Ask Aunt Fran: Healthcare

Well, it’s been a long time, kids, but welcome back to another installment of Ask Aunt Fran, where you, the curious reader, ask me, the curious woman with a little something extra, questions about this transgender-type trip I’ve been on nearly five years now.

If there’s something you’ve always wanted to ask about transfolks but were afraid to ask — well, don’t be afraid to ask! That’s what this here blog thang is here for! If you have my email or my Facebook page, just message me in private; otherwise, email me at franoramaworld@gmail.com. Unless you want the notoriety, all questions will be anonymous. And — my version of the lawyer-weasel disclaimer: The answers I give are pertinent to my own situation. Every transperson’s trip is different; your mileage may vary.

Anyway, this comes up in the thick of Transgender Awareness week (Nov. 13-19), so the timing couldn’t have been better. I had dinner and coffee the other night with a friend I hadn’t seen in years. She knew about the transition, but it’s the first time she had seen Frannie 2.0 up close. And she had some questions.

And one resonates very loudly with me personally and the trans world in general:

“What do you do about healthcare?”

You mean besides grope and stumble and get lucky a lot?

Details coming up …

*****

Just the facts, ma’am (or sir)

Healthcare is one of the most precarious tightropes I’ve had to walk while navigating my personal Twin Towers of Anxiety — transition and unemployment — these past few years. I’ve been lucky so far, as you’ll read. But many people in my situation aren’t.

Anyway, back in September, I was asked, along with Tony, a high-profile local trans activist (giving a female-to-male perspective), to talk to an undergrad nursing class at Southern Connecticut State University. (And we’re scheduled to do the same with a graduate nurse practitioner class there in December.)

The purpose was 1) to inform healthcare professionals that there’s a growing number of out-transgender patients … and horribly few professionals who know the first thing about treating us, much less dealing with us; 2) to foster an understanding of who and what we are; and 3) to let them know the problems trans patients face in the everyday medical world, some of which astounded me.

And there are differences in dealing with trans patients and non-trans patients, where we have some of the symptoms and concerns of both sexes floating around in our bodies. In the case of females-to-males, it could be the need for gynecological services or, especially for those who haven’t had the breast-reduction surgery, exams for breast cancer. In males-to-females, it could be the need for prostate exams, or — in cases such as mine, where I’m on hormones and the girls have grown — the need for breast exams.

And more times than not, lack of understanding and/or prejudice get in the way. Even in a place with the best intentions; early this year, when I went to my extremely understanding general practitioner (read on) for an exam, her staff laid out gynecological tools on the counter ahead of time.

Anyway, in preparation for the September talk, I rounded up a bunch of fun trans facts, which I’ll now share with you. These first few come from the Spring 2012 issue of Stanford Medicine magazine (passed along to me by one of my champions back in the Bay Area, Phoebe Wall Howard):

  • About 700,000 transgender adults live in the U.S., 0.3 percent of the adult population, according to Gary Gates, Ph.D, demographer at UCLA’s Williams Institute, a gender-identity law and public-policy research group. As no national data on this population exist, Gates relied on two studies by state agencies – one by California, one by Massachusetts.
  • Nationally known transgender-rights advocate Jamison Green, Ph.D, estimates that for most of the past 30 years, the number of patients undergoing sexual-reassignment surgery remained the same, around 3,000 a year. Recently, though, that figure seems to be creeping up, Green says, based on his informal observations at healthcare conferences and conversations with transgender people and practitioners. The growth of community-based transgender health forums is further evidence of interest.
  • Transgender people are among the most marginalized individuals in the United States. Invisibility is often seen as a necessity for survival. Fears of eviction and job loss are rampant and well-founded, says Walter Bockting, Ph.D, professor and coordinator of transgender health services at the University of Minnesota Medical School, who has cared for transgender patients for more than 20 years.
  • On average, one person in the U.S. is killed every month because of transgender identity, according to the Transgender Legal Defense and Education Fund.

And here are some more facts, many of them gleaned from Injustice at Every Turn, a survey of 6,500 transgender people conducted by the National Center for Transgender Equality and the National Gay & Lesbian Task Force, published in 2011. It found pervasive discrimination in healthcare settings:

  • 50 percent of the people surveyed said they had to teach their medical providers about transgender care.
  • 19 percent reported being refused care because of their gender status.
  • 28 percent said they were subject to verbal harassment in medical settings.
  • 2 percent reported being physically attacked in a doctor’s office. (Yes, that one boggled me, too.)
  • The survey also found widespread ignorance about the special health needs of transgender people, which can be substantial, even beyond the matter of transitioning. Participants reported rates of HIV infection at four times the national average, with the rates for male-to-female transsexuals the highest: 3.76 percent, compared with the general-population rate of 0.6 percent. The reasons for this high level are unknown, but one likely factor is commercial sex work. Extreme marginalization within society and a resulting lack of self-esteem led these women worldwide to prostitution for financial reasons, says Green.
  • Psychiatric care is perhaps the most desperately needed health service, with 41 percent of respondents reporting they had attempted suicide at least once.

