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.

Summary
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! ><

On Electrolysis and Saving Money

"Money, get away;
Get a good job with more pay and you're okay;
Money, it's a gas;
Grab that cash with both hands and make a stash."
-- Pink Floyd, Money

I had my third hour-long electrolysis session yesterday, and started genital electrolysis in prep for surgery.

The bits of remaining facial hair are being cleared faster and faster. The first session took about an hour, the second took 40 minutes, and this latest only took half an hour. Each time, everything that's visible is cleared, but since hair grows in stages, the dormant hairs have to be cleared in successive sessions. Still, it should take less and less time from here. After zapping my face, we used the remaining half-hour to do a test patch down below.

I was terrified. The pain worried me a little, but mostly I was nervous about the idea of it. I don't hate my body, but I'm not exactly comfortable with it, either. Fortunately, my electrologist has experience with doing genital electrolysis for trans women, which does help ease my mind a bit.

She gave me a fluffy skirt wrap with snaps on it, asked me to wrap it around my waist, then left the room. I followed her instructions, and she came back a few minutes later. She worked like a masseuse, using a towel and the skirt to cover everything except the spot she was working on. For some reason it seems easier to handle a little square patch being exposed. My anxiety went away pretty quickly, but starting the surgery-prep electrolysis also caused the reality of surgery to settle in a bit. After all, this is the first concrete step I've taken in getting ready for SRS.

For the pain, I've been taking ibuprofen before each session. It only dampens the stinging of each zap a little, but I think it keeps the pain from building up as my skin gets more and more tender, and that helps a lot. I'll probably look in to getting some EMLA, which is a topical numbing cream, though I'd need a prescription from my physician to get it.

The pain from the genital electrolysis was... different, and difficult to explain, but the patch she did was not nearly as painful or annoying as when she does my upper lip. Being able to talk and distract myself while she works makes it much easier on me as well; I have a hard time sitting still and quiet for very long. Unfortunately, pain-wise, the worst is probably yet to come.

Hopefully, it will only take around 10-20 hours to clear what I need for surgery. Most surgeons (including mine) do a follicle scraping of the skin graft between removing it and replacing it, but they can't get everything, so most also recommend clearing certain areas of hair before surgery. Personally, I'd rather be safe than sorry, since it can't really be cleared after surgery.

I've also been thinking more and more about cost recently. My electrologist charges $50 per hour, which is pretty average. I looked up how long it takes most trans women to completely clear their face of hair with electrolysis alone, and most sources say it takes about 200-300 hours (though some people manage it in 100, and some have taken 700+ hours). If we go with the low average and say 200 hours, that's around $10,000 on electrolysis.

I spent about $1,300 on laser. Even if clearing the remaining facial hairs with electrolysis takes 10 hours, I will have saved $8,000. Not to mention the 180 hours I got to spend doing anything other than enduring the pain of electrolysis. Even if it had only cleared 1/6th of my facial hair, I would've come out ahead.

There is a lot of heated (no pun intended) debate over the effectiveness of laser, and I know that it's not for everyone, and that it doesn't work well on every skin/hair-type. But for those who are good candidates, and who can find a good price, I think it's worth trying. Of course, take my advice with a grain of salt, as I think you should with any advice about hair removal. =)

Speaking of saving money, my surgery fund is coming along!

I crashed my car a couple of months ago, and the insurance company called it totaled and gave me a check. Since then, I've been carpooling with Erin, and I've been considering saving that money for surgery, but I don't think that's really feasible. I've made Erin late for work a few times, and her work is not very lenient with tardiness, not to mention the fact that her schedule may change at any time. The tension over sharing a ride is only mild right now, but another year of this would probably be a different story.

We've been expecting a tax return of a couple-thousand dollars for a few months now. I filed (our first joint return! =D ) back in February, but after a few weeks of not hearing anything, I got worried and called the IRS. The rep I spoke to said that due to my name change, there was a delay, and that we'd get a notice by mail if we needed to provide more information. Since then, I've been nervous about being audited, or that they'd reject it because we're both legally female, but I just checked my bank account and there was a deposit from the US Treasury. W00t!

