The unresponsiveness of transgender healthcare

I am frustrated and have been for the last couple of weeks. The source of this frustration is my most recent lab results and my hormone replacement therapy (HRT) clinic’s response to them. At my last appointment, I discussed possibly changing my HRT regiment if my HRT levels were not at the proper ranges. My HRT provider agreed to review my HRT prescription after the results came back, either by adding spironolactone (not happening) or possibly by upping my Estradiol dosage (my preference but the clinic is opposed). The results came back a few weeks ago and my hormone levels are still not in the proper ranges. Now, I have to wait until my next appointment in 2021 so that I can potentially get my medications adjusted in light of these results.

This is just one occurrence in what I see as a general trend of trans healthcare being unresponsive and incredibly rigid. To me, the purpose of male to female HRT is to develop feminine features while reducing my masculine characteristics. The World Professional Organization for Transgender Health (WPATH) generally agrees with this purpose. The WPATH standard of care says that you can determine how effective an HRT treatment is by asking “Is a patient developing a feminized body while minimizing masculine characteristics, consistent with that patient’s gender goals?”.1 This is achieved by taking the necessary hormones and medication to result in the proper hormone levels. In my estimation, this makes the job of the HRT provider achieving those proper levels as quickly as feasible without jeopardizing the patient’s health.

It seems logical to me that the goal of HRT providers should be to find the “ideal” HRT regiment as early into HRT as possible, however, the standard practice is not responsive enough to achieve this goal. First, the standard monitoring schedule is fairly infrequent. The standard timeline for monitoring patients on HRT is a physical and blood test every 3 months for the first year of HRT. I believe that this is too infrequent, especially in the first 6 months. At this schedule, there are 90 days between any medication change and the blood test to determine how that change has affected the patient’s hormone levels. Then, since the lab results are not immediately known, it will be another 90 days until the next appointment to discuss how to respond to those lab results (Assuming that the doctor will not change medications in between appointments). This is 180 days between any two medication changes at the standard schedule, almost half a year. If the initial HRT dosage and prescription need to be adjusted only two times to get the proper levels, that will take almost an entire year. Considering that several of the effects of MTF HRT reach their maximum extent in the first 1-2 years, this is an incredibly unresponsive timetable.

Second, the medication guidelines that clinics use are often incredibly rigid. Most clinics have standard medications, dosages, and delivery mechanisms that they want to use. My clinic has a standard HRT regimen that they use for MTF HRT and is incredibly reluctant to deviate from it. This has been a problem because I wanted to start with estrogen monotherapy and their standard regiment is estrogen and an anti-androgen. Even though my estrogen levels are still below female ranges, they are unwilling to raise my estrogen dosage any higher because it is outside their standard practice. My HRT provider has told me that they have never gone above 6 mg estradiol (because the assumption is that I will be in spironolactone) and that they had never heard of other clinics would not do it (which is absolutely untrue, I can find multiple stories of trans women being given 10-12 mg a day). This rigidity in medication regiments limits the options for responding to hormone levels that are not ideal.

In response to my poor lab results and the lack of responsiveness from my HRT provider, I have elected to increase my estrogen dosage myself. I have put a lot of thought into this and I am unwilling to lose time in my transition on an HRT regimen that is not achieving my desired goals. I have a decent stockpile of estrogen from my earlier plans to DIY my transition, enough to take 8 mg of estrogen a day until my next appointment, and still have some leftover. I do not see any danger in this approach, even if the clinic approved 8 mg a day, they would still have me wait 90 days for a blood test. At that next appointment, I will tell my HRT provider that I have done this and they should provide me a legitimate prescription for 8 mg of estrogen in response (WPATH harm reduction policy). I wish that I did not have to take this course of action, however, the alternative is waiting for 3 months on a regiment that isn’t working. I have waited long enough.

Sources:

1.The World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (7th ed.) Retrieved October 27, 2020, from https://www.wpath.org/media/cms/Documents/SOC%20v7/Standards%20of%20Care_V7%20Full%20Book_English.pdf. 46.