One of the deep-seated fears of post-op trans women must be that one day they will face a set of scenarios that deprive them of effective feminisation. And, so deprived, their appearance will decay in the direction of maleness. None of these events are especially likely, but the notion that they could happen is an alarming one.
What kind of event?
It could be for instance a development in their state of general health that makes it dangerous to continue with the type of hormone treatment they take. Perhaps liver disease if they drink too much, making it risky to take pills. Or a skin sensitivity that may rule out patches and gels.
Or the treatment becomes unavailable because prescription is restricted, or is simply banned. There have certainly been unfortunate instances around the country where doctors have been inhibited in prescribing ordinary hormone treatment because of some regional NHS policy. And some individual doctors, with their own hang-ups about treating trans patients, have been obstructive.
But one can also imagine getting caught up in some conflict while abroad on holiday. What happens if taken by some rebel group and held hostage? Or officially arrested and imprisoned? Some of these detentions can last a very long time. And if one's pills or patches or tubes of gel run out, without any opportunity to replace them? The idea of slowly reverting to a male look, and suffering violence as a result, is a nightmare one. I should think that this is one reason why all thinking trans people aim to live inoffensive lives, both at home and away, and do whatever it takes to stay out of jail.
But ordinary ageing has its problems too. Gradual changes in the body's tolerance of medication as one grows older might make it advisable to reduce the level of hormone treatment. But, post-op, too much of a reduction will lead to bone deterioration, as well as a lessening of physical femininity. What to do? The decision on treatment is currently made difficult by the lack of exact information to refer to on the long-term effects of hormone treatment in older trans patients. It may be best to err on modest doses, but increase them gradually if they are not sufficiently effective. In other words, proceed by careful experiment, because there is no standard dosage, and the effect depends on the individual patient's reaction to drugs.
I see my doctor again in mid-January, and will have the usual blood tests. I shall be especially interested in the result for oestradiol. These are my results on each occasion tested since my surgery on 1 March 2011:
14 April 2011 427 pmol/L
29 September 2011 461 pmol/L
12 March 2012 306 pmol/L
6 August 2013 146 pmol/L
These results suggest that my medication, unchanged throughout at two 100 mcg oestradiol patches weekly (taking Estradot), has lately been losing its effectiveness.
And yet it is not so simple, because my body hair continues to reduce, my skin tone is still improving, my breasts continue to slowly grow, and, overall, the photographic evidence (much published on this blog) tends to show that my physical charms - such as they are, of course - have by no means diminished. The Neanderthal Man look has not yet taken over.
I think my point is made, despite the big noses in these shots being much the same! In addition, a hospital scan on 12 March 2013 revealed that my bone density was better than average for my age.
Despite this, I will be concerned if the upcoming oestradiol result is even lower. If it is, I will go back to my doctor to discuss increasing my twice-weekly dosage by 50% to 150 mcg.
There is a precedent: in September 2010, in the run-up to my op, Dr Curtis in London agreed to recommend 150mcg after the latest oestradiol result on 3 September 2010 had dropped to 176 pmol/L. The 50% increase then clearly boosted my oestradiol level considerably - despite being pre-op - and there were no adverse effects whatever.
At this point I am chiefly trying to ensure that I have adequate protection from osteoporosis. But nearly as important is the maintenance of feminine characteristics on which successful socialisation depends. Expect another post on this in late January!