the official medical process altogether, maybe getting their bloods monitored if they have a sympathetic GP but otherwise just swearing off bananas to keep their potassium levels down and sharing their experiences with other self-medders online.

I did that, and they do this, specifically because the official channels through which trans people have to pass in order to receive treatment are often actively harmful. They ask too much of an at-risk population, they don't consider the additional stress trans people under treatment take on, they force even those of us who conform roughly to the standard narrative to lie about our histories just to make extra damn certain we'll get the care we need. In a hundred ways, they are obstructive, unpleasant way beyond necessity, and frequently abusive.

Trans health care only makes sense if you view it as a system set up to protect cis people from mistakenly transitioning. We're second priority to cis people even in our own world.

Okay, now it's 2006/7. I'd been transitioned for over half a decade, been working all that time, living a pretty normal, boring life. But I needed to get THE SURGERY (yeah, that thing everyone associates with trans health care -- and that many cis people choose inexplicably to view as the point where it's acceptable to switch pronouns -- actually took me years to get around to) so I needed to insert myself into the Charing Cross system as I didn't have £8,000 lying around. The way this process normally works in the UK is you go to your GP and request a referral to Charing Cross. Your GP then contacts CX who then take several months to inform her that she needs to refer you to a local psychiatrist instead, who will make the initial assessment and then make the referral. Your GP will then inform CX that this is nonsense, that the patient has been living as a woman for six years, and that requiring her to see a local psychiatrist to tell the NHS what they already know -- that she is a woman -- is utter madness; your GP may make reference to the smear test letters the NHS keeps sending you, and may yell. The word will then come back that a psychiatrist evaluation is required.

So off I went to the local psychiatrist. She was kind enough to go through the whole tedious process, by the book, asking a mid-twenties woman ridiculous questions like, "When did you first feel that you might be a woman?" and, "Why do you feel you need treatment?" in case this was just a phase and I might at any moment try to retrieve all my old boy clothes from the fire I burned them in six years before. I sat through the whole humiliating exercise so that I could get my damn referral and get it I did.

Another six months passed and my initial appointment at Charing Cross came up. I went in to see the doctor -- a man who specialised in trans treatment, who probably saw a dozen trans people every day of every week in a supposedly helpful capacity -- and discovered that I was capable of feeling more humiliated and belittled than when I saw the psychiatrist. He forced me to lay bare my entire life history, asked me irrelevant questions about my sex life, sexual partners, whether I masturbated and how often. He read to me from the letter the psychiatrist wrote, which it turned out not only used male pronouns for me but managed to use the name I'd been given at birth, a name I have no idea how she got, a name that hadn't existed legally for years. He forced me to stop taking anti-androgens and arbitrarily changed my other HRT doses -- the man was not an endocrinologist -- which over the next six months caused my joint pain to worsen and my health to plummet. The experience was horrible and the changed HRT regimen made me miserable but at least I had one of the two signatures I needed to get surgery! At least it was half over!

When I went for my follow-up appointment six months later they fixed my HRT and told me that that horrible doctor had retired! I'd never have to see him again!

But because of that his signature on my recommendation letter no longer counted, so could I please wait another six months...
posted by ArmyOfKittens at 12:50 AM on April 3, 2013 [20 favorites]


You might also check out the #transdocfail link in the FPP.

Also previously on MeFi, since the automagic link thingy below doesn't seem to have picked that up.
posted by MartinWisse at 1:36 AM on April 3, 2013 [1 favorite]


And also - as a non-gender-conforming (and I observe also being a person of color, or disabled, or very young or very old) person EVERY medical encounter takes place through the lens of one's non-conformance.

Being fat doesn't help either, as obviously anything you suffer from is caused by your obesity.
posted by MartinWisse at 1:38 AM on April 3, 2013 [4 favorites]


My earlier comment wasn't particularly well-composed (and neither was I). I will lay out some of my own experience further.

When I first told a therapist that I figured I was trans, she had never talked to a trans person before, despite the fact that she was listed as having experience in gender issue counseling. I had sat on the number for a month before calling, after having sat on the knowledge that I needed to talk to someone for a long time before even googling a number, and when I finally told someone my deepest secret the response felt like, "too weird; can't help." She said that she wasn't comfortable working with me because she wouldn't know what she was doing. She told me this on the second session, not the first, and offered some sort of guided breathing exercises set to aboriginal music in the absence of actual talking for the second session, after breaking that news. I'm incredibly scared, and incapable of thinking on my feet given the magnitude of emotion I'm experiencing with this letdown, so I say yes and lie there feeling terrible on a couch for an hour.

