The Pride Report

T for Two: Accessing Testosterone in Saskatchewan

For transgender and gender-diverse people, transitioning is a long and sometimes rocky road. It can be hard enough to figure out who you are, why you’re hurting, and what changes would make your life better– whether that’s changing your name, dressing differently, starting hormone therapy, or pursuing various surgeries. It can be even harder convincing other people to allow you to make those changes.

Transition-related healthcare has been very strictly controlled by medical professionals for decades. Transgender people were and are often held to much higher standards than other patients in order to be allowed life-changing, life-saving treatments. In recent years, a lot of progress has been made to improve access to transition-related care. Some parts of the process are still murky, however.

For transgender men, and for nonbinary people who are assigned female at birth, transitioning often includes taking testosterone, also known as “T.” In Saskatchewan, it appears that there are currently no laws or official procedures dictating how a person must access testosterone. This means that, for better or worse, two people can have two very different journeys to the same goal.

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The (Almost) Ideal Experience
27 year old, agender, they/them

The first time I questioned my gender, I was quite young. At the time, I came to the conclusion that I thought I was male because I liked females, and that would “make sense. “ That was the way it “should be”– even though it didn’t feel quite right. Years later, I went to camp Fyrefly as a youth leader, and that showed me that gender wasn’t as black and white as I thought it was.

But the biggest thing for me was that my best friend got married, and then they and their spouse both came out as genderqueer! I very suddenly realized that being non-binary was a thing, that you could transition in various ways without having to be a man or a woman. After that point, I started researching gender, transitioning– everything! I finally realized that the best word to describe me was agender: not identifying as any gender.

In the first year, all I did was change my name. I never liked my name; it was a very feminine name that I had always been uncomfortable with. So I changed it and told people I was changing it but didn’t say why. Just that was a really big change, since I was just coming to terms with a new way of understanding myself. I was making a lot of connections with my past and how I had felt for a long time, realizing that it was in relation to this thing I hadn’t known was possible.

In the beginning, I really didn’t know if I’d ever start hormones. I did a lot of research, watched a lot of YouTube videos by trans men, and made trans friends to talk it over with. I knew what T was and what it did. I had my list of pros and cons, the things that would happen that I didn’t care for, and the things that I absolutely did not want. I weighed those for a long while before deciding, Yes, this is for me.

And suddenly it was simple: I was lucky enough to get a new doctor in my community, fresh out of med school. The first time we met, I told her I wanted to go on T. She had no idea what to do… but she was very nice and said she’d make some calls.

My referral to Dr Bettin, who worked in Saskatoon, took only a couple months to go through. At the time, Dr Bettin was known as the trans specialist in Saskatchewan. (I was surprised that there was one!)

Everyone who I had spoken to about HRT had been required to see an endocrinologist to monitor their blood work while on hormones. When I brought this up, Dr. Bettin informed me that as a general practitioner she had all the knowledge needed to follow up on the prescription and so an endocrinologist would not be necessary. I was pleasantly surprised and excited.

And, amazingly, she worked on an informed consent model of patient treatment. While treatment based on informed consent is a standard practice in healthcare, it’s not one that transgender patients are often allowed. All I had to do to start T was to sign a form stating that I was informed of what testosterone could do (and not do), and that I consented to taking it.

Dr Bettin wrote the prescription right then and there.

I got my first bloodwork and started taking testosterone soon after. In the two years since, I’ve taken T in various forms– injection, patch, and gel– for various reasons: I had an allergic reaction to the first kind, and later I didn’t want to use needles any more. I’ve been lucky that the cost of my T has been covered by work insurance throughout all this.

Throughout this process, my personal doctor has been willing to learn anything she needed to know in order to help me. Before I had my name legally changed, both my personal doctor and Dr Bettin had my preferred name in brackets on forms and always referred to me by it.

Dr Bettin, of course, was already the expert, and she goes above and beyond for her patients. One of the things I love about Dr Bettin is that bloodwork and prescriptions always have a sex marker on them, and Dr Bettin takes a sticky note and puts the patient’s pronouns over top of the sex marker on the forms. So when those papers go to a healthcare professional who doesn’t know me, they get the relevant information. This has never been an issue even outside of Dr Bettin’s specialist clinic. When I get into the room, there’s always a story from a nurse: “Oh, this member of my family is transitioning, my brother, my cousin.” Trans people are everywhere, and the healthcare system is becoming more and more supportive of us every day.

However, I also know people who have gone to their doctors and have been given incorrect information. For example, they’ve been told they need psychiatrist notes to transition, which is false. I’ve referred people to Dr Bettin because their doctors refused to go forward with any treatment whatsoever. One person had to call Dr Bettin directly, without a referral, because their doctor was completely unhelpful.

I was privileged to have access to doctors who were both knowledgeable and willing to learn more. I was also lucky that being nonbinary didn’t affect my doctor’s willingness to help me medically transition, since nonbinary people are sometimes seen as “not trans enough,” or sometimes “not real.”

At no point was I required to wait for or attend referrals for any medical professionals beyond my general practitioners when navigating any part of my Testosterone-related care. I had an almost ideal experience in accessing testosterone therapy, but not everyone does.

