The Biggest Decision I've Ever Made

"This is life,
What a f***ed up thing we do,

What a nightmare come true,

Or a playground if we choose,

And I choose."

 -- Offspring, I Choose

Transition has been one set of objectives after another... hair removal, various stages of coming out, therapy, hormones, bathroom issues, work. My life has turned in to a strange series of stepping stones, which I think the rest of the world calls "goals". I have no clue how "normal people" go about their lives like this; I have no idea how I've done it for the past year, but it has definitely improved things for me.

With the bulk of work transition successfully behind me, the next life steps I'm looking toward are marriage, and a legal name change, but I keep asking myself, "What's after that?"

I guess I don't know why there has to be a next step, but it feels like there should be, and I never really planned this far out. Suddenly the road forks in big ways, and I don't know which forks to take.

I hate decisions, especially big permanent decisions. When I was a kid, I came up with all sorts of rationalizations for why my decisions were not important, just to make it through the day without anxiety attacks. Some day I'll write several posts just about all the life "rules" that I came up with during my teenage years, and still use, but for now I'll spare you by sticking to the ones about decisions:

• If I can't decide between two or more options with a reasonable amount of information and time, then all options must be nearly equal, and I may as well just pick one.
• If time and space are infinite, then my decisions are infinitely unimportant.
• If a decision can be undone, and doesn't cause permanent harm, it's ok to try it just to try it.

Unfortunately, the decisions I need to make now are bigger than anything I've dealt with before. Especially with regards to "the" surgery. Rule C above doesn't apply, since it can't be undone. B isn't much comfort now that I'm emotionally invested in my own future (I know, what a weird concept, but it is surprisingly new to me). And A, well, it somehow doesn't seem appropriate to flip a coin or Rock-Paper-Scissors for this one.

Don't get me wrong; if Sexual Reassignment Surgery (SRS) were cheap, with safe and predictable results, I would do it in a heartbeat. Unfortunately, surgery is expensive (around $15,000-$20,000), and comes with many risks and possible complications. For a young and relatively healthy person such as myself, the risks are lessened, but extremely scary nonetheless. This is a major surgery, after all.

There's also the timing issue. Due to the Standards of Care, I can't have SRS until I've been living "in role" for at least a year. Shouldn't this make the decision less urgent? It would, except that $20,000 is not pocket change, and I've failed to save more than a few thousand in the last year. If I want to do this, I'm going to need to start saving aggressively, and even selling a lot of the nostalgic junk I've held on to over the years.

It would be nice if insurance covered any of the cost. The American Medical Association's House of Delegates passed several resolutions in 2008 asserting, among other things, that Gender Identity Disorder is a serious medical condition, that treatment is not "cosmetic" or "experimental" but is medically necessary, and that denying coverage is discriminatory. Most insurers however, go right on with their blanket policy exclusions, or statements that GID is a "pre-existing condition". Of course, I know that's not why most insurance companies don't cover GID. They don't cover it because they don't have to, even though its low prevalence means that paying these costs would likely be much less impacting to their bottom line than most seem to think.

Most reassignment surgeons are also booked anywhere from six months to a year out at any given time, which means I need to know whether or not I'll have all the money quite a while in advance of when I actually have the surgery.

I want the surgery. I know that it would make me feel a lot better about myself, despite the fact that it may only ever matter to me and one other person. In the end, I have to acknowledge that my fears are the biggest thing stopping me, and flying in the face of those fears has gotten me too far to stop now.

I decided a couple of weeks ago that I will definitely be getting the surgery, it's just a matter of when and how. As much as I hate to, I will probably eventually have to ask for some help. For now though, I'm going to see how far I can get on my own.

The Standard Process and Substandard Care

"One pill makes you larger,
And one pill makes you small,
And the ones that Mother gives you,
Don't do anything at all."
-- Jefferson Airplane, White Rabbit

I've been on hormones for a bit over six months now (wooh-hooh!), and you aren't taking them away from me. Ever. Unless I run out, and my dumb doctor and pharmacy can't coordinate to save their lives. Ugh.

