Existing as a transgender person is hard. We face expenses and hazards that few other people share, progressive organizations consider our rights a bargaining chip to trade for what they actually care about, and most of us lose a big part of our social circle when we emerge as ourselves, forcing us to rebuild at a time when we’re subject to tremendous abuse.
While the difficulties specific to trans people in any of various situations—airports and prisons suddenly come to mind—are worth discussing at length, one sphere in particular needs highlighting: the medical system. A lot of us travel by air and too many of us end up in prison, but virtually all of us see doctors, and seeing a doctor is a frustrating mess for people like us.
These are obstacles, annoyances, and outright discrimination trans people face in seeking medical care, and some things doctors can do to help. What follows is primarily from a transfeminine perspective, with nods to transmasculine versions scattered throughout.
Most transgender people change our names at some point in our transition. Unfortunately, making a name change legal is a protracted process that often involves signatures, court dates, waiting periods, and extensive travel. Particularly for people who transitioned as adults, there are a lot of documents to fix, each with its own requirements that depend on getting others fixed first. Transgender immigrants, with documents from at least two countries, face additional obstacles in getting those documents to reflect our current situations. Further, all of these steps have associated costs, which trans people, facing extensive hiring discrimination, are often ill-placed to pay.
All of that is to say that most trans people have a segment of our lives where our legal names and the names we use in our day-to-day lives are different, and that difference is usually fraught with emotion. It is psychologically traumatic for many of us to so much as hear our old names spoken, because of what they represent. More than that, it can be dangerous for us to respond to our old names, because that means outing ourselves in a potentially hostile environment. A deadname being broadcast is easily sufficient to make a crowd start misgendering a trans person, and it’s likewise an easy way to alert those who are hostile to trans people that the deadnaming victim is a viable target for their hostility. Particularly for trans people (and especially trans women) early in our transitions, this hazard can delay widespread acceptance of what our correct names and pronouns even are.
Some of the risks associated with deadnaming are more-or-less unavoidable while we’re in this liminal status. No matter what, our legal names are on our paperwork, and that means it’s possible for us to be identified as what we are and discriminated against on that basis. It’s not hard, however, to add an additional field in one’s filing scheme for a “preferred name,” and refer to that field when dealing directly with patients. Such fields are also handy for people whose legal names have unusual structures that a Western doctor might misidentify, for people who use a name from their own culture and also a Western name, and for people interested in providing a pronunciation guide for their doctors, in addition to protecting trans people from the hazard of deadnaming and encouraging staff to deal with us fairly.
Ignorance of Trans Bodies
Trans people are a tiny fraction of the overall population. A small town might have one or two of us, total, and large cities might have dozens to hundreds. Our rights are still a matter of public debate and popular culture wildly misunderstands what it means to be one of us. This idea, of trans people as niche, bizarre oddities that an ordinary doctor doesn’t need to understand, is encouraged throughout most medical education systems. And when the doctors who made it through the system regarding their fellows who did seek out education in trans healthcare as picking too small a specialty finally get out in the wild, they eventually run into us, and draw many dangerous blanks.
First and foremost, it should not be necessary for us to look for specialists in transgender topics to prescribe the handful of drugs trans people take to induce feminization or masculinization. The associated blood tests are trivial, the drugs widely prescribed for other purposes, and the trans-specific protocols described in detail in the WPATH Standards of Care, available for free online. Even pubertal suppression, a somewhat more involved pharmaceutical procedure used for trans children prior to hormone replacement therapy, is described in this document. This is a minimal body of expertise for a doctor to add to their repertoire that is of enormous benefit for their transgender patients, who can thereby avoid long waiting lists to see trans-specific professionals.
More than that, however, doctors often face our bodies with abject puzzlement in the context of other diseases. Many medical protocols make big assumptions about what sorts of anatomical configurations require what sorts of care and diagnostic attention, assumptions that fail transgender (and also intersex) patients. In particular, there is no medical procedure currently available that can give a trans woman a cervix, but doctors frequently recommend that we get pap smears, a test for cervical cancer. Doctors also often forget that trans women continue to require prostate exams, and especially that the prostate of a trans woman who has received bottom surgery is most likely no longer accessible via the anus. Trans men continue to require the same genital examination protocol as cis women until and unless the relevant organs are removed. Both trans women and trans men require screening for breast cancer.
Another thing: Most of the disease risks in the literature were devised, and are presented, as if cis people are the only people. Almost all of them are in reality based on either hormone environments or lifestyle factors. In practice, this means that trans people’s disease risks are similar to those of cis people of the same gender, not cis people of the opposite gender, as one might expect if the risks stemmed from purely genetic or anatomical factors. The increased risk of blood clots associated with estrogen is relative to cis men, and merely brings us to the risk threshold that cis women inhabit continuously. So, in ways other than what’s described above, treating trans women as women and trans men as men is the most appropriate course, and these guidelines can also assist in devising protocols for patients who are neither of these genders.
Entirely too many of us end up teaching our doctors how to be doctors for trans patients, and that is a burden we should not have to bear. Doctors need to voluntarily seek out training in how to treat trans patients regardless of their intended future specialty.
