Transition takes time. Everyone wishes it weren’t so. Trans people wish it were over in the time it takes you to say “knife”. So do all the people made uncomfortable by transitioning people (which is almost everyone — we do love our tidy boxes). But, there it is: it takes time. Time for hormones to work. Time for hair to grow out so that you seem cis enough to get by (head hair, for most trans women; facial hair, for most trans men). Time to learn speech patterns and social interactions so that you become apparently cis enough to be able to get a job, and/or keep a job, and/or go to the bathroom, and/or not to be a choice target for anti-trans violence.
It takes time. Pretty much a year, minimum.
In my case, it took several years. I started taking hormones, and my body started to change. One of the most visible changes was that my breasts grew. Since I was still changing in the men’s locker room, and still wearing a ballistic vest designed for a male torso for 8 to 20 hours a day, my breasts were inconvenient.
I could hide them, at work. The strategies are numerous. Wear a tight sports bra. Change in the toilet stall. Arrive at work with tight sports bra under opaque undershirt and shuck out of the floppy fleece outerwear and into the ballistic vest while facing away from the men in the locker room. It helps to roll your shoulders forward a little, so that the fabric doesn’t outline the breasts. If you’ve sweated into the vest during the shift, use the toilet stall strategy so that the sweat patterns in the undershirt don’t show the outline of the sports bra. The diciest moment, for me, was doing the bench press during my fitness test. In the bench press, you’re flat on your back, and the down position has your elbows way down past your back. TWO layered compression shirts did the trick, though.
So I could hide my breasts, at work, and I did.
But I couldn’t hide them at the doctor’s office. A nurse would check me in. A doctor would expect me to remove my shirt. I’d have to come out to staff and put the fact that I’m trans in my chart, and all of the medical providers in my region are members of the community, so that might lead to me being outed at work before anyone was ready, which could lead to loss of job, inability to pay mortgage, loss of house, and devastating consequences for my family.
My society’s attitude toward trans people makes it meaningfully dangerous to come out, or even to risk the possibility of having to come out. So I weighed my options and chose my gamble. And I didn’t have a standard physical for over four years. I just saw my endocrinologist, who treats a lot of the trans people in my region, and who was safe to trust. But he was supervising my hormone therapy, not giving me standard screening physicals. I decided that was good enough, and rolled my dice.
When I came out at work it was finally safe to talk to a general practitioner and get basic care, it felt like such a relief. I could finally speak plainly to my doctor, I thought, and be myself. My old doctor, who was great, had moved on to another practice, so I had to come out to a brand new doctor, which I did. My wife, Lioness, came with me. She is wise: she wanted to communicate without saying a word that I had family support, and be a witness in the event that things did not go well.
I say that it felt like a relief, to be able to speak openly about myself, but it was also potentially very stressful. Looking in the mirror, I did not seem very cis, which can be key to being treated like a human being. I had heard horror stories in person from other trans people, and in news stories: medical professionals refusing care, even in life-threatening circumstances; medical staff telling trans people presenting with serious non-trans-related medical problems that “we don’t treat people like you.“.
So I was nervous. I tried to put a good face on it.
The nurse who did the intake wanted nothing but good medical care for me. She was firmly of the opinion that I and my brand-new breasts should get a mammogram. After all, I’ve been an adult for decades! I, on the other hand, did not believe that I should, since my breasts were new and possibly still actually developing, though at the tail-end of that process. I do not think that developing breasts should be irradiated without a very compelling reason to do so.
As I say, the nurse wanted nothing but good medical care for me. So, she made a smiling and enthusiastic pitch for standard medical screening, and started her smiling, enthusiastic pitch thus:
“So, you’re basically a guy, right?”
No. No, I am not. I am absolutely not “basically a guy”. “Basically a guy” is exactly and precisely what I am not. At base, I am a gal. I tried to be a guy, and it turned out I was a gal no matter how much we all tried to make me a guy. I cannot think of a single circumstance when that would ever be an acceptable question to ask any woman, cis or trans.
However, I knew what she was getting at, and when it comes to taking offense, I’m a slow burner. There was about a two-second pause as I struggled to find some response, any response, which would not be counterproductive.
I allowed, “…I have about forty years of life experience in a male-shaped body…”
She grinned happily, a merry ear-splitter of a grin. “Right! So you should…” and she made her pitch. I told her I would think about it. She left.
