November 28, 2015

Access

When you have a habit of moving house almost every year or two for the past 9 years, you encounter a few issues with continuity of medical care. It is sometimes a real pain in the ass to have those patients with no listed GP and whose medical records span about a metric fuckton of different health services in different cities. They may have seen a variety of specialists over the years for a variety of problems. Hard to know exactly what’s going on though, because no matter how eloquent, well-versed or intelligent they are, you do not have that information in front of you. You do not know exactly what you are dealing with.

A doctor who has been neglecting his health for the past however many years? Not quite the worst, but pretty bad.

Last year after coming out as a guy I did not have a GP but I was able to get free counselling at the Sexual Health service at the country town I lived in, which was fantastic. At that stage I knew who I was but not what I wanted to do. I needed to talk. I needed to work out who I was, as a man, as a human being. But I did not urgently need medical attention for those issues.

Let us be honest though, I hear what health care professionals think about transgender people and other minorities all the time. Here are some choice examples:

Why do gay men talk funny?”

Angelina Jolie accepting her child being transgender is practically child abuse”

That nurse is a fucking flaming queer”

Why do gay people need to demand they get rights like marriage, it’s disgusting”

People laughing at ward desk at my admission note of elderly transgender woman who presented with endocrine problem

THAT IS SO GAY

Discharge summary of staff member includes her sexual orientation of bisexual in it even though completely irrelevant

If we give testosterone to the intersex patient who identifies as female but is assigned male at birth maybe it will cure his gender identity disorder”

Endocrinologist referred a transgender patient: ok, I’ll see he, she, heshe in my rooms guffaw

So I was not exactly excited to begin the process of trying to find a GP who was accepting or knew anything about transgender issues.

We do not learn much, if anything about LGBTIQ issues or patients in medical school and neither do nurses or other allied health professionals. Ward clerks? Got no hope there. This stuff should be compulsory and it is not. Just like multicultural things; how many healthcare professionals working in a majority Muslim suburb in Sydney have I had to tell well, actually you can break a fast during Ramadan if it is medically necessary”?

To be honest that LGBTIQ information is not even easily or readily accessible. My mum is a GP, she has had multiple transgender patients over the years and she found accessing resources and referring patients next to impossible. The Gender Centre in New South Wales, for example is a fantastic resource, but how many doctors know it exists or even how to find it on the internet? I certainly did not!

So when I moved to a (large) new town, I let things kind of go for 6 months. I was too stressed out by moving and everything else to contemplate trying to work out how to find a GP. A GP is necessary to get a psychologist and psychiatrist referral, as well as a referral to an endocrinologist if needed.

I got steadily more and more depressed and stressed. Eventually I just could not handle it any more. So I called up the Gender Centre to ask if there was anyone they could recommend.

They did not have anyone listed who anyone had recommended to them.

What? Seriously? So I asked a few of the online groups and one of the guys I knew to be in this area, and I asked one of the psychiatrists at work.

Nope, no recommendations for a GP. Or psychologist. Or psychiatrist. Or endocrinologist. I lost it for awhile.

You know what came to mind? It seems totally spoilt, totally entitled and privileged to say this as a doctor. I realised that I am a patient in a country town in Australia with a speciality problem and I have all the problems of healthcare access that come with that.

I ended up speaking to the counsellor at the Sexual Health service. She did not know anyone off-hand but she said she would ask around and find out what she could as they have a multitude of transgender patients. Being able to talk freely and frankly about things for the first time in 6 months about my incredible frustration was great. About the feelings of being totally isolated. Of being unable to access services. Of friends who refused to use the right name or pronouns. Of extended family who will never be able to understand any decision I make, nor who I am. Of all the people who ask me over and over what the big deal’ is. Why this has to be such a big deal’ when gender is a social construct’.

Anyway she got back to me with a name of a GP and the name of a psychiatrist (both local!). So I went to see my new GP. She was pretty great! She is very understanding and a bloody good doctor, and is not afraid to admit her boundaries. Man, I had- and have- a lot of stuff to sort out, medically, most of which are under control or treated now. Probably the biggest thing is PCOS and weight gain- entirely frustrating.

