"How do I get hormones?"

This is a very common question among transgendered people who want to transition. There is very little information available to the general public about how transsexual hormone therapy or hormone replacement therapy starts, and even less that explains where to go or how to pass through the many flaming hoops involved.

The Standards of Care, or SOC, is what is used in many countries including the United States. The following information is what I've gleaned from my experiences living in California and hearing from other transfolk in this country. Although the SOC is used elsewhere, the social rules associated with transitioning vary greatly from country to country. For example, many people go to Thailand to get sex-change operations because the surgeons are said to be good and because, while many doctors there follow the SOC in requiring the agreement of a psychologist or psychotherapist before surgery is administered, they often only require one visit before surgery. As another example, in the United Kingdom, the National Health system covers sex reassignment surgery and hormones, but that also means there is usually a very long wait to see an appropriate doctor before any of this can take place. As noted below, your location is one of the most important factors in how to get hormones; some of the following information can be applied nearly everywhere, but much of it will vary from place to place even within the States.

The SOC sets forth the following requirements for hormone therapy for adults:

Eligibility Criteria
1. Age 18 years;
2. Demonstrable knowledge of what hormones medically can and cannot do and their social benefits and risks;
3. Either:
a. A documented real life experience of at least three months prior to the administration of hormones; or
b. A period of psychotherapy of a duration specified by the mental health professional after the initial evaluation (usually a minimum of three months).

Readiness Criteria
1. The patient has had further consolidation of gender identity during the real-life experience or psychotherapy;
2. The patient has made some progress in mastering other identified problems leading to improving or continuing stable mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis and suicidality;
3. The patient is likely to take hormones in a responsible manner.
(http://www.hbigda.org/soc.html)

Blah, blah, blah.

Basically, this breaks down into two things:

1. You have to have a therapist who will write a letter vouching that you're ready to start hormones after at least three months of therapy;
2. You have to convince a doctor that you're a legal adult who is sane enough for informed consent and that - here's the secret catch - your gender is as normal and hetero-binary in nature as a gender can be.

Huh?

Let me break that down there. Basically, if the doctor or therapist you're talking to thinks you're too crazy or too weird, you lose the right to make decisions about your own body. Well, I guess that's a given, but as far as trans issues go, the bar for "too crazy" or "too weird" is easy to trip over.

What are some of the things that can cause you to be denied hormones?

Being depressed. Being suicidal, although some estimates suggest that 50% of people with gender dysphoria commit suicide. Being multiple, and probably any number of other similar situations. Being genderqueer, or otherwise "not tranny enough." Being shy or inarticulate, or having social anxiety disorder, if you then come across as uncertain or unclear. And my favorite: being gay, or lesbian, or bisexual, because many doctors consider that this means you're not trying to be a "real" man or woman. One standard response to a someone transitioning to live as a lesbian is "If you want to sleep with women, you should stay male - it'll be so much easier for you!" And of course vice versa.

I have direct experience with this phenomenon. I live near San Francisco, which is as close as you can get to being a "gender mill" - that is, a place where they let just any old person change their sex. At least, that was what I was told when I moved here. People said the Tom Waddell Health Center had a transgender clinic once a week that didn't follow the Standards of Care. When I finally made the decision to transition, I went there - not only did they sound good, but they seemed like essentially my only choice in this area.

It was a disturbing visit. The doctor I saw outlined by memory all the bad things testosterone can do (possibly... pending further study... barring biased assumptions from a sexist culture... but she didn't say any of that) like put me at a higher risk for heart disease, male pattern baldness, anger and violence. She said most of the changes were irreversible. As we parted, she added offhand that she wanted to be sure I knew that I could never stop taking testosterone, because almost all the changes would reverse. On top of that, I explained to her that I was bi-gendered (as I identified then) and just wanted to take testosterone long enough to lower my voice a few notes and become more androgynous. She didn't say anything about my not being able to stop hormones at the time, which is one of the things that made me think she didn't understand anything I said.

The visit before that, I'd been "interviewed" by some guy called Larry, who was a sort of counselor for new "customers," and by another doctor. The doctor was very sympathetic, said I'd obviously thought my gender through a lot and she thought it was very interesting. I didn't tell Larry as much as I told her, because I'd just gone through it all with the doctor, right? so why go through it all again? I could tell Larry had some problems with what I told him, but all he said was that he wasn't sure everyone else would understand and I might have some problems later on. I thought if that happened, I could just explain it to them.