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The Long & Rocky Road
25 year old, genderqueer, they/them

I didn’t question my gender when I was very young– at least, not directly. I just assumed I was “not like others.” At times, I was very uncomfortable with gender roles and expectations that were put on me. (As many people are, even if they’re not transgender!) But as I got older, my unnamed discomfort with my body and with the way I was perceived by other people got worse and worse. It started affecting my mental health, causing an anxiety disorder and depression.

By the time I graduated high school, I found it difficult to leave my house. I had to delay starting university. It took almost half a year of soul-searching and research on the internet for me to finally realize– thanks to the kindness of strangers– that there was a word for what I was experiencing.

I was transgender. There was such a thing as non-binary people, and I was one of them. I was genderqueer: similar in some ways to both men and women, but not quite either. And transitioning could help me get my life back.

I came out to my siblings and my close friends in my first semester of university, and started experimenting with clothing that could help me look more masculine. But it took me almost two more years to work up the courage to find a new doctor in order to start T. I hadn’t been to see a doctor in over four years because of how insensitive and harmful the healthcare system can be about the difficulties trans people often have with their bodies. (That was a problem for me even before I knew that I was trans.) I was terrified of the power that doctors have to control– or deny– a trans person’s medical transition.

I found a new doctor based on recommendations from a TransSask support group. Even so, I felt no guarantees that this doctor would be safe or welcoming. Writing “I want to start taking testosterone” on the patient intake form was one of the hardest things I’ve ever done.

Fortunately, the doctor was supportive and deeply kind. She wanted to help. Unfortunately, she was very, very hesitant to accept that starting testosterone was a good idea. As kind as she was, the implied message I got was that I couldn’t be trusted to know what kind of treatment and results would be best for my body and my mind. My thorough knowledge of testosterone’s effects and potential side-effects was irrelevant. Since my doctor didn’t use the informed consent model (although I asked if she would) I had no choice about how to proceed.

She said that first, I needed to “get a handle on my mental health.” Essentially, she made recovering from my anxiety disorder and clinical depression a prerequisite for starting T. Even though I said that my gender dysphoria from not transitioning was a major contributing factor to both of these conditions, she insisted that I couldn’t start T right away. Hormone therapy, she said, could make my emotional problems worse. While I know that changes in hormone levels do affect people’s emotions, I was frustrated that the fear of potential side-effects was considered more important than the cure for my actual, current problems.

I started medication and therapy, and they helped me function. But they didn’t solve the underlying problem of gender dysphoria.

A year later, I was finally able to take the next step: getting a referral to a psychiatrist. My doctor said that I had to be formally diagnosed with Gender Identity Disorder before getting T was an option. In her own words, she was making me see a psychiatrist as her own due diligence before letting me medically transition. Again, my understanding of my own identity was not enough.

Just being on the waiting list for the psychiatrist took seven months. When I finally got in, my appointment lasted 40 minutes. The second appointment was three months later, and 15 minutes long. Mostly, she listened to me talk and agreed that I had a solid understanding of who I was and what I was asking for. I emerged with a very short letter affirming my gender and recommending that I start T.

The psychiatrist was very welcoming, and well deserves her reputation as one of the most supportive specialists in trans healthcare in Saskatchewan. Yet the overall experience was horrible for me. I still joke bitterly about getting my ‘professional stamp of approval’: “Congratulations, you’re transgender! I guess you were right after all.”

I asked my doctor about starting T three more times over the next year. At last, she agreed and I was referred to an endocrinologist. My doctor said that she didn’t have the knowledge to prescribe T and monitor my bloodwork. Although many doctors are familiar with prescribing estrogen, as it’s a reasonably common treatment for cisgender women, many are unfamiliar with testosterone. So I was put on another six month waiting list.

Six months went by, and then nine. Then twelve. Eighteen. After almost two years of waiting for a call from the endocrinologist, I hunted down a phone number and called them. The receptionist told me that the endo’s waiting list was currently two years long– from that day, not from the date of my referral– and that for an undisclosed reason, the endo wasn’t even actively seeing patients at the moment. The waiting list was not progressing.

My doctor was outraged. Why hadn’t I been informed, or referred to another endocrinologist? She called around and got me an appointment with another endo as an emergency case. The waiting list for this “rush” appointment was another six months.

When I finally saw this endocrinologist, four hours away from home in Saskatoon, the appointment lasted less than 15 minutes. She informed me of T’s effects and I signed a consent sheet. It took longer for me to sit in the waiting room than to get my prescription.

In total, I spent barely one hour actually meeting with specialists I was required to see in order to access T. It still took over four years to get a prescription.

In Saskatchewan, there is an intense need for more doctors with the knowledge and training to help transgender patients. Even those who are supportive and willing to help are not always able. So waiting lists can be years long– which is time spent without necessary treatment. At best, trans patients’ lives get stuck in limbo and we fail to thrive. At worst, we face hopelessness and shockingly high suicide rates.

For years, the struggle to get medical care to help me transition dominated a good chunk of my life. Now that I have access to care, that struggle is gone. I pick up my prescription every six weeks and I focus on what’s important: my job, my volunteering, my art, my friends and family.

There are still bumps in the road, but no roadblocks. That’s the kind of healthcare that everyone deserves. It’s the kind of healthcare we need to make a reality in Saskatchewan, and soon.

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To learn more about Moose Jaw Pride’s upcoming presentation “Pathways to a Gender Transition”, please click the image below:

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