This post is a translation of Dynamiques de pouvoir médecins/patient·es : penser les attendus du soin en santé trans, an edited version of a presentation the author delivered on March 28, 2026, introducing the afternoon for healthcare professionals at the 3rd TransAzur seminar in Nice, France.
The theme of the presentation was “Les attendus du soin” (transl. “expectations of care”).
The author would like to thank the WHSAH team for their help improving
the text. Comments and feedback welcome! Send me an email:
whsah@proton.me.
Translation by alix, Ari, and uriel, with help from the gemma-4-31B-it open-weight LLM, run entirely on local hardware. Our em-dashes are certified organic.
Healthcare providers usually understand that trans people should be treated with respect when seeking care. This includes using the correct name and pronouns, avoiding transphobic remarks, and steering clear of intrusive questions about our sexuality or genitals, among other things. But while these basic communication practices are essential, putting respect into practice involves the deliberate forefronting of trans autonomy, beyond just using the correct language.
To move beyond a liberal, depoliticized perspective where simply respecting pronouns is seen as the primary demand in healthcare, we need to think about the power dynamics that organize the relationship between doctors and patients1.
First, we have to acknowledge that we are not equals; doctors are in a position of power relative to their patients. This is doubly true when the patient is a trans person, and the doctor in question is cis, which most healthcare providers are.
This power imbalance is manifest even in ordinary healthcare interactions. For example, to access transition-related medications, trans people must obtain a prescription from a doctor—which typically means putting a significant amount of control over their transition in the hands of a cis person. This can be especially distressing to patients who feel like they’re “losing precious time” waiting for access to treatment, and notably to minors currently undergoing an undesired puberty. This is a structural issue with healthcare as a system that no individual provider can fix. However, one can take it into account in their practice, and that is what I would like to discuss.
One very simple way to help alleviate this imbalance is to write HRT prescriptions that are valid for as long as possible. That way, if a patient doesn’t feel safe or comfortable with you as their doctor (for instance, after expressing a disagreement), they don’t need to be forced to keep coming back by a rapidly expiring prescription, and have more freedom to explore alternatives.
Keeping in mind this imbalance is also particularly essential in situations where you receive a request you personally disagree with from a patient, or at the very least are not convinced of. For example, a request for progesterone, or a follow-up blood test at one month instead of the usual three. True investment in trans liberation means intentionally refusing to act as a gatekeeper in such situations, and practicing trust in your patients’ articulations of their own needs. That means granting those requests by default. These practices avoid reinforcing the subordination of the patient to the doctor. While it’s true that issuing a prescription confers a certain level of responsibility to the prescriber, the examples I’ve chosen here are deliberately harmless. That being said, less obviously risk-free situations should also be approached with the same mindset2.
Finally, a critical way to account for the aforementioned dynamic is to support people’s self-medication via a harm-reduction approach (for example, by prescribing blood tests), without demanding that the person switch to a prescribed HRT regimen or stop HRT entirely. This is because self-medication (or DIY HRT) is a powerful tool for emancipation from the biomedical power exercised over trans people. Even if it has its limits, supporting it and not penalizing it is crucial.
Whether we like it or not, a doctor’s word carries a different weight than that of a mere mortal. Doctors are often taken at their word without being asked for explanations, let alone scientific references. Yet, they are frequently wrong; they’re human, after all. The difference is that when a doctor is wrong, it is treated as a fluke and quickly forgotten. But when a trans person is wrong while advising another, it’s immediately seized upon as the proof we’ve been waiting for to dismiss and delegitimize community knowledge.
Doing mutual aid, when I find myself explaining to someone that their doctor is wrong, or even abusive, I have to convince them, often by explaining my reasoning and citing scientific literature. Conversely, a doctor never has to make that effort when they contradict something I said in front of their patient during an appointment. While I have no problem explaining and citing sources (in fact, I think it’s critically important for everyone), this double standard is a problem. In trans health, this disparity is not justified by a difference in the quantity or severity of errors made. That’s a polite way to say that the average doctor, who is not trained in trans issues, can make a significant number of mistakes. Even among doctors with a large trans patient base, a profound lack of competence is often evident.
