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A little nervous about Thursday

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  • Well, the title sums it up. First, I'm still very stuck in the closet because I haven't come out at work yet and I need the job, at least for the short term. Second, I started testosterone blockers back in August/September. I like what they have done and continue to do for me. On Thursday I've got an appointment with the endrocrinolgist that works  with people who want to under go HRT. I'm very excited to do so but at the same time nervous about the appointment. I don't know as much as I'd like to about what options there are today. As well, I do have a health plan at work but if I have them pay for the blockers and hormones do they get a report of what medications I'm prescribed that they pay for? If they did then I'd either pay for anything myself or wait until I'm more ready to come out at work.

     

    Anybody have experience with health insurance, prescriptions and reports in Canada?

      January 7, 2017 8:43 PM GMT
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  • Hiya Cynthia,

    I should imagine that whatever your prescribed and the nature of your consultations would come under the doctor patient confidentiality clause, which would cover any subsequent prognosis/prescriptions/medications invoiced to the adminstrators of your health plan, generally the onus is upon the patient to inform any other insurance cover firms of any diagnosis, medications that could prevent you from cover, for example, driving insurance if the condition or medication impacted on your ability to drive safely.

    Assuming you have a clinical diagnosis of a gender identity problem by a specialist, here in the UK once one has been diagnosed and refered to a gender clinic, our national health system regulations and the UK Gender Recognition Act requires that prescripyions/medication and ongoing treatments should be made available.

    I am not sure what the health service regulations are in respect of Canada.

    Cristine Jennifer Shye.  B/L.  B/Acc
    This post was edited by Cristine Jennifer Shye. BL at January 7, 2017 10:16 PM GMT
      January 7, 2017 9:57 PM GMT
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  • Thanks for the reply in regards to insurance. I'm just concerned about my job because it is so important to me right now. It is not just the money either, right now the structure that it is providing day to day will be rather important. Not being able to present fully the way I'd like is hard but I'm finding little things that I can do that help in that regard.

     

    In Ontario, the province I live in, things have really turned around for people with gender identity issues. At one point you first had to be diagnosed by a specialist at a gender clinic with incredibly long wait times just to get an appointment. Then there was a battery of humiliating tests that you had to go through. You then need to live outwardly as your chosen gender for 1 to 2 years before any HRT. You'd then be another few years after that before they'd consider assessing if you were eligable for gender reassignment surugery, if that is what you wanted.

     

    The regulations are no where near as rigid now that it is Gender Dysphoria rather than Gender Identity Disorder in the new DSM-5. You no longer have to go to the gender clinic and convince a doctor there hat you were born the wrong gender. Almost any doctor can refer you to another doctor that monitors the HRT and that's it. The doctor I will be seeing is just an endocrinologist that deals with body chemistry. If your regular physician is comfortable enough they can prescribe the treatment themselves.

     

    Actually, we are a lot luckier here than in most places here in regards to gender dysphoria. Our provincial health care will now pay for gender reassignment surgery, though the waiting list is long if you go that route. There is even a new ruling that they will pay for breast augmentation if you can prove you've been on HRT for an extended period of time with no substantial increase in breast development.

      January 7, 2017 11:31 PM GMT
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  • That's really strict compared to America. There is no gate keeping where I am.
      January 8, 2017 7:08 AM GMT
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  • So, I did have my appointment with the endocrinologist today. She was very nice and very understanding, I will really like working with her. She gave me sume reading material and a few contacts for services in the area. She was not comfortable starting female hormones today. Instead she has asked me to speak with a psychologist in the area that helps people with the gender identity issues, at least twice, and then we will look at starting HRT. I'm totally cool with this idea as I have only talked plans with my family doctor and I don't have a plan for transitioning/coming out other than I want to. So, waiting a few more months definitely will not hurt at this point and at least the spironolactone is having enough of an effect to help with some of the angst that is is causing.

