Can’t You Wait Until I’m Dead? ~ Chapter 8: Ageism Much?
Between teaching the last classes of the term and giving exams, I continued to study medical transition and ways to avoid its pitfalls. While I was looking for information on what it was like for women who hadn’t had surgery to pee in a women’s washroom—wondering if I’d somehow sound different—I found a humorous but distressing post on a website called transgenderzone.com, entitled “To pee or not to pee, that is the question+Going for a thong.”[i] The post discussed her disappointment about how, after surgery, she had to wear pantyliners and heavy-duty panties (“granny pants”) because of leaking. Other users added their experiences and theories, after which, she posted a follow-up to say that she wasn’t leaking after all; she just wasn’t waiting and wiping enough.
What would I need to learn? I was going to be more like a student than a professor for the next few years, and realized that I’d have to lean on the internet, my friends, and my partner for lessons they gained from potty training, puberty, and menopause.
While working from home on lectures and exams at the end of April, I saw Dr. Melnyk’s office number appear on my caller ID and answered it, expecting to have an appointment at Three Bridges. Instead, the office assistant called to set up another appointment with her. When I asked why, she said, “We sent a referral to Three Bridges Community Health Centre, and they sent it back with a suggestion to try the Transgender Health Information Program (THiP). THiP sent it back, too, so you’ll need to discuss next steps with Dr. Melnyk. You can try THiP yourself, and one other place you can try is Catherine White Holman Wellness Society.” I booked Dr. Melnyk’s next available appointment for May 2 and called THiP to find out why they rejected her referral. “We’re run by Vancouver Coastal Health and only see patients twenty-five and under who live in Vancouver. Your GP can prescribe hormones, but if they need an assessment, you can have your doctor refer you to Dr. Gail Knudson at VGH.”
I came across Dr. Knudson’s name in my reading over the past year, in summaries and presentations she made advocating and organizing trans care in BC. She was one of the leading psychiatrists in transgender medicine and co-chair of the Global Education Initiative at WPATH, the association that writes the guidelines for transgender healthcare. Her practice at Vancouver General Hospital had a long waiting list, so she was working to teach other physicians in BC how to care for transgender patients themselves.
I wasn’t keen to sit on a wait list to see Dr. Knudson, so I wrote to the Catherine White Holman Wellness Society, asking them whether doctors there could prescribe hormones for me and they replied, “Our physicians are unfortunately not able to take on new patients right now as we don’t have the capacity.” They repeated that the Trans Specialty Program running out of Three Bridges and Ravensong Clinics in Vancouver would see me if I either lived in Vancouver or was twenty-five and under anywhere in the province. I couldn’t believe this was happening to me in a province and country known for publicly funded healthcare for all!
They offered one other option: “If your doctor is willing to prescribe hormones but needs some advice, you can suggest she call the RACE Line and speak to one of the Trans Care Specialists by phone.” RACE stood for Rapid Access to Consultative Expertise, where GPs in the province could call a hotline and get a call back from a specialist, including ones who specialized in transgender hormone therapy.
I replied, “Unfortunately, I live in Fraser Health now (regret selling my condo in Vancouver!), am fifty, and have contacted Three Bridges and been rejected, so please let me know when you are taking new patients. I’ll try to convince my GP that she can do it herself (she sent me to Three Bridges and then referred me to you), but I am frustrated to the point of considering a trip to the States or using the internet. Could I lie, and list my former address in Vancouver? I suspect that they’ll remember my name after being referred. Do you have a list of GPs who are comfortable prescribing hormones here in the Lower Mainland? Fraser Health?”
Users on several online forums said that the only way they could get gender-affirming care was to do it themselves, turning to internet pharmacies to buy the drugs. I knew enough pharmacology and pharmaceutics to take it on myself, but with a physician's prescription, I wouldn’t have to pay for it out of pocket.
He replied at 8 p.m. the same day:
Dr. Maria Weber works at South Hill Health Centre and is one of our physicians at Catherine White Holman. She is accepting patients into her practice and is very comfortable with hormones. You can register online on their website. Be sure to mention that you’d specifically like to see Dr. Weber for gender transition. I think her wait is about two months. If you’d like to stay with your family doctor and see someone else for hormones, there is an endocrinologist named David Marshall who will prescribe hormones, and your family doctor can refer to him. However, he does not do the hormone readiness assessment and requires you to get that elsewhere. If you are able to pay privately, there are some psychologists who can do this (THiP will have a list). Hope that helps. I will also hold on to your contact information for if we start taking patients again in the future.
I called the family health centre’s patient line, and they sent me to the clinic’s website, where they collected my name and reason for needing a doctor. My hopes for someone confident to guide my transition met a faceless web form, so I wrote, “I’m desperately searching for gender-affirming care to transition from male to female. My partner is also looking for a new doctor.” I clicked submit on Plan A and started work on Plan B.
I needed to convince Dr. Melnyk to start me on hormones herself, and given her inexperience and reluctance, I had to know what was right for me before we talked about it. The most comprehensive medical reference I found on transitioning was UpToDate. It was the physician, evidence-based reference that most universities, hospitals, and independent physicians subscribed to. In it, I found fifty-three pages of dense background and advice on diagnosing and treating patients like me.
