Getting medical care for transgender people can be a challenge. When our daughter’s journey began, her pediatrician was her primary care physician. Unfortunately he did not know anything about medical transitioning, nor did he know of a doctor who could help us. This is an issue in most areas of our country, but it is improving. Most large cities have good resources that are easy to find. In Philadelphia, there is the Mazzoni Center. In New York City there is the Callen-Lorde Community Health Center. Both were trailblazers in LGBTQ health care and support services. Now, many hospital healthcare systems are opening their own centers targeted to providing health care to the LGBTQ community, especially in larger cities.
The farther you live from large metropolitan areas, the harder it is to find care specific to gender transitions. We live about an hour and fifteen minutes from both Manhattan and Philadelphia. That’s a long way to drive for regular healthcare. Depending upon traffic, travel times can double. So we tried to find healthcare closer to home.
Any healthcare provider you choose should be familiar with the WPATH, World Professional Association for Transgender Health, guidelines1. These are considered the standard of care for transgender and gender nonconforming patients. The first step is good therapy to help provide psychological and social support and to complete, or mostly complete, the social transition. Good mental health care for both the patient and their family are necessary to ensure a healthy transition. I can’t stress how important positive family support is to the mental well-being of your child. Some children and adolescents want to begin the medical transition as soon as possible. A well trained therapist can help you decide the appropriate timing for the various stages of the medical transition.
The first medical transition step is hormone therapy. Hormone therapy provides masculinization or feminization through the appropriate use of male or female hormones. Some general practitioners are trained to provide proper hormone therapy, previously called HRT, or Hormone Replacement Therapy. Other times it is better to go to an endocrinologist who is trained in hormone therapy. Hormone therapy is used to change secondary sex characteristics and is partially reversible. For male to female (MTF) transitions, estrogen causes feminization – breasts grow, muscle tone is feminized, body fat distribution changes and the sex drive is changed. For female to male (FTM) transitions, testosterone causes the growth of facial and body hair, deepening of the voice, changes in muscle tone and the sex drive.
Depending upon how young your child is, GnRH can be used to delay puberty by suppressing the natural hormones in the body. This is a totally reversible treatment to delay beginning the partially reversible and nonreversible treatments. Some statistics show that not all gender nonconforming children remain transgender through adolescence and into adulthood. For Anne, this was not an issue. Her gender dysphoria manifested during puberty and was persistent.
The WPATH Standards of Care for initiating any hormone therapies are as follows:
- Persistent, well-documented gender dysphoria;
- Capacity to make a fully informed decision and to consent for treatment;
- Age of majority in a given country (if younger, follow the Standards of Care outlined in section VI);
- If significant medical or mental health concerns are present, they must be reasonably well- controlled.1
Anne’s first physician was an adolescent pediatrician, Dr. R, who included treating transgender patients in her practice. She was the closest physician we could find who could treat Anne. Our therapist recommended her. We had asked the pediatric group and my family practice physicians if they knew of anyone who could provide hormone therapy. Neither practice had a physician trained to provide hormone therapy, nor did they know of other doctors in our community that did. So Dr. R is who we went to – a 30 minute drive from our home. Longer if there was traffic, or during rush hour.
Dr. R was fairly new at treating transgender teens. She worked hard to become knowledgeable about the mental and physical needs of her patients. For MTF patients, both estrogen and a testosterone suppressor (spironolactone) are required. When Anne’s testosterone levels didn’t drop, Dr. R researched options. We even tried a formulary medication that I had to learn to give Anne as an injection. When that didn’t work, she sent us to a pediatric endocrinologist who normally didn’t see patients of Anne’s age (19 at this point), but who would see Anne as a favor to Dr. R. As we were parking for the visit with the endocrinologist, it occurred to me that we should have just gone directly to an endocrinologist who treated adults. In the frustration of trying to find the right hormone treatment levels, and multiple doctor and therapy visits, I messed up. I had gotten into the habit of reacting to each problem as it came up – not being proactive. While we met with this doctor, I asked her if she knew of any adult endocrinologists who treated transgender patients. Guess what – no! More frustration.
Once again, it was Anne’s therapist who helped. There was an endocrinologist in Princeton – about 45 minutes away – who could help Anne. So away we went. After a few months of tweaking Anne’s dosages, the new endocrinologist was able to get Anne’s hormones under control. Finally, Anne had a hormone therapy protocol that worked for her. Initially, Anne was having her hormone levels checked and tweaked every 3 months or so. It took about 3 years and 3 physicians to get her hormone levels figured out, but once stabilized, her checks are just twice a year.
Anne will tell you that as soon as she started hormone therapy, she felt better mentally. She could tell the difference. I’m not sure what the feeling is – only a transgender person could describe it. But this is a revelation from many people who undergo hormone therapy. I noticed another uptick in her affect and mood – she was happier, more comfortable with herself. Each step in our journey just revealed more of our true daughter and confirmed the rightness of her steps to becoming the young woman she is today.
Our therapist was invaluable in helping us find medical care for Anne. Other resources you could use would be area medical facilities with LGBTQ specialities or even affirming policies. If they don’t have an appropriate physician on staff, they may know of one in your region. As you look for health care providers for your child, be prepared to travel and use multiple doctors. For a while, we used our regular pediatrician for Anne’s regular check-ups and urgent care. They are a welcoming practice who were sympathetic to the needs of a transgender adolescent, even if they couldn’t provide the hormone therapy she needed. In addition to the pediatrician, Anne went to Dr. R for hormone therapy, ultimately ending up with an endocrinologist. She now uses the same family practice group that I go to for check-ups and urgent care and the endocrinologist in Princeton for hormone therapy. Just make sure that all of your physicians are open to treating LGBTQ patients with respect and consideration for their needs. Not all physicians are comfortable treating LGBTQ people and can actually cause harm. You may have to really search, but there are caring doctors who have made it a point to specifically help transgender patients.
1Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th Version, 2011, The World Professional Association for Transgender Health, www.wpath.org