      January 12, 2017 10:02 PM GMT
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  • That Much hassle to get on this medication is unwarranted. What I told u is everything u need to know. Do many things aren't in the internet. Why two times. What's to analyze? You are or your not. This is permanent. There's no going back. People can be so ridiculous. And it's people that do not know ****. Unless they are transgender.
      January 12, 2017 10:32 PM GMT
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  • Same old answers, any consultant, doctor or surgeon has a duty of  care, which includes establishing a need, it would be incompetant to just hand out prescriptions, perform surgery on demand, especially in this age of litigation.   It is understandable that they hesitate,

    Some people don't do research, even know what a regime of HRT can do to their endocrine system, how it will effect them, or any adverse side effects that could happen.  be content that when a doctor/specialist does prescribe drugs, they are confident they are making the right decision for you.   Firstly an endo must review your current health do whatever tests are needed, then a second appointment after the tests have been done in a lab to explain what you will be taking and explain what you should do and not do and explain the what if's.   A good example you cannot legally drive a car without first proving your capable of driving one, taking a test and getting a certificate to prove it,   Too many want it now, regret it later.

    Cristine Jennifer Shye.  B/L.  B/Acc
    This post was edited by Cristine Jennifer Shye. BL at January 12, 2017 10:56 PM GMT
      January 12, 2017 10:49 PM GMT
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  • Her suggestion was not about analyzing anything. It was about making informed choices. The doctor and I chatted a bit, it wasn't a 30 second, "No, you need to do x y z first." No, we talked about my plans, if I was "out", etc. and she asked me if I was comfortable with her plan, and I am. I could have started hormones 4 months ago if I really pushed things. Whether I start hormones tomorrow, 2 weeks or 4 months is not important. What's important is that I'm happy with the direction I'm going and I'm totally happy with it.

      January 12, 2017 10:54 PM GMT
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  • http://gendersociety.com/articles/386/how-does-the-two-gender-system-impact-you

    Cristine Jennifer Shye.  B/L.  B/Acc
      January 13, 2017 12:24 AM GMT
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  • Idealy you should have blood tests done, the endo will base the levels of your HRT on things like testesterone levels,   People found to have conditions like AIS, would have a different prescription.   Also other conditions would impact on your health if you were precribed HRT.

    Cristine Jennifer Shye.  B/L.  B/Acc
      January 13, 2017 12:28 AM GMT
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  • My family doctor had ordered some blood work before hand but had ommitted a few tests that she likes to have; prolactin, testosterone, and a few others but I can't remember the names. :P From what she saw there was nothing that raised any concerns such as high cholesterol, diabetes, etc. Her feeling was that I need a better plan in place before starting HRT and I'm good with that. What helps is that I don't have to get another referal to her. I can just call and make the appointment next time.

      January 13, 2017 1:40 AM GMT
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  • The Internet is a wonderful resource and is a great source of information about trans issues. It is a lifeline for many enabling interaction with other trans people. The number of trans sites has increased enormously in the last two years and it provides the information required for people to attach terms of reference for the feelings they have. Some sites are better than others and many comment on the hormone interventions that are used to facilitate a physical transition. Depending on the site, the accuracy of this information varies from completely inappropriate to a very sensible overview. Armed with this information people proceed to buy their medication off the Internet from the numerous convenient but often expensive online pharmacies without any advice from a doctor.

     

     

    Doctor Richard Curtis.   I have been asked by a number of people to write about this issue from the medical perspective. I would hazard a guess that a third of my new patients have recently or currently self prescribed in this way for varying amounts of time. It is fair to say some people choose sensible regimes but others take wholly inappropriate drugs. Before the cynical reader assumes that I am writing this to encourage patients to come and see me, I can assure you that the reasoning which follows would be applicable to cross sex hormones obtained on the Internet is risky. any form of self-prescribing with any drug. It is advice I give my friends and advice I used to give as an NHS GP.

    There are ten reasons why self-prescribing cross sex hormones obtained on the Internet is risky.

    1. Firstly, the quality of the drugs obtained may be of a poor standard. There are some "rogue manufacturers" who do not comply with normal pharmaceutical manufacturing processes and are not regulated. "Drugs" with no active ingredient and pills with cement as a constituent are regularly discovered. There is no guarantee that the pill you think you are taking is what you ordered. Clearly such "drugs" will not have the desired effects and could clearly cause unusual or harmful side effects. These "manufacturers" make the packaging look convincing as this is not difficult to do.