I left feeling like he was going to screw me over, and I was right. When I returned the next Tuesday, Dr. Martinez told me that the group of doctors there had met and decided I wasn't a good candidate for hormones. The messages I got were that they didn't have the resources to help people who weren't in desperate need of it, but mostly that they didn't think I was trans enough for any kind of gender help. Much of what the doctor said to me at that point translated into "You're just a confused dyke with penis envy who needs some nice therapy." Apparently Dr. Martinez had felt that way after our first visit, and rather than ask me more questions, she'd gone to Larry and he'd promptly concurred. It was like anything I told them would get boiled down to either "clearly transsexual" or "clearly confused," and since I'm not a textbook case, no amount of explaining on my part would help.

Having been through that experience and still managed to get hormones (elsewhere!), let me share some tips. There is no One True Way to do it, or one given set of hurdles to jump through: I'll give you the basic ways to do it, problems you might face, and things that might help you out. Combine them as you will.

The basics

There are a few different routes you can take. The main ones are:
1. Go to a therapist, get a letter authorizing you to get hormones, and take it to an endocrinologist;
2. Live in or move to a city where they have a gender clinic (any clinic that handles people transitioning as part of their normal work) and see one of their doctors.

The benefit of a clinic is that it's sort of one-stop shopping for all your transitioning needs, and that hopefully you won't have to educate people too much about your experiences. Some that I know of (loosely organized by country) include:

  • The Albany Gender Clinic (Albany, New York; albany-gender-clinic.com)
  • Philadelphia Gender Clinic (Philadelphia, Pennsylvania; also specializes in castration; http://felixspector.com)
  • The Tom Waddell Health Center (San Francisco, California; may be good for normally-gendered transwomen; http://www.dph.sf.ca.us/chn/HlthCtrs/transgender.htm)
  • Castro-Mission Health Center (San Francisco, California; open to community input and needs, has a queer youth clinic ages 25 and under once a week where many trans youth including myself get their hormones, does not follow the Standards of Care; http://tghealth-critiques.tripod.com and http://www.dph.sf.ca.us/chn/HlthCtrs/castro-mission.htm)
  • Fenway Community Health (Boston, Massachussetts; very interfering in some ways, like requiring that transpeople be non-smokers and have resolved any litigation in which they're involved, and uses an extremely outdated copy of the Standards of Care; http://tghealth-critiques.tripod.com and http://www.fenwayhealth.org)
  • Gender Dysphoria Program of Palo Alto (Palo Alto,California; affiliated with Stanford University Medical Center; http://www.stanford.edu/dept/news/report/news/may3/sexchange-53.html and http://www.geocities.com/WestHollywood/6888/gmed04.txt)
  • Los Angeles Gender Center (Los Angeles, California; seems to primarily offer counseling and referrals to outside services; http://www.lagendercenter.com)
  • The Gender Dysphoria Program of Orange County (San Juan Capistrano, California; note that they have referred only 4% of their clients to have surgery and say that "Surgery does not make a poor patient into a good one. Surgery should come at the end of the rehabilitative process...;" http://www.genderweb.org/~janet/intro1.html#30 and http://jenellerose.com/htmlpostings/counselors_in_sacremento.htm)
  • Oklahoma Gender Identity Foundation (??, Oklahoma; affiliated with the University of Oklahoma; www.geocities.com/WestHollywood/6888/gmed04.txt)
  • Mount San Rafael Hospital (Trinidad, Colorado; famous for doing many sex reassignment surgeries; http://www.moss-fritch.com/biber.htm)
  • Barnes Hospital, University of Washington School of Medicine (Seattle, Washington; www.geocities.com/WestHollywood/6888/gmed04.txt)
  • Rosenberg Clinic (Galveston, Texas; loosely affiliated with the University of Texas Medical Branch; http://www.symposion.com/ijt/hbigda/2001/01_huang.htm)
  • Ingersoll Gender Center (Seattle, Washington; ingersollcenter.org)
  • Green Mountain Gender Clinic (Williston, Vermont; http://hometown.aol.com/grnmtclin)
  • Callen-Lorde Community Health Center (New York, New York; open to community input and needs, probably does not follow the Standards of Care; http://callen-lorde.org)
  • Brisbane Gender Clinic (Brisbane, Australia; http://www.atsaq.com.au/version2/clinic.htm)
  • Melbourne Gender Dysphoria Clinic (Clayton, Victoria, Australia; http://translib.org.au/profdir.html)
  • The Carlton Clinic (Carlton, Victoria, Australia; http://translib.org.au/profdir.html);
  • The Melbourne Clinic (Richmond, Victoria, Australia; http://translib.org.au/profdir.html);
  • Prahran Market Clinic (South Yarra, Victoria, Australia; http://translib.org.au/profdir.html);
  • Centre for Addiction and Mental Health (Toronto, Ontario, Canada; affiliated with the University of Toronto; http://www.camh.net/mental_health/gender_identity_clinic.html)
  • Gender Identity Clinic of the Clarke Institute of Psychiatry (Toronto, Ontario, Canada; http://www.bcholmes.org/tg/autogyne.html, http://ca.geocities.com/wtsgca/genclinics.htm, and http://www.tgirlmagazine.com/english/articles/docs/unsecure/ index_abstract-gender_identity_clinic_of_the_clarke_institute_of_psychiatry_a_report_card.asp)
  • Formerly, the Centre for Sexuality, Gender Identity and Reproductive Health at Vancouver General Hospital (Vancouver, British Columbia, Canada; http://www.transgender.org/transcend/guide/sec280b.htm)
  • Gendercare (Rio de Janeiro, Brazil; primarily in Portugese; http://www.gendercare.com)
  • Dr. Chettawut Tulayaphanich M.D. (Bangkok, Thailand; primarily a surgery center with short-term psychiatry and psychology; http://www.chet-plasticsurgery.com)
  • Saitama Medical College (Tokyo, Japan; not a standard clinic, but has formed gender clinic committees to help people transition; http://www.jinjapan.org/trends98/honbun/ntj981128.html)
  • Gender Identity Development Service (London, United Kingdom; part of the Tavistock and Portman NHS Trust, and mermaids.freeuk.com/gidca.html says they are "the only gender clinic in the UK solely dedicated to helping children and adolescents up to the age of eighteen years;" http://www.tavi-port.org)
  • Bonus: http://www.genderpsychology.org/psychology/therapy.html has a transsexual developmental psychologist's good and bad experiences with therapy at a gender identity clinic.

