Transgender healthcare, being trans in healthcare

Who wants to get granular - making a thread to summarize/discuss the actual evidence in trans health

  • Fk yes, let's get science-y

    Votes: 8 88.9%
  • Polite disinterest

    Votes: 1 11.1%

  • Total voters
    9
  • Poll closed .

frootloop

House Surgeon
Moderator
I've probably over-flooded hatbox with this in the last couple of days, so let's do it here:

My name is Alice. I'm a 28 year old 3rd year house officer. I was born male/raised as a boy. Three months ago, after 13 years of agonizing over the decision, I finally came out as transgender and started living as a woman full-time. I had not planned it in the slightest, so was hilariously lost/confused for a while.


I figure, if anyone is interested, we can use this thread for two main things:

1) Talking about trans experiences - both as a healthcare professional and in life generally. Feel free to ask me pretty much anything, I'm a pretty open book (within reason - if a single person asks about my genitals I will have Inanna rain fire om them). And any other trans/non-binary folk floating around who want to chip in, please do!


2) Medical school teaches you next to nothing about trans healthcare, its provision (or lack thereof) and the out of pocket costs many of us end up bearing.
I've done enough obsessive reading of the guidelines/literature that I'd feel reasonably comfortable putting overviews together. So at some stage I'll do that, then if anyone has specific questions about part of it/wants me to expand a topic, lemme know.


3) I feel like it'd be making this thread a smidge too broad and confusing to follow, so I DON'T want to actually discuss it here - more sound out whether anyone's interested in the actual science part. Expected changes on hormones, transfemme breast development etc. If so, we can always start another thread for that. The science involved is sparse, usually poorly done and relies heavily on data/theories from cisgendered populations, so it's very interesting trying to work out exactly what we do (very little) and don't (+++) know. I've already done a couple of brief literature summaries (for my instagram meme page - much to the confusion of 1200 teenagers) so could start there.





So yep, if you have any burning questions about trans healthcare or even just the idea of being trans, don't be shy to ask. The only condition is that you don't be purposefully disrespectful - which is hardly an onerous requirement

You have a transwoman doctor with essentially zero filter here, so don't hesitate to.ssk
 

frootloop

House Surgeon
Moderator
For vanity's sake, and to show you what a difference three months can make**, here's a selection of pre-transition pics and some from within the last month or so.


**I have had a lot of non-operative work done on my face. I think it's outrageous that so few trans people are even told that non-op facial feminization/masculinzation is very much a thing.

I just had another 90 mins worth of needle work on Thursday, and the swelling is still bad enough that I'm not putting those in a forum post ahaha 20210114_122907.jpg 20200317_180755.jpg 20210114_122917.jpg 20210114_122904.jpg 20211014_111436.jpg 20210930_140854.jpg 20210927_162037.jpg 20211002_150102.jpg 20211005_191001.jpg
 
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spicedapple

Lurker
Hi Alice!

Thanks for sharing your story with us (and your transition pics, you look great!).

I do have quite a few questions for you. I hope you don't mind me basically grilling you for your experience (please don't answer anything you're not comfortable with answering). You're a perspective I don't often get a chance to have any insight on, so I'm trying to make the most of your willingness to share.

1. How was the process for transitioning for you? (both mentally and physically) Where and how did you find help and information? What difficulties did you run into? You also mentioned out-of-pocket costs, what did these look like and how far did Medicare cover you? Do you think it should cover more?

2. What has your experience as a doctor been like in the medical field? I know that medicine tends to be a bit of a conservative sector. Have you run into issues with trans acceptance with colleagues or patients? What has this looked like and has it affected how you practice medicine?

3. Based on your experience, what do you feel needs to be done to raise awareness for LGBTQ+ people and better their health outcomes? Even off my own limited experience, I know that health education tends not to touch on LGBTQ+ subjects (sitting through the incredibly heterosexual, mandatory, Year 10 sex module was an interesting insight into the values of the Board of Studies). What do you as a doctor try to implement, or wish could be implemented in healthcare to make this knowledge and these procedures more available? Any thoughts on current guidelines?

