For the most part, my approach to prescribing hormones is “sure,” but I will note that the one thing I lean HARD on patients about is smoking. If you’re transgender, and you’re on hormones, the number one thing we want to protect is your cardiovascular health. That’s frankly the number one thing I want to protect in all my patients, but anyone taking exogenous hormones is at higher baseline risk. And the best thing you can do for your heart is DON’T SMOKE. It’s a bitch to quit, and I didn’t even smoke much or long before I quit in my late teens, and I STILL didn’t enjoy quitting and had smoking dreams for years. It’s harder to quit than just about anything else up to and including crack and heroin, and that’s coming from a patient of mine who recently passed in her early 60s who’d done all of those things—for years and years—but eventually was able to quit everything except smoking. And that killed her. She developed severe COPD and eventually called to say her blood oxygen saturation was dipping into the 70s, which is incompatible with life. She was lucid enough to decline medical care, including refusing to call 911 or go to the ER. A week later, after both I and one of our outreach nurses had contacted her to ask her to please go to the ER, I got a notification that she’d been found dead. She had been so frustrated that she wasn’t a candidate for a lung transplant.
One of my oldest trans patients is in her late 50s. She’s had blood clots that went to the lungs. Repeatedly. Smoking raises that risk. Estrogen raises that risk. She’s a veteran with PTSD; of course she smoked.
These aren’t theoretical. These are humans I’ve cared for over years of their lives. I have been rooting for them—my beloved former addict, who spoke without shame about her years of homelessness and drug use in the city; my queer elders, who are slowly trading in their motorcycles for power scooters. I want everyone to live their fullest, best life.
Smoking doesn’t fit into that. Please don’t smoke. I don’t want you to die like that—not now and not later. I want you to have the future that you may not be able to see yet, but exists.
Since I moved home as an out queer, word got out, and there’s a whole apartment complex of lesbians in their 60s to their 80s who come see me—sitting next to their wives in the office, nagging about blood pressure meds, tattling about not having gotten the shingles shot they said they would. To be clear, when I was growing up in town, I knew no lesbians. Not one. I knew one gay kid in my class, which eventually turned into two. We were it. To see these women living decades with their wives and being able to squabble like any couple in my office over who was supposed to bring their home blood pressure cuff in for us to check it… it means the world to me.
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