I got another number. I sat on this number for a month as well. At my first appointment I was welcomed warmly, but I was still emailed two ridiculous, personal, invasive questionnaires that seemed to have been made thirty years ago and asked to fill them out and return them. They worked to reinforce the seemingly dichotomous notions that, simultaneously, A) maybe this was all just some weird perversion and me a weird sexual deviant (nb: I was a virgin), and B) the leading nature of the questions made me feel as if I wasn't a weird sexual deviant early enough, often enough, or specifically enough to be trans like the women the questions were designed for.

At this point in my life, I knew I was trans. I had had trans feelings as far back as I could remember (even as I didn't voice them or act on them like you're "supposed" to), I simply didn't know that those feelings were trans feelings. I quite seriously assumed I was the only person in the entire world who had those feelings stretching into my early 20s (thanks in no small part to the portrayal of trans people in the media - I knew I wasn't that, so obviously I wasn't trans), but now I knew what it meant and I had a path towards relief. It followed, then, to me, a simple construction of if trans, then HRT. I knew I was trans and I knew the treatment I needed. I have had a certain amount of experience with a similar construction - I had been prescribed antidepressants and benzodiazepines in the past with, sometimes, no therapy or even particularly involved questioning from a GP. And yet, here, with this particular issue: nothing. My therapist adhered to the WPATH guidelines of at least three months of talk therapy, and occasionally made noises about whether something I had shared in a session made her feel like writing me my letter sooner or later. Naturally, I was inclined to gravitate towards the genre of things that elicited the "sooner" noises. If you have undergone therapy before, you may have found, like me, that a relationship like this isn't the most fruitful for solving problems therapy is meant to solve.

Eventually I did get that letter, and I have briefly touched on some of the uncomfortable interactions with my doctor above. It's fucking weird walking into a doctor's office and having to sheepishly hand him a letter that someone else has written to assure him you're genuine. To this, I will add: I have one trans friend who is much prettier and much more passable than me, and she enjoys better treatment from him despite the fact that we have been seeing him for roughly the same amount of time. He gave her an email address to contact him at if she needed anything, for example. On the phone with the staff, when trying to push for a female hormone panel to be added to my bloodwork along with the male hormone panel, there's a lot of confusion and double-taking, and then it doesn't get added. Some of that is just the general grumpiness of the woman at the front desk, who scowls at me even when I compliment her nail color, but ugh.

In the midst of this, I was losing my health insurance - aging out of my father's plan. The individual market in the US is a bad place to be if you're trans (if you're anything, really). I wasn't deniable under pre-existing condition clauses because I had been covered continuously throughout my life up to this point. However, the first company I applied to straight up rejected me, with "Gender Identity Disorder" stated as the reason. This doesn't make the most sense, since all of these policies specifically and explicitly exclude any and all costs related to gender transition in any capacity, but hey. In my state they're allowed to do that (maybe in all states, but certainly in mine). I was accepted by the next company, but with coverage nowhere near as useful to me, and it was more expensive. Still, it hurts to get a letter that rejects you so plainly.

Perhaps I'll add more, tomorrow, if I think of it, but I see that ArmyOfKittens has posted a tremendous writeup of her own. I will only add that I have a friend trying to wind her way through the NHS currently, and I know for a fact that I never would have made it over there. I could not have survived the required "real life test" of living as a woman without any hormone support, and I'm appalled at that practice. I can't even imagine how many people that hoop alone prevents from moving forward with their lives. I'm a trembling bundle of anxiety as it is, and can barely make and keep the appointments I do. That seems terrifying, barbaric, and completely unfair to me.
posted by Corinth at 2:05 AM on April 3, 2013 [12 favorites]


I could not have survived the required "real life test" of living as a woman without any hormone support, and I'm appalled at that practice. I can't even imagine how many people that hoop alone prevents from moving forward with their lives.

That sort of thing only makes sense if you believe it's really, really important to make sure nobody ever regrets undergoing transition, that only people who really are trans (in the narrow, particular way being trans is defined in these programmes of course) start transitioning.
posted by MartinWisse at 3:18 AM on April 3, 2013


I see from the explanations that my confusion arises from a failure of imagination on my part -- the inability to fathom that things could possibly actually be as bad as they really are.
posted by jacquilynne at 8:08 AM on April 3, 2013 [4 favorites]


Corinth: When I first told a therapist that I figured I was trans, she had never talked to a trans person before, despite the fact that she was listed as having experience in gender issue counseling.
WHAT THE FLYING FUCK??? How do these people get to keep their licenses to practice? (Edit: Oh, right: they make money off the mentally troubled, who are far less likely to bring the system against them.)

