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! ><

My First Electrolysis Session

"After all this has passed,
I still will remain;
After I've cried my last,
There'll be beauty from pain."
-- Superchick, Beauty From Pain

On Saturday I had my first electrolysis session.

Not. fun.

I haven't done much in the way of hair removal thus far, mostly because I've never been very hairy, even before hormones. The hair on my arms is pretty light, I've never had any back or chest hair to speak of, and I can deal with shaving my legs on the rare occasion that I actually wear a skirt.

I have, however, been getting laser hair removal on my face for almost two-and-a-half years now. It was actually the very first step I took towards physical transition, and I started just a couple of weeks after coming out to Erin. I wasn't sure at the time if I'd end up transitioning or not, but I knew that I hated my facial hair enough to get rid of it regardless.

I spent more on it than I probably should have, but on the plus side, they gave me a two year guarantee, so I've been going back once a month since then without paying anything more. Laser has eliminated 95% of the hair on my face, but there are a few hairs it just hasn't cleared. Still, I don't regret starting with laser versus electrolysis, because it has saved me a lot of time and pain, while costing about the same in the long run. Laser was also enough to get rid of the beard shadow on my face, which helped me dramatically in passing as female.

I've now started electrolysis for two main reasons, to clear up what's left on my face, and to start genital electrolysis in preparation for surgery. To put it simply, in sex reassignment surgery, some of the outside skin gets moved to become inside skin, and I need to get any hair removed from those areas before then.

Back when I started laser, I did a lot of research on the differences between laser and electrolysis. The only thing I learned with any certainty should probably be obvious: never trust an electrologist or laser tech to tell you which method works better. Both fields are chock-full of the kind of propaganda and superstition that's spread around so often, even the pros believe it. The truth, as far as I can tell, is that both methods work, and both have many pros and cons.

As far as effectiveness, laser is more like lobbing grenades, where electrolysis is more like sending in a sniper. The grenades are quicker and easier, but you have to be more careful not to damage the scenery, and there's a lot more luck involved. (Yes, I'm a dork, but it's a good metaphor. =P) Electrolysis also seems to be more dependent on the skill of the technician, for better or worse, while laser is more dependent on the area being treated, the skin type, and how dark the hair is.

Technically speaking, most laser hair removal devices don't actually involve any lasers, but use xenon flashbulbs, which flash high-intensity light at the skin. The skin itself lets most of the light pass through, but the hair's melanin (pigment) absorbs the light. The hair briefly heats up, effectively frying and killing the follicle around it. The hair is then left to eventually fall out on its own.

An average session of laser hair removal for me involves lying down, and being given goggles to protect my eyes from any errant flashes. They then spread clear goo on my face to keep the skin cool. Next, the tech dials in the intensity for my skin type and progress, and presses the small flasher part against my cheek. The machine beeps, I feel a sting, the tech moves the flasher gun about a centimeter, and then repeats.

The pain is semi-intense, but manageable, though I usually forget to breathe until they stop, and it always makes my eyes water when they go over my upper lip. Each monthly session only takes about 15 minutes. When they're finished, they clean the goo off my face, apply lotion, and give me an ice-pack to go. After each of the first few sessions, the room smelled like burning hair, and my face was red and tender for a couple of hours.

Electrolysis, on the other hand, uses a tiny needle-like electrode. The tech inserts the electrode in to each follicle, next to the hair, and zaps it at the root with an electrical current. They then grab the hair with tweezers and pluck it out.

At my first session on Saturday, my electrolysis tech began by joking about how every trans person she's talked to says that electrolysis is the worst part of transition, which got me nice and psyched. =P

She wore medical gloves, and glasses with little telescope-y magnifiers attached. She also dialed in the intensity, starting low to see what I could handle, then raising it a few times as she worked. Though I couldn't see exactly what she was doing, it seems like inserting the electrode stings, but is bearable, since it's being inserted where there's already an opening in the skin. The zapping and plucking hurts much worse. The pain was pretty manageable at first, but as she slowly moved across my face, my skin became more sore, and the stinging became more intense. The only things I can compare it to are laser hair removal, and getting a tattoo on my back, but it easily beats both.

My upper lip has the most hair left, mostly because the laser techs were afraid to zap too close to my lips. While the electrologist progressed across my upper lip, my eyes were watering like crazy; If you've ever plucked your nose hair, it's like that, but more hurty. Thankfully, Erin came with, and at this point I asked to hold her hand. I also had to ask the tech to stop a couple of times, so that I could sneeze and blow my nose.

