Deep breath....
OK, probably none of you are still attentive to this thread.... but just in case someone else reads it later I wanted to answer a few of the really insightful questions you all have posed.
1) Long term studies? Actually there is one good one: Mortality and Morbidity in Transsexual Subjects Treated with Cross-Sex Hormones. Van Kesteren, P, et al. Clinical Endocrinology. 47, 337-342. 1997. Basically they followed over a thousand transgender people for up to 40 years, with an average of ten years in the study. About 95% of all Dutch transgender patients are treated at their clinic so they had a good populations. They found no significant difference in the morbidity or mortality between transgender men and cisgender (non-trans) women. There was no mortality difference between transwomen and cisgender men, but there was an increase in morbidity due to thromboembolic disease among transwomen. However this all but disapeared when they switched to transdermal estrogen in transwomen at greater risk (ex: age over 40.)
There are certainly other decent studies in the literature, but that is sort of 'Framingham for transpeople,' so if you read one.... read that.
2) Conservative versus Progressive politics. Actually it doesn't seem to sort well based on that. I know physicians who are otherwise pretty darn conservative who treat transpeople. And I know a couple of transgender women who are physicians.... who are pro-life. I also know one transwoman physician who is pro-life and homophobic.
No. For real. I'm not making that up.
3) Ethics of treating transgender people?
That is really a tough one... even for me (who treats a lot of transgender patients in my practice, and who am transgender myself.) But I will break it down as easily as I know:
There are 4 basic tenets of medical ethics: beneficence, non-malefesance, autonomy, and justice. I am really not comparing 'treating' versus 'not-treating' but rather whether one should be more liberal about treating people since that is the usual quandry.
Benefecince... are you helping? Well, there are several studies (albeit small) that show improved outcomes in transgender people. In aggregate there seems to be a decrease in suicidality from 20-30% to 1-5%. That coupled with the fact that true regrets are exceedingly rare argues for it. Of course if you take the subjective experience of your patients (the ones you are supposed to believe) it is an overall positive.
Non-Malefesance. The best argument I can make for this is patient safety. In the US, your change of being murdered in your lifetime is about 1:18,000. That number for transgender people is 1:12. (Source HRC.) In my own experience with transgender patients and friends I don't find that to be an outrageous figure. Largely the vulnerability to transphobic violence has to do with one thing only: visibility. As a sad example.... Gwen Araujo was not murdered till the realized she was trans. Physicians hold the key to providing patients the safety of passing. While for some, this is next to impossible, for many, adequate treatment is the key to passing, which for many equals safety. If you deprive them of this treatment, you place many transpeople at far greater risk than failing to treat someone's hypertension.
Autonomy.... um... nuff said.
Justice is the idea that everyone in a moral medical system has an equal distribution of the burdens and benefits. This is the antithesis of transcare for many patients. Most pay out of pocket (even if they have insurance because they will be denied.) Somehow it is OK for insurers to say 'we exclude GID' but not OK if they say 'we exclude diabetes.' In addition, the burden placed on transgender people by some to get treatment is pretty high. If someone with NIDDM faced the same sorts of hoops to jump, about 2% of all diabetics would have an A1C <9. The equivalent for a diabetic would be to say: 'well, before I treat you, you have to spend 3+ months with a dietician and exercize therapist... paid for out of pocket... and I want to see that A1C fall at least 1 point before we give you glucophage.' The only way that we get away with this is that selling hormones to transpeople is a lot easier than selling a colonoscopy to anyone.
And using the excuse that diagnosing and treating transgender people is somehow harder than treating people with other mental illnesses is.... just bunk. The reason its so hard? No one ever gets taught in med school or residency. However, having treated a lot of transpeople I can tell you... GID is WAAAAAY easier than NIDDM or Bipolar disorder.
4) Need for lots of therapy before treatment.
Eh... not really. The HBIGDA (the medical professional organization that promulgates the standards of care (SOC) for treating transgender people) SOC no longer have theapy as a requirement. Moreover, I have many successful transgender patients who've never been to therapy. Its like any other psychaitric issue... like depression... a experienced primary care provider can diagnose and treat 90% of patients, while a small percentage will need therapy.
With regards to surgeons... it depends on the surgeon. Many of those with a lot of experience do the same thing: if its not an obvious diagnosis they ask for a letter of referral. Though many will take such a letter from a primary care provider.
With regard to the evidince base supporting a need for therapy to ensure safe treatment (and no regrets)... there is none. The pre-treatment therapy concept was basically 'what seemed like a good idea' to those who started treating transgender people many decades ago. In the only study that looked at this, there was no difference in outcome between MTF patients who had surgery without therapy or a set duration of a real-life experience when compared with those who met the traditional requirements. So this is like treating kids with DKA with bicarb.... seemed like a good idea at the time, but didn't hold water when it was actually examined.
5) Is GID a mental illenss?
Yep. Here is my argument:
http://www.makezine.org/giddisease.htm
6) SRS?
Most transmen want 'top surgery' - mastectomy aka chest reconstruction. Many can't afford it - see 'justice' above.
Some transmen want lower surgery - there are two options: phalloplasty (make a penis from something else) or metaidioplasty (aka 'meta') which takes the hypertrophied clitoris and moves it to the right place and tries to 'beef it up' making you, as a friend of my calls it 'hung like a light switch' - the clitoris elongates to only an average of 5cm after long term hormones. Some also get a urethral extension through the neo-phallus and may get 'scrotoplasty' which creates a scrotum from the labia. Neither of these surgeries is great....
Most transwomen want bottom surgery. If the options for transmen and surgery are like a '72 Pinto and an '82 Escort, the options for transwomen are... a Mercedes.... a Lexus... or a Caddilac. Much better cosmetic result. Unfortunately many transwomen will never be able to afford this.
I hope that helps.... if any of you are interested in more information, I'm happy to respond by email: nickgorton at gmail dot com.
Nick Gorton