(Thank you for your anecdotes.)
posted by IAmBroom at 9:15 AM on April 3, 2013


Just to provide some context, estimates of transgender prevalence are in the 30 per 100,000 range for MtF folks and 4 per 100,000 range for FtM folks, though earlier research suggested it was more rare and the trans community argues that it is more common.

The idea that being trans* is so rare that doctors can't be expected to know much about it has been raised by many doctors I've visited. It's certainly true that most medical schools teach nothing about gender transition, so many doctors are unprepared to deal with us. But the figures cited are ludicrous, because they are based upon how many people have accessed genital surgery. That figure has increased over time (that's why being trans* used to be "rarer"), but it represents the tip of the iceberg of the trans* population. I note that:

1. Most people who don't identify with the binary sex they were assigned at birth have not accessed any medical services at all, because the social costs of transitioning are so high. But as these costs go down because trans* people receive more civil rights protection, more of these individuals will come out, and more will wish services.

2. When initially founded, gender clinics only treated people transitioning to female. Thus, older "officially trans" populations are comprised mostly of transsexual women. Today, however, young trans* men outnumber young trans* women in social surveys, because the social costs of transitioning to male are less than the social costs of transitioning to female, and because genderquerity in people assigned female at birth is more socially tolerated than it is in people assigned male at birth. Thus, the medical statistics showing trans* women to outnumber by trans* men by 7.5 to 1 are deeply flawed.

3. These statistics are based on an ideology that genitals determine gender, and that a person has not "really transitioned" until they have had genital surgery. But the substantial majority of trans* people do not access such surgery. This is due to many factors. Many want it, but can't afford it, as it is quite expensive and not covered by most people's insurance, should they have medical insurance at all. Others are considered "poor medical candidates" for surgery for various reasons (including, for those of us who are intersex by birth, prior infant genital surgery). And many have no interest in such surgery. It can reduce or eliminate the capacity for sexual sensation, it makes you sterile, and nobody but your intimate partners generally sees your genitals in any case.

My (also trans*, also intersex) spouse and I have had many negative experiences trying to access medical care. These negative experiences tend to drive trans* people away from seeking medical care at all. By framing trans* people as rare and not training doctors to meet our needs--and to treat us as people, not as freakish--medical institutions create the very context that allows them to frame being trans* as a very rare "condition."
posted by DrMew at 10:01 AM on April 3, 2013 [10 favorites]


DrMew, the specific study I cited used demographic data from the New Zealand Passports Office, not people trying to access care, and that the statistics were based on birth certificate-->passport discordance (i.e. genital or karyotype-->identity). The numbers for care access and surgery are about an order of magnitude smaller. Your point is nevertheless well-taken. I have no doubt that recorded prevalence will increase as social exclusion decreases.

Still, even if transness were ten times more common than the NZ numbers suggest, it would still remain uncommon if not rare. Rare does not mean unimportant, neither does it mean undeserving. In epidemiology it means less than around 1:1,500, and I don't say this to justify maltreatment, insensitivity, or ignorance. I offer it only as context in a fight against an oppressive system where medical providers can be allies as much as they can be adversaries.

I also apologize for medicalizing trans*ness as a "condition"-- when I have a hammer, everything looks like a nail; you can imagine what things look like when I have a clinic.
posted by The White Hat at 10:45 AM on April 3, 2013 [1 favorite]


At this point in my life, I knew I was trans. I had had trans feelings as far back as I could remember (even as I didn't voice them or act on them like you're "supposed" to), I simply didn't know that those feelings were trans feelings. I quite seriously assumed I was the only person in the entire world who had those feelings stretching into my early 20s (thanks in no small part to the portrayal of trans people in the media - I knew I wasn't that, so obviously I wasn't trans), but now I knew what it meant and I had a path towards relief. It followed, then, to me, a simple construction of if trans, then HRT. I knew I was trans and I knew the treatment I needed.