Dr. B came in. She had reviewed my chart. She led with, “So, I assume you’ve had both surgeries.”
Both surgeries? My mind raced. Surgery #1, in her mind, must surely be genital surgery, because people seem to be congenitally incapable of conceiving of trans people without thinking genitally. Was surgery #2 breasts? Most people don’t know about facial feminization surgery, so although FFS was factually likely, perhaps, it (a) probably wasn’t what she was thinking, and (b) was obvious on its (my) face that I hadn’t. Well, when in doubt, speak plainly with your medical provider:
“Which surgeries do you mean?”
Suddenly Dr. B looked uncomfortable, and I realized that she had taken a shot at seeming knowledgeable, and missed her target. I told her what surgeries I had had, at that point. She became more flustered. We discussed my medical history, and talked about mammograms. She agreed that the standards were not developed with my situation in mind, and that perhaps we should wait a couple of years.
I had no specific complaints; I had just wanted an annual physical and to meet my new doctor when there was no particular urgency. She confirmed that I had no complaints, and then said, “I don’t think a physical exam is necessary, do you?”
Now, a physical exam was clearly the correct medical protocol. I had not had a physical exam in over four years.1
I should have thought faster, at this point. Or taken more time. Yes, I certainly did want a physical exam from a capable professional, because I had not had one in over four years. Which she knew. But my mind, already whirling and trying to make a good thing out of a trying situation, came up with something like this: “No, I guess not, if you think it’s not necessary.”
She agreed, and fled the room. She did not actually run, but her pace was definitely on the spritely side of brisk.
Discussing it, afterward, Lioness and I agreed that I had not received good medical care. Unfortunately, unless we chose to make an actual stink about it, it would be a year before I could get a regular physical again, unless I wanted to pay out-of-pocket.
Now, unlike some trans people I have no difficulty interacting with my body, on a daily basis. That is not the nature of my dysphoria. So, I am able to pay routine attention to my own body and do the usual self-monitoring. I was fighting enough battles on enough fronts, being in the middle of social transition. I decided to wait a year. During that year, I called in and changed the designated Primary Care Physician for myself and my family. I don’t need a medical provider who pretends to knowledge she doesn’t have, and who flees the room to avoid touching me, and my wife and I did’t want such a doctor examining our children.
It was less than a year later when I found the lump.2 I took it to the doctor the very next day (my new doctor had seen me once already for a pre-surgical screening). She referred me to a specialist (that same day). They ultrasounded it and scheduled me for surgery for removal (that same day) and biopsy.
What said the biopsy? It was cancer.
Fortunately, it was Stage 1 and there was no sign that it had gone anywhere. I had caught it early and they had probably removed all of it. There will be followup screening. But if everything follows statistical norms, then in a few years my chances of longterm survival will look just like everyone else’s. Or, at least, everyone else’s who is a trans, and a police officer.
Everybody loves a happy ending.
But consider Alternate Trans Gal (ATG), trying to get by in this world.
In my case, who caught it? I did. Who treated it? A team of medical professionals at a premiere medical complex in New England, a facility where I myself have assisted at staff trainings on how trans people are actually people, and how to treat us as such.
ATG might not be that lucky. It would be very easy not to be that lucky.
Suppose ATG’s dysphoria were such that she could not comfortably handle or examine her body? She would not have found the lump. Eventually systemic symptoms would drive her to the Emergency Department, where they would find Stage 4 cancer in multiple tissues.
Suppose that, being trans, ATG could not get anyone to hire her, so she had no medical insurance? There would be no casual medical visits to examine a small lump which might just go away by itself, and no doctor would see it until, at earliest, there were significant systemic symptoms. At that point, she would have a metastasized cancer and would probably be Dead Woman Walking.
Suppose ATG’s doctor refused to examine her because she was trans, because the doctor’s society had taught her explicitly and implicitly that people like ATG are disgusting, or disturbed, and because the doctor’s medical school training never contained a single mention of people like ATG and how to treat us like people? (See the previous links; for instance, what if ATG lived in Africa, or Idaho, or Illinois, or further down the Eastern seaboard?) Suppose, in other words, that ATG’s doctor had been like my Dr. B? The doctor might not refer ATG for followup care, and ATG would die of cancer.
Suppose any of the specialists said, “I don’t know how to treat people like you?” ATG would not receive an ultrasound, would not have prompt surgical removal of all of the cancerous tissue. And AG would die of cancer.