Including the tax return, but not the insurance money, we have about $18,000 saved, with between six and nine months (six is if there's a cancellation in November) to bring that up to $22,000. Thinking of other things that money could go to is a little depressing, but it will be worth it, and I'm excited to think that we may actually be able to save up the money in time. =D

New Doc, New Meds, New Prescription Madness

"You kn-kn-know what I want!
Gimme more. Gimme more.
Pretty please, a prescription!"
-- Mindless Self Indulgence, Prescription

I usually avoid talking very specifically about my body, but this is pretty limiting in a transition blog. Physical changes are a huge part of my transition, and if any place should be safe to talk about them, it should be here... I just worry that I'll make other people uncomfortable. Since I've really got to stop worrying so much about other people, I'm just gonna give you a heads up: I will talk about my boobs. There, I've said it. Whether you know me or not, if you think you might be uncomfortable with me talking about anatomy, nobody will blame you for ducking out. =P

As usual, I've waited far too long to talk about what's going on in my life, and I've got quite a backlog, so let's catch up on hormones. =)

My first endocrinologist sucked, so about four months ago, a month before my hormone prescription ran out, I decided to look for a new doc. I had three goals in mind: find someone who cares, is in my insurance, and prescribes *progesterone. I got a big list of endos and ratings of said endos from various trans friends, then narrowed it down by insurance, and started making calls. The only one within my plan that was taking new patients however, was only accepting referrals from a primary care physician. The good news was that there was a PCP in the same office that works closely with the endo. The bad news? The physician was booked about a month out, and the endo three months. =/

*(Progesterone is a primarily female hormone often prescribed as part of both post-menopausal and transsexual hormone replacement, but many docs are afraid of it, because some synthetics have been known for nasty side-effects, and its full effects on development aren't well known. Progesterone is key in breast development, among other things, but there is still a lot of disagreement as to how much is gained, and which meds, if any, benefit trans-women the most. Part of the problem is that most of the data comes from post-menopausal women, and broad testing with trans-women is virtually non-existent.)

Since I wouldn't see the new endo for a while, I called my old doc to ask for an extension on my prescription, and she told me that she would grant it, but never followed up. Fortunately, my appointment with the new PCP was just a few days after my prescription expired.

The new physician was awesome! She listened, she answered, she genuinely cared. I know, weird, right? She even chatted with me excitedly about my (then) upcoming wedding, and gave me a three month extension to last until I could see the endo. About a month later, when I went through my legal name/gender change, she was also nice enough to write up a letter of recommendation for me to present to the judge.

When I finally saw my new endocrinologist, she was just as cool. She was extremely enthusiastic in getting to know me and explaining things to me in detail. Before I could even bring up the progesterone, she asked, "How's your breast growth?" I explained that I'd had some growth spurts in the beginning, but nothing much since then, and she immediately followed up with "We should get you on progesterone!" =D

Of course, there's always a hitch. To save myself from having to go in at different times for different prescriptions, I waited for my other two to run out before filling the progesterone. When I did, the pharmacy informed me that I could now get three months of the spironolactone and estradiol, but that my insurance would only let me get one month to start on the progesterone. That seemed reasonable, but when I got home, I realized that they only gave me half my normal dose of spiro. It turned out that the new endo had accidentally prescribed it wrong. =/

Unlike with my old endo though, I was actually able to get a hold of one of the new doctor's staff, and they immediately sent a correction. The pharmacy then told me that I should just take the spiro at the correct dosage, and that they'd get it corrected at the 45-day marker when my supply is gone.

Last night, I called in a refill on the progesterone, but when I picked it up, they said they only had enough for 5 days, and that they'll call me in the next few days when the rest is available. I also asked them about the spiro, and they told me that they'll probably just refill for three more months when I run out.

