Our Bodies, Ourselves (19 page)

I felt like a car running on the wrong kind of gas. I did not fully understand how wrong it was until I replaced testosterone with estrogen when I transitioned genders in 2002. I now have an amazing sense of well-being and harmony that I never knew before. Now my body just hums.
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A trans man says:

From the moment I realized I was transsexual, everything changed. Although I'm now legally and “aesthetically” male, I was raised and socialized female, and no amount of hormones or surgery can ever erase that. Nor should it. I have no interest in denying my past, for the years I lived as a woman make me a better man today…. I am a strong, proud, transsexual man; I love my life and my body (and am now more inclined to take good care of it); I have a wonderful wife and family; and I am working hard to make the world a better place for those who share my experience.

Becoming the gender you always identified with may seem to others like a radical, gender-transgressing act, but in many ways it is more like coming home.

Few prospective, large-scale studies exist regarding transsexual health. However, the Dutch endocrinologist Louis Gooren, founder of a groundbreaking trans clinic at the Free University Medical Center in Amsterdam, has reported on a thirty-year follow-up of more than three thousand patients.
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His good news: The trans people seen by the clinic were not at any more risk of early death than cissexual (non-trans) men and women. Although presumably the trans men and trans women at the Dutch clinic faced some of the health issues touched on in the paragraphs below, they ultimately suffered from the ills of their affirmed gender: heart disease was common in trans men, as in natal men, probably influenced by increased abdominal/visceral fat and high levels of cholesterol and triglycerides. The trans women tended to gain excess weight and were more likely to develop metabolic syndrome, a group of risk factors (including high blood pressure, high cholesterol, and insulin resistance) that occur together and increase the risk for coronary artery disease, stroke, and type 2 diabetes.
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What follow are a number of health issues for trans men and trans women in the United States.

Cross-sex hormone therapy is central to gender affirmation treatment for many if not most transsexuals. At the same time, hormone therapy presents risks. The large randomized, controlled Women's Health Initiative studied certain forms of reproductive hormone therapy in postmenopausal women and demonstrated elevated risks of stroke, blood clots, and breast cancer. (See
Chapter 20
, “Perimeno-pause and Menopause,” for more information.) Trans women who have not had their testes removed must take high levels of estrogen to suppress testosterone; this increases their risk of thromboembolic disease—the development of blood clots—and calls for close and regular health monitoring. Speaking of his study of three thousand patients, Dr. Louis Gooren highlighted one particular estrogen: “Use of the female hormone ethinyl estradiol [a component of the contraceptive pill but used by trans women in higher dosages] was associated with
an increased rate of cardiovascular death and stroke. This was not the case in former users, i.e., those who once took ethinyl estradiol but now take another type of estrogen.”
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For trans men, methyltestosterone taken orally in high doses can cause liver damage. Taking cross-sex hormones, therefore, can create special health issues for transsexual people.
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The Endocrine Society (endo-society.org) has published an online listing of medical conditions that can be exacerbated by cross-sex hormone therapy.
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“Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline” is a thorough, evidence-based 2009 guideline with risk factors and recommended protocols.
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The book
Fenway Guide to LGBT Health
(fenwayhealth.org) is another excellent resource. It addresses sexual functioning, observing that feminizing hormone therapy “tends to reduce libido, reduce erectile function, and decrease ejaculation,” while testosterone use is known to increase libido.
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If you are a trans person taking hormones, it is vital that you have access to medical providers who understand the implications of cross-sex hormone treatment over a lifetime, who will check regularly to identify and treat possible side effects and risks, and who will stay current with future studies that may reveal which forms and applications of the hormones have the fewest risks. Unfortunately, lack of insurance coverage deprives many trans people of this necessary care.

In general, because transgenderism is currently defined as a psychiatric condition, U.S. health insurance does not cover hormone treatment or gender affirmation surgeries for trans people. These are most often available only to those who can afford to pay out of pocket for medical care.

One of the many health consequences of this inequity is that a trans person who can't access or afford medical hormone treatment may end up seeking cross-sex hormones from friends, on the street, or online without benefit of the careful screening, quality control, appropriate dosages, and ongoing health care that are so important when anyone is taking hormones. A major risk of obtaining cross-sex hormones on the street is needle sharing, which carries a risk of HIV and hepatitis exposure. Testosterone is usually given by injection, so this is an issue for trans men. Trans women who are frustrated by the presence of facial hair or by futile attempts to raise the pitch of their voices may resort to high-dose estrogen injections as well. (Another danger: Oral testosterone preparations available on the street, often taken by bodybuilders, can cause fatal liver damage.)

