Locating proper care goes beyond receiving a prescription; it involves establishing rapport with a system that has not consistently provided adequate care to trans patients, and learning to interact with it in a way that suits your needs.
Know Your Provider Models Before Your First Appointment
Different gender affirming care approaches are available. The older gatekeeping approach required patients to first spend months or years in psychiatric evaluation before accessing any medical treatment. The informed consent model on the other hand requires that a provider explain the risks, benefits, and alternatives to a treatment, and if you understand and agree, the treatment can be given.
For most patients the informed consent model is plainly faster and less paternalistic. It recognizes the fact that adults are capable of making decisions about their own bodies when correctly informed. The WPATH standards of care, which most respectable clinics follow, have been moving step by step in the direction of promoting patient autonomy as a core guideline. When vetting a provider, ask them directly which of the two models they follow. If they are elusive, that already tells you something.
Sequence Your Interventions Intentionally
Transition processes differ depending on individual goals. However, hormone therapy is a typical first step for those pursuing MTF feminisation. Feminising hormones will generally be prescribed for at least one year before consideration of any surgical options.
Hormones won’t affect the voice, Adam’s apple, or facial hair, all of which can be significant sources of dysphoria. Hair removal, particularly facial stubble, and voice training won’t necessarily reduce dysphoria by themselves either, but for many people, they’re vital, and can be incredibly affirming as the body changes throw into sharper focus all the ways it hasn’t.
Treat Blood Work as a Tool, Not a Formality
One aspect that many people don’t realize is how important monitoring really is and how foundational it is to the process as a whole. Hormone replacement therapy is not a set-it-and-forget-it kind of deal. You need to check in on your hormone levels regularly, as well as liver function, cardiovascular health, and often bone density.
All of this is best done by an endocrinologist who has experience with trans care. A PCP who is informed about trans healthcare is also a suitable candidate for managing routine monitoring. You want someone looking at your labs with your goals in mind and your whole health in mind, not just someone checking it against a cis norm. Make sure your provider is looking at your lab work in a way that realistically reflects where you are.
Build a Support Structure That Goes Beyond the Clinic
The medical aspects of transition are not enough on their own. The social and psychological realities are equally important, if not more important, and it is often these areas that are more difficult to find help and resources for.
For example, a third of trans participants in the 2015 U.S. Transgender Survey who had seen a healthcare provider in the past year reported at least one negative experience related to being transgender. That’s not a great sign for the health of what we might laughingly call the “care” system, nor is it a great motivator for trying to rely only on therapy. When there’s all the potential in the world for therapists to unintentionally pathologize your identity / relationship / desires / whatever else is going on that you’re trying to get your head around, the last thing you want to be doing is defending yourself.
But if therapists are only one leg of a stool and your online and real-world communities make up the other two, you’re setting yourself up to be able to figure out what’s useful and what’s absolutely not while having a few people who can tell you where the papers are hidden.
Plan for Long-Term Health, Not Just the Transition Period
This is a detail often unnoticed by many. Most discussions during early transition are about current changes, which is logical. However, hormone use in the long term has health consequences that must be monitored, and adding them to your health plan from the beginning is much easier than trying to include them at a later time.
Time and again, we hear that cardiovascular health and bone density will be looked at over time. Body fat redistribution and muscle mass changes are bound to influence your heart in the long term. Estrogen alters calcium processing and bone mass maintenance in the body. Anti-androgens can have an impact on your red blood cells. None of these are reasons to run away from HRT. But they are reasons to ensure you have a provider who is monitoring them and pushing for the tests you require, rather than assuming they will be offered to you.
Preventative care will have to be adjusted to your specific anatomy and your hormone status. A pap smear schedule that doesn’t take into account your surgical past, or a bone density which is never started won’t do. You are entitled to demand what you require.
Taking Ownership of the Process
Gender-affirming care is more effective when you’re driving, not just along for the ride. Be proactive, ask questions, do your research, build a supportive care team, and plan ahead. It’s not always straightforward, and you may have to push for what you require, but being as specific as possible will increase the likelihood of receiving the care that works best for you.