Related to the situation above, doctors often panic when they encounter a patient taking hormone replacement therapy who is also visiting them for some other reason. Whether because they imagine HRT to be optional or cosmetic rather than literally life-saving or because they have no idea what it actually does and cannot be arsed to learn, doctors frequently imagine that pharmaceutical estrogen or testosterone “complicates” any medical treatment they might otherwise prescribe. From there, they recommend or insist that their trans patients discontinue hormone therapy while being treated for these unrelated conditions, and often refuse to provide any medical care until this unreasonable demand is met. Given that these same doctors do not insist that cis women and men block their endogenous estrogen and testosterone, this is a clearly discriminatory as well as an ignorant practice.
Further, many doctors are so suspicious of hormone replacement therapy that they respond to any news of ill health in a trans person with the insinuation that these health problems are caused by their hormones, and then suggest discontinuing hormones as if this were a reasonable, or even the only, solution.
Leaving aside that trans women in particular already endure constant mortal peril at the hands of violent bigots in the name of existing as who we are, and therefore that the expectation that any condition we’d see a doctor for could possibly scare us more than life already scares us is downright ridiculous…hormones do specific things. By their nature, they do a lot of specific things, but they still do specific things. The idea that a trans person’s hormones are somehow responsible for everything that goes wrong in their life thereafter, from broken bones to irritable bowel disease, is a lazy tactic that does little more than turn sick people away from those who might help them in the name of expedience. People already get dismissed from hospitals and doctors’ offices because doctors weren’t curious enough to figure out what was actually wrong with them; we, alongside overweight people, simply have one more way for annoyed, incurious, bigoted medical professionals to so harm us.
Putting the blame for random medical problems on HRT is the sort of bigoted claptrap many of us receive continuously from our families and from society at large. It’s a rhetorical bludgeon that works much like talk of devils and karma, to try to convince us that our own insistence on being who we are is the problem and that detransitioning and resuming our cisgender masquerade would make everything better. It blatantly has nothing to do with us, the transgender patients trying to get our anemia, asthma, and ingrown toenails treated, and everything to do with making the world a little tidier for bigots, by getting rid of us.
This hazard even invades trans-specific healthcare, with trans women being expected, by standard protocol, to cease estrogen for at least six weeks prior to bottom surgery, justified with the same blood-based risks that cis women have all the time. As before, no one asks cis women in surgery prep to bring their risks up to what men endure by blocking their estrogen for weeks. This bit of discrimination is only for us, because cis hormones are ordinary, but ours are weird and strange.
Knowing what our medications do and don’t actually do is incumbent on everyone in the medical profession, as is recognizing that few of us consider our hormones optional. We are whole, organic, real, complicated people and should not be treated as though the one thing that makes us most unusual somehow causes all of our problems and being a little bit more “normal” will therefore fix them. It doesn’t work like that.
Know What We Deal With
Trans people in general, and trans women in particular, face enormous discrimination. In addition to being murdered at such staggering rates that it is our most common demise, it is legal to deny us housing and employment on the basis of our transness in many parts of the world, including much of the United States. Many of us are cut off from our families, divorced by spouses, and otherwise severed from much potential social and financial support, and must endure discrimination and institutional misgendering to get survival assistance from governments and nonprofits. The result is that very few of our lives have the glitz and glamour of Caitlyn Jenner’s, and many of us have very limited means. Expensive treatments, including cosmetic-but-not-actually-cosmetic procedures like facial hair removal, might as well be paid for on the hides of mythical creatures for how accessible they are to those of us on the edge of homelessness…or who are already on the other side of that edge. Any aid in securing reduced prices or insurance coverage for our care, including care that is nominally unconnected to our being trans, is profoundly welcome and often means the difference between getting better and an emergency room stay a few weeks later.
Frequent poverty and continuous abuse from society at large and also the people closest to us means many of us have or eventually acquire mental health problems, including C-PTSD, depression, and anxiety. The fact that we were so affected by the abuse we endured does not mean that our stories of that abuse are less real, however much common narratives assume the “crazy” cannot make an accurate accounting of ourselves. They also do not mean that ceasing to be visibly transgender by returning to the closet will save us. Even if that horrid foolishness had not been dealt with in the previous point, the damage has already been done and being closeted is itself traumatic.
All of this comes together to make trans women disproportionately homeless, disproportionately sex workers, disproportionately users of illegal drugs, and disproportionately afflicted with the diseases associated with illegal drug use and sex work, including AIDS. Our oppression compounds itself, and this society goes through a lot of trouble to facilitate downward mobility for the marginalized. A medical professional who pretends to any level of treating “the whole person,” or who wants to make sure the solutions they propose are even possible for their patients, needs to recognize and understand the limitations and difficulties imposed on us and how non-negotiable they really are. Further, such a professional needs to divest themselves of any notion that such harms come only to the deserving.
Those of us who are transgender and also marginalized in other ways, such as race or disability, know that it gets even harder. Doctors need to know that, too.
I have been deadnamed by many doctors, all of whom endeavored to correct their error after the fact. I have been forced by inadequate medical records to leave off my “alias” that is more real to me than my legal name is. I have received prescriptions I cannot afford without substantial hardship. I have had a doctor insinuate that going off hormones would solve my digestive complaints.
Doctors need to do better.