The psychiatrist was really very good too. So, the background to this is that in many places around the world, specialists who do not work regularly in gender stuff can be judgemental or not know the evidence. In selected places the people who run gender clinics are still like this though these people being employed to run transgender medical services is rare. Overall though, people who do not like transgender people do not exactly volunteer to be involved with their medical care. Online though, there is a lot of suspicion regarding medical specialists. Some of it is understandable but some of it is actually paranoia. Fortunately I had already chatted at length to a few trans people who did assure me that it was best to just be honest and talk about my worries- especially as I had not made my mind up to do anything.

I was honest with my psychiatrist. I disclosed absolutely everything that could possibly be a factor in a medical or psychological decision, including the non-stereotypical bits (I like some girly things, puberty did not distress me that much). At the end I asked him what he thought and he said the following (paraphrased).

To be honest, this all seems very straightforward! Your diagnosis of gender dysphoria is pretty obvious and is well within what is typical of the experience that people have. My role as a psychiatrist is not to be a gatekeeper’ but to make sure that you are of sound mind to make an informed decision, in other words to make sure you are not suffering from an acute psychotic episode or anything that would constitute not having capacity for informed consent.”

No-one had ever worded it quite like that but it made total sense. My GP had suggested the psychologist I currently see and my psychiatrist said she was very good and said basically that the next step was for me to have the minimum 3 months or more of seeing a psychologist to decide what I wanted.

So I saw my psychologist and she is incredibly excellent, very competent and very professional. Like my GP and psychiatrist I would recommend her to anyone and I am seeing her also about the other non-gender related stuff. It also turns out that she is the psychologist in this area to see about gender stuff.

I want to make the point that my however-many-months of seeing a psychologist were incredibly important to me. There are a lot of quite complex questions that go through your mind in this process. One of them is what kind of man, woman, individual you are. You are not just the same but with a different gender marker’. That is simply not true. For many people, even if their general identity was pretty well formed or set solidly, there are inevitably all the questions that arise when you occupy a different position in society. Even if you see yourself exactly the same, other people do not. And it is probably more common to see yourself a bit differently if you did not grow up knowing who you were, gender-wise. Gender, sexual orientation and gender expression are pretty important things in the society we live in, for better or worse. An example is how the reception to me critiquing feminism now versus when I identified as female has changed. In addition, living with what is an incredibly large amount of stress every day for 28 years (I did not really perceive that I was any different until I was maybe 3 years old) means that you got shit to work through. Working through those issues is not a cakewalk or anything.

It is frustrating if you want to just get through the process to the other side where you see an endocrinologist but it is 3 months of incredibly valuable time. The more prepared you are I think the easier it is from what others have said to me. Delaying things ad infinitum however is not beneficial to anyone.

Transition is not a binary function. It is not just hormones and surgery”. Some people have hormones. Some do not. Some have surgery on their chest. Some do not. Some have their gonads removed. Some have external genitalia altered. Some do not. There is social transition. There are all the legal parts of transition. Truly, it is a spectrum of a multitude of binary decisions (at least 6) and other things that are better considered as a spectrum!

For me, therapy was about getting myself to the point where I accepted a decision I had already made - to take hormones. It was a difficult decision. It was not particularly exciting. It was sort of happy and sort of sad. An incredible relief; incredible sadness; different kinds of stress.

Soon I am going to see the endocrinologist in Sydney. I have to take a day off work for this. Travelling up there and back means several hours of travel in one day (there and back). I do not know what is coming. Will they say my medical issues are too high risk? Will I have to do a number of things prior to starting testosterone?

It has been hard but it is nothing compared to the people who do not have access to a sexual health service, or a GP who is sympathetic, or who live somewhere where there is no access to treatment. Or have access to treatment but the specialists are not sympathetic. Or who live in countries such as the US where healthcare is prohibitively expensive.

So I am sort of blessed and sort of cursed. I would say it has been OK so far but it has been really hard. Telling the same story over and over again is tiring. I am incredibly grateful though for the healthcare professionals that have helped me through this whole journey so far. Without them I could not have done anything.


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