    The non-clinic route

    If there is a clinic in your area that provides these services but is too strict, slow, or expensive for you, the alternative is to find a doctor that takes your insurance (if you have any) who is open-minded about trans issues.

    Nobody said any of this was easy!

    In my experience there are two ways this can go: you can get a doctor who doesn't know anything about transgender issues but is open-minded, and educate them, and bend them to your will... insert evil laughter here.... Or you can get a doctor who has already been trained by other transpeople to be supportive in the transition process.

    About the latter possibility, Kyle Scanlon (who writes the TransScribe column for qtonline.com) says,

    Check out your city's gender clinics, if it has any. I'm not for a second suggesting you actually make use of these gender clinics, by the way. I'm merely suggesting that once you contact the gender clinics you explain that you'd like to talk to some other trans identified individuals. Bypass the bureaucracy of the medicos, and skip right on over to your TS brothers and sisters! Once you're actually sitting and talking with some of the gender clinic clientele, you'll be able to find out this HUGELY important piece of information. Where/who are the trans men and women who are NOT involved with the gender clinic?

    The key here is that you want to find and meet as many transsexuals - men or women - receiving a prescription for their Hormone Replacement Therapy. Ask them the names of their doctors. Ideally, an FTM guy might want to find a doctor well-versed in treating other FTMs, but if all you want is a quick 'scrip for hormones, sans expertise, any trans-positive doc will do.

    In cities without such clinics (i.e. most cities) you can look for a trans support group of some kind, there or in nearby communities; failing that, find the queer community and ask around about transgender resources, groups, or individuals; failing that, get online and look for listservs or websites for trans people in your area; failing that, start calling doctors or therapists and asking them whether they've ever had transgendered clients and whether they'd be willing to learn more about it in order to help you.

    Failing that... maybe think about moving somewhere else.

    Pitfalls

    Insurance is one big pitfall; location is another; people's prejudices are a third, although they factor into the first two.

    Your location may be the most important variable here, although I'd say your ability to ask for what you want and set firm boundaries with any doctor who wants to play power games with you are at least tied for first place. But it will be much easier for you, potentially, if you are at least near an area that has a trans-aware or trans-friendly medical community. All you need is one person who knows the ropes in your area, one doctor or therapist who may not be able to help you personally but knows someone who can, or one fellow transgendered person who knows the dirt on different doctors and therapists where you are.

    The one tip I can offer is that many doctors will continue your prescription once you have it. They don't know whether you got it by the same standards and rules that they would have required themselves; they just know that some doctor somewhere trusted that you were stable and self-aware enough to make this decision, and that it would probably mess you up at this point to just cut you off. In fact, at least one version of the Standards of Care notes that a doctor may want to bend them in order to accomodate someone who has been taking black market hormones.

