How to ask my doctor to prescribe hormones?

[SamKelley]

Hi everyone,

I've been seeing a clinical psychologist for 6 months after admitting to myself I'm a transgender woman. I've been making good progress however my psychologist won't recommend me for HRT because she doesn't do that and would prefer to leave that to someone medically trained (a psychiatrist).

I'm in Australia and it seems there's a 6 month wait list to see a psychiatrist, before I can even get a referral to an endocrinologist, which could be late next year.

I have an excellent GP who really cares and has been invaluable in helping me coordinate and manage my process however he isn't interested in prescribing hormones as he has no experience in it.

It seems to me there are some pretty clear paths and guidelines in WPATH and transgendercare.com to follow. I value my relationship with my doctor. At the moment I'm considering taking matters into my own hands (with regular blood works). But before I do, is there something I can say to my doctor to help him take on the challenge, or is there some shorter path to HRT?

I'm 39 and admitting this to myself - having to spend 9-12 months in stasis is just too long.

Thank you for any help you can give

Sami xox

[Blush]

So I see the WPATH as a set of recommendations, not rules. Everyone's different. Bring up the wait times to your doctor - they'll be more sympathetic to your case then. Ask your GP about at least starting spironolactone while you wait. It's a pretty harmless drug that goes a long way. Call around to different psychiatrists - ask them if they'd be open to evaluating you for gender dysphoria and writing a letter of recommendation concerning their findings for you to proceed to treatment. Then go from there!

[SamKelley]

Thank you Blush. I have asked my doctor about supervised hormone treatment, but I think it will be worthwhile being more specific about Spironolactone.

I've called all the psychiatrists who specialise in GD that I can find, and spoken to some endocrinologists about whom they will take referrals from. So far all GD psychiatrists (about 6 in total?) have 6-12 month wait periods.

[Ms Grace]

If your doc has no experience with prescribing HRT then it is wise of them to not do so. Every person is different and it isn't simply a case of one size/dosage fits all. It's better that an endocrinologist does it. As for self medicating that is even more dangerous and is not recommended at all, you could potentially cause yourself some serious damage.

Tell your therapist to pull her finger out and get you referred to someone who can see you and refer you to an endo ASAP. If you are willing to see a psych without going via Medicare you may get in a lot earlier than six months. Which city do you live in?

[SamKelley]

I'm in Adelaide. I've elected to see a psych privately not through Medicare because yes it was quicker. Money is no object. My first psychiatrist appointment is in Victoria in April, I'm happy to travel anywhere for treatment.

I don't want to sound desperate; I'm not, I just believe time is our most valuable asset (and irreplaceable).

I'm seeing my therapist again next week. Actually her argument is that only a psychiatrist would recommend HRT because they have medical training, doesn't hold water... because an endocrinologist is medically trained.

[Ms Grace]

Some people don't really know how to refer. My psych sent me to a second psych for a "second opinion" before he'd refer me to an endo. That's in Sydney, got in within 4-6 weeks. It might be that this time of the year has the books flooded since the psychs need to take holidays too. Forum  admin Cindy is from Adelaide, she might be able to help you with some advice later today.

[SamKelley]

Thanks Ms Grace. I really appreciate any help! It seems Australia is very cautious and reserved from my experience so far.

[Ms Grace]

Yes and no. Sydney and Adelaide have large trans populations so they're certainly more accustomed, I guess it just depends on who you are dealing with.

[StillAnonymous]

I always knew that I was transgender, but I sincerely began finasteride to prevent balding, which is something that runs in my family.

I was able to start that no problem... no need for signing paperwork like I did for Estradiol and Spiro, and a low-dose of it was an effective antiandrogen for me.  Maybe you can ask your physician to prescribe finasteride to preemptively prevent balding, or for prostate health?  From what I have heard and read about, although I am no medical professional, finasteride has less risks than Spiro (although all medication has some risks to it, and I think they are particularly interested in the liver when prescribing finasteride).  I'm just suggesting this as something you can discuss with your physician as an alternative, and something they may have experience with while not using it for HRT.

Just reading and copying off of my paperwork for Spiro (I keep with me in case of a medical emergency):

"Spironolactone
WARNING: Spironolactone has caused tumors in animals.  These studies used larger than normal doses for a long time.  Use this drug as you have been told.  Do no use this drug for other health problems.
COMMON USES: It is used to get rid of extra fluid.  It is used to raise potassium stores in the body.  It is used to treat heart failure (weak heart).  It is used to treat high blood pressure.  It is used to treat some people with high aldosterone levels.  It is used to treat some kidney problems.  I t may be given to you for other reasons.  Talk with your doctor."

I hope this might help.

