Life Kit - How To Start Hormone Replacement Therapy

Episode Date: September 13, 2021

Medical transition-related treatments like hormone replacement therapy are associated with overwhelmingly positive outcomes in terms of both physical and mental health for transgender people. But, it can be hard to know exactly how to get started.In this episode of NPR's Short Wave, reporter James Factora explains where to start, common misconceptions about HRT, and the importance of finding community through the process.You can read James' full reporting for VICE here.Learn more about sponsor message choices: podcastchoices.com/adchoicesNPR Privacy Policy

Hey, LifeKit listeners. We wanted to bring this episode to you from our friends at Shortwave. It's about starting hormone replacement therapy. It's a smart resource we wanted to share. Here's the episode. You're listening to Shortwave from NPR. Navigating the U.S. healthcare system can be extremely difficult for trans folks. A lot of trans people face medical discrimination. A lot of trans people can live in places where they don't have access to affirming providers or might not have insurance. Some trans people might have insurance, but might not be able to get procedures covered, even if they have, quote unquote, good insurance.

And that's an unfortunate reality. Even finding information about trans healthcare can be a challenge. You know, just a lot of reporting on trans stuff tends to be by cis people. And this isn't always the case, but a lot of the times that means like from the get-go it's kind of being portrayed in this light that isn't actually geared towards trans people, but is really more about centering cis people. That's James Factora,

a trans journalist who covers queer and trans news, culture, and health. And they recently wrote a piece for Vice called A Beginner's Guide to Hormone Replacement Therapy. Gender-affirming hormone therapy or hormone replacement therapy or HRT is basically just when you take hormones by any variety of delivery methods

that can mean a shot or like a pill or a gel, for example, to align what you look like, what you sound like, to be more aligned with who you already know you are. And more colloquially, a lot of trans people refer to it as a second puberty. Medical transition-related treatments like HRT are associated with overwhelmingly positive outcomes for both physical and mental health. But it can be hard to know exactly how to get started. And that's why James wrote this guide.

I wanted to talk about questions that I hadn't really seen being answered. You know, because people deserve to read information about their health in ways that is like conversational and accessible and doesn't just make you feel like you're a lab rat. So James's piece and this episode are geared towards folks who are interested in starting HRT or already have. We'll talk about first steps, common misconceptions, and the importance of finding community through the process. I'm Maddie Safaya, and this is Shortwave from NPR. Today we're talking with James Factora. They wrote a great piece for Vice called A Beginner's Guide to Hormone Replacement Therapy. It is incredible and very thorough, and we won't have time to get into everything, so please make sure to click the link in the episode notes for more.

So James says the first step is finding a provider who can prescribe hormone replacement therapy. If you are lucky enough to have a primary care provider that you like and trust, you can ask them for a referral to someone who specializes in HRT. Another option is to go directly to an endocrinologist or other HRT providers like Planned Parenthood. Which not all Planned Parenthoods provide hormone replacement therapy, but a lot of them do. And for a lot of people, that might be their most accessible option for a number of reasons. Regardless of the route you take to finding a provider, James says talking with other people in your local trans community is really important. A big theme here is kind of, you know, talking with your local trans community, whether that's online or, you know, just like among your friends.

You know, it's good to know who people who you know have had good experiences with, who they might not have had good experiences with, and, you know, like any number of, like, needs that you specifically might have because, you know, not all HRT providers are created equal. Before your first appointment, it's helpful to prepare some interview questions for a potential provider to help you determine whether they're the right choice for you. So that can mean asking any of the things that you need to know, like how much experience they have,

either in general or with somebody who shares your identity. If you are a trans masc, you're trans femme, or don't identify with those two things. Are you familiar with treating non-binary folks? What's your familiarity with intersex patients? Ask about what the different options are that they can prescribe you. So basically, you just want to make sure that you're working with somebody who caters to your needs.

I feel like the most important thing to look for probably is what model the provider uses. James says that providers usually use one of two models or approaches when prescribing hormones. One is the standard of care model. In this model, your medical practitioner will talk with you about the effects of HRT and a general timeline of changes you can expect in your body. This model also requires a psychosocial assessment and a referral by a mental health practitioner before prescribing HRT. Basically, that just means that whoever is conducting this assessment will ask you about your identity and how you experienced dysphoria and how long you've experienced dysphoria and what the impact of your gender presentation has had on your mental health, specifically like the stigma attached to that gender presentation, and what kind of support that you might have

from people in your life. There's another model that James says is gaining more widespread use, and that's the informed consent model. In this framework, much like the standards of care model, you're informed about the effects of HRT and the options that might be best for you. But here's the big difference. A psychosocial assessment is not required. Instead, the focus is on personal autonomy.

