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! ><

Updates on Electrolysis, Surgery Prep, and the HRC CEI

"Easy now, hush, love, hush;
Don't distress yourself, what's your rush?
Keep your thoughts nice and lush;
Wait.
Hush, love, hush, think it through;
Once it bubbles, then, what's to do?
Watch it close, let it brew;
Wait."

-- Wait, Helena Bonham Carter as Mrs. Lovett (Stephen Sondheim's Sweeney Todd)

The updates are slow(er than usual), because life is simple and relatively routine. That's probably a good thing.

Another two hours of electrolysis down. I've started doing sessions every two weeks, instead of one, to allow some time for the dormant hair to cycle back in. We're still doing about 30m at the beginning of each session to re-clear my face, and the rest of the time on the lower area. So far I've logged just under 5 hours on my face, and about 6 hours down below. My electrologist still leaves the room while I change in to the towel skirt thingy, but it seems like a silly ritual at this point. All other pretense is gone, and she doesn't even pretend to keep me covered any more. =P

My insurance won't cover a physician checkup until August, so I'm still managing the pain with just an Ibuprofen or two, but I'm considering calling to ask if my doc will prescribe some EMLA (numbing cream) over the phone. Some electrolysis sessions, I feel like I can take about anything, and I almost fall asleep while she's working. Other days, the pain consumes me, and I start getting visions of that one Fight Club scene ("I tried not to think of the words 'searing', and 'flesh'." "Stop it! This is your pain."). =P

Speaking of surgery prep, I've still got a lot to do in the next few months. Besides electrolysis, I need a psychological evaluation and two letters of recommendation from therapists (one being a PhD/MD), I need to get HIV testing, and I need to work with my endocrinologist regarding my pre- and post-op changes to my hormone regimen.

The most pressing of these is probably the letters. My primary therapist has agreed to write the first, but I'm having a hard time finding someone with a degree and familiarity with GID to write the second letter. I've been calling various people suggested by trans friends, with no luck so far. I'm sure I'll find someone to write it; it's just another thing I want to get out of the way. =)

As I mentioned before, my set SRS date is in February 2012, but I'm on a cancellation list for November. When I scheduled, there were a lot of personal advantages to having my surgery done in November, but those pros are slowly being overwhelmed by the possible advantages of waiting until the scheduled date in February.

The Human Rights Campaign (HRC), a major organization focused on the advocacy of BLTG rights (you've probably seen their bumper sticker logo: a blue square with a yellow "=" sign), releases a Corporate Equality Index each year. Basically, companies volunteer to send in a survey and information about their TGBL-related policies, and HRC scores each company on a 100-point scale. My employer has consistently gotten 100 points each year that they've participated (2009, 2010, and 2011).

As of 2012 however, HRC is changing the criteria by assigning 10 points for having trans-inclusive benefits-- health insurance that covers GID therapy, hormones, surgery, etc. Since my company seems pretty proud of their CEI rating, I've informed the powers-that-be that we are in danger of losing our 100, unless they add an inclusive insurance option by the end of this year. They definitely listened, but I probably won't find out what they've decided until around November. It's an off-chance, which is why we've been saving and planning for paying for it ourselves. But as the date approaches, waiting three more months for even a small possibility of saving twenty-thousand dollars is sounding more and more worthwhile.

We've also found out that Erin isn't eligible for family medical leave through her work until she's been there for a year, which will occur in January. She gets 40 hours of PTO a year, and at the moment, she has to save every minute of it to be able to go to Cali with me in November, which really isn't fair to her. Finally, waiting until February means the date is no longer uncertain, and gives us that much more time to settle the funds.

I was really looking forward to November, but logic dictates otherwise, and I think (hope) I can deal with waiting just a little longer.

By the way, if you want to see the CEI ratings, here are the 2011 results (ratings start on page 38):
http://www.hrc.org/documents/HRC-CEI-2011-Final.pdf

And a few previous years:
http://www.hrc.org/documents/HRC_Corporate_Equality_Index_2010.pdf
http://www.hrc.org/documents/HRC_Corporate_Equality_Index_2009.pdf
http://www.hrc.org/documents/HRC_Corporate_Equality_Index_2008.pdf

Does your company participate? What's their rating?

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.

Seeing Through the Fear

"And now I think I am alive,
And that I see reality,
But the truth behind my mind,
Is your insecurities"
   -- Dub FX, Rude

Fun fact about being trans: I wake up every morning feeling like I must be completely insane.

Maybe I should back up a bit. Stick with me if I wander, please.

I've said before that the reason I like the word "transgender," is that it allows me to continue finding a definition for myself, but this is really only part of the story. While it's true that I don't like to be confined to boxes, the main reason I like the word is that I am absolutely terrified of failure. If labeling myself as transgender has the least specific meaning, then it has the least expectations to live up to.

"Transgender" covers a lot of gender variant groups, most of which I don't identify with, and some of which I don't even understand. It includes crossdressers and transvestites, who often retain some form of identity matching their biological gender, but temporarily take on aspects of another. It includes drag kings and queens, who exaggerate gender cues for fun or entertainment value. It even includes those who like to genderf'ck, mixing cues from both genders in order to break down the social binary.

Though none of the above fit me in any major way, there are other terms that I do identify with, including "transsexual." A transsexual identifies with a different sex / gender than the one they were assigned at birth, and seeks to remedy this by taking steps to change their body to match their mind. Like most things in the trans community, the word transsexual changes its scope and definition depending on who you talk to and when.

Many people want to pin down the meaning of transsexual, and remove it from the transgender grouping, out of fear that the medical community will stop supporting us if they suddenly realize how little GID (Gender Identity Disoder) really follows any rules. Some people want to abandon the term completely, since it seems to imply that this has to do with sex, when in fact there are transmen and transwomen of every sexual orientation. More on these subjects later, I'm sure.

My therapist once asked me as a session was ending, "Would you say you're a woman?"
To which I replied "If I felt free to say anything I wanted, yes."
She told me that I could say anything to her, and I just smiled and left, knowing that's not what I meant, but not knowing how to explain it. What I'd meant was that I was afraid of how the world would look at me if I went around saying how I feel.

This journey has a lot of uncertainty, and though I knew the risks when I began it, this is, without a doubt, the most difficult thing I've ever done in my life. I, who don't do anything without being sure of success, am going through this without knowing how it will turn out. I, who value personal connection and identifying with other people above almost anything else, am risking alienation. I, who have never moved to a better state, out of fear of losing contact with people, am risking burning bridges.

Yet, after waking up every morning with so much self doubt, I still know that this is what's best for me. Why? Because of the excitement I feel with every step forward, that I am finally becoming myself. Because I can see with my analytical mind, that I am not changing myself, I am correcting a wrong. Because I know, though it took me a long time to understand it, that I am female inside.

So please, though I know my body still doesn't fit the part, and it never truly will, forgive me if I call myself a girl. It may sound crazy to you, but it keeps me sane.

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.