I’m probably not going to die of cancer. But I’m under no illusions: I got lucky, and also I was able to advocate for my own care in a way that many people can’t. My society teaches a lot of medical providers not to treat people like me properly, or at all, and a lot of them never learn differently. Having transitioned, I can no longer even travel within my own country with the level of safety I used to take for granted. Next time I might not be so lucky. I might not be able to advocate for my own medical care. I might not be conscious.
Next time it might be a femoral bleed after a drunk driver plows into my taxi while I’m visiting a friend in, oh, Oregon. The sort of accident that just happens to people sometimes. And then some paramedic may learn somehow that I’m trans and recoil in horror and fail to stop the bleeding.
And then I’ll be dead.
Grace
What is a physical exam? People I know, in NZ, just go to the doctor if they have a specific issue.
Great post, and yes, infuriating issue. Thanks for posting this.
Grace – thank you as usual for posting. I’m really sorry you (and other trans people) have to deal with issues like this, and hopefully your posts will be part of the awareness raising that will help make these attitudes be a thing of the past.
standgale:
It is a check-up, a physical assessment of your general health and well-being by a medical professional. It’s usually approximately annual. The assessor asks questions designed to elicit information which would warn them that you need a more complete assessment. They look places you can’t look (down your throat, at your back, at your genitals), and assess from a theoretically better knowledge base (you look a bit jaundiced; do you have any pain? No? Let’s screen you for pancreatic cancer) and palpate areas most people don’t know how to assess (lymph nodes, testicles, liver, spleen, intestines, if you’re over a certain age, rectum). The idea is to catch illness, especially cancer, early, when it’s much easier to treat and more likely to be treatable at all.
Annual wellness checks, check-ups, physicals, whatever you want to call them, are so thoroughly proven to be generally effective at saving lives and reducing necessary future treatment that they are free on pretty much every health plan, because they reduce costs.
Yes, and best wishes to them, and I’m sure many of them live to a healthy and ripe old age, because bell curves are like that, but statistically, they are more likely to die younger, of undiagnosed or late-diagnosed cancer or other illness.
Grace
Thank you, Grace, as usual.
For reference, Grace, annual physical health checks are not a normal part of the healthcare system in any country I’ve lived in except the US (in this case, the UK, Israel and Australia), at least not for people under 60, and they are generally not considered to have much effect on survival rates. I don’t see how that’s really relevant to your post, however, given that you are American and part of that healthcare system.
http://umm.edu/health/medical/reports/articles/breast-cancer
HRT tends to make breast tissues denser, making early detection of cancer more difficult without a mammogram. Though mammography has a risk of false positives in denser tissue as well, so there is that.
You point out a serious problem, and one I have some familiarity with. But I have also seen seriously messed up care given to anyone who wasn’t a cis gendered heterosexual white male in a tax bracket above 30 percent. The sad fact is that 4.5 out of 5 people suck at their jobs even when it is a life and death issue. All we can do is try to steer our business to the talented tenth.
Eytan Zweig:
Thank you, Eytan. I did not know that.
Dammit, that’s another assumption I have to go examine, now. I haven’t time! But the fact that some countries which have medical systems reasonably comparable to that of the US don’t do routine checks prompts me to wonder how sound the evidence for such checks is.
In my own case, factually, it’s possible that even if Dr. B had followed protocol and done a medical exam, my own lump would not have been palpable at that time. But, of course, that’s the operation of random chance. Had my physical chanced to be on a different date, and a doctor or nurse examined me shortly prior to my finding the lump, they would very likely have found it.
So in cases like mine, and thinking on other people I know who have had cancer detected during physicals, it’s hard not to believe in the efficacy of routine screening. But that’s rationale based on anecdote, not evidence.
Grace
I am so glad you caught it early, and that you were able to do the kind of preventative care that can catch those things.
I’m inclined to agree with brian about the general state of health care and competency. I have never found a good therapist or psychiatrist who was willing to listen to what I have told them or follow up on it. I had to figure out myself that my depression was tied to my allergies, and probably mostly sleep deprivation. There is still no doctor I’ve found willing to work with me about that theory, so I treat myself. For the record, I’m doing much better than I used to when I was on medication.
