Ok, I know I'm piping in late, but I would like to contribute by making a case of defending antidepressants
First of all, and that's to Paige, I believe that your family doctor is really well-intended. If she is anything like mine, she has been through 'thousands of cases' with gender dysphoria of some sort. However, if she is also honest (like mine!), she will refer you to a specialist — this is usually a psychiatrist/sexologist, who are trained as medical doctors, but specialise in sexual and gender issues.
I would never take the first opinion regarding neurological drugs coming from a general practitioner. I'm not belittling your doctor (as I'm not belittling my own, who is a fantastic doctor in all regards, including having a warm personality, which is not that common among doctors around here) but just saying that you really, really need an expert looking at your case.
A good, honest expert will start with the following issue: on one hand, you have some form of gender dysphoria, which is not 'curable' (except through transition). On the other hand, you have some form of depression (and there are many forms, not all of them are of the melancholy type, which is the most common one, and one of the easiest to treat — the other types are not easily recognisable as 'depression' and therefore much harder to treat), which responds well to medication and therapy (you really need to combine both).
GD also usually comes together with anxiety, that's true. Fortunately, anxiety is very easy to treat medically, and this is really my point...
Because depression and anxiety are so common these days, a LOT of research has been put into developing new-generation drugs. In particular, the newest generation of drugs do NOT 'dumb you down' and they do NOT create sleepiness. Older generations of anxiolytics, for example, tended to rely upon 'calming down' people in order to let them worry less about things. But not only they caused sleepiness and apathy, but, worse than that, most were addictive, requiring larger and larger doses over time.
The newer generation of drugs acts in completely different ways. Take a look at depression, for instance. It is generally accepted that depression comes from either a lack of serotonin production (the hormone that induces the 'reward' effect in the brain, i.e. when we feel pleasure of accomplishing something) and/or the brain flushing out the serotonin so quickly that it barely had no effects. Serotonin is mostly produced in the intestines, and it can be synthesised artificially, so, as you can imagine, the first attempts to regulate the levels of serotonin in the brain was simply to
add more serotonin to the body, in the hope that enough would reach the brain.
In the first case (lack of serotonin production), this seemed to have an effect, at least at the beginning. Then, over time, the drug would lose the effect — you would need higher and higher dosages, until there would be a point that no dosage would ever provide enough serotonin, which baffled the researchers. Worse than that: such drugs would not have the least effect in the second case, because the brain would flush out all extra serotonin anyway.
Clearly the reason why increasing the dosage did not produce results required to be better understood. And fortunately, researchers figured out how the brain got its serotonin: it actually flows
inside the central nervous system, and it is regulated by some 'gates' that admit the serotonin into the nerves, and closes the 'gates' afterwards, so that the serotonin doesn't get flushed out too quickly. If serotonin production is too low, then, no matter how 'open' the 'gates' are, it will never reach the nerves into the brain; on the other hand, 'leaky gates' that allow serotonin to escape too quickly did not react to having extra serotonin around — it would still escape as before.
The addictive effects — and why it is worthless to increase the levels of serotonin beyond a limit — were also quickly understood, because we have other 'gates' allowing neurotransmitting drugs to be administered in a similar way. In particular, one of those 'gates' lets nicotinoids through, and yes, as you can guess, this is very closely connected to tobacco addiction. As you can imagine, this was very well studied for decades, once the scams of the tobacco companies were exposed: scientists wanted to understand what exactly happened and why tobacco was so addictive.
The explanation is actually curious. Those 'gates' into the nervous system are sort of created 'on demand'. That means that everybody has gates for letting naturally-produced nicotinoids through into the brain — they act as messenger molecules and are critical for working (so, yes, we all produce nicotine derivatives naturally and cannot live without them
). What happens with smokers is that they increase the available nicotine in the body, which gets metabolised into the right kind of nicotinoids, and suddenly there is way too much of those molecules around! What does our body do? It creates
more gates, and this means that more nicotinoids can flow into the brain (and yes, that's why smokers report a need to get their regular intake of nicotine to increase their cognitive abilities). However, there is a limit to how many 'gates' our body can build. When that limit is reached, no matter how much more nicotine is inhaled, the body will reject it all. That's why almost all smokers will smoke more and more but eventually reach a plateaux, a level of daily intake which they will never raise again, because all excess nicotine will simply be flushed out of the organism, and thus has no effect. There is a point of equilibrium there.