Thank you so much for sharing this. It's rare enough that I see someone talk about their experiences and really see myself in it, and it always makes me feel a little less weird, a little less inauthentic as a trans person.
posted by Dysk at 12:44 PM on April 3, 2013


Just to add to the stories going round (particularly ArmyOfKittens' point about the NHS and trans care): I went to my (incredibly obliging, sensitive, and polite, if slightly clueless) GP about gender identity issues two full years ago. I explained to him how I felt, and that I wasn't quite sure what I wanted to do, but that I knew I wanted to do something about it. He told me to come back in two weeks, and he would research. I had reached out to one of my good friends who is trans a few months earlier (when trying to figure out what the fuck I thought I felt, how to square that with some of my opinions and perceptions of the world, and what to do about it), and she is pretty activisty, and active in the local trans community (not that I knew there was such a thing, at the time) so she'd given me a pathway document for my PCT (amongst many, many other invaluable favours) - basically, a document of the standard process for referrals onward to a Gender Identity Clinic outside my administrative area, so it would be approved and funded. I showed up to my two-weeks-later appointment, and my GP tells me that he's been doing a lot of reading, emailing, and calling around, and has ascertained that he should refer me to a GIC. I tell him it might not be as simple as all that, and hand him the pathway document. It specifies that a diagnosis of Gender Identity Dysphoria or a transsexual identity must be made by a psychiatrist, and that a GP can then make a GIC referral with that psychiatrist's endorsement.

After a three-month wait for a psychiatrist, I spoke to one for maybe three minutes in a waiting room. Clearly, she had read my referral just before she was due to see me, and came out and basically explained that she didn't have the first fucking clue about anything gender-related, and would refer me on to one of her colleagues. Another three months later, and I saw a perfectly friendly and respectful psychiatrist, who asked me lots and lots of questions about my childhood, what I wanted to do exactly, how I felt, and about my rather colourful and extensive mental health history (it includes such gems as schizophrenic episodes, and diagnoses of borderline personality disorder, acute depression, anxiety disorders, bipolar, epilepsy centred on the emotion centre - what the fuck? - and a long, long list of medications that hadn't helped with anything) and then basically said 'I will endorse a GIC referral if you want. Take things at your own pace, and always remember that what you do is up to you to decide. Don't necessarily pin all your hopes on the system helping you in the ways that you want.' and did the paperwork to facilitate that. My GP made the referral, and two months later (after he's started chasing it up angrily with the PCT due to the inordinate amount of time they're taking getting back to him about their decision, if not allocating the funds) gets a phonecall from someone at the PCT, telling him to refer me to a psych in a city ten miles down the road. My GP is confused, what with normally getting these decisions by post and email both, and not over the phone, but obliges. A month later, this psych's office writes to my GP telling him that they can't honour the referral, due to him being in a different PCT, and my PCT not having funded the referral. My GP becomes very angry at this (especially as I have pointed out to him several times that the pathway document does not require a second opinion, just an endorsement from someone in the position that the psych that endorsed my referral occupies) and starts pulling strings behind the curtains (personal friends on the PCT board). Another month passes. I get a phonecall from the psychiatrist in the next city's secretary, saying they have a time available TODAY, can I make it? I point out that I can't (I would literally not have been able to make it there for the time offered, given our relative locations and my reliance on public transport) and enquire as to why I am being offered a time, given that I don't need to see this psych. A long and increasingly heated discussion ensues, with the woman on the other end telling me in no uncertain terms many times that the only way to a GIC in this area is through the psych she works for. It concludes with her hanging up on me mid-sentence, asking for maybe the twentieth time what in the process of my referral hasn't met the requirements set out in the pathway document (which is legally binding for the PCT). A week later, my GP has sorted things out behind the scenes, and my referral finally gets approved, and officially made to the GIC.

That was about a year ago. Since then, nothing. I have heard nothing. I have had no communication from the GIC at all. I have called them a few times, and sent them a letter to change my address when I moved house (which I confirmed with them they had done by having them read my details off their system) but at the most recent call a month ago, they told me they still hadn't started processing my referral, and that they were terribly backlogged. Since my referral was made, PCTs have stopped existing, being replaced by a new system that I am not familiar with, and with no clear documents of processes (or indeed any process or procedure at all) for trans care that anyone in the local trans community (many of whom are involved in stakeholder groups within the NHS) are aware of. The way the referral process works, the GIC would have applied to my PCT for funding when my referral was made, which would have been fine (the funding of that referral already having been approved due to my GP calling in favours to get some people at the top to look at my situation and decide to put things right). Now, I presume there is another body to whom they will apply for the funding. I don't know if they'll approve it. Neither myself nor my GP know who to contact to find out. So not only will I be waiting for some indeterminate amount of time still, but at the end of it, I may just have to go through the entire process (or a more arcane or stringent process) again, to meet the funding requirements of the new organisation.