There you are. Some of the things trans patients in general face in the world at large. Not all of us are fortunate enough to live in the Bay Area (where there are plenty of health professionals to deal with trans patients, and San Francisco will now provide sexual reassignment surgeries for uninsured trans residents).

Man shots — or how not to start with healthcare when you have no idea where to turn

Back in September, at Southern, Tony talked to the class about the outright prejudice he encountered at institutions here in Connecticut and in Massachusetts, just trying to get a hysterectomy and trying to find healthcare professionals who would deal — and sensitively — with someone who’s a man except that the plumbing doesn’t quite match. Apparently and most unfortunately, what he faced is the norm and not the exception. (I thought healthcare pros swore to uphold the Hippocratic Oath, not the Hypocritic Oath.)

After hearing him, I thought, “Jeez, my story is nothing. I’ve gotten off lucky so far. ” And I have. Very lucky. In my crazy, screwy life, it does seem as if the Universe has, on the healthcare front, led me to one right step after another. Looking back now, I have no clue how I did it.

One of the things I had to figure out in my skull after I came out to myself at the beginning of 2008 was whether I was going the hormone route. I knew all along I didn’t want the sexual reassignment surgery — after all, I still liked girls, and the thought of cutting the plumbing off always did made me cringe. I just wasn’t sure how far I was going with this physically. Or was there an actual physical component to my own trans trip?

What I knew at the time was that hormones, as any woman can tell you readily, are nothing to mess with casually. And there was an organization called WPATH — the World Professional Association for Transgender Health — that had formulated a protocol through the decades for healthcare pros treating trans patients; the Standards of Care required that patients undergo therapy with a professional who has experience with gender treatment, as well as a mental health screening, before being cleared for hormones or surgery.

And while I’ve discovered that a number of transfolks are downright against the SOC, I chose what I thought was the best path for myself. I knew that I knew nothing about the possible effects of hormones and that I should leave it to the professionals. I would take a conservative approach to my transition; after all, I was nearing 50 and was in no rush, otherwise I would’ve done all this at a much younger age.

(This past July, WPATH slightly eased its stance for its seventh version of the SOC: “A mental health screening and/or assessment … is needed for referral to hormonal and surgical treatments for gender dysphoria. In contrast, psychotherapy – although highly recommended – is not a requirement.”)

But a few months later, I found myself wrangling with my general practitioner in Fresno at the time — and heading in the opposite direction.

He had done a blood test on me and told me that my testosterone levels were low. Yeah, doc — tell me something I don’t know … 😉 … but he wanted me to start taking testosterone shots.

In my mind, that answered a lot of questions, as it related to my gender and my physical makeup — maybe physically I was, indeed, female all this time, plumbing aside. As you can imagine, this also posed a dilemma for me. I wasn’t ready to go through hormone replacement therapy yet — hell, I didn’t even know how to go about finding a doctor, let alone a shrink, something I would never have even conceived of doing — and I didn’t quite know how to tell my GP, a man working in the conservative northwest of town, that there was a distinct reason I didn’t think testosterone would be a good thing for me.

It didn’t get contentious, but I was resisting him as we moved along into 2009; on my occasional visits, I would ignore him when he brought up the topic. Finally, that summer, after he insisted again, I asked him what the big deal was with testosterone, as my brilliant football career wasn’t gonna happen at that point. What were the consequences? He told me loss of bone density, loss of muscle mass and lack of sex drive. Not that I was having sex at that point, but the other two things scared me. I had visions of broken bones, of “I’ve fallen and I can’t get up!”

So what’s a girl to do? Until I could chart a path to HRT, I started coming in once a month to take my monthly man shots. And I didn’t know where to start with finding a gender therapist — who the hell knows how to start medically transitioning in a red-state area of the country with no healthcare support? I was in a weird limbo.

I’ll have an Absolut Peach and cran and a shrink recommendation …

This is not in any textbook or how-to manual that I’m aware of, but I found my therapist one night on the patio of a bar.

