Article on Transsexualism in the New England Journal Of Medicine

This is a very quick post to say that there was a nice article on transsexualism in the New England Journal of Medicine this week. It’s advice on the hormonal treatment, mainly of MtFs, but a little on FtMs.

http://www.nejm.org/doi/full/10.1056/NEJMcp1008161?query=featured_home#t=article

It’s great to see transsexualism treated as just another medical condition..

Different Types of Testosterone

I’ve noticed that people often find my blog whilst looking for information about testosterone, so I thought I should post something about it. Because testosterone is broken down by the digestive process you can’t just take a tablet, you have to find a way of getting it into you and bypassing the liver. These are the ones that I have tried:

Sustanon

Injections of hormones every 2-3 weeks. This is the form of testosterone I started on, meandered off, and then came back to. It’s ok, not great, but it works for me. It’s got upsides, firstly it’s cheap which means that GPs are willing to prescribe it, also if I am caught out and need a private prescription it’s easier to organise. It’s licensed for treatment of transsexuals and a lot of GPs aren’t willing to use unlicensed products without hospital supervision.  The big upside for me is that I can inject myself, which is great, I couldn’t afford to take time off to go to a GPs to get a nurse to inject me. A lot of GPs haven’t been entirely happy with  me injecting myself, but once I point out that I can put a central line in they give up.

The downside is that that the injections themselves are fairly painful, and they sometimes mean that I walk with a limp for a day or so afterwards. If I’m actually sticking to my running training I have to time my injections so that I am on a rest day the day afterwards. It’s actually really difficult to stick a needle into yourself knowing that it will be painful, I have tried to persuade my wife to do it but she can’t really manage it.

The other downside was the fluctuations in hormone levels, before I had a hysterectomy I found that if I was low at a certain point in my cycle I would have a period. I was initially prescribed it every two weeks by Russell Reid which was ok, but then it was reduced to every three weeks by a NHS endocrinologist, which was the dose he used for hypogonadal biological males, and things turned into a rollar-coaster. This was annoying. Also my moods would go all over the place. Now I’ve had my ovaries removed (yahay) this isn’t an issue, and I can easily go for about 6 weeks between doses without noticing a problem. Other than the increasing risk of hip fracture that I get if I am low testosterone for that long.

Testogel

A clear colourless gel that you put on your skin. I tried this before I had my ovaries removed,  I was hoping it would surpress the menstrual bleeding that was happening on high does sustanon. It was great – with a dose every day the hormone levels were stable, and the mood swings were much better. There was one big downside: it made my wife’s hair fall out as she developed male pattern balding! Of course she wasn’t my wife then, she was the totally hot girl that I’d just started dating. Of course I should have made sure that I had a shower before I cuddled her skin to skin, but our relationship was in a very passionate stage and was just got carried away a little too often. Fortunately she wasn’t pregnant or this could have caused a miscarriage. A lot of FtMs who start on the gel report that the changes seem to be slower, though I can’t help wondering if there is an element of placebo effect here, as it’s well known that injections cause a greater placebo effect than tablets.

Buccal Testosterone:  ’Striant’

I can’t even remember what the brand name was for this, but google tells me that it was ‘Striant’. It was horrible. It was a small tablet that you had to put under  your top lip and suck gradually throughout the day, it tasted dreadful, and made food taste dreadful. Also I worried that if I kissed my then-girlfriend-now-wife she would get some more male pattern balding.

Andropatch

I nearly forgot about Andropatch! It was a patch that you put on your skin and it slowly released testostone throughout the day, or at least that was the plan. Usually it would fall off around lunchtime, my hormones would dip, and then if I was unlucky I would have a period, oh, and it made my skin really greasy, some people find that it makes their skin bleed. It’s not available anyone in the Uk anyway, which is a shame, because it wasn’t as bad as Striant.

Nebido

I may be the only trans man who has never taken Nebido, as it is rapidly becoming the most popular form of testosterone. It’s a an injection that you only have to take once every 12 weeks. That’s the up side, the downside is that you can’t inject it yourself, this doesn’t seem to bother most people but it does bother me, as I really value my independence with hormones. If I can’t make my own I can at least inject my own. I have had some limited successful experience with using it professionally and it seems to be ok, no not treating trans people, treating bio men who need hormones for other reasons.  The main downside is cost, I don’t think it’s ethical to use taxpayers money for the more expensive option when sustanon is so much cheaper. I know that the drug company that makes Nebido is trying to make ‘male androgen deficiency’ into some sort of hormonal disorder and I despise this  disease-mongering. Therefore I shall, on principle, refuse to be prescribed Nebido in an ineffective one man boycott.

