Testopel: After Almost 2 Years

Back in 2014 I got sick of injecting testosterone intramuscularly.  When beginning to transition FTM, there isn’t much of a better method of getting a high degree of control on testosterone levels quickly than injections.  However, after a few years (I went over 4), it is not uncommon for the muscles to start tightening and building deposits of scar tissue.

Back When I Started Testopel

I’m continuing on testopel and have been extremely happy with the process.  The cost is a drawback, but it happens to coincide with my high-deductible health plan almost exactly – so the rest of my family’s medical needs are covered by insurance immediately.   I also save the money in my HSA, which means that it isn’t taxed. Basically, the government is giving me 25% of the money towards the pellets.

I initially felt some fatigue towards the end of the 4 month cycle, so on the third cycle I was increased to 11 pellets (from 10) and that seems to have diminished the fatigue.  It was really nice that my doctor was open to the discussion about the cycle and tinkering with my exact levels, which are generally in the 600-800 ng/dL, 1.6% free (80-140pg/mL free).

Life Insurance

I just wrote an email summarizing my experience thus far with attempting to get life insurance, so I figured I’d also toss it up here.  I wrote this email to a regional advocacy group, seeking advice in case they have seen experiences like this before.  I first wrote about this issue back when it happened in the beginning of 2012.

 

 

I was wondering if you have had any experiences with transgendered persons being denied for life insurance for reasons related to their transition?  

I transitioned female to male in 2009-2010.  During my transition I completed a MS in physical chemistry and began teaching college-level science and technology courses full time.  I saw a therapist regularly for nearly 2 years and participated in a FTM support group at the <place I’m not mentioning>.  There were no complications from my top surgery and I am physically fit.

I applied for life insurance in October 2011.  After a delay, State Farm’s underwriters denied my contract in December 2011 for the following reasons:

– I was within 1 year of my top surgery (January 2011)

– I had mentioned in therapy sessions that I might be getting a hysterectomy in the future

– My initial gender identity disorder diagnosis was accompanied by a mild depression diagnosis, which gave them cause for concern of a “suicide risk”.  This diagnosis was removed by my therapist when I began hormones in March 2010 and was able to function fully.

– They were concerned I was not “well adjusted” or “functioning normally”.

I have decided that I do not desire a hysterectomy and am attempting to clarify their other items of contention.  I had an appointment with another therapist at the <place I’m not going to mention> recently in an effort to show that I continue to “function normally”.  I am concerned, however, that the underwriters may still pick and choose details from my medical file.  

It took some time to get back to trying to get life insurance because it is so frustrating that I did nothing but help myself become mentally healthier for 2 years and the insurance company is holding that against me.  As my wife and I continue our life together, it is important that I do have a life insurance policy.  

If you have any advice or resources that might be helpful that would be much appreciated.

I have my emotional energy back and am determined to get life insurance taken care of before my 28th birthday (October this year).

Five Years In

It was resolved 5 years ago that I would begin the new year living “full time” as a male, but truth be told I had been operating as a guy for quite some time.

Five years is a good chunk of time. In the 65(!) unpublished posts I have saved in wordpress, one of them is titled “Post Transition?”.  I discussed some feelings of being past the transition in many ways, having achieved my main goal of top surgery and after a few years of T having experienced most of the symptoms.  Life was getting much bigger than the emotions and feelings of dysphoria, depression, and helpless struggle.  I chuckle now that I wrote that post over 2.5 years ago.

I was nervous then that the transition would fade off into distant memory and I would lose connection with the good times on the front end of my transition (and during my transition).  I suppose with effort, I could let that happen, but it hasn’t happened organically.

 

The more comfortable I get with having transitioned and being on this side, the more connected I am to my entire life.  It’s multi-faceted, a mixture of slight discomfort with rationalizing my experiences for others, guilt being priviledged to experience a survivable transition, and curiousity for how intertwined all experiences I have are.