What causes the addiction? Well, once created, those gates will take a long, long time until they get (naturally) destroyed for lack of use. That means that smokers who stop abruptly will suddenly have lots of unused gates requiring nicotine to work — and because that nicotine is withheld, the organism responds by demanding it strongly, through what we know as withdrawal symptoms. Eventually, over time, the organism will know that there will not be extra nicotine in the body, and start dismantling those extra gates — but this can really take a lot of time: at least, several days, but possibly more.
Now the good news for the depression researchers is that the gates that open for serotonin are really very similar. So, when extra serotonin is around, the body starts creating more gates. This will naturally let more serotonin flow to the brain and thus fight depression; but there will be a demand for more and more serotonin until a limit is reached, when the body is unable to create more of those gates (just like with nicotine). At that point, either the flux of serotonin is enough to make the depression disappear, or, well, you're stuck — that drug will not help you more, because the limit is reached. Once again, stopping the flux of serotonin abruptly means that a lot of gates will 'demand' the extra serotonin, and therefore generate all sort of withdrawal symptoms, just like with tobacco addiction — and that's why most antidepressants must be 'phased out' over weeks or months, to allow the organism to dismantle the extra gates for serotonin, until they are back to 'normal' levels.
Ok, but this strategy does not help with those people who have enough serotonin, it's just flushed out of the brain too quickly. So the next generation of drugs started to work on the gates itself — basically, switching them on and off on demand. On people where the levels of serotonin are too low, the gates would be kept open for longer periods, so that more serotonin could reach the brain; on those when it would be flushed out too quickly, the gates would be closed, so that the serotonin could not escape easily. Such drugs were revolutionary once developed.
Nevertheless, they weren't perfect. It seems that these gates are very security-conscious — they must be, since, after all, they let molecules enter the brain, our most important organ. When we start taking drugs that artificially open and close the gates, at some point, there will be a saturation level: the gates themselves will not react to the drug any more. Note that the drugs themselves are synthetic molecules that bind to specific points in those gates, opening or closing them; they are not exactly like the natural counterparts, because we want to avoid most of the undesired side-effects from such drugs (like overloading the liver, for instance), and so they have just the 'key' for the 'gate' and nothing else. Nevertheless, the gates seem to be clever enough to figure out that there is suddenly an increase of 'keys' in the bloodstream, and this means that some gates start refusing to open up, in spite of having the correct 'key'. The solution is to increase the dosage, hoping to affect more gates; again, this will reach a level when the number of available gates which still accept the 'key' has been exhausted, and so the dosage increase will not have any further effects. And, again, such drugs are
also addictive, because, if the supply of 'keys' is suddenly drastically decreased, a lot of gates will 'demand' more 'keys', and this will produce withdrawal symptoms — which, by the way, are far more intense than those from stopping to smoke tobacco.
The pharmaceutical industry, however, has not given up. The current generation of drugs (as far as I'm aware) does something rather clever. Because the problem with the previous generation seemed to be a reaction to an excess of synthetic 'keys', they have developed new drugs that artificially enhance the production of
natural keys. This is actually quite clever, because there are natural mechanisms for keeping the levels of the 'natural keys' within a safe level. What seems to happen with people with depression is that the production of those natural keys is somehow being prevented, so we have much lower numbers of them that we ought to have; artificially raising them to natural levels will get the whole serotonin cycle working correctly — and not being flushed out too quickly — while not forcing the organism to create extra gates, or get gates that stop functioning. If too many 'natural keys' are produced, because the dosage is too high, the organism naturally rejects them, and they are flushed out of the system; no harm is done that way. As a result, the current generation of drugs is not addictive, and doctors can tune the dosage so that enough 'natural keys' are produced, but not too many, so that the excess does not need to go to waste.