[AnonyMs]

Since you can travel I'd recommend calling the psych Dr Michael Scott in Neutral Bay, Sydney. I know of a number of people who have been to him and all very happy with it. Assuming you don't have any other problems it should be relativity easy. Last time I heard he had a 3 week wait list. He also does SRS letters, which might be handy later.

http://drmichaelscott.com.au/

There's some other psych's in Sydney, some don't have very good reputations. You can search the forums for them.

It might be a good idea to ask your therapist to write a letter to the psych saying your history with her. Perhaps it will speed things up a bit.

There's also an awesome endocrinologist in Sydney, Dr Jonathan Hayes, if you have any problems there. He has interstate patients (I asked). Last time I asked he has 6 week wait, but works out of 3 offices around the city and that was only one of them. I think the others might have been shorter. You can search the forums for him as well.

[SamKelley]

Wow, thank you. StillAnonymous - I hadn't thought of that, and I do have male pattern baldness on both sides of my family. I'm a little worried about post-finasteride syndrome, which affects some people, but it seems unclear yet what percentage of people. I was planning to avoid it if possible and start spiro for a few months until I can book an orchiectomy. But now you've got me thinking...

AnonyMs, thank you for the names, that's fantastic. Dr Scott looks nice, I'll let you know how I go .

Thank you also for Dr Hayes' name... I really want an endocrinologist who will give me the greatest outcome, and who cares, not just someone who prescribes. I'll have a look into Jonathon.

That's a big help everyone, thank you

Is there anyone else good in Adelaide?

[AnonyMs]

Thank you also for Dr Hayes' name... I really want an endocrinologist who will give me the greatest outcome, and who cares, not just someone who prescribes. I'll have a look into Jonathon.

Dr Hayes does implants, and these are I believe by far the best way of getting HRT. He definitely cares, just search the forums to see what people say about him. I generally don't trust doctors and I think he's wonderful. If I moved to Adelaide I'd likely continue to fly back to Sydney to see him. With implants it seems to be settling down to visiting once or twice a year. Far more often at the start though.

You'd want to get GP referrals to both the psych and endo so you don't have to pay full price. You only need the referrals when you turn up, not for the booking. If you don't mind paying all of it yourself you don't even need the referral at all.

Is there anyone else good in Adelaide?

Probably, the main problem there seems to be the waiting. However the person you need to get an answer from is Cindy. She knows everything about Adelaide.

[AnonyMs]

I was planning to avoid it if possible and start spiro for a few months until I can book an orchiectomy.

Some SRS surgeons, Suporn at least, may refuse you if you've had an orchiectomy. Personally I'd just wait a bit and get SRS.

Dr Hayes prescribes spiro and I've asked him more than once how safe it is. He's assures me that its an well established drug and is safe. He does take regular blood tests though to keep track of things. Perhaps you're GP would be comfortable doing this, as its is used for other things than transition. You can't stay on it long term without risk of osteoporosis, but that shouldn't be a problem.

[Ms Grace]

Dr Hayes is great, I wish we could clone him!

[Cindy]

Hi Samkelly,

South Australia has more problems than any other state outside of WA.

We are still governed by a law called the Sex Reassignment Act 1988, which will hopefully be repealed soon. This archaic law prevents people practising in SA unless licensed by the Attorney General and prevents access to the public hospital system in SA for TG issues.

Psychiatric support for adults is through the SA Gender dysphoria clinic, as you may know. The waiting list is crazy due to the number of referrals rising exponentially; and the shortage of psychiatrists interested in TG issues. After getting a referral to them keep phoning and ask for any cancellations to try and get an earlier appointment.

The alternative is the O'Brien St Clinic, not sure what their list is like but I doubt it is good.

There are two endocrinologists for TG adults Dr Rosie Jones (Adelaide Menopause Clinic) and Dr Tony ..... (name has just gone out of my head) Endocrinology at RAH. Neither will prescribe unless you have a referral from a psychiatrist. Both ends are world class and vastly experienced.

If you want surgery you have to see the psychiatrists. If not some GP's will prescribe HRT, mine does but I'm post everything so am outside of the Act so I can get HRT anywhere.

For under 18's the WCH Endo unit looks after them by saying they are children with an endocrinology disorder. While under 16's can be given blockers, in Australia generally getting HRT before 18 is nearly impossible without the Family Courts permission. Again we are trying to get test cases up to change this.

Gender surgery for under 18's in Australia is not allowed by law.

Trying interstate is an option but check that they will take a referral from an SA GP. They may not, I don't know.

I know this won't help but the medical fraternity is extremely frustrated by the lack of funding and care for TG people and we are being used as a whipping post between the Federal and State health services.
We all know that the critical time is between referral and seeing the gender unit, and the major risk to clients health and safety is during this time. But the Federal and State health bureaucracy just don't seem to care about TG adults.

I am happy to discuss any thing further that may help.

