Monday, July 25, 2011

Letters to a Surgeon

Won't you please,
Please tell me what we've learned?
I know it sounds absurd;
But please tell me who I am.

-- Supertramp, The Logical Song

I can has two letters of recommendation for surgery! =D

As I wrote before, I was having a tough time finding someone for my second letter, as required by the WPATH Standards of Care (and more importantly, as required by my surgeon). I'd collected a couple of suggestions from trans friends and called a few psychologists, with no luck. Among those I'd called was one prospect, a Dr Beckstead, who was out of town. I waited until he got back in near the end of June to leave a message, which he promptly returned a few hours later. He said that he had experience working with trans clients and writing these letters, and that he'd be glad to meet with me. W00t!

I had an appointment with him on July 7th, and he was awesome! He was very courteous, kind, patient, and a great listener. For some reason, I'd expected a battery of dry evaluation tests, with ridiculous questions questions like, "How often are you angry?"

Instead, we sat and chatted casually for an hour about my transition, the ups and downs I've experienced, my emotional state during various stages in my life, etc. The hour flew by, and by the end of it, I'd rambled off my entire life as it relates to my gender. He told me he'd be happy to write a letter for me, and agreed to have it ready the following week. I picked it up on the 14th, and... wow.

I expected half page or so. This sucker is four pages long, and recounts nearly every detail I shared with him, but in a more cohesive, less rambly way. It's really interesting to see a summation of so much information about myself. Even though much of it is a direct interpretation of what I'd told him, being reworded and peppered with his observations makes it feel slightly surreal, like hearing a recording of your voice for the first time and wondering, "Is that really what I sound like to other people?" Even though none of the information is a secret, the letter feels very intimate, and makes me realize just how much I expose my naked thoughts and feelings to the world. I'll cherish it always. =)

My regular therapist told me long ago that she'd be happy to write a letter if/when I decide to have surgery, so I also set up a recent appointment with her to go over the details. I hadn't seen her for the better part of a year, but most everything I had to share was good news, so the session had the odd feeling of catching up with an old friend, then paying her for it. =P

She offered to mail her letter, and it arrived on Saturday. Her letter is much more what I expected, basically just an overview of our therapy and her recommendation:
Dear Dr. Bowers,

This letter is in regard to [Vivienne]. Vivienne is a male to female transsexual woman who I have been treating for Gender Identity Disorder (GID) since March of 2009. [Vivienne] has been on hormone replacement therapy since July of 2009; she has undergone a legal change of name and gender marker and has been living full time as female since April 2010.

I have spent many clinical hours with [Vivienne] addressing issues pertinent to her gender identity and transition. I am confident that she is psychologically and socially prepared to complete a surgical transition to female. [Vivienne] has considered all aspects of gender reassignment surgery and will continue to live a productive and emotionally healthy life as a woman. Therefore, it is my recommendation that she be considered for further medical or surgical procedures as she wishes.

For the sake of completeness, I've also included some of Dr. Beckstead's letter below. I've pared it down to around 1/2 the original length, but it's still pretty long, I wouldn't blame anyone for thinking it's TL;DR and skipping it. ;)
Dear Dr. Bowers,

This letter is to document my assessment of Vivienne and my recommendation that she is eligible and ready for male-to-female sex reassignment surgery (SRS). My evaluation is based on 1 individual evaluation on July 7, 2011. After this meeting, I was confident in making this recommendation. Vivienne has also met with another local therapist, who is highly competent in gender-identity issues, starting in March 2009 to the present. Regarding Vivienne, she is 29 years old, employed, and married, with no children. My overall impression of Vivienne is that she is intelligent, thoughtful, warm, sensitive, easy-to-get-along with, independent, practical, and confident about her choice of SRS.

History of Gender Dysphoria & Sexuality
[Vivienne] describes herself as an awkward, emotional child that never felt right being who she was... She was never into sports but also never interested in “girlie toys” but building toys. She would always play female characters in video games, not only preferring the identity but also being attracted to the character’s characteristics. She sees herself as always having feminine mannerisms and that people considered her to be homosexual or the “gayest straight boy,” which caused her to question and explore if she were gay. She relates that this focus on sexuality clouded her exploration and acceptance of being transgender.

She describes always feeling out of place in men’s locker rooms and bathrooms and never using the urinal. She hated gym class because she would be forced to change in front of people and would often leave her shirt on while swimming, always feeling awkward in her body but never understanding why.