So basically, the informed consent model kind of takes away all of those barriers and really centers the patient's needs and desires and trusts trans folks to be the authority on their own body and, like, what they want and what they need and helping people understand what their options are and providing them basically, like, with all of the information that they need in order to make an informed decision and then letting them make that informed decision. All right, let's next up. I want to get into something that is very complicated, and that is

insurance. I don't want to spend a lot of time on it because you covered it really well in your piece, and there's a lot of resources there. You know, some states have made it illegal to exclude trans health services. Some have not. Medicaid coverage is similarly variable. And I'm wondering, James, if you can talk about what people can do if they don't have insurance. Yeah, yeah, totally. So if you don't have insurance or if you find yourself in the unfortunate situation where you have insurance but you're denied coverage. You can pay for it out of pocket. One study that I cited found that out of pocket that can cost anywhere from $970 to $3,200 a year.

It really depends on what your delivery method is, whether you're on estrogen or testosterone. The T-gel, for example, tends to be more expensive than the shot. You know, there are also some startups virtually, which I think can be a good option if you live in a state where you can't access care in real life. It's worth noting that testosterone, for whatever reason, is a schedule three controlled substance, and that can kind of complicate your access to hormones if you decide to go that route. And it's also worth noting that can be a little more expensive than just the baseline cost of hormones out of pocket. So, you know, like whether it's Planned Parenthood or like a community health clinic, it's worth looking into like whether you have places in your area that can work with you like on a sliding scale basis based on what you're able to

pay. When it comes to the actual physical health effects of HRT, we should say that this therapy, like many therapies, will be different for everyone. Some people might see changes immediately, others won't. James highlights a number of these effects in their piece, but says there's one area in particular where there are some big misconceptions. And that's reproductive capability. Historically, there's been this misconception that going on hormones, whether that's, you know, testosterone or estrogen, totally, totally nukes your reproductive capability. And, you know, that was kind of like an assertion that was made with very little evidence. And more and more data is coming out to prove that that's not the case. There have

been studies that have shown that people who stopped taking testosterone for like four months had fertility levels similar to cis women when they were undergoing fertility treatments. Another study found that like some trans women were able to regain fertility after stopping hormones for five months. But at the same time, like one of the patients in that study was not able to produce viable sperm after four months. And, you know, obviously, like, if you are interested and able to preserve your, you know, reproductive stuff before you start hormones, you can always, you know, do sperm banking or egg banking. But obviously, like, that's probably not the case. The good news is there's a lot more options available to trans people now than like ever before. And we're getting like a more complete portrait of what it looks like to be like a trans person on hormones who wants to have kids. James and I also talked about HRT and its impacts on mental health. Now, both of the experts James talked to reported that after starting HRT, patients often report feeling decreased rates of suicidality and depression.

However, it can be good to have a therapist to process kind of, you know, this second puberty with. And that's not saying that like everybody like needs to have this kind of support. But as with like any change in your life, HRT can be like an adjustment that you might want support through. Yeah, and this is also another situation in which you can and like should turn to community, whether that's like to kind of like talk through any feelings that you might be having

about like, oh man, like my voice is dropping or I'm growing breasts. How crazy is that? It can be really cool and like affirming to like have other trans people who have been through the same stuff to kind of like talk through some of the stuff that you're experiencing with them. Okay, James, is there anything that you want to leave our listeners with before we go? I don't know.

I feel like people are always conceiving of transition in this sense that it's like, oh, this is like an irreversible choice. This is like an irreversible decision that you're making. And there's this implication that you can't turn back. But when you go on hormones, that's a choice that you make. And it's only one of millions and millions of choices that you're going to make throughout your life. And as you age, your hormone profile changes, your voice changes. You might lose or gain weight throughout your life like these are like your body is constantly constantly changing and ultimately again like transition is just one way of giving you like more control over these changes that can happen to you and one of the really beautiful things about transness really is just the understanding that you can do whatever you want with yourself and your body and like your identity. You're the authority, no matter what kind of gatekeeping that you might face. And really what medicine and science are doing is catching up with what we have already established,

which is that like we are the authorities like of our own bodies. Thanks to James Factora for sharing their time and expertise with us. Make sure to check out their full piece in today's episode notes for everything we didn't get to. This episode was produced by Britt Hansen, fact-checked by Indy Cara, and edited by Viet Le. Special thanks to Andrea Mares Flores Marquez for all of her help. I'm Maddie Safaya. Thanks for listening to Shortwave from NPR.