In 2008, the World Professional Association for Transgender Health (WPATH) issued a public statement encouraging a shift toward viewing these treatments as medically necessary. The WPATH board of directors “urges state health care providers and insurers throughout the world to eliminate transgender or trans-sex exclusions and to provide coverage for transgender patients including the medically prescribed sex reassignment services necessary for their treatment and well-being, and to ensure that their ongoing healthcare (both routine and specialized) is readily accessible.”
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Dr. Norman Spack, a longtime advocate and health-care practitioner for trans youth and adults, compares the U.S. system with international models: “In the Netherlands and Belgium, national health insurance covers all costs related to evaluation and treatment of transgendered individuals, including children…. This discrepancy in coverage across nations raises questions about U.S.health insurance policy decisions.”
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Many trans people cannot afford or choose not to have surgery to remove their reproductive organs. Long-term health, therefore, often requires screening of body parts and organs associated with a gender with which you don't identify. Pap tests for trans men are one example. Health providers in the forefront of trans health care have worked out protocols for a sensitive and respectful approach to this crucial screening. The Sherbourne Health Center (checkitoutguys.ca) addresses trans men's need for ongoing Pap tests and offers a tip sheet for health-care providers.
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The
Fenway Guide
observes that some trans men who cannot tolerate ongoing pelvic exams consider complete hysterectomy.

Breast tissue exams can be an issue for trans men as well. According to the American Cancer Society and Gender.org, there may still be risk of breast cancer even after sexual reassignment surgery such as chest reconstruction, because breast muscle wall tissue remains. Breast tissue cells might be present in the nipple area as well as throughout the chest area.
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There have been a very few reports of prostate cancer in trans females, but since estrogen is one of the treatments for prostate cancer, they almost certainly had the condition before beginning cross-sex hormone treatment.

Cross-sex hormones reduce fertility, and this reduction may be permanent even if the hormones are discontinued. Some trans women choose to bank sperm before estrogen treatment or surgical removal of the testicles, to preserve the option of having a biologically related child in the future. Trans men who are on testosterone therapy and then discontinue it may continue to ovulate, even though menstrual periods have stopped. Thus there is a reduced but not entirely absent pregnancy risk. The ovaries of trans men retain eggs. Although there is a medical procedure that harvests eggs and preserves them through freezing so a trans man could donate eggs to a partner or surrogate, this option is not generally available, and the life span of frozen eggs is limited.
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Puberty puts transsexual teens at extreme risk, as their bodies develop the secondary sex characteristics—penis growth and facial hair, or breast growth and menses—of a gender that feels strange, unfamiliar, and unwanted. Trans-sexual teens are at high risk of depression, self-mutilation, alcohol and drug abuse, and suicide in part because it is difficult for people under the age of eighteen to access appropriate medical treatment.
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In the United States there are only a few pediatric endocrinology or adolescent medicine programs that work with trans teens.

Following a model developed in the Netherlands, the Gender Management Service Clinic at Children's Hospital Boston offers a temporary hormonal treatment to halt puberty for teens who, after careful screening, are diagnosed with gender dysphoria. This fully reversible treatment gives teens an extra two years to decide whether to take the irreversible steps of cross-sex hormone treatment and surgery. Delaying the development of secondary sex characteristics can reduce social ostracism and psychological distress as well as the need later on for surgeries such as breast reduction or facial hair removal. Interviewed in 2010, Dr. Spack said, “We are beginning to see great success. Patients aren't trying to commit suicide, they're bullied less at school, relationships are better, and mammoplastic surgery may not be necessary.”
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Most medical practitioners have not yet learned how to treat trans people with appropriate understanding and respectful care. Saber, a trans man whose gynecologist feared that he might have ovarian cancer and sent him to a nearby city for an ultrasound, found that despite his home physician's efforts, the health facility was unprepared for him:

I state my name and that I am here for the ultrasound to check my ovaries for possible cancer. She looks at me and says, “But you're a guy.” I explain that I am transgender, female-to-male, and that I am pre-op; that I still have all my female parts. She looks at me and then my chart and says again, like perhaps I am just very slow, “You're a guy, you don't have ovaries.” I can tell the word transgender has no meaning for her. She says that she will be right back. After waiting at least fifteen minutes, my partner says, “I am going to go see what is taking so long.” My partner comes back in and says, “Everyone is gone. The place is empty. It's dark.” Appalling as it was, my partner and I still laugh about the absurdity of it all.

Saber, who subsequently joined the Minnesota Transgender Health Coalition, adds:

Until I can have the surgeries I need, I will continue to be seen in the gynecologist's office on a regular schedule so that if I were to get breast cancer, ovarian or uterine cancer it would be detected early. Unfortunately I cannot afford the surgeries, and so am stuck for now. As long as I have some female organs left in my body I will have to go in for gynecological exams looking like a male
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