Therefore, it is important to exercise humility to account for these realities. When, as a doctor, you don’t know something—whether because of the limitations of the scientific literature or because of your own lack of familiarity with that literature and/or trans experiential knowledge—it is better to simply say you don’t know. Taking the previous example of a patient asking why hormonal monitoring is done every three months rather than sooner: rather than inventing on the spot that “hormone levels aren’t stabilized before then”3, it is better to answer that you don’t really know, and that you’ve always done it that way without questioning it. The goal is not to shirk your responsibility to provide reliable information, but to make your knowledge and its limits visible, rather than unintentionally maintaining an aura of omniscience which, in the end, only hinders access to knowledge and the empowerment of trans people. It is a matter of transparency and honesty4.
Similarly, consider the example of refusing a patient’s request. If you refuse a request because you don’t feel competent in a specific area and don’t want to take responsibility for a prescription, that is understandable, but you must say so clearly. For instance, it is better to say, “No, I don’t prescribe bicalutamide because I’ve heard about a hepatic risk and I’m not familiar enough with the subject,” rather than, “No, I don’t prescribe bicalutamide because it’s too dangerous for the liver.” The former does not exempt you from working to expand your expertise to encompass things that are frequently requested, but it avoids sabotaging the person’s future care pathway. In the first case, the person can do their own research, return with information on bicalutamide, or go elsewhere if it’s important to them; in the second, you’ve given them inaccurate information, making it harder for them to move forward. Even if you do know the subject well, for instance if you genuinely believe bicalutamide is too hepatotoxic to prescribe based on having explored the literature5, this does not exempt you from the importance of providing context to your recommendations. Providing detailed information to justify your refusal, so that your patient understands how you arrived at your conclusion, shows that you are taking their request and their ability to understand the subject seriously.
Additionaly, humility allows you to recognize that community and experiential knowledge benefits patients in ways that medical providers can’t. It is critical not to delegitimize this knowledge, as doing so can prevent your trans patients from accessing vital resources.
Another significant power imbalance in trans healthcare stems from the fact that in most research, trans experiences are conceptualized by cis people or filtered through the lens of cis priorities. A particularly salient example is the way HRT is systematically framed as a risk in medical literature. This position is illustrated in discussions regarding the cardiovascular health of trans people. This particular topic, which is rarely seen as a priority by trans people themselves6, is wildly overrepresented in trans health literature and is always framed by what cis people feel is the potential risk posed by HRT. In actuality, it’s well established that this risk is low, and that a substantial part of the observed increase in cardiovascular risks for trans people—which can be significant, especially for trans women—is linked to unfavorable socio-economic conditions and minority stress78. Additionally, restricting access to GAHT and broader transition services has been shown to cause preventable suicide deaths among trans patients9—a risk that cannot be dismissed.
Beyond research, approaching HRT primarily as a potential health risk also creates problems in clinical practice. The risks of HRT are often presented by cis healthcare providers in a decontextualized and frankly alarmist manner. The fact that providers feel the need to discuss these risks (which are generally minor) at length, absent any specific request from the patient10, and in contrast to most other medications with a similar or even more serious risk profile, should be cause for reflection. This isn’t to say that risks should never be discussed, but discussing only the risks (and never the benefits, unlike what we would do for any other treatment) and failing to adequately provide context for them is a form of hijacking informed consent. Just a reminder: the idea behind informed consent is not to list every conceivable risk because you feel the need to cover your own ass (but rather to provide adequate, pertinent, information as to a treatment so a person can understand and consent (or not) to it. Such behavior belies a lack of trust in the ability of trans people to fully and rationally comprehend the consequences of the treatments we seek out.
