MD refuses RX for HRT due to mental illness?

[Tomast]

I'm in need of advice.

I am 27, and been openly FTM since i was 15. I was a huge tomboy as a kid, but didnt know anything at all about the ability to transition until highschool, having grown up catholic, i was unaware of homosexuality until i was about 12. I didnt even know what sex was until i was 11 tbh.

I have tried to get on HRT since i was 16. Without success.

I live full time as a man, bindimg every single day since i was 15,  been to therapy since i was 10 years old, almost consistently.

I am diagnosed with schizoaffective disorder, coupled with borderline personality disorder. I have been hospitalized over 30 times, in my late teen years due to intense mental illness issues.

Anyway flash forward to present day. I live in the bible belt, where its extremely difficult to find a competent doctor at all, let alone one who will work with transgender individuals and help with transition. There seriously are 0 psychiatrists available currently, until next february.

I have managed to become a patient of the only physcisian in my town who prescribes gender dysphoria related HRT. Im also seeing a psychologist who specializes in sex therapy.

Im intensely frustrated, since ive been to this doctor for 8 months now, and i am not one step closer to him agreeing to prescribe horemones.

He says due to my mental illness he isnt comfortable proceeding with treatment at this time. He wants me in to see a psychiatrist. But, there ISNT one available.

Ive jumped through countless hoops. Having been in therapy in good standing for about 7 or 8 months now... Making significant progress in managing my mood disorder, and without any severe psychotic symptoms. Even if i took medications, the psychosis will never truely subside. I took meds (many many different med combos for over 15 years) with limited to no success.

I also was a severe alchoholic for many years, but ive even quit drinking, so my mental health would improve. And it has, quite dramatically. No relapse, no withdrawl, i quit cold turkey because i knew it was the best for me and my girlfriend of 8 years that i stay sober from now on. And its been a lot easier to quit than i thought it would be.

But none of this seems to make my doctor comfortable with proceeding.

I even went in over a month ago to see a specialist for a very thorough mental health exam, and the report indicated im mentally sufficient to make a decision about starting HRT.

The only thinhs the specialist mentioned was making sure i can be stable mentally for a sustained period of time. Be alchohol free, and to actually discuss the cost of HRT.

All of which have been completed. As best i can currently, you know?

Ive waited for over 10 years to further transition. Im sick of being viewed as a female in public, or at best, a 14 year old boy.

Every visit to my doctor leads to him wanting me to seek further help for my mental disorder. Every visit leads to him coming up with a more innane reason for holding off on even drawing my blood to see my horemone levels.

I am also intersex, undiagnosed. But its fairly obvious, i am incredibly androgynous, and my gentials are clearly ambiguous. He heats this concern for me and does nothing at all to examine further and see if it is true or not.

He gave me a pap smear recently and barely even glanced at my genitals, which wouldve set of alarm bells???

He seems apathetic to my situation and even slipped up calling me female pronouns last month. Im fed up with the run around.

My therapist wont write a letter of reccomendation either, and seems equally apathetic to finding a real solution.

I do completely understand the concern my doctor has. Testosterone can make mood and psychotic disorders worse.

But at the same rate, if he is worried about me having a psychotic episode, the strategy for rehabilitating me, is exactly the same wehether or not im on HRT. So what gives?

My girlfriend says im not being assertive enough. And mayne im not. But its so incredibly frustrating and it seems unfair the way this has been going for me.

What should i do? I see him tomorrow and hope to review the psychological assessment. If i cant get into a psychiatrist to try treating my scizoaffective disorder with medicatiins, i may never get on HRT.

Its so rediculous. Ive been off medication successfully for over 2 years and am doing quite fine. Its actually been quite an accomplishment for me. To think i have to do this because of someone else making these descisions for me, is breaking my heart. Its truly stressing me out tocthe point im starting to feel like life just is BS and not worth living.

How much must i have to conform just to be taken seriously?

Im so confident, if i had never mentioned my schizophrenia to him back in november id be on it already. Since i dont present as schizophrenic, (in a typical fashion, if you have met someone sufgering a psychotic disorder usually they are quite illogical or can have disorganized speech)

Ive worked very hatd for years to behave in a "normal" range. The psychological assessment said im quite high functioning for someone with schizophrenia.

Maybe i should have lied and ommited it? Im an honest person though. I didnt think itd be such a huge deal. But its really set me back in my transition goal, and been a real damper on my self esteem. I felt great before hearing i cant get on HRT because the doctor is "not comfortable enough yet".

I have so much to say to him. But im unsure if it will make amp lick of difference. Hes very unpersonable and autonomous.

Feels hopeless right now.

Any advice?

[Dena]

Welcome to Susan's Place. The standards which I transitioned under required that I be certified not to have any mental condition that would interfere with my ability to make a decision about my care. It appears this could be the problem or you have run up against a medical system will not treat you under any condition. I would ask each doctor what is required for them to give you the treatment you are after. If you find a doctor that says under no condition will you receive treatment, you will have to find a way to receive treatment from another doctor. If your condition is properly controlled, it shouldn't prevent you from being treated but you will have to prove it beyond a doubt.

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[FTMax]

First, I would fire your therapist if they aren't willing to help you. There's no use spending money on someone that won't do their job. If there are no other local options for therapists, there are quite a few that offer online services at very low cost.