Despite having a wonderfully sapphic wife, my queer life is extremely heterosexual and lacks diversity of many kinds.  I work for a company in an industry where certain ethnicities generally hold different roles in an office where we have 5 women and 50 men.  Being introverted, it has been my choice to withdraw from many social events, including most that link me to the GLBT* community.  My transition isn’t a topic of conversation, almost ever.  Only at home and on other rare occasions is my pre-transition life included in discussion.  I don’t need to talk about my experiences injecting testosterone, but I need to talk about growing up as the oldest of 4 sisters.  I don’t need to talk about the strategies I employed for binding, but I need to talk about being a small girl trying to play soccer with mostly boys in grade school.  I’m slowly trying to establish more relationships in my day-to-day life where these things can be understood, but it’s a slow road.

Life has gotten to be so grand.  The middle-class life I had growing up led me to college, which through hard work and parental support led me to graduate school, which through hard work led me to a few good jobs.  My current job is an 8-5 job that lets me have evenings and weekends for enjoying the rest of the fun life has to offer.   I’m sure the rest of the things that life has to offer will continue to intertwine with my transition.

 

Testosterone Injections: After 3 Years

It’s been 3 years and 9 months and some-odd days since my first injection of testosterone.

I don’t really look forward to my next injection of testosterone each week.  I’m not sure if I take the transformation for granted (I probably don’t, because I wouldn’t dare skip a shot), or if I just dred the pain associated with the 23g needle stick in my thigh.

There are a variety of methods for testosterone administration, the main 2 being injections and gel.  The only other option I have seen utilized in the trans* community is subQ pellets.  Gel administration, daily with a 15(?) minute waiting period after application doesn’t seem like a reasonable substitution for the 10 minute dredded needle stick. Beyond not being able to shower or cover the area with clothing within a short period of time following the application of gel, you also cannot come into contact with other creatures.  The only time I wouldn’t cover myself up or shower would be to enjoy contact with my wife.  So no, not likely to be able to work the gel in.

I’m at the point, professionally, where the costs I could barely handle at the beginning of my transition (copays for every mental health visit, testosterone, surgery) seem much less of a worry now.  Maybe it’s because the bulk of them are behind me (except testosterone on a 6-month basis), but it’s probably because my income is both significantly higher and more stable.  I’ve been working in the professional world for 2 years since graduating with my masters degree and have a position with a growing company that has me reporting to top-level management.  Long paragraph drawing to a close, I’d like to look into pellets.

Feminine Behaviors, Percieved as Homosexual

It’s interesting, and disappointing. Somewhere in the midst of the heterosexual priviledge that is inherent in being a male attracted to women, I have developed a distaste for any of my behaviors being labeled as gay, feminine, etc.

Deep down in my core I know that I’m masculine, that I am butch, that I am testosterone fueled- but somehow I can’t help but associate the gay/feminine labels with a lack of strength, a lack of desirability to women, a lack of capability.  The most frustrating side to this is that it is simply not true, that someone who is feminine, gay, female, whatever, is not strong in any relation to their behaviors.

The brutally honest side to this is that I have a number of behaviors that I developed growing up as a female.  Some of those relate to how I handle my emotions, carry my pitch while speaking throughout a sentence/paragraph, or any number of subconscious actions.  I don’t want the summation of my behaviors to inhibit people from seeing the bulk of my persona.  I don’t always understand or enjoy these behaviors, they’re just a part of me because of my history.

I feel like I’ve been digging a rock from beneath the earth’s surface for the last 4 years.  That rock is mostly visible now, but still submerged such that it’s not entirely clear what the shape is on the bottom side.  I’m that rock. I’ve been digging myself out of the dirt I covered myself in for 20-something years, being free and expressing myself until the bulk of the rock is basking in the sunlight.

I enjoy my hobbies with a greater intensity now.  These hobbies are 100% mine, developed when I wasn’t nervous about someone’s perception of them or reactions to them.  I have to carry that same freedom into the rest of my life, because I don’t want to be investing a bunch of time trying to dig this rock totally out of the ground.  I’m going to continue to explore and be myself, male, but I’m not going to remove myself from the earth to such a degree that I become unrooted.  If you’ve ever dug a rock up, you know that the last part, tipping it out of the hole, can be the hardest part.  I have no interest in that.

