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From the Chicago Tribune
Program puts transgender process on an easier path
New system avoids months or years of barriers
By Jenni Prokopy
Special to the Tribune
June 23, 2010
Ten years ago, when Candice Hart began her transition from male to female, she faced the possibility of losing everything, including her relationships and career. That, in addition to the process she had to undergo in preparation for the transition, was agonizing, she said.
“I lived in fear that I would be denied access to hormones or other services that I believed were necessary for me to live my life,” said Hart. She said the therapist who would approve her hormone therapy was a virtual stranger who held the keys to her new life.
Hart’s experience is common for those following the traditional path for transgender treatment: months or years of costly, time-consuming counseling that are barriers for many. It also can be so overwhelming that many people abandon the idea or suffer severe emotional and psychological damage, said Hart, vice chair of the Illinois Gender Advocates.
In April, the Howard Brown Health Center Iaunched a new program designed to minimize some of the emotional suffering and reduce barriers to care for those seeking access to hormones. Officials hope the program, in which patient and health care provider work as a team, will set a new standard in the Chicago area for consistent treatment that will empower patients and create healthier outcomes for members of the transgender community, whether or not they subsequently move forward with sex-change surgery.
“We have chosen this as the model that works best for the population we serve,” said Kelly Ducheny, director of behavioral services at the center who helped develop THInC (Trans Hormones — Informed Consent). She said other health care providers with the necessary interdisciplinary team could adopt similar approaches.
“If an organization has the dedication to do that … (and) people are competent at providing the service, absolutely we would love to see that,” Ducheny said.
The THInC protocol is a three-step process, now a requirement for hormone treatment at the center, one of the largest LGBT (lesbian, gay, bisexual, transgender) organizations in the country. Howard Brown’s main location is located in the Lakeview neighborhood popularly known as Boystown and is convenient to Andersonville, two North Side neighborhoods that are home to large LGBT communities.
THInC patients start by providing a full medical history and receiving a physical exam, including blood tests to examine liver function (which can be affected by hormones). A second appointment with a hormone advocate ensures the patient can demonstrate “informed consent.” If the patient has all the information necessary, plus the cognitive ability to decide to move forward — having considered both the short-term and life-long consequences of hormones — informed consent is granted.
The advocate then helps develop a transition plan, including ways to address workplace and relationship issues.
At a third appointment, the patient and health care provider discuss test results, review the transition plan and decide which hormones, if any, are appropriate and begin treatment. An optional fourth step is participation in a support group.
Earlier this month, about 60 LGBT-focused mental health professionals and community members gathered at Center on Halsted to discuss the program.
Braden Berkey, director of the Sexual Orientation and Gender Identity Institute at Center on Halsted, said the collaborative aspect of THInC is “powerful.” Transgender individuals exploring hormone therapy are not mentally ill and shouldn’t be “pathologized,” he said.
Throughout the health care system, patients consent to all kinds of medical treatments every day, and using hormones to align a person’s physical body with gender identity should be no different, Berkey said. The key is informed consent, ensuring each patient understands the risks of hormones and is not impaired from making a fully informed decision.
Liam Lair, a patient who participated during the pilot phase, said he felt “a great sense of relief of being able to be transparent with myself” throughout the process. “I really did feel like they were advocating for me.”
Lair said the program allowed him to follow the life narrative he experienced, instead of trying to fit into a narrow gender definition.
Those in the LGBT health community say THInC is a radical change from the traditional treatment model for transgender individuals. Many physicians follow standards of care developed by the World Professional Association for Transgender Health Inc., which recommend a minimum of three months of psychotherapy and a letter from a therapist documenting an individual’s “real-life” experience living in their chosen gender.
The traditional approach contains barriers to access, according to many in the LGBT health community. While the THInC program can take as little as four to five weeks to start hormone treatment, the traditional process can take many months or years. Some people without health insurance can’t afford extensive psychotherapy, and even those with insurance may not be covered.
The therapy process can be frustrating and demoralizing, especially for someone who has already planned their transition for years and feels like the resulting letter is more like a permission slip. The process often leaves patients feeling ashamed and angry, say Berkey and Ducheny.
“We think those letters are unnecessary and pathological,” said Ducheny. The THInC program is designed to empower patients to make choices about their bodies and their transition, she said, not make them feel like they are unhealthy individuals.
Hart has thought the same thing: “Why does someone who has these strong convictions have to jump through flaming hoops?” She said people spend years wanting to be authentic and genuine, but they can still be denied access to what for them is necessary treatment.
Another unhealthy side effect of the traditional model is illegal purchase and use of hormones, said Pamela McCann, public health administrator with the city’s Office of LGBT Health. Some people simply can’t get treatment under the traditional model, or abandon the system out of frustration with a variety of barriers to access.
“Hormones are a necessary intervention for so many members of the transgender community. If they’re not able to access hormones within the routine prescription process, then many members look outside for medications, and that means street drugs,” she said. Any program that prescribes and administers hormones in a safe and healthy environment is “a very positive thing,” McCann said.
To make the THInC program as accessible as possible, Howard Brown provides care on a sliding scale to those not covered by insurance, Medicare or Medicaid. While program participants must complete all three steps of the protocol, they may also coordinate with a health care provider outside of Howard Brown.
Currently, the center treats six or seven new patients each week in the THInC program, said Ducheny: “We have seen a significant increase in the number of people accessing hormones since we put the new protocol in place.”
© 2010, Chicago Tribune