The first article, Transsexualism: Epidemiology, Pathophysiology, and Diagnosis, written in 2015,[ii] said that I was one out of between three hundred and twelve thousand people assigned male at birth (0.008 to 0.3%) who identified as female strongly enough to seek medical help. It talked about the neuroscience of gender and the bed nucleus of the stria terminalis, a brain region I studied in graduate school, and the article suggested that mental health professionals work through other possible co-existing conditions before diagnosing gender dysphoria. The dire warning for doctors was that prescribing hormones or performing surgery would have “far-reaching consequences,” and they should only proceed with the assurance of a psychologist or psychiatrist.
The second article, Treatment of transsexualism, written in 2013,[iii] defined my condition in such outdated and triggering terms that I decided not to mention UpToDate to her, and hoped that she hadn’t read that chapter already. “Transsexualism is the condition in which a person with apparently normal somatic sexual differentiation of one gender is convinced that he or she is actually a member of the opposite gender.” Granted, they wrote it in 2013, but I studied the neuroscience of gender in 1988 and couldn’t believe that a word so neanderthal as “convinced” was still in a modern reference. Medicine has a long history of labelling women’s health concerns as “hysteria,” and most of what they don’t understand they call “functional,” “psychogenic,” or “psychosomatic.”
Fortunately, the author updated the literature review section of the article in 2016. For me, being over forty, it recommended a combination of spironolactone to block my testosterone and estradiol patches to produce female-pattern body changes. Estradiol would decrease my body hair and redistribute my fat, including to my breasts. Doctors discouraged oral estradiol in patients over forty due to the increased risk of blood clots, and I was reluctant to go on oral estradiol after other women wrote about extreme mood swings.
I knew from studying pharmacology and working in the pharmaceutical industry that most oral drugs undergo first-pass hepatic metabolism, which involves the liver reducing their effectiveness. This means that patients need to take higher doses orally than with injections or patches, making it difficult to predict blood levels. The psychoactive actions of estradiol are dose-dependent, like emotional changes during periods, menopause, and pregnancy, so oral estradiol causes more mood swings than patches. My insurance covered the expensive patches, so my decision was easy.
The article described “genital sex reassignment surgery” as a last step, and it advised “MTF transsexual persons” to work closely with a mental health professional in preparation and after the surgery. They described surgery as the combination of gonadectomy—removing testes, known as orchiectomy—and genital “cosmetic” surgery. Referring to what was often a lifesaving surgery as “cosmetic” made my blood boil again, but it prepared me for the dated language I’d face.
Even in 2013, most surgeons performing genital surgeries referred to them as “gender reassignment,” “gender confirmation,” or “gender-affirming,” to convey their importance beyond cosmetics. The section on surgery concluded that sexual satisfaction depended on the quality of the neovagina, ignoring, as generations of doctors had done before, the clitoris, and said that late-in-life “subjects” like me were more likely to experience regrets after surgery. I’d have burned the article if it wasn’t electronic.
The third article, Primary care of transgender individuals,[iv] summarized the routine screening Dr. Melnyk and I would work through in the years ahead, including the time courses for body changes, and screening for various diseases, such as breast cancer, prostate cancer, high cholesterol, and osteoporosis. Aside from a mammogram, I’d been through the other tests already and noted that my risk of breast cancer wouldn’t be any higher than before starting hormones. On the plus side, my risk of prostate cancer would probably decrease when testosterone fell, and estradiol would reduce my risk of osteoporosis until I stopped taking it.
The paper I found next was the key to moving forward with my transition. Guidelines and Protocols for Comprehensive Primary Health Care for Trans Clients, written in 2009 by Sherbourne Health Centre and Rainbow Health Ontario,[v] was the most comprehensive, step-by-step description of medical transition I found anywhere on the web. For a physician, it outlined what to do at each appointment, including questions to ask a transgender patient, which blood work to order, initial doses to administer, and how often to follow up. I printed it off and gave it to her at our appointment, and she agreed to consider moving carefully through established protocols if it was what the province expected of her now.
She had one request in exchange: she’d be more comfortable if I provided her with proof of my counselling sessions. I’d only talked with the psychologist over the phone that one time in Sarah’s pickup truck, so I gulped hard and considered what it would take to make it over that hurdle.
[i] Steffi, “To pee or not to pee, that is the question+Going for a thong,” Transgender Zone, April 28, 2016, http://forum.transgenderzone.com/viewtopic.php?t=2605
[ii] Vin Tangpricha, “Transsexualism: Epidemiology, pathophysiology, and diagnosis,” UpToDate, January 13, 2015, https://www.uptodate.com/contents/transsexualism-epidemiology-pathophysiology-and-diagnosis.
[iii] Vin Tangpricha, “Treatment of transsexualism,” UpToDate, October 15, 2013, https://www.uptodate.com/contents/treatment-of-transexualism.
[iv] Jamie Feldman, and Madeline B Deutsch, “Primary care of transgender individuals,” UpToDate, July 28, 2015, https://www.uptodate.com/contents/primary-care-of-transgender-individuals.
[v] Amy Bourns, Guidelines and Protocols for Hormone Therapy and Primary Health Care for Trans Clients, LGBT Health Program (Toronto, ON: Sherbourne Health Centre, 2015).