Understand that I didn’t want to see a therapist. Ever. I swore as a messed-up teenager that I, an A student, should be smart enough to figure out what’s wrong with me and that no headshrinker would ever get inside my skull and make me even more fucked-up. I took it as a badge of pride and honor that I had never gone to see one.

But I had to swallow my pride if I were going this hormone route. Besides, this wouldn’t be forever. And on top of it, I was already starting with what gender professionals call RLE — real-life experience. I was out and adjusting well to living as my better half part-time in the Tower District of Fresno, the area where I hung out, by Christmastime 2008. And after my layoff from The Fresno Bee the following March, I was moving to full-time, as I was figuring out whether to interview for my next job as Fran or as Fran — by the summer, the only times I was ever in boy drag were riding my bicycle (T-shirt, shorts and doo-rag) and in bed (T-shirts and panties). I was working on passing in the everyday world, even without estrogen — and with regularly injected testosterone, to boot.

And it was while hanging out one night in the Tower early that July that things started falling into place.

I was in a sleeveless dress that Saturday night, feeling slightly elegant and vivacious, and hanging out on the patio at the Landmark, my usual bar, nursing my drink — back then, my drink of choice was what I shorthandedly called a “Peachy” with the bartenders: Absolut Peach and cranberry juice. And I ran into Frank D, one of the Tower semi-regulars, who was doing work at the time at Fresno State’s radio station, KFSR. And he introduced me to his girlfriend, Lori, and the two of us hit it off.

She asked me a lot of questions about the transition; I told her at some point that I was debating on whether to start with hormones, but that I had no idea where to even look for a gender therapist.

“Well,” she said, “I’m a therapist. And it just so happens that I know a gender therapist in town.”

Bingo!

She gave me her card and the name of the gender therapist. I still wasn’t ready yet, but by the end of August, I was, indeed, prepared. I called S, who had been a Fresno State psychology professor and whose classes included deviant sexual behavior; my friend Megan, who’s now doing social work, had her for that class.

And, to the best of my knowledge, in a city of a half-million and a region of around a million, she was the one and only gender therapist.

S took me on because of Lori’s recommendation, and on September 8 — exactly a week before I came out to my parents — I went to her office for the first time. I was dressed rather conservatively — white top, knee-length black skirt, pointy black flats. I looked and felt the part. She told me she was astounded that I had gone this far on my own without hormonal support. (At that point, it had been a year and eight months since I had my epiphany.)

I discovered one disconcerting thing ahead of time. By that time, out of work six months, I was making a steep-enough monthly COBRA payment for health insurance (over $200). But unfortunately, S told me, she was not in my insurance network. I would have to pay for her out-of-pocket — $95, cash money, per hour visit. She had wanted to see me twice a month, but no way in hell I could swing that. This would be hard enough. So it was once a month.

Anyway, it didn’t take long for S to see that I was pretty far along in my emotional transition, and two months later, she arranged for me to see a professional who would give me a psychological test. It was a long, involved test with about 600 questions to mouse-click on a computer.

And two months later, on my first visit back to S after going home for the holidays, she gave me a letter of recommendation to give to my new GP.

Again, this speaks to the terrible lack of healthcare professionals available to transpeople. Again, in a cowtown of a half-million and a region of a million, there were but two physicians who administered hormones. One was right there in Fresno, but as S told me, he administered estrogen in oral form, and pills weren’t as effective as injections. The other worked out of a clinic in Selma, the Raisin Capital of the World, 20 minutes south of Fresno by the 99 freeway, a community and a practice with a huge population of Mexican farmworkers and their families. And this doctor worked with injected hormones. And she was a post-op.

A doctor who’s trans? Twist my arm, willya? How did I get so lucky? Pretty easy choice here.

And in February, I made my first drive to the clinic in Selma. With my COBRA, it would be $25 a visit.

As for my therapist, I kept seeing her monthly for another year. My last visit was in March 2011, a couple weeks before my 99 weeks of unemployment ran out. By that time, I didn’t feel as if I needed her anymore, and my money situation made it easy to cut the ties.

The doctor

It took some adjusting to get used to Dr. B. Her bedside manner on my first visit turned me off right away and upset me on the back end — crusty demeanor, back turned to me much of the visit.

Now keep in mind that over the next two-and-a-half years, I got to see her heart. And it’s a good one. But on first blush, I was wondering just what the hell I got myself into. And she told me bluntly that I needed to drop some weight before she would start with the hormones. She also prescribed a cholesterol drug — $10 for a 90-day supply at the Walmart near where I lived. I almost didn’t come back. I mean, if I was gonna be treated this curtly by someone who was allegedly in my “community,” what were my chances in the everyday world in the long run?