This conceptualization of HRT as a risk, or as something that isn’t entirely “safe” (contrary to all medical evidence), also manifests in how HRT is prescribed. For instance, estradiol is frequently started at doses too low to be effective, and then increased too slowly—without any scientific basis or justification for this approach. This is also seen in HRT monitoring, which includes not only hormone level measurements but also often completely superfluous tests (prolactin, fasting blood glucose or lipid panels every three months for non-diabetics, TSH, liver enzymes, etc.)11. These tests are not useful—studies show these parameters are not typically affected by HRT, and they aren’t measured this frequently in the general population, or even in cisgender people on the same types of medication. Forcing them upon trans patients over-medicalizes the process of obtaining HRT, and can make blood draws unnecessarily burdensome (by requiring fasting, for example). Furthermore, they inevitably create a risk of false positives and overdiagnosis 12.
One of the most serious consequences of the cis hyperfocus on HRT risks is the paradigm known in the community as “trans broken arm syndrome.” This refers to the tendency of healthcare providers to attribute unrelated medical problems to a person’s HRT or transition13. This results in a twofold neglect of trans health and wellbeing, as the patient is both denied appropriate medical care for the real cause of the problem, and pressured to pause or reverse their transition. Trans broken arm syndrome can be further extended to encompass the failure of healthcare providers to account for the impact of systemic transphobia on a patient’s health, even though this has been repeatedly shown to be a major social determinant of health for trans people. Concrete instances of this are commonplace yet rarely recognized as such.
For example, fatigue is sometimes attributed to HRT, even when the patient’s hormone levels are perfectly within expected range. Fatigue is a broad and multifactorial issue, which can stem from many different underlying problems—but as a result of trans broken arm syndrome, it often ends up minimized and normalized when it affects trans people. Another example is chronic pelvic pain. This is common in the general population, especially among cis women, and is often poorly managed or ignored. When a transmasculine person on testosterone experiences this type of pain, however, it is very often almost immediately attributed to testosterone. Yet, evidence of a causal link between testosterone and new-onset pelvic pain is tenuous at best; such pain is common in people not taking testosterone, and pre-existing pelvic pain is generally relieved by testosterone. Behind this misattribution seems to lie a form of cissexism that views testosterone is an ontologically masculine hormone and therefore necessarily harmful to the ovaries or uterus, organs seen as ontologically feminine. This idea is reflected in the long-held belief that a hysterectomy should be mandatory after five years of testosterone to avoid vaguely defined uterine ailments (cancer, “organ decay,” etc.).
Consciously avoiding these cissexist lines of thinking is essential to providing quality healthcare to trans people. Start by asking yourself: as a doctor, how would I treat a cis person with a similar problem? Would I expect to see these health problems in a cis person taking these hormones? And crucially, always check whether your intuitions, which are not immune to the biases of societal cissexism, are actually supported by literature, and reflect on how these biases may impact your patients’ care. Avoiding trans broken arm syndrome means ordering diagnostic tests, referring to specialists, and proposing treatments, rather than stopping at the easy explanation that HRT is to blame. It means examining and taking accountability for the urge to compel a patient to stop HRT, or imply that it’s expected for them to be in pain because they chose to transition. In the case of fatigue, alternative explanations, such as the recognized impact of repeated COVID-19 infections, should be explored. These reflections do apply to more serious health issues (for instance, the role of HRT versus that of COVID-19 can also be questioned in the case of a stroke in a young person).
To summarize, while the baseline expectation in trans healthcare is respectful communication, we should also demand:
A bit of housekeeping to conclude: there are, of course, material limits to applying these principles, not least the time available. My goal is also not to set the bar so high that it discourages the few doctors who are truly invested in promoting trans health, especially since providing trans healthcare can be an unprofitable and politically fraught endeavor. This text may come across as somewhat fragmentary and critical, but I do want to give credit to positive behaviors and initiatives. My goal is simply to offer a few avenues for reflection and improvement for the doctors who read this. I hope I’ve been able to achieve that :)
Jacobsen, K. (2024). Prioritizing Trans Autonomy over Medical Authority in Gender-Affirming Care: The Role of Risk and Uncertainty. Bulletin of Applied Transgender Studies, 3(1–2), 1–19. https://doi.org/10.57814/eay5-ey57↩︎
For example: prescribing testosterone during a known pregnancy, prescribing 5-alpha reductase inhibitors (DHT blockers) despite their poorly characterized psychiatric risks, prescribing oral minoxidil for hair growth, etc.↩︎
Which is false; see:
biyokea. (2024). Pourquoi attendre 1 mois et pas plus
pour une prise de sang après un changement de dosage ?