The session lasted a little over an hour, and she cleared most of the remaining facial hair. Hair grows in cycles, with one set of follicles being dormant while another set grows, so I'll have to have my face done at least a couple more times to clear everything.

Once she was done, she had me hold a metal rod with a cord sticking out, and I started wondering why she wanted to electrocute me. She applied what smelled like VapoRub to my face, then pressed a metal roller to my skin, and I could feel a very mild current as she rolled it around. Apparently this is called cataphoresis or electrophoresis, which reduces redness by causing pores and blood vessels to constrict, and helps transfer medicinal substances into the tissue. Who knew?

She asked me not to touch my face or wear any makeup for a couple of days, to avoid infection. Most of the redness went away after a couple of hours, but my face was sore for the rest of the day, and there are still some tiny red spots and slightly tender areas four days later.

I definitely plan on taking some pain meds before my next appointment on the 18th. Since I normally avoid meds, they're pretty effective when I do take them. That should be enough to get me through the rest of my face work, but I don't know what to do for the genital electrolysis. Some people go as far as using numbing cream, or even local anesthesia. I'm really not looking forward to it. =/

After just one face-clearing session, I wouldn't say that electrolysis is the worst part of my transition, but we'll see if I feel differently about it after the surgery prep work. *knock on wood*

Video: Documenting my Voice(s)

"And if you're still within the sound of my voice, watching this video,
I just want you to know that it always made me rejoice,
Just to have you so near, there's a place for you here,
If you're still within the sound of my voice."
-- Linda Ronstadt, Still Within the Sound of my Voice

Video documentation, ZOMG!

I wanted to show the progress that I've made on my voice over the last year, and the only way to really do that is to record it, so voilà! Just a heads up, I switch in to my old voice-- or at least, as close as I can get to my old voice-- which may look/sound a little weird. ;)

Something else that really helped in figuring out my new voice is the fact that I've always done a lot of impressions. It took me about three months of reading and watching videos about the human voice to get the basics of it down, but about seven or eight months before I stopped having to think about my voice every time I spoke. I also took a vocal feminization class, which ended up not helping me in the slightest. These days, the new voice is habit; it's the way I talk when I wake up, and it's the voice my internal monologue uses. =)

Holidays, and Planning for Surgery

"Did you ever have to make up your mind,
Pick up on one and leave the other behind?
It's not often easy and not often kind;
Did you ever have to make up your mind?"
-- Lovin' Spoonful, Did You Ever Have to Make up Your Mind

Whooh! It's been a while. Shall we catch up? =D

The holidays came and went, and Erin and I kept Christmas small in order to save money for other things. I saw family, many of whom I only see at Christmas, and some of whom hadn't seen the new me yet. Quite a few people gave me that soul penetrating curious stare, as if reconciling it all in their heads just requires looking at and through me for a while. I can't say it really bugs me; it never feels malicious, just weird. =)

Quite a few other family members complemented me on my looks, including my mom, stepdad, aunts, and a few cousins. As someone with chronic self-esteem issues, I treasure every piece of unsolicited praise I get. More importantly, I think most of them have had time to adjust, and those that have just act normally now, which is nice.

So far this year has been pretty uneventful, except that I've been thinking about surgery lately. A lot. It feels like the concept is always looming over me, waiting to consume my thoughts whenever I have a free moment. As I wrote here, I plan to have the surgery eventually, it's just a matter of when. I know that I wouldn't have been ready six months ago, but each day that the thought has been left to marinate, I've become a little less afraid, and a little more anxious to just get it over with.

Marriage put even more urgency on it; I feel guilty for holding back our lives with this huge financial burden. Erin has said many times that she doesn't mind helping with this, but I know that the sooner it's done, the sooner we can start working towards other goals.

It's the money that complicates the timing the most at this point. I'm thinking (hoping?) that around November 2011 would be a good time in many ways. It's far enough out that I can hopefully book it, and can hopefully have the funds ready, but close enough to satisfy my wanting to have it done with already. Thanks to a court ruling almost exactly a year ago, SRS is considered a tax deductible medical expense, making the end-of-year timing even more beneficial. Of course, if I want to schedule it for then, I need to figure out if we'll have the money and who will be performing my surgery soon.