I’m going to have to remind myself that my behaviors, regardless of their percieved status on various spectrums, are my male behaviors.  I know that many people who identify on the cisgendered or heterosexual sides may not see or understand how a guy like me could _____ like that, but their understanding doesn’t need to be my #1 concern.  My understanding is.

Top Surgery Follow-Up, ~2 Years Post-Op

I had surgery with Dr. Buckley on January 10th, 2011.   It was, it seems, a long time ago.

 

Two years later, I don’t have any regrets.  My chest is not perfect, nor is any other aspect of my body (or life).  Top surgery was, however, a huge improvement to my quality of life and is an event I appreciate being able to not have to look back past the moment in time.  I’m fairly introverted, but I would have no issue taking my shirt off in 99% of naturally appropriate situations.

 

Let’s be super critical for a moment, then let it go: My left nipple is a nice, mostly round, flap of skin from my previous nipple.  It is obviously deformed if you get close to it in any way, and there’s no erotic sensation to it.  My drain site scars  (under the arms) seem out of place from the rest of my nicely aligned scars.

Some things really turned out nicely: I’ve gained some weight (mostly fat) in the last 2 years, but still not dog ears or skin flaps.  My right nipple does a good job actually looking like a natural nipple.

 

The pictures (in a mirror, LR is reversed):

Chest Now

US Testosterone Shortages

It doesn’t look good folks.  Our neighbor to the north, Canada, has been experiencing testosterone shortages frequently- and constantly since early 2012.

Many pharmacies in the United States are having difficulties filling prescriptions for testosterone cypionate, mine most recently suggested swapping the 100mg/mL 10mL bottle for a 10 x 100mg/mL 1mL bottle.  Oy vey.  (I’m sweating out the major inconvenience of cost, etc, of this option- but that’s not the point of this post)  I’ll be asking my pharmacy to check supply of the 200mg/mL as well in the morning and will report back.

The cause of these shortages is mostly due to manufacturers having issues meeting the general standards for contamination set out by the FDA to protect us.  By all means, I’m not against the FDA- I appreciate that they enforce regulations that ensure chemical purity.  This is why I don’t purchase essence of rhino horn or any other bullshit off the internet, because I care about what goes in my body.

The FDA does monitor drug shortages in the United States- but at the time of writing, does not have information on the testosterone shortage.

From the FDA:

Q. What can FDA do to address drug shortages?

A: FDA responds to potential drug shortages by taking actions to address their underlying causes and to enhance product availability. FDA determines how best to address each shortage situation based on its cause and the public health risk associated with the shortage.

For manufacturing/quality problems, FDA works with the firm to address the issues. Problems may involve very low risk (e.g. wrong expiration date on package) to high risk (particulate in product or sterility issues). Regulatory discretion may be employed to address shortages to mitigate any significant risk to patients.

FDA also works with other firms making the drugs that are in shortage to help them ramp up production if they are willing to do so. Often they need new production lines approved or need new raw material sources approved to help increase supplies. FDA can and does expedite review of these to help resolve shortages of medically necessary drugs. FDA can’t require the other firms to increase production.

When a shortage occurs and a firm has inventory that is close to expiry or already expired, if the company has data to support extension of the expiration dating for that inventory, FDA is able to review this and approve the extended dating to help increase supplies until new production is available.

When the US manufacturers are not able to resolve a shortage immediately and the shortage involves a critical drug needed for US patients, FDA searches for overseas companies that are willing and able to import the drug during the shortage. When a firm is located that is willing and able to import, FDA has utilized regulatory enforcement discretion for temporary importation to meet critical patient needs during the shortage. FDA evaluates the overseas drug to ensure that it is of adequate quality and that the drug does not pose significant risks for US patients. The information about the imported drug, and how patients can access supplies is posted on the FDA Drug Shortage website along with the Dear Healthcare Professional letter from the company that is importing the drug. FDA cannot always find a firm willing and able to import a drug during a shortage, however it is something we explore when there is a critical shortage and US patient needs are not being met.