For those that don't know the process, maybe I should start with the basics. Transsexualism is interesting in that it has both psychological and physical sides to it, maybe we'll get in to that more at another time. Decades ago, many tried "curing" it psychologically, which usually turned out badly. Nowadays, it's generally accepted that it's much more healthy to treat the body to match the mind, rather than the other way 'round. Sure, you run a few minor health risks, but a lot less people are killing themselves.

Eventually, the medical community adopted a semi-standard set of treatment guidelines, which are called the WPATH-SOC (World Professional Association for Transgender Heath - Standards of Care), formerly the HBIGDA-SOC (Harry Benjamin International Gender Dysphoria Association - Standards of Care, after a German doctor who did a lot of work to help transsexuals in San Francisco in the 50s and 60s).

The SOC has a lot of good information in it, but the main effect it has is to limit most physical treatment to those who have gone through psychological counseling and received a letter of recommendation for treatment. For hormones, usually a therapist will require three months of counseling before giving you "the letter," and for major surgeries, a year of being "full time" (living as your preferred gender socially, usually including work and/or school).

This makes sense on some levels, because it limits treatment to those who are serious and ready, but it also causes a lot of problems. Some people don't have money for therapy, especially since most insurance companies have specific exclusions for Gender Identity Disorder in their policies. Some people are perfectly well adjusted, and feel they shouldn't be forced to undergo mental therapy for something they've already figured out. Finally, some therapists are just bad, and either ignore the SOC completely, or get a gatekeeper complex and go on power trips, withholding letters and making trans people jump through unnecessary hoops.

Without the SOC, support from the medical community would probably be a lot harder to find, so I think of the Standards as a necessary evil, though it would be great for us to work out a more ideal solution some day.

Personally, I didn't mind starting with some therapy. The cost thing sucks, but my therapist is awesome. Since I am relatively well adjusted, I only went in every couple of weeks until the three month marker, when she gave me the hormones letter, and now once a month.

I took the letter to the endocrinologist she recommended, who first requested blood tests to make sure giving me hormones was safe. She then gave me a prescription for six months, with a plan to do follow up work before renewing at six months.

A couple of weeks before the six month marker, I had an appointment with my doctor, who gave me instructions to:
1. - Get new blood work done.
B. - Leave a message on her answering machine, telling her when to call me so that we could discuss the results.
Three. - Have my pharmacy fax a prescription refill request to her.

By the way, she also mistook me for a FtM at first, asked if I'd had a pap smear done, and received confused looks in response. I'm still not sure what to take away from this one besides a good laugh.

I went to IHC to get my labs done, so that I could at least have that covered by insurance. The next week, I left a message giving the doc a few days of wide open time in which to call back. No call.

I asked my pharmacy to send the refill request, and I left another message with another wide open time frame. No call.

I ran out of pills, so I called my pharmacy to check on the status of the request, to which they replied, "She declined it, because she wants to discuss your labs." SO DO I!

I left a third message, and a few days later she finally called me back, but I missed the call because I'd gotten sick. She leaves a message that says "Have the pharmacy fax over another request, and here's my pager number."

I have the pharmacy send it again, and leave a message on the pager. Two days later, on Saturday of all days, she calls me again. "Your labs look fine, I'll approve the fax request, but I haven't received it." Ok, ok, ok, I know you probably couldn't tell me about the labs in a message because of patient confidentiality and all that, but couldn't you approve the request, and then mail the results to me? That is, if you can't be bothered to do your job and call me.

And what's this about not receiving the fax? I confirm with the pharmacy that they have the right number, they send it a third time, and finally get a response. My spiro is renewed for five months, and my estradiol for one month. Wait, what!? The pharmacy says they'll call the doc to work it out. "Good luck with that!" I say, but by some miracle, they fixed it that evening, and both are now for five months.

I'm still confused as to why five, instead of six, but I don't care anymore. Once this is up, I'm likely finding a new doctor anyway.