I know, this description is a bit boring, but I have to admit that I find all of this incredibly fascinating
so that's why I also wished to share it with you. Basically, my point is that there are available drugs with tremendously sophisticated mechanisms to fight depression — and the current generation has little or no side-effects, does not induce sleepiness or 'dumbing down' (rather the contrary, certain combination of drugs will even give you a 'boost' to your energy levels), and has no addictive effect.
Why are the older generation of drugs still around, if the new ones are so much better? Well, there are many reasons. First of all, not all people react in the same way to all kinds of neurological drugs — you might be especially sensitive to one kind but not to other. Or the newest-generation of drugs, even though they are safer and have few side-effects, might not be able to raise the level of 'natural keys' to the serotonin gates in a way that it actively fights depression; in that case, there are combination drugs which might boost the effect, or, well, if all else fails, maybe an older generation, with a more direct approach, might produce better effects — and, eventually, once depression is cured, you might move to newer-generation drugs to avoid the withdrawal symptoms, and reduce the dosage, and so forth.
All this, as you can imagine, really requires an expert psychiatrist to know what needs to be done, what dosages are appropriate (the lowest possible that has a positive effect), how your organism is reacting, and what the actual results are. There are many, many drugs (and drug combinations) to deal with depression; and just because one or two drugs failed to achieve an effect, and had terrible side-effects besides, that doesn't mean there aren't other solutions around — it mostly means an uninformed doctor, who might just know a handful of popular drugs, and nothing else.
Each solution needs to be tailored specifically for each person. In my case, because I suffer both from anxiety and severe atypical depression (as its name implies, it doesn't have the typical symptoms of melancholic depression), I needed a complex cocktail of three drugs, all of which interact in well-known ways, which attack anxiety AND depression simultaneously, while keeping side-effects at a minimum, for my body type, age, and other health complications — so obviously 'my' solution will not be appropriate for anyone else. What I can say is that anxiety disappeared completely after just two weeks and didn't even need therapy for that; depression is much, much harder than that, and although I'm much better in almost all regards, I'm still unable to work (a problem that comes from atypical depression...), even though my mood is excellent in all other aspects, and I've certainly learned quite a lot from therapy about myself...
So... to conclude... yes, gender dysphoria cannot be fought with drugs and therapy (unless, of course, we are talking about HRT and transition...), but the associated negative effects, usually coming from depression and anxiety, can. The WPATH protocol demands that doctors start treating what is actually treatable through drugs and therapy. In many cases, if depression and anxiety are successfully controlled, gender dysphoria, while it cannot be eliminated, it might be at least bearable.
Interestingly enough, a number of studies shows quite clearly that some sort of hormonal therapy
will have a positive effect in fighting depression and anxiety associated with gender dysphoria; however, it is not a recommended form of therapy, even though it is very popular in the USA and with clinical sexology expert doctors who have been training in the USA. The rest of the world has a mixed approach; in my country, the national health service will never prescribe hormones before depression and anxiety are controlled, although private doctors might have a different approach. Again, the point here is that there
are options, and you really ought to have a few opinions from experts.
Remember, depression will not 'go away' on its own. Anxiety can be controlled, for example through mindfulness meditation; you can also naturally increase circulating serotonin by doing sports and participate in social events, both of which will help in fighting depression; but if all of those are really connected to gender dysphoria, then you need an expert to see what options you've got.
And now you can always tell the doctors that there are several generations of drugs available, and ask them to try the latest and greatest first, to see how well you respond. If not, there will always be choices. In the words of my psychiatrist: 'if all else fails, we even have electroshock therapy — not the kind that was done in the early 20th century, of course, but a contemporary approach — with which our institution has had a lot of success in fighting chronic depression'. Ouch! No, I'm not really interested in going that way myself
... but somehow it's nice to know that doctors, these days, are willing to think out of the box to find a treatment that works...