FDA works to find ways to mitigate drugs shortages; however, there are a number of factors that can cause or contribute to drugs shortages that are outside of the control of FDA.

If you have a moment- email the FDA and request that they start monitoring this shortage (and help push manufacturers back to producing quality products).  They can me reached at drugshortages@fda.hhs.gov.

Information from the American Society of Health-System Pharmacists, continually updated: http://www.ashp.org/DrugShortages/Current/Bulletin.aspx?id=638

 

 

Update, 3/12/13

I’ve heard back from a number of entities, rather quickly.

First off, props to my pharmacy (Walgreens) for presenting me with options.  Option #1, keep 100mg/mL concentration and purchase 10mL vial for ~$125 because of name brand.  Option #2, move to more available 200mg/mL concentration and have insurance cover 3 x 1mL vials – “3 month supply”.  I find the 1mL vials to be totally assinine and I deplore trying to precisely inject 0.25mL from a 3mL syringe, so I chose option #1.  Completely privileged choice I’m able to make based on my employment- and a consideration I made due to my current health insurance plan being a high deductible with HSA plan.  Hello tax-free $$.  The pharmacist I spoke to today stated that the generic manufacturer (Sandoz) has discontinued the 100mg/mL concentration, hence the brand name being the only one available.

Which brings me to the 2nd communication.  Sandoz was nice enough to email me back.  I asked: “I see that you have discontinued the 200mg/mL concentration of this medication, do you have plans to increase production or even continue the 100mg/mL concentration?”  A customer relationship associate responded “We have not discontinued making the product at this time, however the product is temporarily unavailable with no eta. Thank you.” I’m not sure there’s a difference between discontinued and “unavailable with no eta”.

Last but not least, the FDA. “Thank you for your email message. We are doing everything within FDA’s regulatory authority to ensure that the products listed in your email below continue to be available for patients. The main reason for this shortage is the  discontinuation of production by the manufacturing company. …  It appears the 10 ml vial is available from West Ward and Paddock.” 

There are a number of options for testosterone delivery.  You can be less picky than me and accept the 200mg/mL concentration (if available in your area).  You may have luck getting your insurance company to cover the brand names at generic prices due to the unavailability of the generic.  Compounded gels are also an option, as theevolutiononman reminded us in the comments section.  For myself, I choose to never use a topical hormonal treatment due to my female partner.

More Surgery?

I had very successful top surgery in January of 2011 at 10 months on testosterone.  I consider the surgery very successful because it a) relieved a huge amount of dysphoria and b) resulted in the chest I was expecting.

 

Top surgery was the first surgery I had in my transition, and it will likely be the only one.  If I had significant genital dysphoria, I could get bottom surgery.  I’m not going to knock the results of bottom surgery, improvements have been slow to the methods but the capabilities are expanding across the globe.  The thing about bottom surgery, is that I just don’t think it’s for me.  I’ve talked before about how I’m chill with my body the way it is now, so I won’t rehash that here.

What I’d like to discuss is- the hysterectomy.  I currently have all the “plumbing”.  To keep up with the analogy- there’s no water flowing, but the pipes aren’t busted.  My uterus and ovaries don’t bother me, physically or emotionally.  Don’t get me wrong, I HATED my period.  I got one on March 1st, 2010- and haven’t bled again. (I started 50mg/week testosterone on March 8th, 2010)  Nevertheless, at 3 years on testosterone, I haven’t experienced any breakthrough bleeding.  The only motivation left for a hysterectomy would be the anecdotal evidence from case studies that FTM persons get uterine/ovarian cancer.  In discussing the general risk factors for these cancers and my lifestyle choices (moderate-high physical activity, pap smears and pelvic exams once every 2 years, regulated testosterone), I don’t have any motivation built up to push past the possible side effects of a hysterectomy.

