How to start medical transition?
Many of the actions that may be included within the process of transition can be handled independently. However, getting access to medical interventions requires going through a process of assessment. In this text, you'll be able to find basic information that will make it easier for you to start that process and will allow you to understand the rather confusing situation of trans people within the Polish healthcare system.
Good specialists will not impose any specific way of transitioning on you. All steps should be individualized and tailored to each individual's specific needs. Although stereotypically a "full" transition should consist of hormonal therapy, change of legal gender marker, removal of gonads and genital surgery, nothing prevents a person from choosing whatever works best for them.
The biggest obstacle here might come from the unclear legal status of the sterilization in Poland. More often than not, doctors will not want to perform surgeries such as gonadectomy before the patient changes their gender designation in documents.
What does it look like in theory?
Adequate assessment is needed to gain access to gender-affirming medical procedures such as hormone therapy or mastectomy. According to the Polish Sexological Society recommendations, the diagnostic process should not be based on verifying the probability of someone's identity, but on confirming that you meet the following conditions:
- you have been experiencing gender dysphoria for at least 3 months;
- gender dysphoria is not a result of other psychological issues;
- your condition is stable enough to implement medical interventions without harm to your health — you may suffer from other mental problems, but they should be under appropriate pharmacotherapeutic or psychotherapeutic supervision.
The number of specialists participating in the diagnostic process may vary, but it should usually include two specialists: 1. a psychologist, preferably with a sexology specialization. Psychological assessment is probably the most time-consuming part of the transition process as it usually requires at least several visits. 2. a psychiatrist or a physician with a sexology specialization. According to the law, a psychologist is not a doctor, so he is unable to provide you a medical diagnosis. Most of the time it will be a psychiatrist with a sexology specialization, but it can also be a gynecologist, an endocrinologist, or an internist with a sexology specialization.
At the moment, the catalogue of diseases and disorders used by the Polish National Health Fund (NFZ) is ICD-10. The diagnostic unit closest to sexual dysphoria is "transsexuality" marked with the code F64 — we strive to collect documentation with this specific code. In the following years, with the implementation of ICD-11, the code and name of this unit will change, but for now this has a very moderate impact on the actual diagnostic process itself.
With letters from aforementioned specialists you can schedule a visit with an endocrinologist to set a dosage and get a prescription for hormones (for more information, you can check other English resource pages such as UCSF Guidelines or Rainbow Health Ontario Guide). The letters will also be helpful in the top surgery clinics or during the process of changing the legal gender marker in official documents.
What does it look like in practice?
The model mentioned above is used fairly often and keeping to its guidelines will eventually allow you to start medical transition. However, this is not the only path - compliance with Polish Sexology Society (PSS) recommendations is not regulated in any way. This means that individual doctors will apply them in different ways: some will obey them almost religiously, some will completely ignore them and, with a better or worse effect, will draft the process in their own way. This has both positive and negative sides: on the one hand, the model based on the recommendations of the PSS may be relatively expensive and prolonged, so doctors who do not fully apply it may provide a way for people who cannot afford going through with it. On the other hand, it can lead to many pathologies and medical errors.
Common variations of the diagnostic process include the following scenarios:
- a sexologist may not require a letter from psychologist and may conduct the assessment basing it solely on their own expertise;
- some sexologists and/or endocrinologists can write a prescription during the first appointment without any letters or diagnoses (in accordance with the so-called informed consent model);
- if the sexologist is not a psychiatrist, they may require an additional letter from a psychiatrist saying that there are no contraindications against transitioning.
- the sexologist may decide to write the prescription for hormones and assign the dosage themselves. There's nothing wrong with it if they are also an endocrinologist, however, if they are not, there is a very high chance that they are not qualified for that. In this case, you can ask the sexologist for a letter and then bring it to a qualified endocrinologist along with the letter from a psychologist.
- there may be a possibility to bypass the sexologist diagnosis, as some endocrinologists will prescribe HRT basing it only on a letter from psychologist and/or psychiatrist.