4. Finally for my own insatiable curiosity, if you have started hormone therapy, have you found it has impacted you in non-physical ways? (ie has it affected your mental and emotional balance and 'normal'?) There really isn't that much information out there about this, and as a cis woman who gets mildly weepy while PMSing, I'm curious as to if you've experienced similar symptoms on HRT.

Ok, I hope I haven't overwhelmed you with a wall of open-ended questions. Thanks again for offering your perspective!
 

frootloop

House Surgeon
Moderator
Hi Alice!

Thanks for sharing your story with us (and your transition pics, you look great!).

I do have quite a few questions for you. I hope you don't mind me basically grilling you for your experience (please don't answer anything you're not comfortable with answering). You're a perspective I don't often get a chance to have any insight on, so I'm trying to make the most of your willingness to share.

Hello! And thank you (although it's difficult for me to see that) 😊 hopefully once the swelling goes down from all the stuff that was jammed in my face on Thursday I'll be starting to see in the mirror what I've always seen in my mind.

I wouldn't have offered to share if I minded, so don't worry. I know transwomen are a relatively rare breed who aren't usually as easily identifiable as transphobes seem to think, and that (for obvious reasons) most of us tend to avoid probing questions - so I realize a lot of cis people have well-intentioned questions/genuinely want to understand us better but don't really have any sources of information beyond the very generic stuff you find online.

Which is why my almost compulsively-oversharing ass has volunteered to share. So with that in mind:

(N.b. Because I tend to waffle, replying to this all at once would make for a VERY long post. So I'll do it piecemeal)

1. How was the process for transitioning for you? (both mentally and physically) Where and how did you find help and information? What difficulties did you run into? You also mentioned out-of-pocket costs, what did these look like and how far did Medicare cover you? Do you think it should cover more?

I'm very early on in my transition - I only started HRT/came out (did everything all at once. Very dramatic. Very dumb), so I'm still finding out haha.

Mentally
Mentally it's been unreal. I was diagnosed with bipolar at age 19 and haven't really been properly euthymic at m/any stages since then. The ranging mood storm and tidal waves of affective instability which have been ever-present for a decade... turned to an idyllic duckpond within about 3 weeks on HRT. Now, because I started HRT and started living as a woman full time at exactly the same time, I have no idea which triggered what - I'm guessing it's a mix of both. The way I experience anger has completely changed - it takes longer to seriously annoy me and my responses to it are far less... testosterone-y.

The one downside of plummeting testosterone levels is that the AMAB (Assigned Male At Birth) brain's cognition goes to sh** without it. I've been quite the scatterbrained ditz (and someone who already has ADHD being extra ditzy is... so bad it's almost funny). But that will fade.

Physically
I've been utterly dumbfounded with how quickly my body is changing. I come from a family of competitive male swimmers, and was/am very much built like one - broad shouldered, and an absolute rectangle from armpits down to very narrow hips.

I have a waist now. And like, enough hips to actually hold women's jeans up. And the beginnings of a boot. And thighs that jiggle, with a way smaller thigh gap than I started with/most AMABs have. Like, to the point that the girl I'm dating (who knew me pre-transition) looked at me in confusion one day and went 'When the hell did you become an hourglass, and how has oestrogen never done that to me' 😂

As for breast development, we're moving into territory that even I'm hesitant to get into *too* much, but suffice to say that I feel like zero to proper A cup in 3 months ain't bad.


Difficulties
Not 100% sure which difficulties you're asking about - you mention some specific ones in later questions so I'll answer those then


Out of pocket expenses
New Zealand doesn't have Medicare, so I'll just list what I've had to pay for thus far (basically all of it)
- Psychiatrist for the gender dysphoria diagnosis (no longer needed in my region to start HRT, which is great - changed just after I started) ~$250

- Endocrinologist appointment for HRT $175

- Pills mercifully only $10 total for a 3 month supply

- Laser hair removal face (theoretically entitled to, but you have to fight the sh*t out of the social services people and that takes forever) and chest $1800 total. Am about a third to a halfway through those courses

- White light IPL facial hair removal (for all the white/blonde/red/light brown hairs laser can't hit) $180/session, will likely need 6 or so

- Entire new wardrobe and shoes and stuff has been at least $700, more like $800 if you include makeup and skincare stuff

- The semi-permanent hair extensions (the flowing black hair did not grow out of that short blonde cut in 3 months haha) were $800 to buy/have put in. Then $150 or something to dye. And then I need them moved up (because the hair they're attached to obviously grows, and they slip slightly) and recoloured every 2 months, which takes literally 4 hours (I have 2 full packs of them in hahah) and so costs about $250 a time. Honestly, the hair has been my biggest passing asset so far by a LONG way.