    2. I commonly ask patients who have self-prescribed how much their drugs cost. Generally, they have paid much more for them than the high street chemists would charge with a private prescription. Testosterone injections and Oestrogen are actually quite cheap but patients are paying several times more than they need to. Hence the Internet is not necessarily a cost effective opt

    3. Prior to prescribing any drug, doctors undertake a risk assessment based on the individual patient's health to date, family history, age and the results from any test to determine the adequacy of kidney and liver function. Properly functioning liver and kidneys, which metabolise and excrete most drugs are essential. I undertake routine blood tests prior to prescribing. Whilst most patients are fit and healthy, the odd patient does have underlying problems, which they are unaware of. For instance, excess alcohol consumption can lead to abnormal liver function. This means that the body cannot adequately process drugs, particularly oestrogen, causing an inappropriate build up which may in turn lead to increased risk of adverse effects. Some patients do not realise that a family history of thrombosis, for instance, as well as having a personal history themselves, means that additional caution, counselling, baseline tests and monitoring, would be appropriate. The drugs used by doctors in every branch of medicine are tailored to the individual. So a "one cap fits all regime" is substandard practise.

    4. The exact drug used is important. Different drugs have different risk profiles and careful counselling of the patient and informed consent is a necessary prerequisite, particularly for the higher risk formulations. For example, the risk of thrombosis is much higher for Ethinylestradiol, which is found in contraceptive pills, than for 17 ß-Oestradiol, which is why the former has fallen from favour. There are patients who put themselves onto this drug who should not be on it and put themselves at significant risk of serious side effects. There are transmen who take things like growth hormone or high doses of body building steroids in addition to the usual Testosterone injections without understanding the implications of this.

    5. Few patients are aware of the mechanisms of absorption, distribution, metabolism and elimination of drugs. An at risk individual may not appreciate the way different delivery methods impact the tolerability and drug load the body has to deal with. For instance, the shorter acting Testosterone formulations have quick cycling peaks and troughs every two weeks. A high peak over the normal range for Testosterone is much more likely to lead to complications than the longer acting slower onset injections such as Nebido. Similarly, the troughs are often troublesome and a more balanced daily administration utilising the transdermal delivery method may well be more appropriate for some individuals. Such discussions are an essential part of the doctor's role in helping patients to achieve their physical transition in the safest and most stress free way.

    6. The actual dosage chosen by patients varies markedly. Some take very tiny doses and really may as well not bother. Others overdo it without due concern. One of the basic tenets of prescribing is to use the lowest dose to achieve the desired effect. Every individual varies in their ability to absorb drugs, particularly orally, as well as the ability of these drugs to work in a beneficial way. Again the "one dose fits all" impression given by the Internet is misleading. The Internet doesn't generally mention the long list of drugs which can increase or decrease the absorption of oestrogen for instance. Doctors are used to keeping these things in mind and advise accordingly.

    7. Patients very under appreciate the impact of what is called co-morbidity. Co-morbidity is the impact that other health problems may have on the risks associated with taking cross gender hormones. Compromised liver and kidney function has already been mentioned. In transmen, this may be something called haemochromatosis, a relatively common inherited condition which predisposes the person to make too many read blood cells. If this is significant, it can increase the clotting tendency of the blood, causing a thrombosis in the form of a pulmonary embolus or deep venous thrombosis in the leg. Testosterone also has this effect and means dosage frequency or formulation (the method of delivery of the drug e.g. injection, gel or patch) adjustment may be necessary from the outset. Those with diabetes, high blood pressure, a history of strokes, heart disease or clotting tendency can all be made worse by the administration of Oestrogen. Failure to appreciate this and look out for the early relevant symptoms can jeopardise subsequent treatment.