    I'm definitely not suggesting that anyone go out and buy testosterone or estrogen on the street. What I'm actually saying is that if you happen to be in the Bay Area for a little while, and you go to the Castro-Mission Health Center listed above... well, you're supposed to live in San Francisco to go there. But they have a lot of homeless clients as well as a lot of people who live outside of San Francisco (like in Oakland and Berkeley, and farther) and who they know can't get hormones any other way. And so you can go there, and say that you don't have a San Francisco address, and go into the system as being homeless; you can even give them an out-of-city address or phone number that you're "staying at" or where you can "get messages," although you probably won't need it. And you can go through their (usually reasonable and communicative and not lengthy) process of getting a prescription for hormones, and then return to your own home town or state or country and stay on hormones there. Shhhhh.

    But don't abuse that system, because they are hurting for money - as is the entire state, unless you happen to be a San Francisco city supervisor, in which case you're getting your salary tripled --

    But I digress.

    That touches a little on the subject of insurance. Or it should. Many clinics and some individual therapists and doctors operate on a sliding-scale basis and take cheaper insurances or have low fees. This is good, because many insurance companies won't cover sex reassignment surgeries and some (*coughcoughBlue Crosscoughcough*) won't cover anything relating to sex reassignment. Many others say that they only cover "medically necessary" procedures and continually change their rules about what that means. A really savvy doctor will not put anything trans-related on your medical records and will find another pretext for prescribing hormones. Vague, general reproductive or hormonal disorders are favorites.

    As far as prejudices go....

    There is sort of a Standard Transsexual Story (tm) that many doctors expect to hear. And because many doctors expect to hear it, some of them think that people who deviate too much from it shouldn't transition. Sometimes they are too focused on protecting people from their own decisions, especially if it's a decision that that particular doctor doesn't understand. And so, many people who are trying to transition end up modifying what they tell the doctor about themselves in order to better fit into the Standard Transsexual Stereotype, either preemptively out of fear or in response to medical demands and rejection.

    The Standard Transsexual Story tends to be something like... you always knew you were different... when you were little you refused to play with (dolls/trains), insisted on wearing (dresses/pants), only played with the (girls/boys)... when you dream you are always the sex to which you want to transition... you are horrified by your body especially your genitals and just want to cut them off sometimes... ideally, you are too grossed out by yourself to even have sex... you have wanted a sex change all your life and you are so deeply gender dysphoric as to be nearly suicidal. My friend Damon summed it up sarcastically once:

    Why, when I was a kid, never wore any pansy dresses or played with dolls or had long hair with braids or *ever* played with My Little Ponies. I demanded wot be called Fred and I liked girls and that's why I'm a normal redblooded trannyboy. (stands up, spits and grabs crotch, looks down at the screen and sits back down)

    It is definitely one tool that you can use to make the transition process go faster, and it symbolizes a certain small amount of privilege that "normal" transsexuals may sometimes have over genderqueers. However, some people find that it is not their experience and that they do not want to lie in order to transition. Some of us look to Louis Sullivan, a gay FTM activist in the 1980s who wanted to transition at a time when everyone refused to treat trannyfags and transdykes and bisexual transfolk. He worked very hard to educate doctors and raise awareness of that part of the trans community until doctors began to let go of their homophobia in that area.

    If this describes you, you may find it helps to use....

    The tips

  • Be very clear ahead of time on why you want hormones and what specific effects you want to get from them;
  • Find out as much as you can ahead of time about the possible negative side effects and how you might deal with them so that you can show that you are making an informed decision;
  • Know how to describe your gender identity and your experiences with that as simply and clearly as possible;
  • Practice sounding calm, mature, and confident (take a Toastmasters course if necessary!)
  • Find any literature you can provide them about people with similar experiences or identities who transitioned (books, articles, printouts of web pages)... but make sure if you do this that they understand that you are giving them other examples to help them understand you, NOT saying that you think these people are cool so you want to be like them - particularly if you seem young, because young people are often stereotyped as not knowing what they want and mindlessly trying to copy their idols.

    All the other information may help you, but I think these are the most crucial things I can tell you. For many people, especially people in a position of power like doctors, it ends up being all about how you present yourself and how firm and clear you can be - while still behaving maturely and with respect. This can be tricky with a doctor or therapist who's being a prick, especially if they are the only one in your area who serves transgendered people. If they are - don't take their word for it. Make those phone calls and find out if there is anyone else, however inexperienced, who might be better for you to work with.

    If you have suggestions, comments, or questions, feel free to deluge me with /msgs. And most of all, good luck!

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