I'm really sure that routine transgender care, including maintenance of long standing hormone regimens, falls well within the capacity of primary care providers. I expect, though, that primary care providers will be able to continue to conflate their desire to avoid caring for certain patient populations with their ethical duty to refer patients for whom they cannot provide the appropriate standard of care. It is very easy for a PCP to claim lack of expertise, particularly with a less common condition/demographic, and create a situation where they cannot be blamed for dumping the patient onto a specialist... which is entirely unfair to the specialists.
Well...yes and no.
Speaking as a primary care doctor, who does not harbor any personal discomfort with transgender people, I'm not in total agreement with that bolded statement.
What defines your "capacity" as a physician is largely self-defined, and involves some honor code/personal ethics - i.e. being honest about your own boundaries as a physician, and admitting what you're good at, and not so good at. Which involves setting aside some personal ego, which is hard for a lot of people.
It is "easier" for me to care for MTF patients, hands down - and this is for a number of reasons. Like I said in my previous post, I already have a lot of experience prescribing estrogen-related medications, because I do a ton of that for other medical indications (birth control, heavy periods, painful periods, alleviating menopause symptoms, etc). I am very aware of the risks and side effects of those medications, and could probably counsel someone on those medications while half-asleep. I've even had to counsel patients on these risks in my fair-to-middling Spanish, and have been able to do it.
Estrogen-related compounds are also very easy to prescribe and dispense. Certain forms of them are even available over the counter.
Testosterone supplementation, on the other hand, is less common - aside from FTM transgender patients, we really only prescribe that for hypogonadism, and, honestly, the urologists and endocrinologists have kind of cornered that market...the number of men with hypogonadism is miniscule compared to the number of women who want contraception, as you can imagine. Testosterone carries a lot of side effects, but I prescribe it so rarely that can I legitimately say that I can do a good job counseling you on the risks? Can I honestly say that I will remember to screen you appropriately, at appropriate intervals, when I do it so infrequently?
Plus, testosterone, unlike estrogen, is a controlled substance that requires a DEA, and it also carries a fairly high street value. So, if you lose the prescription for it, it can cause some legal/paperwork issues for the office, that they may just prefer not to deal with. In some states, NPs and PAs are not allowed to hold a DEA license, which means that you can only ever see the physician whenever you come for refills....logistically a tall order, in some primary care clinics.
Now, the offices that you went in order to try and establish care should have explained this to you, fully and with dignity. It sounds like they did not, and THAT is definitely not fair to you. And the endocrinologist has no excuse - that's just discrimination. But I wanted to explain non-discriminatory reasons why a PCP might not be able to care for you. I hope that my post makes sense....
(And, in all honesty, if a FTM patient came to me and said that they needed refills, they had been stable on their meds for a long time, no one else would help them, and that they understood that this is not my forte but were willing to chance it anyway, I'd probably prescribe them their meds. I would just be a little anxious, that's all, and spend a lot of nights re-reading hormone guidelines.
)
I know that for myself, I'd always choose quality of life over quantity, and the quality of my life is so much better than it would be without HRT that it also effects the quantity. I sincerely doubt that I would have survived this past decade had I not been able to access the surgery and hormonal therapy which I needed in order to be comfortable in my body. I think you are doing exactly the right thing, in providing the care the patient needs and desires to the best of your ability given the information that you have available, and continuing to seek out more knowledge as you go. It may not be the ideal situation, but it is definitely not doing any disservice to your patients.
Thank you. Your post was very helpful.
If I understand what you are saying correctly, you would be willing to chance the risk of a complication, and getting sick or possibly even dying, if that means that you can live life on your own terms. And if that's the case, and my MTF patient feels the same, then I feel a lot better about refilling her meds.
I wish that she would have told me this, but she's in her 60s and British, and hyper-polite and soft-spoken in a way that only the English can really pull off. When I explained my concerns about hormones and clots to her, she just smiled sweetly and said, "Well, doctor, you know best." <GULP> No, no, ma'am....I really don't. Really.
Based on your posts, I see that you're a pre-clinical med student, but trust me....there is no better way to make a young physician's heart spasm in fear than to assure them that they know best and that you trust them. I don't know if I'll ever get used to it.
️ Thank you.