She recalls that a pivotal time for self-acceptance and identity was when she worked in the Philippines for six weeks in 2008. Transgender issues were more prevalent, obvious, and accepted. This compelled her to do research for a couple of months on transgender issues, which helped her “put the pieces together” and realize that transitioning was worth the risks of social rejection. This process led to her talking with her then girlfriend, which Vivienne describes as emotional because her girlfriend was afraid of losing her. However, once her girlfriend realized the possibilities of staying together (her girlfriend is bisexual) and that Vivienne would be happier, both were okay with the decision and she has been supportive ever since. They married in September 2010.

Vivienne describes having slight “bi-tendencies,” open to the idea that she could be with a man if she met one with whom she fell in love; erotically and emotionally, however, she states that she has always preferred women and does consider herself a lesbian. She relates never being sexually aroused or interested in female clothing or going through a cross-dressing phase of buying and purging clothing. She describes herself as “not that girlie of a girl,” and typically wears jeans and a t-shirt. She has never been interested in wearing feminine-typical clothing because she believes women can wear what they want and still be a woman. She does relate how thinking of her body as female, especially being able to have sex and interact the way she wants as female, is arousing. In her words, “It’s never about the clothing but about the expression of myself through my body that is important.”

Overall, she describes feeling uncomfortable about her body, although less now because she appears female, but she feels “squeamish, weird, awkward” when she does think about her current genitalia and knows that she would be happier and excited with “the correct body” and wants “everything to match.” She is considering breast augmentation but wants to give hormones more time to have an effect. She is also determined to eat better and exercise more.

She states that making the decision for SRS has been difficult, mainly because of finances and her concerns about its effect on her wife and their relationship. She reports exploring and evaluating the risks of surgery, especially with concerns about having a good sex life and sexual sensation, but she states that she sees herself having more fun and pleasure with the correct body.

Social Support, and Current Life Stresses
She describes her relationship with her wife as equal, where both can discuss and resolve issues, and her transition has strengthened their relationship. They can lean on each other for support. Vivienne also states that she has not lost a single friend or family member’s support.

Current stresses for Vivienne include saving money for surgery and a house and managing any guilt about putting her wife under this pressure. Vivienne states that she also worries about body issues and what people think of her (e.g., has she offended someone).

Mental Health History and Status
Vivienne reports that she has suffered with anxiety and depression since childhood. Vivienne sees herself as independent and able to “deal with it” on her own. Vivienne describes having strong emotions but also strong logic that help her maintain balance.

She describes her anxiety as worrying too much about what people think and feel, trying to please them, and then blowing things out of proportion. Her depression was strongest when she first came out and feared its impact on others, which involved breakdowns of wondering if she was doing the right thing. Vivienne states that since her transition, her depression has gradually disappeared as she expresses who she is more: “Not needing to pretend has helped a lot.”

Overall, she states that her sense of independence and responsibility can become to extreme and turn in to anxiety. Vivienne considers that she will always be anxious but has learned to manage it better. Ways that help her to cope currently include expressing more with people who care, processing issues with her wife, and using reality as a check-and-balance.

Vivienne demonstrates the capacity to understand anticipated physical, emotional, and social changes and drawbacks associated with SRS. She is realistic about the changes that can and cannot occur through SRS. I consider her eligible and ready for SRS because she has consolidated her gender identity in the last 2.5 years during her use of hormonal therapy and full-time, real-life experience. She is highly supported by her spouse, family, friends, and job. Her mental health is stable and she does not suffer from any self-abuse, psychotic thought patterns, severe psychological or personality symptoms, or impaired decision-making skills.

These are letters #4 and #5 that I've had to acquire throughout my transition, the first to start hormones, and the second and third for changing my legal name and gender, which shows the kind of crazy hoops we trans folk have to jump through. =/

Anywho, everything's coming together nicely. Now I just wish I didn't have six more months to wait! ><


  1. I can totally picture you having that conversation. Did he even add any analysis or did you basically explain yourself to him? :-)

  2. Vivi,

    Congratulations on getting your letters. I certainly relate to your comment of "cherishing" them. I feel the same way about mine. I read my letters and feel my progress and growth. Here's to that next big letter!

    Best Wishes,

  3. >> These are letters #4 and #5 that I've had to acquire throughout my transition, the first to start hormones, and the second and ...

    This really should not be necessary (but it is). It represents a lot of time and money that would be better spent elsewhere. We can hope that the new WPATH SOC (it comes out on 2011-9-24) includes a route for transition including medical assistance and legal recognition for anti-psychiatry transsexual people and others who people who reject mental health "services".
    I hope the medical professionals at the WPATH symposium are listening to the need to promote patient health over mental health professional wealth, caring not for patient wealth. I fear they are not.