One good thing about insurance not covering surgery is that I'm free to choose any surgeon I can pay for, but deciding on a surgeon for something so life-altering is extremely difficult. Researching surgeons is frustrating at best. The internets have provided a lot more information than might have been had 20 years ago, but not nearly as much as you might think.

The major surgeons have websites with pages of text on things like aftercare, but never much detail on their technique. They'll post pictures of their best patient results, but these aren't always informative as a sampling, especially when they haven't posted new results since 2004. Talking to other trans women helps, but each person obviously only gets one reassignment surgery from one surgeon, so it's nearly impossible to compare things like sensation. It's also (understandably) a very private thing for many people, so it's tough to find a large enough sampling to feel like I really know a surgeon's work and range of outcomes.

My main concerns are good sensation, good aesthetics, and no complications. Since I'm big on informed decisions, I've only been considering the surgeons I can find the most information on. This also has a side effect of leaving me with the popular surgeons, who also have the most experience. So far, I've been focusing a handful of them: Toby Meltzer, Pierre Brassard, Suporn Watanyusakul, and Marci Bowers. These are all excellent surgeons, and I've seen pictures of good results from all of them. With the exception of Dr Suporn, they also use the same basic penile inversion technique, though everyone has their own subtle variations.

Dr Suporn works out of Thailand (Chon Buri), where more reassignment surgeries are performed each year than in any other country. As far as I can tell, his fee is around 500,000 Baht, which is about $16,000 US, but I would also have to pay for travel. His technique is well known for providing greater vaginal depth, which is something many trans women are concerned about. This seems to be a holdover from a time when the standard techniques didn't provide enough depth to have intercourse. Being a lesbian, depth is not really a priority for me. ;)

Traveling also comes with its own set of complications. If I went out of country, I'd likely stay there for about a month to recover. I would want Erin to come with, but bringing her would increase travel costs, and there's no way we can both take a month off of work. She could come home early, but she's scared of traveling alone (and I don't blame her). I've also spent a month in another country without her before, twice, and we both hated being apart for that long.

Dr Brassard works out of Montreal, Quebec, which would come with some of the same travel issues. From what I can find, his cost is around $18,000. I haven't done much in-depth research on him, mainly due to being put off by the travel concerns. Based on what I've seen, he uses more of the urethral mucosa than most, and I don't think I like what this does to the look of the final result.

Dr Bowers used to be in Trinidad, CO, but recently moved, and now works out of San Mateo, CA, about an 11 hour drive from SLC. I called her office for her cost, and it's about $22,500. Marci is a trans woman herself, and learned her technique from Dr Stanley Biber, though she has made many of her own modifications and improvements since taking over his practice when Biber retired in 2003.

While many surgeons recommend a "second stage" outpatient procedure called a labiaplasty at least three months after the initial surgery, mainly for cosmetic improvements, Marci is often touted as performing a "one stage" procedure. Labiaplasties cost around $4,000-$5,000 dollars, plus another trip to the surgeon, and more healing, so that's quite a savings, but some people still opt for a labiaplasty after SRS with Marci, and some people opt not to get one after SRS with "two stage" surgeons, so I don't know how much weight to put in this.

Dr Meltzer works out of Scottsdale, part of Phoenix, AZ, which is also about 11 hours from SLC. I emailed his office, and they quoted his current cost at about $25,000. Of all the result pics I've seen, his outcomes seem the most consistent and "clean", but I especially like the aesthetics of his results after the "second stage" labiaplasty. Though the labiaplasty could be performed any time down the road, this would obviously put my total cost much higher.

Overall I'm thinking it's between Meltzer or Bowers. Yes, they're the most expensive, but for good reason, and they're both close. Here's where I need your help.

If you're trans, do you have an opinion on any of these surgeons? If so, please tell me why you feel the way you do, good or bad. Also, does anyone have any other surgeons I should be considering? I've also briefly looked in to McGinn, Alter, and Reed.

And finally, I've got around $12,000 saved, and we should be able to save most of the rest by the end of the year, but every bit added will help us feel safer, less anxious, and more confident. I've set up a donation button on the right side of my profile, where people can send money to my cause. I personally hate asking for money, so please know that it is with a very humble heart that I ask for donations. This is a daunting cost for a newlywed couple; while I secretly hope donations can help us fill in the unknown gap, we will figure this out one way or another. If you donate anything at all, feel free to brag about it... or leave it anonymous if that's more your style.

Thank you, and I love you. <3