Cindy

[SamKelley]

Thank you Ms Grace and AnonyMs. It sounds like Dr. Hayes is the go, I'll do some further research tonight then give his office a call tomorrow. HRT implants was what I was hoping for, and I've also been through a dozen GPs to find two fantastic ones - the difference really is night and day.

Cindy, thank you so much for your input. I'm aware of the AG's archaic involvement and know that the specialists in SA are trying as hard as they can to cope. I'm also aware that they're in the middle. I've spent 5 months finding a psychiatrist who has a wait list better than December 2016. I now have appointments in April 2016 at the Gender Clinic Victoria, which is a lot better.

I believe the Sexual Reassignment Act 1988 repeal came into effect April 2015. I can't post links (yet), however Google "sexual reassignment repeal bill 2014".

Dr. Tony Roberts is possibly who you're thinking of. I've spoken to Dr Roberts' office about the delays and asked who else Tony might take a referral from. I don't want to speak for Tony; however their answer was helpful and it's worth speaking with them.

For the record, the latest DSM-5, ICD-11 (proposed), and WPATH guidelines now allow referrals from psychologists (not just psychiatrists). It appears to me this leaves only one bottleneck in the system: That psychologists are not yet willing to make referrals for HRT, and endocrinologists are not yet willing to take referrals from psychologists.

The reason cited by my psychologist was they're not medically trained, and that they would want to monitor the HRT from a medical perspective. However I would argue that is the job of the endocrinologist and GP - NOT the psychologist. So the argument is moot imho.

It took me one week to see a clinical psychologist who specialises in GD. If we can change this bottleneck/perception, this frees up resources and releases pressure on the entire system.

[AnonyMs]

For the record, the latest DSM-5, ICD-11 (proposed), and WPATH guidelines now allow referrals from psychologists (not just psychiatrists). It appears to me this leaves only one bottleneck in the system: That psychologists are not yet willing to make referrals for HRT, and endocrinologists are not yet willing to take referrals from psychologists.

These sound a lot more important than they are.  They are not laws, no one has to follow them, and many don't even when they say they do. All you need to do is find out what the particular doctors your seeing want and do that. Having said that I think Dr Hayes does usually want a psych referral, but I'm not entirely sure.

[Cindy]

Thank you Ms Grace and AnonyMs. It sounds like Dr. Hayes is the go, I'll do some further research tonight then give his office a call tomorrow. HRT implants was what I was hoping for, and I've also been through a dozen GPs to find two fantastic ones - the difference really is night and day.

Cindy, thank you so much for your input. I'm aware of the AG's archaic involvement and know that the specialists in SA are trying as hard as they can to cope. I'm also aware that they're in the middle. I've spent 5 months finding a psychiatrist who has a wait list better than December 2016. I now have appointments in April 2016 at the Gender Clinic Victoria, which is a lot better.

I believe the Sexual Reassignment Act 1988 repeal came into effect April 2015. I can't post links (yet), however Google "sexual reassignment repeal bill 2014".

That I think was when the review came in under Tammy Franks

Dr. Tony Roberts is possibly who you're thinking of. Yes! Sorry Tony!!

I've spoken to Dr Roberts' office about the delays and asked who else Tony might take a referral from. I don't want to speak for Tony; however their answer was helpful and it's worth speaking with them.

For the record, the latest DSM-5, ICD-11 (proposed), and WPATH guidelines now allow referrals from psychologists (not just psychiatrists). It appears to me this leaves only one bottleneck in the system: That psychologists are not yet willing to make referrals for HRT, and endocrinologists are not yet willing to take referrals from psychologists.

The reason cited by my psychologist was they're not medically trained, and that they would want to monitor the HRT from a medical perspective. However I would argue that is the job of the endocrinologist and GP - NOT the psychologist. So the argument is moot imho.

They will take referrals from clinical psychologists - there is a  big difference. Both Rosie and Tony do their own monitoring.

It took me one week to see a clinical psychologist who specialises in GD. If we can change this bottleneck/perception, this frees up resources and releases pressure on the entire system.

For sure. Be aware there is a psychologist in SA who states they are a clinical psychologist and who does not have the required degrees. Their opinion is not accepted as clinical information by either of the Endos

[Cindy]

I'll just add from AnonyMs post. DSM is not relevant and has not been in Australia for years. WPATH SOC are guidelines and have no authority in Australia.

[Stephanie2]

My primary care doctor didn't want for me to mess with hormones, even after I mentioned I had gender dysphoria. She saw how large the boobs were and ordered a mammogram for me, which turned out fine. The next appointment or two she asked if I still wanted to be a woman and I said yes. She still seemed confused about the large boobs and ordered another mammogram. At that point I said that I would like my hormones checked. That got the ball rolling. now I get to see an endo and psychiatrist. I am prescribed the estrogen patches plus the spiro. I just had my next appointment and now have the assessment completed with the psychiatrist. This means that if the VA ever starts to pay for the SRS, then I am good to go.