The possible side effects of less bladder control, lower sex drive, damage to the vaginal structure, and fluctuations to hormonal levels are very deterent for me. Beyond the possible side effects is the known discomfort of having a surgery, being out of usefulness for 2 weeks with a full 4-6 weeks for overall recovery. It’s just not a surgery that seems medically necessary for me.

I’m not trying to tick past checkpoints of life here. I’m willing to take care of my uterus and ovaries as a part of my body. Could I have them removed? Sure. Are there risks keeping them? Of course. Are there risks having them removed? Yes. I’m just finding that the balance of risks for me leans more towards no hysterectomy.

Past Year Recap

Hmm, given that my last completed post is from January 2012… and now it’s March 2013… I’ll do a fast-forward recap of my life last year. Nothing all that exciting in the trans-department- but the rest of life was full of… life!

 

When I posted last in January 2012, I was employed full-time by a for-profit college as an instructor.  I taught science, IT, and general life skills classes to students 19-50 yrs old.  One of the many serious downsides to the job was that the health insurance excluded all trans* care.  I contacted HR, they let me know that the company had just signed a 2-year contract, so it would not be reviewed for a long time. After 6+ months of working M-F nights and Saturday days I was done, and looked for a new job.

The job market is still tough in the United States, especially when you’ve got a few years of experience in each of 3 fields.  In the meantime, my wife and I got married in February 2012.  We had a nice small wedding, including our dogs and closest friends/family.

In May, I found a job working for a fantastic small-medium business doing technical support and programming.  It was great to get back to working days, and it was even better to be on a health insurance plan that covers trans* costs again.   During the 90 day window while I waited for my health coverage to kick in- I ran out of T.  I asked my GP at the time for a refill and made an appointment for the day after the health insurance kicked in, but she declined to refill until I visited the office for bloodwork, etc.  I was able to “borrow” some T from a friend until my benefits kicked in, and I found a new doctor.

My original general practitioner specialized in trans* medicine, but is very strict/controlling about levels, other mental health issues, and overall physical health.  While many of those things can be good, once I had a routine testosterone level setup and given that I’m generally on top of my well-being, I didn’t feel like playing those games anymore.  My new general practitioner specializes in trans* and OBGYN medicine.  More on that in another post.

In November, I was promoted to manager of information technology at work.  At this time, my wife and I start talking timeline for things like children, any further surgeries, major vacations, etc.

And that’s pretty much last year.

Transman Wedding Stuff

I’m getting married in less than a week! It’s incredibly exciting, an overwhelming peace that comes from loving someone and celebrating your plans to spend the rest of your lives together.

I do however want to discuss a few wedding preparation things that I feel like I didn’t have a lot of resources for due to trans* related stuff…

 

Firstly- the ring. My left ring finger is about a 6-6.5 size, which is very small compared to the average male. Most brick and mortar stores carry down to a size 8, which can be sized down to a 7.5 at the most. To get a masculine wedding band, I needed to either special order a ring through s store or directly order a ring online. A few stores quoted me at 6+ weeks for the special order, a few stores were able to get a ring within 2 weeks (tungsten/titanium rings). As I narrowed down what I wanted to a tungsten ring (I like the weight of the ring, even in my small sized ring), with a diamond or a few, with my fiance’s name engraved on the inside- I knew it was easiest to order directly from an online store. Amazon.com didn’t have the ability to engrave a ring, but several online stores did.  We had a good experience with Titanium Kay, where we were about to exchange sizes easily.  This was a big deal because when trying to find out what your ring size is- the width of the ring matters, and most size samples aren’t in the range that I was looking at.

 

Secondly- my tux.  This really ended up not being a big deal.  Even being in smaller stature, at any fully features tuxedo rental shop- you’re going to have options in your size.  I was nervous at first, because I went to a Savvi formalwear shop in high school for a dance and they were both rude and condescending to me, but they would only special order me a small vest if I purchased it.  (no renting)  Because of this experience, I was nervous about waltzing (ok, I walked) into Men’s Warehouse.  However, it turns out my money is as good as everyone else’s, and I was able to rent the right-sized tuxedo for my wedding without a hitch.