- The total for the cosmetic work to my face is already sitting close to $10,000

(I would *love* to go into all the stuff I've had done, the evidence/rationale behind the various bits of it etc if anyone would actually be interested. But that'd be a fairly lengthy post of its own)

- Oh, changing my name was something like $80. I actually found the process of legally changing it very easy, it's the 'getting every agency and company you're associated with to update your name' part that's hard. I also think it's hilarious that changing gender marker on your birth certificate takes months of family court hearings, but when getting a new driver's license I just ticked female and now that's an official govt record.

Obviously easier access to funded laser hair removal (and not just the face) would be nice. Having speech therapy referrals not take 5 or 6 months to go through would be nice. Not having to pay a couple hundred bucks to get your HRT (i.e. to see the endo or special interest GP) would be nice.

My main complaints are surgical though:
- MTF (male-to-female, not a term I particularly like, given that those are *sex*-based terms and I am trans*gender*, but it's a commonly used one and the short acronym is handy) bottom surgery, i.e. vaginoplasty until recently came with a wait list of upto 30 years. They proudly tell me that's down to 10 years now, as though that's timely provision of healthcare. It isn't my biggest concern so I'm not *that* worried about the wait, but for some it's agonizing. I think it's over $20,000 privately, and you'd probs have to go overseas for it

- MTF top surgery (sorry FTMs out there, my knowledge around your service provision is a bit limited) i.e. breast augmentation is... theoretically available. But there's no real pathway, guidelines, criteria etc so I gather it depends on how pushy your doctor is willing to be and how receptive the local plastics department is. What I've heard informally is that the wait is 2-5 years depending on where you live. Privately, about $15,000 - 18,000 for implants, or for a smaller lift autologous fat grafting is more like $8,000 - 10,000

- Facial feminization surgery. THIS is where my rage is directed. The government explicitly states that this is 'cosmetic, not gender-affirming'. Not gender-affirming. The thing you interact with the world with, that you see the most and forms a huge part of how you view yourself. The thing with a decent amount of sexual dimorphism, so one of the biggest stumbling blocks to 'passing' (not to mention putting you at pretty high risk of getting violence'd. Society does not like non-passing transwomen).

The thing that caused such severe and prolonged dysphoria that I attempted sewerslide over it more than once.

That's 'cosmetic, not gender-affirming', and therefore there is NO public funding for it. There are next to no plastic surgeons in New Zealand who will touch a transwoman's face (believe me, I've asked enough of them), and overseas the average cost of FFS is $20,000 - 40,000 USD.


I don't have $30 - 60k NZD, so I took out a depressingly large loan (I've got a givealittle page, on the off chance anyone wants to help me repay it) and I found a dermatologist brave enough to be like 'I can list the differences between male and female faces, and you know which bits you hate. So between us we can come up with a plan to non-operatively/chemically sculpt and feminize your face'.

That's been about $10,000 so far. And I do need two minor surgeries (like, under LA type minor, but still several thousand each) as well as a projected $8,000 more in injectables over the next year to make sure the changes are permanent.






So yeah, being trans is expensive. I'm the happiest I've ever been, but also very broke and relationships with the likes of my parents have suffered greatly.

Which is why all the people who go on about how transwomen just want access to women's bathrooms for nefarious purposes are hilarious. Plenty of cis men manage to do those things without going through all of this hahah
 

frootloop

House Surgeon
Moderator
2. What has your experience as a doctor been like in the medical field? I know that medicine tends to be a bit of a conservative sector. Have you run into issues with trans acceptance with colleagues or patients? What has this looked like and has it affected how you practice medicine?