So now, even though I'm getting meds for three months at a time, I had to go in yesterday for the progesterone, I'll have to go back in a few days for more progesterone, then back in two weeks for the spiro, again 45 days later for the estradiol, and repeat. Despite my efforts, my three prescriptions will never be on the same schedule again. *sigh*

Anywho, I've now been on progesterone for one month, and I've definitely noticed a few effects. Like with my first hormone post, I'll just present the evidence, and let you decide what's unrelated/psychosomatic and what's not. =P

• My breasts have been tender and itchy almost constantly for the last month, which indicates growth to me. This is basically what it felt like off-and-on when I first started hormones. Their shape has also rounded out a bit, and they look more natural.
• I've noticed some skin changes, and the weirdest thing, the tattoo on my back sometimes "raises", and I can feel bumps where the lines are; when this happens, it's also itchy.
• My skin is a little more oily, and I've gotten a few more zits than usual.
• My anxiety is back, which is odd, because progesterone is supposed to be calming. Of course, this could easily be due to a lot of other things going on, too. =P

I really haven't experienced any extreme side effects so far; the acne is a little annoying, but hopefully that will fade after a few months, as it did when I first started on hormones. Otherwise, med-related things are going pretty hunky-dory, and still far better than when I had to deal with my old endo. =)

Wedding Day!

"Now we're together nearly every single day, singin'

Doo-wah-diddy diddy-dum diddy-do;

We're so happy and that's how we're gonna stay, singin'

Doo-wah-diddy diddy-dum diddy-do;

I'm hers (I'm hers), she's mine (she's mine),

Wedding bells are gonna chime"

 -- Rick Springfield, Doo Wah Diddy Diddy

Short post! I have a ton that I've been meaning to update on, but for now, I just wanted to say that it's my wedding day! Hooray!

At first, we were thinking about just having a simple ceremony at the courthouse. Then we decided that we should do that, but move it outside. Next we moved the venue to Erin's mom's house, to go back to simple. And then we thought, "If we're having it at Erin's mom's, we might as well invite more people.", and it has kept on building.

Fortunately we've still managed to keep it fairly simple, as weddings go, and the toughest part has been trying to let go of other peoples' expectations and pressures. We just don't care as much about the stupid little details as we do about being surrounded by friends and family, and I'm pretty sure we've managed that.

Since Erin and I have been (living) together for almost five years, this really isn't going to change much for us, so I'm more nervous about something going wrong than I am about actually marrying her. I need to just take a deep breath, focus on my wonderful bride and the people around us, and let that which does not matter truly slide. =)

Work Transition: My Birthday Present to Me

"So if you think it's scary, if it's more than you can take,
Just blow out the candles, and have a piece of cake!
Happy Birthday! Happy Birthday to you!
Happy Birthday! Happy Birthday to you!"
 -- Weird Al Yankovic, Happy Birthday

Disclaimer: 
All opinions posted here are my own, and not necessarily representative of the company I work for

On Monday I transitioned at work. A few people have asked me what that means, and each time, I suddenly remember that this isn't all self-explanatory. Outside of work, I've been dressing how I like and going by my new name and female pronouns for a few months now. At work, however, none of these changes had happened yet.

I came out to all my coworkers in November, but so far, I had decided that I wasn't quite comfortable enough with the new me to make the transition leap at work. I continued wearing a sports bra, baggy t-shirts, androgynous earrings, no makeup, and talking in my old voice. About a month ago I decided I was finally ready, and that pretending to be male was getting a little bit too awkward.

I informed my supervisor and started meeting with HR and management to plan it all. We created different communication plans for my local teammates (one meeting a few days beforehand to prepare them), the local center (a top-down communication to all leadership, so they can be prepared if any rumors or concerns surface), and the various other teams and people I work with globally (basic communication from their leadership). We planned for a new name tag, badge, preferred name in the system, etc. When it came to the bathroom issue, I told them that I was worried about it because I know it can be a very sensitive issue for a lot of people, but they reassured me that it was no problem and that I would probably just use the women's.

A couple of weeks before transition, the HR rep met with me and told me she would be meeting with legal the next day to review the plan. She wanted to get a clear idea of my thoughts on the bathroom issue so she could represent them properly while discussing it with the powers that be, so she asked, "What if, for some legal reason, they say you have to use the men's room?"

Anxiety set in. After a pause I choked out, "I guess... I wouldn't transition at work."

"Then how would you continue your whole process?"
The tears started, "I guess... I would have to leave the company."
"Wouldn't you have to face this kind of thing at any company you work for?"
"...Yep."