I’m sure someone will take this post and use it as evidence of why artifical hormones are bad. So it’s worth taking a minute or two to consider the alternatives to artificial hormones.

Ostrogen and Progesteron

I did try living without any testosterone at all. Before I transitioned I tried coping just on female hormones. On the surface it seemed like quite a good solution, my body made the hormones itself so it didn’t require any prescriptions, and it was the ‘natural solution’. But it had some big disadvantages as they kept trying to turn me into a woman which was weird. Also instead of a consistent supply of hormones there was this strange ‘cycle’ thing, with a gap where there were no hormones at all, and where blood kept appearing out of places that blood really shouldn’t appear from, which made sex really messy for 1 week a month. If you have having sex with a woman that means that for 50% of the time sex is off the cards because one of you is bleeding. Some women, presumably finding this totally impossible, resort to having sex with men, but this carries a very big downside:  Pregnancy

Pregnancy is a truly awful business, in the days before modern medicine it used to kill about 1 in 5 women, which is actually quite a lot,( and my wife thinks that paragliding is a risky hobby). The worse thing about pregnancy is how it ends. Have you ever actually seen a child being born? No? I advise you not to.  That large baby is clearly not meant to fit through that small hole. If you like to have sex with men on a regular basis you could get pregnant about 12 times throughout your life. Maybe even more.

The only way to make being a woman vaguely bearable is artificial hormones,  you have to take artificial female hormones to stop you randomly bleeding the entire time, and having 12 babies. Given that you’re going to have to take artificial hormones anyway you  might as well take testosterone which has all of those benefits and more  as you get admission to the land of male privilege where can to oppress women all day long.

Being born with XY chromosomes

Ideally I would have chosen this option, none of the awful pregnancy / bleeding / random hormone rollar-coaster, and all the cool things about testosterone without having to actually inject it. For some reason this just isn’t an option. XY guys, you really don’t know how lucky you are, you think standing to pee is the coolest thing? You’re so wrong.

Should Doctors be the gatekeepers of Gender?

Doctors are in the semi-artifical role of ‘gatekeeper to your new gender‘. Transsexualism is a disorder, and it needs to be diagnosed by a doctor, who then prescribes some treatment. When the treatment goes wrong then you have  a legal action, as it was the doctors responsibility to make sure that that the patient didn’t regret the treatment. Most transsexuals don’t like this model, they want to be able to choose what treatment they want and when, some want to go faster and some want to go slower.

Sometimes I wonder whether we should dispense with this model of transsexualism being a ‘disorder’ that requires ‘treatment‘ and instead make it a that we make a free choice whether to have hormones or surgery or not. There would still need to be some medical professionals involved, hormones need to be prescribed and monitored by someone competent and medically qualified, surgery  requires both a surgeon and an anaesthetist. I also think that there would need to be some form of screening to check that you were of ‘sound mind’ or something and were capable of understanding the consequences of your actions.

Of course this would have a lot of downsides. Firstly it would mean that if you regretted treatment it would be your own fault, and you would have no one to sue, you would have to take responsibility for the consequences of your decisions about medical treatment. I don’t think patients really get this concept, in general most people don’t understand balancing risks and benefits and like to have someone to blame if things go wrong.

In the UK  treatment is sometimes available on the NHS to transition, but it is not available for cosmetic surgery, because that’s a ‘choice’. So if it was thought of that gender reassignment treatment was a choice in that way then there would be no chance of funding being available. So their would be no chance of free treatment.

In the UK we have pretty effective legal protection against discrimination, this is based on the fact that we have a disorder that we cannot change. If I got a facial tattoo I could legally get fired from work, if I had a sex change I do not get fired from work, if that happens I can sue my employer. If it was seen to be a choice then people would be able to fire us if we changed sex.

All in all I think that transsexuals benefit quite a lot from the current model, and it should really remain that way. What do my readers think?