Ok, practicing medicine while trans... Bearing in mind that I've only been doing that for a couple of months, I've found the actual practicing medicine part fine. A lot of nurses have been immediately protective, a lot of other nurses have just started completely ignoring my instructions. But from watching others over the years, I'm pretty sure the ignored instructions are more related to me being a woman than me being trans (something a lot of them aren't aware of anyway).

The patients have been fine by and large, I get the odd shocked look if my larynx betrays me mid-conversation, but otherwise most of them don't notice or don't care. Have had the odd irritating one, e.g. medical team is leaving the bedside and the patient makes a point of loudly saying 'Goodbye guys, girls and... [looks at me] whatever you are'. But nothing particularly vicious.

Dealing with my employer while trans and its impact on my career prospects... is something I know better than to publicly comment on. The word 'unsurprising' pretty much sums it up.
3. Based on your experience, what do you feel needs to be done to raise awareness for LGBTQ+ people and better their health outcomes? Even off my own limited experience, I know that health education tends not to touch on LGBTQ+ subjects (sitting through the incredibly heterosexual, mandatory, Year 10 sex module was an interesting insight into the values of the Board of Studies). What do you as a doctor try to implement, or wish could be implemented in healthcare to make this knowledge and these procedures more available? Any thoughts on current guidelines?

I mean, I feel like the world is well aware of us now. Working on 'maybe stop caring how other people live/identify when it doesn't affect you, and treat them with respect' is the hard part.

Like, I was told today on one of The Economist's many TERFy articles in support of Dave Chappelle that he has the right to freedom of speech from the public. And I do not, because I'm a trans lesbian, so I'm part of the LGBTQ+, apparently a public organization. I'm being authoritatively told, in public, that I am not an individual human being and I don't have rights. You can't make them hear their own words, either.

So we do need to 'cancel' people like Dave Chappelle - his little 'jokes' are what emboldened this transphobe (and MANY others) to publicly say stuff like this. Bigots should simply be told 'ew, gross, you're not getting a platform' *glares at Netflix*. Freedom of speech A) does not apply to hate speech and B) does not require the likes of Netflix to platform this sh*t.


As for health education in schools, gender and sexuality are not actually difficult concepts for kids to understand. If my two and a half year olds can identify me as a girl, despite knowing what I used to be/look like, then it should be easy to teach to teenagers. 'Some boys like boys. Some girls like girls. Some people don't much care what you are. Some people don't like anyone at all. Some people we thought were boys are actually girls, some people we thought were girls are actually boys, and some people aren't a boy or a girl. We should respect all of their identities and treat them like human beings'.

Like, obvious lack of nuance there, but the point is these curricula should not be hard to create.



I have lots of thoughts on the guidelines (incl the surgical stuff I mentioned in my last post), but those are... something I can expand on later if you want

4. Finally for my own insatiable curiosity, if you have started hormone therapy, have you found it has impacted you in non-physical ways? (ie has it affected your mental and emotional balance and 'normal'?) There really isn't that much information out there about this, and as a cis woman who gets mildly weepy while PMSing, I'm curious as to if you've experienced similar symptoms on HRT.

Yep, I started hormones 3 months ago, and ooooh yes.

- My bipolar mood roller coaster has ground to a stop
- I'm calmer, slower to anger, less explosive when angry
- I'm SO GODDAMN MATERNAL. Every time one of my kids does something cute my nonexistent uterus aches for more, and the way I interact with them has changed in a way I can only describe as 'more motherly'
- I'm hungry all the time, not that that's an emotional state per se
- I do cry very easily when something is really sweet or... I don't even know, very odd stuff makes me misty eyed
- While my moods have been more stable, I'm certainly prone to what essentially amount to teenage girl sulking episodes. Puberty...
- My baseline default has shifted from 'sour and sarcastic' to 'happy and nauseatingly bubbly'. Unsure how much of that is hormonal and how much of that is 'oh my god I get to be me in public now'

Other assorted unexpected oddities include a subtle change in how I perceive certain colors, a heightened sense of smell and being prone to sudden waves of overwhelming nostalgia. Which I don't really know what to make of.




I hope all thar answered at least some of your questions - I'm still very new at all this (despite having sat firmly in the closet for 13 years), so some of the stuff like 'how does it affect your career' I can only partially answer (well, no, bad example, I've *very* much discovered the answer to that one).
 

