Following my previous posts about gender transition from CAFAB to male, I finally had my appointment with Dr. Vanek at Legacy Clinic on California Street near Montrose in Houston. I’ve been waiting months for this because the earliest new patient appointments for HRT are usually ages after that first, gut-wrenching phone call.
I have some tips for people seeking this kind of medical care–some practical things I wish someone had told me–and I’ll be explaining exactly what informed consent means. Also, you know, a more personal story.
Check out the easily skimmable headers! Whoo. Who loves you, baby?
So the first step to figuring out how to transition medically, for me, was ascertaining how to pay for it. Legacy Clinic, as well as other LGBT+ focused clinics around the US, offer treatment on a sliding scale. To receive benefit from this, however, you have to go to a financial consultation. Mine was scheduled at 9am. They told me to be there at 8:45. My amazing and super-helpful financial coordinator (shoutout to Patty) got me in at 8:50, and she went over all my documents and worked with me where my documentation wasn’t perfect.
Here are some tips for you:
- bring a bill or official-type document (bank statement, government benefits letter) mailed to you within the last month. If that letter is two months old, it’s too old. This is your proof of address.
- Have your last three months’ income statements on hand or the current year’s SSI letter if you’re on disability.
- If you have custody of children, bring copies of their birth certificates. Only children under 18 living with you the majority of the time count toward your household size.
- You’ll need to know your social security number and bring a valid state photo ID like a driver’s license.
I’m lucky enough to have Medicaid, which, while it does not pay for transition-related expenses at this time, does pay for certain parts of the visits. My sliding scale requires me to pay 20% of the standard treatment costs. Some people will pay 60 or 80 or 100% depending on their income. Some people will qualify for a grant. If applicable, they bill your primary insurance or Medicaid first and whatever Medicaid or insurance won’t cover is then subjected to the sliding scale. You will always be told how much you need to pay–just ask–and payment is due at time of service. If you absolutely cannot pay but desperately need a visit, you can tell them and they will try to work with you.
So here’s the great thing: informed consent. This means if you really know you’re trans and that hormones are for you, if you don’t need to spend months in therapy talking it out with a shrink because you’ve already talked it out with friends and family and lived your truth for a while, then you can just say so and the doctor will take you at your word.
I’d heard a lot about informed consent, but I didn’t know what the paperwork would actually look like. Somehow I imagined it would be like a little lecture from the doctor and then I’d initial on the dotted line. In actuality, there’s a multi-page document that lists all the risks associated with HRT and explains exactly what to expect when you start T and tells you what T does not change. It even breaks down the time table to help you manage your expectations. The following information is taken from Legacy Community Health Center’s “Informed Consent for Masculinizing Hormone Therapy.”
Permanent changes on HRT
- New facial and body hair (arms, legs, back, abdomen) starts within 1-6 months and is complete within 1-2 years.
- Lower voice starts within 3-12 months and is complete within 1-2 years.
- Clitoral growth (1-4 cm) with sensitivity/tenderness as it grows starts within 3-6 months and is complete within 1-2 years.
- Hair loss at temples and crown and potential male pattern baldness (depending on family history) starts in less than a year and varies as to an end date. (Dr. Vanek recommends a biotin supplement to help preserve head hair.)
Changes which revert if you stop HRT
- Muscles get bigger and stronger (depending on your exercise regimen — Dr. Vanek insists you will get nothing but flabby muscle if you don’t exercise daily and lift weights)
- Periods stop
- Redistribution of body fat to male pattern (increased abdominal; reduced in buttocks, breasts, and thighs)
- Acne (may be severe, and is most notable in the first years of therapy — Dr. Vanek insists her patients take good care of their skin)
- Increased red blood cells (hematocrit)
- Coarser skin and more prominent veins
- Increased metabolism and secondary weight gain if not attentive to diet (Dr. Vanek insists on carb cutting and lots of protein to accompany the exercise regimen)
- Increased libido and change in the way orgasm feels
- Mood changes (typically less emotional and more stoic, but depression also possible)
Things HRT will not change
- Adam’s apple (though I’ve heard that those trans men whose voices deepen appreciably may notice an Adam’s apple type protrusion, informed consent suggests not to count on it)
- Breasts (these may become thinner but do not go away)
- Penis (your clitoris will grow, but you will not be able to pee through it or use it for appreciable penetration without surgery)
- Bone structure (although I’ve heard that some people do have masculinized facial features after starting HRT, informed consent warns me not to get my hopes up)
- Chance of pregnancy (periods may stop, but that doesn’t necessarily mean ovulation stops)
Risks and additional benefits
- Brain structures are affected by testosterone and estrogen. The long term effects of testosterone on those with natal estrogen have not been scientifically studied. The effects may be beneficial, damaging, or both.
- People on masculinizing hormone therapy seem to have the following problems more often than those who are not on hormone therapy: Stroke or heart attack; blood clots in the heart, brain, lung, or leg; weight gain from bigger muscles and more fat; acne; sleep apnea.
- People on masculinizing hormone therapy may or may not have the following problems more often than those who are not on hormone therapy: High cholesterol similar to natal males; liver inflammation (usually temporary).
- Testosterone may increase the risk of developing diabetes due to changes in ovaries and potential weight gain.
- Testosterone does not protect against cervical or breast cancer.
- Smoking cigarettes or using tobacco may combine with testosterone for a higher chance of heart attacks, stroke, high blood pressure and/or cholesterol.
It goes on to detail how you will be monitored (closely) and to warn you that if you use drugs, take unauthorized vitamins, or try to take more or less of the testosterone or a different kind than prescribed without the doctor’s input, you may lose your right to a prescription. If you do not follow the doctor’s orders, you may not be given a refill. You can choose to stop HRT at any time, but some things are, as stated, irreversible.