Things that make my day

Thinking about it challenged me to name 10 things that make my day. I’ve decided to do a medical edition: here’s ten things that make my on day at work.

• Thrombolysing an MI

I only started thrombolying during my last job. Everywhere else you have to ring up a cardiologist who comes in and treats the patient. Which isn’t a  bad thing, it’s great. But it’s not doing it yourself, and there’s something amazingly satisfying about treating something as dramatic as a heart attack yourself. I’ll never forget the first time I said ‘Lets do it, this is for thrombolysis’ and everyone lept into action around me.

• Treating a DKA

Diabetic Keto-Acidosis. This is what happens when people with diabetes don’t take their insulin. Or don’t know they’re diabetic. When you first see one they are drier than a proverbial crisp. In a desert. They look like they are going to die. And unless you do something about it they are going to die. But you leap into action, you do something about it, and the next morning they are sat up eating breakfast.

• Giving someone their confidence back

I’m convinced that loosing confidence after an illness is often the most disabling bit, and getting your confidence back is a long slow process. It’s not often you can suddenly give someone their confidence back. But when you can it’s amazing. I’ll never forget the time that I reassured someone that they weren’t any more at risk of sudden death and are able to get

• Doing good palliative care.

This is an odd one to say that I enjoy – but it is one of the most valuable thing  you can do. Recongising that you can’t get things better, and stopping increasingly futile painful things. Letting them slip away at peace with themselves, and their family, and above all pain free.  I think a lot of the time I do it right – we get thank you cards from the relatives.

• Turning around a patient with severe sepsis.

This is as satisfying as a DKA – it’s great the way you can get someone from  ’nearly dead’ to ‘eating breakfast’ overnight. Just doing the simple things correctly, and sometimes it works.  Quite often actually.

• Getting to the bottom of something complex

It’s an old fashioned thrill, taking a good history, doing a proper examination, and presenting it all on the post take ward round the next day. Even better if you could get them better, but it’s still satisfying if you can’t.

• Draining ascities
• Putting a chest drain in an empyema

These are good procedures, because they  make your patient feel better, almost instantly. And you get the satisfaction of doing a procedure, and that’s always a good thing as well.

• Getting the cannula no one can get

The best bit about this is the look of relief when the poor patient realises that they won’t be being prodded by endless moron’s with needles.

• Discovering something new

Well that’s why I’ve just started on an PhD.

Carry on Doctor

My boss is currently in the throes of a horrendous personal crisis. Not that you’d  know. She’s a picture of professionalism. Here on time. Doing her job perfectly, and then occasionally popping off to cry in her office. This got me thinking about my the horrendous personal crises my colleagues have worked through.

Once one of my house officers began to have some PV bleeding when she was 9 weeks pregnant. I rang the O&G reg on call who did a scan which showed that she was still pregnant so she carried on working. 2 days later she had a miscarriage, she choose to manage it conservatively and came into work whilst still bleeding.I know of a Doctor and Nurse who were taken hostage at what they thought was gun point, it turned out to be a banana, but it was still quite stressful. She was back at work the next day, and the nurse was off sick with ‘stress’ for months.

Until 2007 Doctors never took time off sick. The main sickness management issue for hospital doctors was trying to stop them working when they were not physically fit to do so. We were professionals, taking time off sick would endanger our patients and inconvenience our colleagues. There was a saying in hospitals

‘There is no excuse to be out of the hospital, you are either here as a patient or as a Doctor’

I was told by a consultant that when he was young if any of the juniors called in sick they would have to be personally examined by the Consultant on call and told whether or not he was fit to work. But gradually it changed. As we stopped being treated like professionals we stopped acting like them. We started taking time off sick when we were ill, we started taking our annual leave. But I’m still hopelessly old-fashioned. When my colleagues call in sick I suck air in through my teeth and mutter. I think that as a profession we should take pride in the fact we hardly ever take time off sick. It means we’re more dedicated that the professions that take time off work all the time.  Nurses often take more time off sick than Doctors.  Though that’s to do with the fact that Nurses are currently working in totally horrendous conditions and have little control over their working conditions apart from call in sick.

Pick yourself up, dust yourself off, and come back for the next shift.