    8. All long-term drugs should be monitored closely. Any patient on repeat prescriptions will tell you that they have to see their GP once a year to review their medication. Things change; the body is a constantly evolving organism. From one year to the next, it is not the same. Over many years in Practise, my experience is that patients do not understand this. It is often said, "but it has been fine up until now". The effect of aging is the most obvious example. Over forty, the body is starting to show significant changes. It is slowing down and does not tolerate drugs as well as a twenty year old. Fifty plus, sixty plus, seventy plus all show step changes in the factors to take into consideration in re-prescribing. Remember, it is not always possible to know what is lurking within us. Cancers can take ten years to become evident. Arterial disease causing heart attacks and strokes is not obvious until you actually have a significant heart attack or stroke. The risks of these types of things are known better by medical practitioners and a change in medication is often prudent to mitigate against these risks. I suspect patients think of monitoring in terms of blood tests and admittedly, these are a part of it. Recent research suggests that it may not be necessary to measure anything other than full blood count and Testosterone levels, with LH / FSH if post hysterectomy may be all that is needed in transmen. In post-operative transwomen not on Ethinylestradiol, liver function tests are somewhat redundant but Lipids and Glucose are probably not. An annual Oestradiol plus LH / FSH to monitor adequate replacement as requirements change over time is probably useful to inform decision making. But for both groups, an annual blood pressure reading is hugely important. Oestrogen is well known to increase blood pressure. We have not studied sufficient numbers of transmen for long enough to know what the actual long term risks are but high blood pressure may be the first marker of increased cardiovascular risk. Genetic men have a higher incidence of coronary heart disease and it is not known whether this transfers to transmen taking testosterone. A prudent change to the dosage and method of administration plus adequate management of other conditions and drugs is all that is proposed. It is not say that withdrawal treatment is necessary but one wants to be an alive trans patient - not an avoidably dead or ill one.

    9. It follows from the above that adequate supervision of hormone administration will facilitate early or appropriate management of unrelated illness or untoward effects of any drug. Untoward effects do occur, including thrombosis as a DVT or PE, polycythaemia and breast cancer. Cancers generally happen and increase thrombotic risk; high blood pressure happens.

    10. Finally, common sense dictates that self-prescribing potent drugs with a multitude of surrounding issues which are poorly understood is a dangerous idea. Consult those who are expertly aware of all the above. I am a great fan of DIY but still realise a professional tradesman has far more skills and experience than I and on average, is going to do a better job. It is not a perfect world and even doctors don't always get it right. Patients are even less likely to.

    There are reasons why people decide to self medicate. But I believe however, it is false economy financially, physically and emotionally in bearing the burden of prescribing. I have not gone into every possible scenario but can certainly say that it would be extremely likely if all data was analysed, everyone who self prescribes would have some issue pertaining to one of the above points. Don't do it!

     

     
    Cristine Jennifer Shye.  B/L.  B/Acc
    This post was edited by Cristine Jennifer Shye. BL at July 5, 2017 12:44 AM BST
      January 13, 2017 1:36 PM GMT
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  • That is a very good read and a wonderful article. Personally, I'd never consider self prescribing and buying hormones, online or street hormones. As the author mentions, I'd have no idea what to order or how much to take. Risking my life or doing self harm is not worth shaving a few months off of taking hormones.

      January 13, 2017 2:10 PM GMT
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  • Still there is so much the internet doesn't tell people I personally know this . I been on hormones a very long time. And transitioning well
      January 13, 2017 2:24 PM GMT
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  • When u take time off from taking hormones the body goes Into menopause. Or could not a guarantee. Bet the web didn't share that to. I'm sick right now cause I didn't stay on top of my medication. I ran out and fell badly sick. I'm sure everyone differs. But that's me. Much the internet won't tell u.
      January 13, 2017 2:28 PM GMT
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  • Why are people so stuck in endos. Where I live they won't help our kind. I use a regular doctor that is well trained for this.
      January 13, 2017 2:31 PM GMT
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  • All I will say is every female emotion you can't or can even imagine is possible on hrts. With out being born with the parts it goes into bypass. Like default. I can get all female feelings. All I wanna say.
      January 13, 2017 2:35 PM GMT
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  • They all start with the smallest doses I wouldn't self medicate. I could tell u proper dosages but I won't contribute to self medication. There's no doctor to monitor blood work. I'm st the highest dosages allowed by the medical professionals. And that is set according to my blood work. Wrong dosages could drop blood pressure to almost nill. In the danger zone. Skin gets extremely cold. I know these things. I been there. Be careful
      January 15, 2017 11:55 AM GMT
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  • So, my GP talked to the Endocrinologist that I saw. It turns out that if she feels I'm unready to start HRT she has to refer me to fill out this form that they Transition Readiness Evaluation, just to cross Ts and dot Is. He mentioned that because I was not able to relay the full story to her, she was distracted because her daughter was sick and brought her to work rather than cancelling my appointment, if I was able to explain the full story to her she might change her mind. Also, there are a few others that will fill out this form and I will search for them and see about getting it filled out sooner than the other person I'm already in contact with that is not available until the end of February.