“I understand that taking masculinizing hormone therapy will make changes in my body that can be noticed by other people. Some people who have taken hormone therapy have been hurt or treated badly or unfairly by other people because of the way they look. Other people have been hurt, ignored, or left by family and friends because they took hormone therapy. I understand that LEGACY can offer me information about getting counselling or support if I feel this would be helpful now or in the future.”
“I understand that taking masculinizing hormone therapy to transition gender has not been researched well and that the use of hormones is not approved by the Food and Drug Administration (FDA) for transitioning gender. The FDA is the organization that approves drugs to be used by healthcare providers; it decides what drugs to approve based on large research studies that show that drugs are both safe and effective. Masculinizing hormone therapy has not been studied enough to be approved by the FDA to transition gender. This means my medical provider is suggesting hormones for gender transition based on their experience, not on evidence from research studies. Medical providers do not know how taking hormones for a long time will affect my body and do not know if I will have health care problems when I get older because of taking hormone therapy.”
The First Visit
Even though Clancy came with me, she couldn’t come into the exam room with me. The doctor explained she has such a brief time to see each patient that she prefers to keep it just to the one person to deal with. I was really nervous, but knowing Clancy was in the waiting room cheering me on helped immensely.
I sat for about 35 minutes in the exam room waiting to talk to her. The nurse took my vitals and a basic medical history, and when Dr. Vanek arrived, she did a quick physical. She assessed me and asked me questions about whether I had socially transitioned, if my parents and kids knew about where I was and that I identified as trans.
It got very emotional. Dr. Vanek was professional and politely detached, and I came apart at the seams a little, crying as I tried to explain why I had waited so long to go on hormones. As I tried to explain that it’s complicated in my little town, that I needed my kids to be old enough to (kind of) understand. It was hard. I had to be very honest and forthcoming. (If you’re not ready to be that vulnerable, you’re probably not ready for informed consent.)
When she was satisfied that I knew my own mind, she arranged for a huge order of bloodwork (which is only good for three months after it’s done!) and had the nurse bring me the informed consent form. I was instructed to go to the desk to arrange for the bloodwork and make my next appointment. Currently it’s October 6th, but I’m going to try to get in sooner. You can ask about the waiting list at the desk, and they have a patient portal which will allow you to keep tabs on things online.
You do not get a prescription for hormones on your first visit. After all that waiting, you will still go home without a scrip and probably expect to wait a few more months. You will wait at least two weeks, because that is how long it takes for the test results to come back.
The Personal Part
I met a fantastic trans man working at Legacy and talked to him about my treatment plan and issues. He reassured me, gave me some information on an FTM support group on Facebook, and generally was ridiculously cute. He even gave me some inside info on how to get in as soon as possible in future.
Anyway, I’d been really worried lately about what it would be like if I went on hormones. Fears that I won’t look like a man, I’ll look like a freak. I’ll be visibly trans and not just dykey. It’s a dangerous, strange category to opt into, at least by mainstream society’s standards.
However, I love other trans guys. I think they’re pretty hot, to be honest. (I know a lot of y’all have met Aleksandr Voinov; don’t even pretend he’s not insanely attractive.) Transitioning medically (hormones and/or surgery), transitioning socially (wearing masculine clothing, using pronouns other than she/her), or whatever, I really think they’ve got something special going on. And I realized talking to this great guy today that I’m not even a little afraid of joining the ranks of the bearded and irrevocable.
I’d built it up in my head like I was going to be a hairy-tittied sideshow act, but so what? That means nothing.
Fuck your patriarchal beauty standards.
It’s sad and a little scary that the trans men transitioning medically right now are pioneering a great unknown. Historically, we aren’t many in number–so many people don’t realize trans men are even a thing, even if they know about trans women–and haven’t mustered much scientific and medical research. There are risks and question marks all over this process. But I know I need it. I can’t be who I am without it. What more wouldn’t I sacrifice to get a ‘sir’ out of folks now and then?
And that’s why I know informed consent is the right path for me. I know what I want and need. I’ve been living this truth for years. I want to be in control of my fate and where it takes me.
Plus, you know, I have a Clancy. She’s been listening to me work through my issues for ages, and she was there today to support me. She took me to an amazing restaurant at the corner of Montrose and Westheimer for lunch, and we talked about the appointment, about the future, about her plans and my plans and how neither of us quite fit in. I love her so much it’s ridiculous.
Then there’s my amazing friends list on Facebook who liked and commented on my post about the appointment and sent me so many well wishes and so much love. It’s incredible to know that people are watching and cheering me on, trying to give me the strength and will to follow the path ahead. (And extra ♥ to Ruth, who sent me supportive messages on Kik! And to Z, who texted me. Thanks, y’all.)
So what if I don’t emerge from transition looking like Chris Evans? Literally no one looks like Chris Evans. Even Chris Evans doesn’t always look like Chris Evans. If no other guy on earth looks like that, why should I hope to? Why worry about how physically attractive I’ll be when I’ve always known I’ve got an attractive personality? People will still like me if I look visibly trans. They’ll still be my friends, if they’re worth being friends with. People have been liking me for years looking like this, and me adding some chest hair to the mix and developing some acne isn’t going to change that I’m a likeable guy.
I’m not losing anything. I’m gaining control over how people perceive me. I’ll go from being a fat perceived-as-woman to a fat probably-a-guy(?). And that’s okay. This world is small-minded and easily confused. But I’m willing to go out and show it what I’ve got.