Joe was a big chap, so big he couldn’t really breath properly at the best of times. Add in a pneumonia and things weren’t looking great. When I first saw him in A&E  he  seemed to be getting better. I know people this fat have a tendancy to go downhill bloody fast, so I sorted out a bed on HDU.

‘He’s getting better mate ,’ said my SHO, ‘ you’re just bored because we haven’t had any ill people tonight so you’re trying to find some’

‘Hopefully he is’ I replied ‘ but I’m in charge and he’s going to HDU’.

I wanted to put an arterial line in so I could monitor the amount of Oxygen and Carbon Dixode in his blood and intervene when it got out of hand. HDU was the only place that knew how to nurse an art line.

It was a struggle that night. He breathed more easily when he was lying down at 45 degrees. But he wasn’t comfortable that way so insisted on spending the night on a chair and told us to ‘fuck off’. He had so much fat between the artery and skin I couldn’t get a art line in. After 5 attempts he told me to ’fuck off’.  A few hours later his Carbon Dioxide levels went up so I put him on BIPAP. That’s a tight-fitting masks that blows the air into your lungs which reduces the work involved in breathing and improves oxygenation and reduced CO2.  This lasted  about 20 minutes until he told the nurse to ‘fuck off’  and went to sleep.

He seemed ok in the morning, his CO2 was worse so we persuaded him to let us put the BIPAP mask back on. Ten minutes later he was unconscious. 20 minutes later he was intubated and ventilated.

30 minutes later I was sitting in the canteen, eating a fry up, and saying ‘fuck’ a lot. Maybe if I’d managed to get the art line in I could have intervened earlier and stopped him going to ITU. The anaesthetists told me that I didn’t do anything wrong. The respiratory physician told me I didn’t do anything wrong. But I went to bed that morning convinced that I’d killed him.

I really didn’t want to come back to work. I wanted a  less stressful career where I couldn’t accidently kill anyone. Perhaps a nice job in an office. I could do powerpoint presentations and get involved in petty feuds over whose turn it is to buy biscuits. But I couldn’t.  However bad I felt, whatever happened, I would have to turn up. I would go to handover, write down a list of the sick people, and put the crash bleep on my belt. Part of being a Doctor is just carrying on when bad things happen. Because however bad it was people still need you. There can be no break. No time off with stress. If I didn’t turn up for the night shift no one else would do it.

Bizarre thing found in my Blog Stats

I’m not as obsessed with my blog stats as I used to be. I still tend to check them once or twice a month, week,  day. WordPress shows you know what people were typing into google when they found your blog. So I know that a lot of you are looking for free MRCP questions, or stuff about testosterone or pregnant men. Today I came across something really bizarre:

‘How does a male doctor have sex with a female doctor?’

What? Now I’m fairly used to being asked ‘so how do transsexuals have sex?‘  Clearly someone wishes to know how doctors have sex, so in the public-spirited nature of this blog I’ll let you into a secret.  Sometimes when two doctors love each other very much indeed, or are drunk at the mess party, then they will decide to have sex. When they have sex it’s in just the same way that any other grown-ups have sex.Believe it or not Doctors have very similar anatomy to Other People.

Very rarely some doctors will find that they have sex with someone who isn’t a doctor or nurse. Very rarely they will have sex with so called ‘other people’ .  This is usually difficult as Other People think that you can’ t discuss the traumatic details of todays bowel resection over dinner. The sort of joke that is hilarious to most doctors is considered ‘sick’ by Other People. Although the anantomy might be the same dating Other People isn’t as easy as it seems.

Where are all the locums?

As I was finishing my clinic today I caught the eye of  Mags from Medical Staffing, she was lurking outside my clinic room, looking like she was about to cry. This can only mean one thing: she was about to ask the ultimate favour.

‘Z would you be able to go home and then come back tonight and do the night shift?’

As it happened I was worrying about money at this point, my house had a few unexpected bills, and then there’s the fact we’ll have to move to do some research, and my wife’s job isn’t secure. So a few hours overtime would help out nicely thank you. I managed to sleep this afternoon and even manged to do some cleaning. This is the second week of nights I’ll have done in the space of a month, neither of them have been rotated. The fact is that out in the sticks we can’t get the registrar’s to fill the rotas. We get registrars on the training programme but when they leave to have a baby, join the army, do a PhD we never get a replacement. So there’s 6 of us trying to staff a 10 man/woman rota.