She told me that she took a conservative approach to hormone therapy, that she was using the same protocol on me that she formulated for herself when she transitioned a few years ago. She also told me if I were to undergo treatment, I would have to follow her orders regarding hormones. And that included leaving my treatment to her. Meaning I parted ways with my GP in Fresno — thankfully, no more man shots. (And for what it’s worth, when I had the conversation with him on my final visit, he said he had no experience with transgender patients, that this was new to him.)

Anyway, at the end of April, I took my first injection of Estrodial (a synthetic estrogen). And since I’m not squeamish of needles, Dr. B gave me my prescription to shoot myself every two weeks — $38 for a three-month supply, $48 if I needed extra needles. That was doable financially.

And the upshot was that within two days of my first shot, 35 years of chronic depression was gone. It was something that was never clinically diagnosed, but I think I know depression — black moods that last for days and weeks and months. I had had them since puberty and just accepted that being depressed was simply a natural part of everyday life. I still have my black moods from time to time, but they only last a few hours, maybe a day or two at longest. This has been the best thing to come of my hormone therapy — and it was what finally sold my parents on Frannie 2.0, the medical element of my gender matter. (I refuse to call it “gender identity disorder,” another topic for another time.)

I’ve been shooting myself for two-and-a-half years now. And to wrap up a tangent from before: Yes, bone density and muscle mass are concerns when taking estrogen, as well as a greater chance of blood clotting. But there are ways to fight against all that; in addition to my usual meds and vitamin, my daily regimen includes a magnesium capsule daily, plus two calcium pills and two aspirins daily — one each when I wake up and before I go to bed.

And I told you that I got to see my doctor’s heart with the passage of time. Well, my COBRA ran out in August 2010, and without health insurance, I didn’t know what I was gonna do. She told me that since so many of the girls she saw were out of work, she had them on a sliding scale based on their ability to pay. And for the rest of my time in California, my every-three-month office visits cost $30 — only $5 over what I was paying with health insurance.

Now that I’m back home …

I caught another bit or two of luck on the healthcare front after moving back to Connecticut in August.

Actually, you’ll have to rewind to June 2011. That was when I wrote an op-ed piece for a former newspaper of mine, the New Haven Register, to coincide with the state Senate preparing to vote on adding transgender to Connecticut’s anti-discrimination laws. (The bill passed.) I wrote it for the opinion page as well as the website (and did an accompanying video for the website), and much to my surprise, it ran on the front page two days before my 50th birthday.

And I got a Facebook friend request from V. She told me she and her husband were fans of mine in my days as the music writer/entertainment editor and had wondered where I had gone — at least until he saw the paper that morning. And she worked with a lot of trans patients — though mostly female-to-male, as her specialty was OB-GYN — and that she was curious about my trip, as she wanted to understand it better.

So we became Facebook friends, and I would answer her questions best as I could. And when I moved home, we became friends in real life as well. She’s seeing me until I can get a job and get on my feet, and she gave me the name of a practitioner to see when it comes time to refill my hormones. And since I’m also still jobless (though hopefully not much longer), she also steered me to a free colonoscopy program at Yale-New Haven Hospital for people with limited incomes.

So yes, I’m a very lucky chica, and the universe — and certain people — have indeed been looking out for me.

It astounds me when I look back and draw the line backward from step to previous step to previous step in my healthcare story. What if I had not gone to the Landmark for a drink that night three years ago and found my indirect connection to the only gender therapist in the area? What if I hadn’t gone to her and learned about a general practitioner who’s transsexual and knows all there is to know about my situation? What if I were a more shy, less gregarious person, and had not put myself out there on the front page of a newspaper with my story — would I have found the NP who’s taking care of me for now, now that I’m home? And I wouldn’t have even ended up with an op-ed piece in the Register in the first place had I not worked there for a long time?

Any break or alteration in the thread of my narrative and my life would’ve been a lot different — and a lot less healthy. And maybe I wouldn’t have found my way to hormones, my depression would’ve worsened — especially as the unemployment continued — and I wouldn’t be here to write about it now.

Speculation aside, the fact remains that there are very few healthcare professionals in this state, let alone most places, who deal with transgender patients, let alone know how to. I’m lucky and I know it. I’d just like for my health and healthcare — and that of everyone else in my situation — to be on a level playing field with everyone else’s and not so damn reliant on chance and fortunate breaks.

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