[Why wait 1 month and not more for a blood test after a
dosage change ?] https://hackmd.io/@biyokea/pds1mois.↩︎
In this regard, there is also value in making the decisions one makes for their patients visible and explicit (for example: preferring monotherapy and not spontaneously suggesting anti-androgens; preferring the transdermal route and not spontaneously offering oral estradiol as an option).↩︎
An assessment that, in my view, would
generally be unjustified; see for example:
Aly. (2020). Bicalutamide and its Adoption by the
Medical Community for Use in Transfeminine Hormone
Therapy. Transfeminine Science. https://transfemscience.org/articles/bica-adoption↩︎
Rytz, C. L., Pattar, B. S. B., Mizen, S. J., Lieb, P., Parsons Leigh, J., Saad, N., Dumanski, S. M., Beach, L. B., Marshall, Z., Newbert, A. M., Peace, L., & Ahmed, S. B. (2024). Transgender and Nonbinary Individuals’ Perceptions Regarding Gender-Affirming Hormone Therapy and Cardiovascular Health: A Qualitative Study. Circulation: Cardiovascular Quality and Outcomes, 17(9). https://doi.org/10.1161/CIRCOUTCOMES.124.011024↩︎
Flentje, A., Sunder, G., & Tebbe, E. (2025). Minority stress in relation to biological outcomes among sexual and gender minority people: A systematic review and update. Journal of Behavioral Medicine, 48(1), 22–42. https://doi.org/10.1007/s10865-024-00539-6↩︎
Streed, C. G., Harfouch, O., Marvel, F., Blumenthal, R. S., Martin, S. S., & Mukherjee, M. (2017). Cardiovascular Disease Among Transgender Adults Receiving Hormone Therapy. Annals of Internal Medicine, 167(4), 256–267. https://doi.org/10.7326/M17-0577↩︎
Cooney, E. E., Muschialli, L., Yeh, P. T., Allen, C. L., Connolly, D. J., Kaptchuk, R. P., Kennedy, K. S., Wong, B., & Kennedy, C. E. (2025). Provision of gender-affirming care for trans and gender-diverse adults: A systematic review of health and quality of life outcomes, values and preferences, and costs. eClinicalMedicine, 88, 103458. https://doi.org/10.1016/j.eclinm.2025.103458↩︎
It should also be noted that even when a request for information about HRT risks comes from a trans patient, that request is not “neutral.” Trans people are also subjected to and influenced by alarmist narratives on the topic. While it is, of course, crucial to answer these questions about risks honestly, the fact that they come from a trans person rather than a doctor does not exempt the provider from questioning why the question is being asked. This implies, for example, reminding the patient of the role of factors other than HRT in trans health. This reminder doesn’t have to be purely philosophical and can lead to concrete recommendations, such as suggesting they connect with trans communities, as this can be a factor in resilience against minority stress.↩︎
This is about the general case, some exception applies. For instance, people on bicalutamide should get their liver enzymes monitored periodically.↩︎
On this subject, see the example of
prolactin detailed in the article
biyokea. (2024). Prolactine et THS. [Prolactin and HRT].
https://hackmd.io/@biyokea/prolactine↩︎
Trans people also sometimes have a tendency to apply the “Trans Broken Arm Syndrome” to themselves. The consequences are obviously different than when this misattribution comes from healthcare professionals, but it remains potentially harmful. As a doctor, one can encourage trans people to question this attribution, which is often linked to various internalized transphobic biases—without, of course, imposing one’s own view.↩︎