We talked some more and she reassured me that she just wanted to clarify my feelings-- that nothing had actually been decided yet. I tried desperately to calm myself down. I felt pretty stupid, but she was really sweet about it, and asked me to come talk to her first thing the next day since she was meeting with them earlier in the morning.

Thankfully, the next day, she told me that the meeting had gone well and that I would be using the women's restroom. They decided that there would be more questions/complaints/awkwardness if I were using the men's room, than if I were using the women's. Yeah, I could've told you that. =P

Day 1 (Monday)
On Monday, April 5th, I went in to the office as myself for the first time. I met up with the HR rep, who sat me in a meeting room to give me time to breathe and make sure I was ok. I think I was shaking. When I was ready, we went to the security office and got a new badge printed out, complete with new name and picture.

When I got to my desk everyone was very natural and easygoing about it, which helped a lot. One of my awesome female coworkers gave me a necklace, because "Every woman needs a black necklace that can go with anything."  So. Sweet. =3

There were a few slip-ups with the name, but I never got a chance to correct anyone before they did it themselves. I was still terrified of the bathrooms and avoided going for most of the day. At around 5 hours into my shift, I finally decided that it wasn't worth a bladder infection and convinced myself that I'd have to get over my fear eventually. I decided to use the upstairs bathrooms, to hopefully avoid seeing anyone I know. I actually didn't end up seeing anyone at all. On the way out I decided that I looked pretty good, and that I should've gone a long time ago just to see myself and boost my confidence.

Day 2 (Tuesday)
On Tuesday, the internal systems finally updated with my "preferred name" and new picture, so that people can look me up or email me using Vivi. Partway into the day my boss's boss called a random meeting and brought in Birthday cake for me and my supe, whose birthday was on the 4th.

"Happy Birthday Michelle and D  Vivi"

LOL

I was worried about my voice for most of the day, so I kept talking really quietly, and trying not to cough. The bathrooms got easier to use, especially since there was never anyone else in the ones upstairs.

Day 3 (Wednesday)
We had a team meeting early Wednesday morning, which I decided to call in to from the comfort of my pajamas. The whole meeting, I kept thinking about how much I hate my voice, and how the more afraid I am, the worse it sounds. On the drive in to work, I used my phone to repeatedly record and playback my voice, to reassure myself that I don't sound that stupid. Shortly after getting in, a co-worker randomly told me that my voice sounded good, and that he didn't recognize me on the call at first, which made me feel a lot better.

A few of the women on my team sometimes take breaks together to go on walks or over to the gym, and they invited me. A social activity and forcing myself to work out? Sweet!

I used the bathroom a couple of times without too much anxiety, but I know I'll tense up the moment I finally see someone. Everything else is already starting to settle back into normalcy. My boss's boss commented on how it was as if everything had changed, and yet nothing was different. I couldn't agree more.

In other news, today is my birthday! After 28 years, I'm finally free to be myself. Oh well, better late than never I suppose. =)

Control Issues

"All the people slip away,
Despite connections I have formed.
In my struggle to be human,
I feel more and more deformed."
-- System Syn, Beneath the Sand

I've escaped my shackles only to find myself in a larger cage.

I'm supposed to feel less anxious, damnit!

It's been almost a year since I put the pieces together and realized what they meant. Eight months since I told anyone else. Seven months since I started doing something about it, and since then I have done a lot.

I tell myself that these are relatively short time periods, and I am honestly very proud of myself for continuing to do what I know is right for me. I feel elated with the progress I've made, and that's exactly the problem.

The Story so Far

"When everything is going wrong,
And you can't see the point in going on,
Nothing in life is set in stone,
There's nothing that can't be turned around."
-- Garbage, Androgyny

Hi! I'm 27 years old, I live in Utah, my favorite color is blue, and I am transgender.

To give you the basics, I was born physically male, and while I don't think that I truly identify with either "traditional" gender role, I feel more female than male internally. I will not ask you to agree with this. All I ask is that you keep an open mind and make as few assumptions as possible, and I will gladly answer any questions you have. Questions, as I've really learned in the past few months, can be a great sign that people care.