LMG!

MBBS IV
Administrator
I’m worried, given the amazing questions already asked and answered, that this will seem really superficial, but I’m honestly curious how you chose Alice. I’ve been thinking about names and their significance a lot lately because my sister is about 2 weeks away from having a baby. I would love to know the story (if there is one) behind your selection. And, alternatively, if it’s not that big a deal for you, I’d find that interesting, too.
 

frootloop

House Surgeon
Moderator
I’m worried, given the amazing questions already asked and answered, that this will seem really superficial, but I’m honestly curious how you chose Alice. I’ve been thinking about names and their significance a lot lately because my sister is about 2 weeks away from having a baby. I would love to know the story (if there is one) behind your selection. And, alternatively, if it’s not that big a deal for you, I’d find that interesting, too.

So because teenagers on Instagram tend to mistake my chemically-altered appearance, age and loud opinions to mean that I know what I'm doing, my little sort-of-blog, sort-of-meme account gets enough messages that I've met no fewer than FIVE other trans Alices. Which seemed oddly high, because I know a grand total of one cis girl called Alice.

All of them (and me... kind of) were largely drawn to it for the obvious 'in Wonderland' reference. The whole Alice in Wonderland universe, some of her experiences while she's there etc already resonate as a trans person (or, clearly to a few of us), but I think there's a bigger reason. It's pretty well documented that a huge proportion of trans kids develop dissociative traits as coping mechanisms, which I guess makes sense - gender dysphoria can make living in your own skin very cognitively uncomfortable, and society tends to react rather poorly to us, so dissociation gets you out for a bit. I used to (reflexively and - with almost no effort - at will) be able to flick open a pair of internal eyes and disappear. Nothing quite as complex or awesome as Wonderland, but conceptually similar enough that the story resonated pretty strongly.

(Honestly, for the longest time I assumed everyone could casually disengage their minds in the same way/extent and at will. Now I can't even get there at all without a good few minutes of meditation first - my brain has evidently gone 'nope, nope, nope, no more of that maladaptive sh*t, we don't absolutely hate it here now')


Anyway, my name is... kind of based on Alice in Wonderland. There's a pair of - of all things - horror video games based on the premise that Alice's family die in a fire while she's very young, her hallucinations go south and she winds up in an asylum: American McGee's [the creator's honest to god name] Alice, and Alice: Madness Returns.

Madness Returns is the one I haven't been able to shut up about it for years - the whole story arc is her traipsing through Wonderland (initially almost willfully blind to what's going on) trying to work out what's causing all of her distress, before eventually freeing herself from her own internal torture-chamber. Which obviously resonates as a trans person who had lived in the closet for 13 years (then kept wondering why they were miserable) and as someone with bipolar disorder.


Sooo I'm Alice. Middle name is Lilly - for literally no reason other than that I liked it.
The only other name which even came close was Adora, but I tossed that thinking that it was a purely fictional name and I didn't want to be *that* obviously named after a cartoon character (who's character arc isn't thematically all that dissimilar to Alice's/my loose conception of my own, hence the appeal) hahah. Found out much later that it's an actual name. Still, Alice feels right.




Could I have explained all that in like 50 words? Probably. Do I feel weird saying I borrowed a video game character's name, and compulsively over-explain that decision as a result? ....yes 😅
 

LMG!

MBBS IV
Administrator
frootloop thank you so much for indulging me, honest to god that’s exactly the kind of story I was hoping for (as in, the detail!). Thank you, Alice 😍
 

frootloop

House Surgeon
Moderator
frootloop thank you so much for indulging me, honest to god that’s exactly the kind of story I was hoping for (as in, the detail!). Thank you, Alice 😍
Hahahah honestly, in any other context I'd have just sarcastically gone wElL hOw DiD yOu PiCk YoUr NaMe? But in other contexts it's usually some random at work asking invasive questions. For example, and I sh*t you not, 'Have you thought about like, what sort of size threshold you'd get breast implants at?'
- cis male doctor I don't know *quite* well enough for that to be an appropriate question. In the staff workstation hahah

(My reply was not hugely inventive, and also centered around size)


But I never really get to tell that story in full, so thank you for asking 😝
 
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