As far as HRT - Are you able to travel, and if you are, have you investigated any other resources within a 100 mile radius? You would be looking at 4-5 trips there per year for the first year, and 1-2 after that. Lab work can be done locally and faxed, prescriptions can be picked up at any pharmacy. That would be my first recommendation if it is possible for you.

The clinic I go to for HRT does a brief behavioral interview prior to prescribing. They want to see that you are in a good place mentally, emotionally, etc. before putting you on hormones. Obviously most of us are at least a little screwed up due to dysphoria, they get it. They really want to see that you are proactively managing your health. So for folks with mental health concerns or an addiction history, they would want to know the steps you've taken thus far to improve, and what you're doing to either further improve or maintain.

So taking that approach, I would sit down with your doctor and ask some very specific questions:

1. At what point would you be willing to prescribe someone with my background HRT?
- Nail down a specific answer like "when I have a referral from a psychiatrist" or "when the results of your psychological assessment are X, Y, Z".

2. What would demonstrate to you that I have reached that point?
- Again, a specific answer. "A referral letter from a psychiatrist that you've seen for X months" or "consistent results on multiple psychological assessements over a period of X months".

3. What credentials do you require from an outside professional who would be assessing me?
- If he wants a referral letter from a mental health professional, ask him what kind of degree they need to have. A Master's level therapist may suffice for most people, but if he's putting up a fight he may want a PhD level therapist or psychiatrist.

4. Would you be willing to sign a treatment agreement if I put all of this in writing?
- This is just a gauge to see where he is at the end of the conversation. Ideally he will say yes, you will put it in writing, and you will both sign off on it. That way you'll each have a standard to hold the other to. If he says no, probe more and ask why. If he has given definitive answers to the prior questions there is no reason he should fear signing a document that says as much.

I know you mentioned that he is the only doctor in town who will prescribe trans HRT - do you have references for him from other trans patients? Are there any local or state based support groups for trans people that you could check in with to find other resources?

[Tomast]

Thank you for the advice given.

Todays appointment went much better than expected.

My doctor did originally want me to see a psychiatrist. But after recieving the 15 page evauatiin i recieved from the psychologist, he seems much more comfortable with moving forward with beginning HRT.

He admitted he was, "chicken" to start hrt for me. Since it is a permanent change for my body. He said he mostly works with trangender women, and as far as i am aware i am his only FTM patient.

He said he had reservations and worries about if i took the horemones and 2 years down the road i would regret this decision.

He did find it comforting in my evaluation and from my own presentation that besides the typical imulsivity associated with borderline personality disorder, that my gender dysphoria has been lifelong and enduring. He seems confident enough that this isnt a quick impulsive descision to just "try out changing my gender".

He also finds it comforting that ive tackled my alcoholism head on, without incident, and that my mood disorder is well managed.

I even agreed to begin taking an antidepressant medication, so that also helps.

He wants to have me meet with my psychologist again, at our next appt, and discuss the results of my evaluation, and see where to go from there.

Hopefully she will feel comfortable with the progress ive made over the last 6 months, and call him to give the OK to begin treatment.

I hope all goes well. I have been waiting for this for 13 years now. And im looking forward to getting on with my life.

So fingers crossed, and with more work in the coming years, i will finally be at a place ive only dreamed i could be. Healthy, high functioning, and with the body ive always wanted to see myself with.

It would be a life changing experience, to finally be myself.

[FTMax]

Fingers crossed for you! That went much better than it sounded like it would.

As far as his worries about potential regrets, almost every treatment I've ever undergone (including both HRT and surgeries) involves a consent form which basically says "This is what is going to be done to you by Dr. Dude. It is intended to do A, B, C. You may also experience D, E, F, etc. as a result of this procedure/treatment. This has been reviewed with you, you understand the intended and unintended outcomes, and wish to move forward with the procedure/treatment."

It's kind of a catch-all. I may still have a copy of one of mine. I can go try to pull it up if you think it would help him to have.

[Randi]

You've been off your psych meds for 2 years, and no longer drink.  I assume it has been a while since you have been hospitalized.

As you know the psychiatrists will never say you are "cured". 

One thing I learned years ago is that mental health professionals can only measure behavior.  They can't tell what's going on in anyone's mind.  If you can behave like a normal human being without psych meds then, for all practical purposes, you ARE a normal human being.

I know that WPATH guidelines, and others, state that mental health issues must be dealt with before allowing transition. 

If you can learn to control your behavior, act "normal" in daily life without the aid of psychoactive drugs and stay away from alcohol then, in effect, you HAVE dealt with your mental illness and can proceed to work on gender issues.

Best Wishes,
Randi

[Tomast]

Hello all! Good news, I may be starting T tomorrow!

Been prescribed Prozac and after consulting with my therapist, mydoctor is comfortable moving forward with HRT.

My month followup from starting Prozac is tomorrow, and hopefully we will begin T tomorrow.

[FTMax]

Congrats! Glad to hear it!

[Tomast]

I did end up starting T yesterday every 2 weeks.

It's awesome. I've been a bit grumpy, and I didn't get hardly any sleep lastnight. I felt weird and restless and really hungry. Now I'm up and about and feel nauseous. I hope I feel better soon. Got a lot of adjusting to do.

I wonder if I felt like this 1st time around in puberty. It was 17 years ago though so I can't really recall. Haha

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