I have been taking anti-androgens and oestrogen for a year and a half or so, now, and am monitoring my bloodwork with my GP's help (or well really, with the help of the internet, medical texts, and the local trans community, though my GP signs off the forms to get me the numbers, and actually draws the blood). To get him to do this (GPs are specifically forbidden from prescribing cross-gender HRT within the NHS, for example) I had to point out that if I came to him saying I was taking heroin, and after he'd advised me to stop I'd said no, he would help me practice harm reduction, and how was this any different? I'm no endocrinologist, though - I err on the side of not risking my health, and I'm sure I could do 'better' with proper help (though it's apparently very hit-and-miss with endocrinologists around here), and well, it doesn't put me any closer to eventually having the downstairs remodelled. By a surgeon.

(And in case anyone is wondering why the huge wait? Well, Tory cuts to the NHS, coupled with what I mentioned previously: "the number of Gender Identity Clinic referrals in the UK has risen by roughly 10% year-on-year for the last decade, except the last three years, where it's been between 20% and 25%.")
posted by Dysk at 1:26 PM on April 3, 2013 [10 favorites]


I came back to add something that has been included since I posted. It bears repeating:

Who you (want to) have sex with does not have any bearing on what your gender is.

If you were born with a set of male genitals and want to have sex with women, that does not preclude you knowing that you are in fact a woman. (I can't even bring myself to qualify this with the wishy washy 'supposed to be a woman.' I think wording that is demeaning.)

(I'd make that blink, but ya know.)
posted by bilabial at 1:47 PM on April 3, 2013 [1 favorite]


Thanks for responding, The White Hat, on the issue of how common it is to be trans*. Let me just point out that the study you cited (which was behind a paywall. . .) is based upon how many people in New Zealand have gone through the procedures necessary to have an "X" put on their passports. This possibility was championed by intersex people, and by some genderqueer people, but many many trans* people aren't interested in having an "X" on their passports, even if they can qualify. Most trans* men and trans* women want an M or F on their passport, not to be designated a third sex, or sexless. And many genderqueer people who do approve of a nonbinary category often still don't want to have to be outed and challenged at national borders. My impression, from those I know in New Zealand, is that the group that has really been motivated to change their sex to "X" are intersex people.

Anyway, I appreciate your desire to be a good ally in the medical world.
posted by DrMew at 2:16 PM on April 3, 2013 [1 favorite]


Just another story for the list.

I (mostly) don't fancy men, so I thought it would be useful to save some sperm before getting on hormones. The local psychiatrist wouldn't refer me to Charring Cross until I went full-time. So I'd actually been full-time for about two year by the time it came to sort out the sperm bank. My very helpful GP wrote to them and this is the letter I got back:

You wrote to my colleague, Dr C, about this patient of yours who is wanting to store sperm prior to gender reassignment surgery.

Unfortunately, we would not be able to provide this within NHS funding. We are only able to offer sperm storage for men who are undergoing sterilising treatments for cancer.

In terms of your patient adjusting to their gender reassignment surgery, I would be concerned that wanting to store sperm would suggest some uncertainty about whether gender reassignment is an appropriate course to be following.

Finally, the only way the sperm could be used in the future would be through a surrogacy arrangement. At present, we do not offer surrogacy through the unit here and are not intending to do so in the foreseeable future.

I am sorry that we would not be able to offer sperm storage for Z303.

I have sent a copy of this letter to her for her information.

With best wishes

Your sincerely

Dr X

It all got sorted in the end but did need me explaining how not everyone is straight, getting my request sent to the ethics committee and me paying for things myself.
posted by Z303 at 4:08 PM on April 3, 2013 [2 favorites]


I went through part of the "game" and had to stop. It is way too much like what I went through for proper pain management. I fought for years, took so many NSAIDs that it probably caused part of my kidney cancer,and suffered, due to doctors not willing to help me, until I had fantastic insurance and got to my mid 30s.

When we had no money and I was in my 20s? They let me suffer for years, not even willing to look beyond the basic things. The medical establishment sucks. It is worse for anyone who doesn't fall right into some basic, normal line that they think you should.
posted by SuzySmith at 4:14 PM on April 3, 2013 [1 favorite]


I want to thank the gender-noncomforming Mefites who are sharing very powerful testimony here. I hope it feels like something other than the kind of Trans 101 teaching obligation that we cisfolks feel inexplicably entitled to.
posted by liketitanic at 7:38 AM on April 4, 2013 [2 favorites]


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