I know it doesn’t compare to your experience, but when you’re seventeen and suicidal and the doctor feels like he needs to tell you he is “not your friend” after you just told him you didn’t have any friends but him, every medical care experience becomes an exercise in negotiation – how much of my dignity am I willing to compromise to get the care I need?
http://www.socialworker.com/feature-articles/reviews-commentary/trans-bodies-trans-selves-book-review/
At least some aspects of care are improving as better evidence based practice methods are becoming more widely used. The grad school I am in at least has an elective in lgbt issues for social workers, which they didnt have at all a couple of years ago if I recall correctly. The NASW has made advocacy for transgendered equality one of their 30 or so priorities so at least it is on the to do list. (As a profession we tend not to be very focused )
I know that is cold comfort in 2014, but at least it is more hopeful looking than in 1981.
I didn’t mean that I necessarily thought it was a good idea, it was just context to help explain why I didn’t know what the US physical check was.
I think it’s generally a good idea – especially for men (more specifically: people socialised as men) as they, at least in NZ, tend to literally never go to the doctor and it is a point of pride not to have done so, even after they’ve been hospitalised for something that could have been prevented (source: mother, who is a nurse). If there was some kind of social pressure to go semi-regularly, not only might even very basic checks flag some issues, but it gives them the oppotunity to bring up the stuff that was bothering them that they were to embarrassed to admit they were worried about.
Certainly in your case, where annual checks ARE standard and considered effective (even if they’re not effective, the important point here is that they are believed to be), refusing to do one is simply refusing healthcare, which is appalling.
standgale:
Yes, that’s an important aspect of a regular check-up which I didn’t touch on. It’s the “while I’m here” effect.
Yes. That’s the nub of it.
Grace
I’m glad you’re ok, and I share your concern for all the Alternate Trans Gals who might not be so lucky. When you talk about a “physical exam,” do you mean a clinical breast exam, specifically? There’s controversy about how useful that is, when not combined with mammography. Part of the problem is that it’s a single exam, so it doesn’t find changes the way monthly self-exams do. And, while I’m not trans, I have some experience with body dysphoria, and I take any opportunity to avoid having somebody touch my breasts. It’s a difficult situation, because the manual breast exam might or might not have any value, so it would make sense for the doctor to offer the patient a choice about it. But it’s a problem for dysphoric patients, who are unlikely to ask for the exam (even if it’s offered with a lot less negative bias than Dr. B did) or to follow up with regular self-exam.
Or are you talking about the more general kind of physical exam, where the doctor looks in your ears and down your throat, and listens to your heart and lungs with a stethoscope, and things like that? There are some health benefits to seeing a doctor regularly, but a lot of those benefits seem to come from checking for high blood pressure and diabetes, from observations with clothes on, and from stuff people say.
Adrian:
That’s the kind I’m referring to.
For self-exams (whether breast, testicular, skin (mole monitoring), or whatever), that’s best done by the individuals, if they do them. For one thing, you can do them as often as you like, so you’re likelier to catch things earlier. For another, you get to know the territory, so you’re more likely to notice changes.
Grace
brian, there’s one more category of people who are less likely to get good medical care– fat people. Fat people are at risk of being told to lose weight instead of getting any attention for their actual symptoms. Or being told to lose weight even if it’s ineffective for their medical problems.
I’m not sure why so many people are focusing on whether physical exams are medically necessary. They are very, very standard in American medical care, and a doctor not being willing to do one because they’re uncomfortable interacting with a patient is a hugely different thing from explaining to a patient that actually, X procedure is now thought to not really be necessary so are they ok with skipping it?
When my doctor told me that for someone with my history, current research says yearly Pap smears are unnecessary, I was really pretty relieved, and was happy to get good medical advice. But this was clearly not because she was uncomfortable doing the exam on me specifically, which would not only have been humiliating at the time, but would most likely make me reluctant to seek out even non-preventative care from someone who couldn’t bring herself to touch me.
For what it’s worth, I was quite a bit intrigued that yearly checkups weren’t generally considered necessary.
However, I entirely agree that a doctor who won’t give a checkup because they’re too uncomfortable dealing with some category of patients is not going to be a good doctor in general for those patients.
Wow. Just…wow.
Grace, I am very, very glad to hear you are okay and were able to catch this early on yourself. I am disgusted by the treatment you received, and I’m sorry. Thanks for sharing this with us.
Docs I don’t know about, but a lawyer is required to resign if for any reason he/she cannot represent any client effectively. I can’t just tell such a client that he/she does not need a particular legal service because I don’t feel comfortable doing the work.
If finding someone who can do it is likely to be difficult I’m required to help look.