This makes it very difficult for us to produce a universal guide: in practice, depending on the doctor you go to, you may come across radically different approaches to treatment. The best way to get information about the approach of a given doctor is to go to support groups for trans people and use the search option (e.g. by entering the name of a given doctor or the city in which we are looking for a specialist - some cities also have local groups). The two largest Facebook support groups for trans people in Poland are: • NieCisowianka- Grupa Wsparcia Osób Niebinarnych, Trans i Inter oraz nie-cis • Grupa Wsparcia dla Osób Transpłciowych
Not every psychologist-sexologist or physician-sexologist will be willing to carry out the assessment process for transgender people, and even if they have it in their offer, it does not mean that they will do it without causing you any harm. Before making an appointment, it is advised to write an email to the physician/psychologist asking if they treat trans patients and/or check the opinion about them in support groups.
If you live in a small/medium-sized town or in the countryside, in the vast majority of cases, appointments will involve traveling to one of the bigger cities nearby.
Questions and answers
What exactly do sexologists ask about during the diagnosis?
A lot depends on a specific specialist and questions can be very different. Most often, however, they will revolve around a few specific topics:
- Your current mental state (mood, daily functioning, problems in other spheres of life) and discomfort connected with gender dysphoria.
- Making sure that you are aware of the changes that are to take place in your body and in your life.
- How long have you been identifying in a given way, what were the early signs of transgender identity.
It often takes a form of a request to bring in the so-called "życiorys" (eng. resume), i.e. a document (usually a couple of pages) in which you write down the history of your transgender identity and gender dysphoria. It doesn't have to be a full autobiography and you can only focus on the gender experience.
Unfortunately, incompetent specialists may inquire about sexual behavior, such as masturbation practices or preferred sex positions. You do not have to answer questions like that, you can refuse.
Do I need any additional tests to get a diagnosis?
Among optional tests listed by PSS are uterus ultrasound, breast ultrasound and cervical swab for transmasc patients; and urological tests for transfem patients. Some specialists skip them completely, some may require them to make a diagnosis (this especially applies to gynecological tests). If you have a strong dysphoria that may be triggered by those tests, you can refuse and refer to the PSS recommendations, which specifically allow skipping these tests in the patients with a very strong gender dysphoria.
Some psychologists will require the MMRI-2 questionnaires to issue a psychological assessment. Unfortunately, this may come with a significant cost. Some sexologists may require a karyotype test. There is no clinical justification for that, but it is sometimes required by the court for the legal gender marker change. It is, however, less and less common, and many doctors and patients skip this step.
Prior to the publication of the latest PSS recommendations, many professionals required trans people to perform routine tests such as MRI of the head, EEG, or fundus oculi examination. Taking those tests doesn't make any clinical grounds if you are not not suffering from any neurological issues. So if a specialist requires you to have them, you can decline by referring to the recommendations of PSS.
Can the diagnostic process be carried through the public healthcare?
It is possible, but it can be very difficult. Very few people with a sexological specialization take appointments via the National Health Fund, and those who do very often provide very low quality services (one of the few exceptions will be Dr. Aleksandra Krasowska from Warsaw).
For those reasons, the majority of people decide to go through diagnosis privately.
How long can the diagnosis take?
It's impossible to tell. Record holders who chose the right doctors were able to wrap up in a month or two. Those who were unlucky enough to come across doctors using the so-called gatekeeping (hindering or prolonging the diagnostic process) could get stuck for years. The most common number will be about half a year. Factors that may prolong the diagnostic process include:
- doing it via the National Health Fund: it most likely won't take less than a year;
- doctor's incompetence and/or transphobia;
- issues such as co-existing mental disorders and other health problems.
The common duration is 4-6 visits with a psychologist and 1-3 visits with a doctor-sexologist. If you want to speed up the process, you can try to arrange appointments faster (in case of less busy doctors it is possible to schedule two appointments within a week for example).
Even though there is no way to make sure you won't come across a gatekeeping doctor, you can try to probe your specialist for information, by asking them how many visits they will require before issuing a diagnosis. Doctors who postpone everything, leave it for "later" and are unable to give you a clear date even after a few visits, may not be trustworthy.