Until 2007 this sort of job would have been filled by overseas doctors hoping to get their foot in the door of the NHS, and eventually get onto a training rotation and get a Number. But now the chances of overseas doctors getting a training rotation is very slim and there are far fewer of these doctors around. So we struggle to recruit. I rake in locum money, in the mean time my ward is short staffed.

Ch Ch Changing..

I still can’t believe how much I’m changing as a Doctor with every year that goes by.

I can now safely deal with the majority of the emergency admissions without any help at all. In fact when I see someone sick, really sick, about to die sick I can usually sort things out. This time last year I found dealing with incredibly sick people whilst totally on my own really stressful. Looking back I don’t know why. Cardiogenic shock? Just deal with it. Get on. Get ITU if they can’t support their airway. Massive GI bleed? Sepsis? Just crack on and do what you can. When you can’t do any more? It’s sad, but you can at least make sure they are comfortable and their family are aware of things.

I’m a totally different doctor to the person I was a year ago.

So looking back what have I learnt?

Foundation Year 1

I was one of the first of the new Foundation Doctors, though everyone still called us PRHOs. It was about learning the basics, how to prescribe effectively, which painkiller worked for what sort of pain. When to call for help. That was important. How to keep your list of patients organised and know where everyone was. What the different blood tests meant, and how to canulate anyone and everyone.

Parts of it are still etched onto my brain. The first time I broke bad news, the first time I filled in a death certificate. The first time I dealt with someone who went to ITU. The first time I saw a GI Bleed become shocked, the first time I saw someone with COPD develop CO2 retention. I didn’t really see enough of it to become competent at anything. Apart from at running the ward, I was good at that.

Foundation Year 2

This would have been a total waste of time if it hadn’t been for the fact I was locuming as a medical SHO all the way through and revising for my Part 1. This was where the basics of medicine were sketched out. My first successful cardiac arrest, how to manage renal failure, pneumonia, STEMIs and non-STEMIs. But there was always help whenever anyone looked sick.

SHO 1 / ST1

Things stopped changing so fast now. I still didn’t really have the confidence in my own diagnosis but it gradually improved. Bit by bit. For my first two jobs I hated doing the ward round on my own, and being left alone with all these lives, by the third job I could get the ward work done in the morning and then go to clinic in the afternoon – popping back to check the blood results before I went home. I remember the first time someone died with no one but me having written in the notes. I got the hang of dealing with the problems of most of the major organ systems.

Then it was learning how to deal with sick people on my own. Bit by bit. I still felt out of my depth when I was on my own with them. I did everything that needed doing, but I always worried that I’d missed something.

ST2

I guess this was when I really got the ‘sorting out sick people’ skills. When I learnt to lead arrests and learnt to deal with most things that threw themselves at us. It was also where I got the hang of the beginnings of knowing when to stop and realised what I was going to do with my life

Will I continue to change and improve at this rate? I certainly hope so. The next three years are scarier because I’m about to start a PhD. Part of me’s scared – what if I don’t have a clue what I’m doing? What if I’m just not an academic. I know I like teaching, I’m quite good at Audits, and I have a head for figures.

I get the feeling that when it comes to research I’ll be starting at the beginning again.

Temporary Pacing and Jump Starts.

I have recently learnt the hard way that it’s worth getting your car serviced. The first thing that broke was the little bleeper thing that warned me if I was leaving the lights on, not something that seemed worth fixing you’d think. But then the battery ran down. The first time I had to call the AA out to jump start me. The second time I walked to Halfords and brought some jump leads. I managed to jump start it easy enough, it was all in the instruction booklet that came with the jump leads.

A few days later we were putting in a temporary pacing wire, as we were connecting it up I noticed that it was ‘Black to Black and Red to Red’.

‘Oh just like jump starting a car’ I joked to release the tension.

Later that night I got paged from the coronary care ward. All sorts of pace maker related disasters ran through my mind.

‘Z, do you know how to jump start a car, Julie said you mentioned something about it?’

‘Yes, I do as it happens, but why?’

‘Jackie’s car won’t start’

The jump starting was considerably  less stressful than the temporary pacing.