      January 31, 2017 11:34 PM GMT
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  • took me an hour to read finish this thread. really useful to understand.

    thanks for sharing :)

      July 4, 2017 7:56 AM BST
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  • One of the primary reasons for people to turn to the internet pharmacies is because of the lack of good care, at least here in the USA.  Most doctors are not schooled nor care about us and thus when scheduled, usually only provide "solutions" that they have "cut and pasted" from guess where?  Yup, trans web sites that share information on their transitioning.  This is why a drug like Spiro is prescribed time after time to eliminate testosterone when the truth is Spiro is a T "blocker" and is used primarily to reduce sweling in extremities in people who have congestive heart failure.  And the "myth" of the "success" of this drug gets passed down not only to the medical field, but also m2F transitioners years after year.  Virtually all are ignorant of the potential for brutal side effects.  And then many girls think that if 100mg is a "normal" dose, that 200 or even 400mg will help them transition even faster!  

     

    As there is no money to be made in our community due to such a small incidence of trans folks in the overall population, there have never been any clinical studies done over time to find what really works and what doesn't.  Only a handful of medical types have taken it upon themselves to go further and thus provide good care.  There are a few here in the USA that are m2F women and are doing remarkable work, but there are not enough of them.  

     

    Fact:  I knew a TON more about HRT and transitioning than my general practioner and endo.  I no longer consult with them on any matter regarding hormones.  I truly feel they wish I would just go away and not bother them.  Their wish has been granted...(smile)

     

    Traci xoxo

    <p>Traci</p>
      July 4, 2017 9:31 PM BST
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  • The great thing about the UK National Health services and the UK Gender Recognition Act is that genuine doctors will treat all patients with the same jaded attitude.   Seriously though, most doctors, will if they don't understand the complexities of Transgender disorders will refer a person to a someone who knows what is what, waiting times vary from area to area, due to financial limitations, an over burdened health service.   We do have specialist gender clinics.   I should imagine in a lot of countries where people have to pay private medical insurance, a doctors response and attitude will depend on if a policy covers such treatments, so in those cases it is all about an ability to pay.I had my surgery done in Berne, for several reasons, they did the procedure I thought was best for me, secondly it was expediant once I was ready for it, without a lengthy wait, and in the event something went wrong or there were complications it was'nt as far away as Thailand. but it was'nt the cheapest.

    Cristine Jennifer Shye.  B/L.  B/Acc
      July 4, 2017 10:23 PM BST
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  • The USA has primitive care at best with only small isolated pockets of genuinely concerned and knowledgable practioners willing to work with us.  Most underprescribe proper dosages erring on the cautious side and often write scripts for things like ethinyl estradiol or premarin which have been proven to be either extremely risky or basically uselss.  To get them to open their eyes and and look at us as patients who actually grasp what they need more so than the doctors themselves is most often futile and creates an adversarial position between doctor and patient.  To find a doctor willing and open to viewing us as "equals" in this is rare and worth the effort to work with. I'm fairly certain that a large proportion of our community has spent countless hours researching, questioning, and sifting thru tons of available information out there to be able to come up with solid protocols to get started and safely and effectively go forward.

    But there's so many hurdles for us to overcome within the medical and insurance world and everybody's situation appears to be different. 

    One day, some day, there will be an actual "Tranny Handbook" which provides proper and realisitc guidelines and protocols based one's age and situation.  Until then, we just plug along the best we can!  The UK at least has a mechanism in place to work with us.  The USA is helter skelter...

    Traci xoxo

    <p>Traci</p>
      July 6, 2017 4:40 PM BST
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