Which mental disorders can hinder the assessment process?
Specialists may extend the diagnostic process because of disorders that significantly destabilize a person's mental health and may affect their ability to make decisions (e.g. an ongoing episode of mania).
Patients with the following psychiatric problems can also suffer from a prolonged diagnosis: • borderline personality disorder; • personality disorder of the dissociative type; • schizophrenia; • body dysmorphic disorder.
This being said, no disorders are an absolute contraindication for transition — trans people sometimes also suffer from schizophrenia or dissociative personality disorders. Specialists who rebuff their patients for those reasons demonstrate incompetence. Unfortunately, patients with the above-mentioned disorders may encounter ableism and the diagnosis may drag on indefinitely, so it is even more important to make good research before scheduling an appointment with a given doctor.
Can a non-binary identity or non-compliance with gender norms interfere with the diagnostic process?
With competent specialists — no. Unfortunately, not all specialists have appropriate knowledge to handle such cases. Acknowledging a gender identity other than binary; non-heterosexual orientation; atypical gender appearance (e.g. a trans man with painted nails) and/or striving for non-standard medical transitions (e.g. microdosing testosterone or top surgery without hormone therapy) may serve as a reason for some specialists to prolong the diagnosis or refuse to make one at all. Such approaches are fortunately less and less common.
Some non-binary people avoid the above threats by pretending to be binary during the diagnostic process. Others are looking for non-binary-friendly professionals through support groups.
Can a minor also go through a diagnostic process?
Yes! However, it requires consent of at least one legal guardian. This is not a requirement that can be skipped. For people aged between 16 to 18, it may come in a form of a written consent, for people under 16 years of age, the legal guardian must be present during an appointment. Along with the diagnosis, there comes a possibility of treatment with puberty blockers (before the age of 14) or a hormonal therapy. Mastectomy is also a possibility if both legal guardians provide consent.
Only some professionals will accept minors (especially those under 16). The Facebook support group for parents of transgender children run by Ewelina Negowetti is an invaluable source of information here. The group is not public, it can only be accessed by contacting organization grouping parents of LGBTQ+ children My, Rodzice in any of the following ways. • private message on a My, Rodzice fanpage • e-mail: email@example.com • phone number: 663 925 154
How often does a doctor refuse to provide a diagnosis?
Rarely. It most often applies to people with severe comorbidities and/or mental illnesses (e.g. schizophrenia) or to non-binary people. In all cases, this is a symptom of a doctor's incompetence.
How much will the diagnostic process cost?
Again, this is a difficult question, because it depends primarily on the number of visits. If all goes well, it could cost around PLN 1,000 (approx. 220$) for just appointments with doctors.
If you are a transfem person and you cannot afford it, then Milo Mazurkiewicz Solidarity Fund offers a possibility of financing the transition. The Fund collects applications several times per year so it is best to regularly check the Fund's social media, so as not to miss it.
What is a F64.9 diagnosis and is it bad if I got it?
F64.9, or "gender identity disorder, unspecified", is an entity sometimes used for non-binary people, or when the doctor decides, for any reason, that their patient does not fit into the F64 "transsexuality" criteria. Unfortunately, a diagnosis such as this one is often associated with issues, whether from other doctors or in court, due to being associated with instability or uncertainty.
If you've been given a diagnosis like that, you could try to clarify your concerns with your doctor and ask them to make a new one. If the doctor doesn't want to agree to this, it is also possible to go to another specialist, who will be more accepting and when presented with all the existing medical documentation, could issue a new diagnosis.
My specialist requires me to have functioned in a different gender role for a couple of months before giving me a diagnosis. Is that a reasonable requirement?
No. Change your specialists.
The so-called real-life test is an outdated and harmful diagnostic requirement. In the past, it was required for trans people to have had a long period of functioning "as a woman"/"as a man" before agreeing to producing any diagnosis. This was to weed out "real" trans people from imitators but in practice it had a negative impact on the mental health of patients and exposed them to violence from society. No national or international guidelines include a real-life test any more, and anyone imposing such a requirement is acting in an incompetent and harmful way.