Paths And Possibilities (Warning: Anatomical Content!)

So, the dance continues - more blood tests before there can be a decision on my being cleared to start on testosterone.

Before this starts to sound like a complaint, I should mention that I dearly love my doctor - doctors, actually, both my primary and the sort-of-specialist (by experience rather than training) who will be overseeing the medical aspects of my transition.

What those aspects will be is still a bit up in the air. I have numerous health problems, enough that I originally assumed the answer to any query I might make about hormone therapy would likely be, “Are you insane?” But then came a time when I knew I needed to ask - and now I have two new allies whom I cherish.

And I appreciate that they are concerned about the whole person. They’d like me to actually live long enough to enjoy this new life I’m pursuing! I confess, I’d like that too. And my health is a mess, neglected through many, many years of depression and near-hopelessness. (And if that doesn’t sound like an accurate self-portrayal to those of you who know me, then I invite you to take this moment to appreciate what a great actor I am!)

So I understand the need for this sudden whirlwind of testing - but the dance is driving me crazy. Because every time I come to a possible turning point on this path, I get the jitters. Will this be the moment when I run up against a wall, or will there still be an open door, even if open only a crack?

Not many things make me jittery. Public speaking? Sign me up; I like being on stage! Test-taking? Hey, I thought the GRE (the grad-school version of the SAT) was kinda fun. Physical danger? I used to be a pretty decent juggler, and my favorite toys were lit torches. Job interviews? Well, I loathe job-hunting - but the interviews themselves only make me pleasantly nervous. Not like this.

Which makes me realize how important this whole transition thing feels to me... how deeply emotionally invested I am in it, even if I play calm about it most of the time.

So as I collapse here, recovering from this latest attack of the jitters, I’m going to take the time to sit down and write about the actual medical processes of gender transition - what it is, how it works (and how it doesn’t work), what choices and risks are involved in it - so that those friends and readers who haven’t devoured as much of the library and/or the internet as I have (or at least not its more esoteric portions) will have more of a clue what I’m talking about, and why it’s such a complex, and occasionally nervewracking, path to enter on.

You see, voracious reader that I am, and deeply fascinated by all things gender-related since childhood, I often forget that others don’t really know how all this stuff works - that it’s not a part of most people’s world. And even those who are fairly trans-savvy tend to have more knowledge of the opposite path, since it’s more often seen. (Both in the media and in real life, interestingly enough; statistics vary, but there are definitely more transwomen than transmen out there - at least when it comes to those who choose to physically transition. Exploring the reasons for that might be another blog entry all on its own!)

To a great extent, the media still refers to “getting a sex change” (or in the old parlance, “having a sex-change operation”) as if it’s a one-step choice and a clearly-defined, one-size-fits-all process - you go to Geneva with a beard and a penis, and come back with D-cups and an hourglass figure (or vice-versa). Of course, as Americans, we get most of our understanding of such stuff from media outlets that aren't necessarily dedicated to telling the whole complex story... and I don’t just mean Jerry Springer. Hmmm... so did your favorite 80‘s TV-series have a “sex change” episode, in which a main character meets up with an old college football buddy who is now unexpectedly wearing high heels (and looking killer in them)? Seems like every series had one (and they always fascinated me - I vividly remember seeing that ep from “WKRP In Cincinatti,” and I just randomly caught a rerun of the one from “The Love Boat”... boy, was Gopher a jerk in that one!)... and please note, if you will, that the transwoman was always played by a “real” woman, so that she would appear to pass flawlessly as a mainstream-gorgeous female... unlike the reality for many true transfolk. And I don’t think I’ve ever seen one involving a male transperson... well, not from that time period, anyway. (If you know of any, I’d be curious to see them, so please let me know! And yeah, I love the future version of Meg in the Family Guy time-travel episode...)

In reality there are probably as many ways of making a gender transition as there are opening combinations on a chessboard. And it really is a lot like chess, complete with strategic decision-making, positional play, and of course, the occasional sacrifice of one piece for another!

There are three basic stages to a “complete” gender transition. I’ve put “complete” in quotation marks because it implies something that isn’t true: namely, that one is not “finished” transitioning until all three stages have been accomplished. More on that in a bit.

The first stage is generally hormone therapy. Estrogen helps to “soften” the angular male face and body; testosterone “hardens” the more rounded female form. There are other effects as well, and this is the realm in which transmen definitely have it easier than transwomen. Testosterone can be almost magical in its masculinizing effects - but estrogen can’t un-grow a beard or un-deepen a voice. (Thus those transitioning to female may also need electrolysis, voice retraining, even cosmetic surgery - if they can afford it.) But hormone therapy alone can do quite a lot toward making one’s body feel (and look) more comfortably right - and some transpersons stop there, never seeking any surgical changes at all. For some, it’s simply good enough, and the rest doesn’t matter; for others, it’s a question of cost - surgeries are expensive, as is the loss of time involved. Of course, hormone therapy isn’t exactly cheap either, and there are decisions to make regarding dosages and methods of delivery (oral, sublingual, topical, injection, etc) that can affect how well and how safely it works, as well as lots of monitoring, especially for those who have health issues to begin with.

The second stage is generally “top surgery" - mastectomy or mammoplasty. There are a number of different options for each type of surgery, and they can differ greatly both in cost and in results. For transmen, so far I’ve counted about about half a dozen different possible techniques; the choices depend in part on how much money you have to spend, in part on what you’re starting with (techniques that work well on someone with an A cup may not even be possible on someone with a double-D) and in part on what you’re aiming for (i.e., if you want to ever be able to take your shirt off in public, that requires more reconstruction than a simple mastectomy). For some, top surgery is the only medical transition procedure they ever choose - no hormones, no further surgeries. The presence or absence of breasts is, after all, one of the biggest gender-cues that people respond to, one of the hardest to hide and/or to fake realistically... and one of the biggest pieces of looming “wrongness” in one’s own body-sense.

The ultimate stage is, of course, “bottom surgery,” referring to changes in the genitalia. There are plenty of transfolk who never take that step; the financial cost here is highest - as is the personal cost, because it can involve loss of sensation and/or sexual responsiveness, as well as certain pragmatic difficulties (such as learning to urinate all over again, hey, what fun). And this is definitely the realm in which transwomen have it way, way better than transmen; procedures for female-to-male genital reassignment are far less advanced than the corresponding male-to-female surgeries. The choices for transmen are all compromises of one sort or another. (Do you want normal size or sexual responsiveness? Can’t have both. Oh, and you don’t mind a bit of really bad scarring, do you? Or maybe a lot of really bad scarring, some of it on entirely unrelated parts of your body...) So far I’ve counted probably about a dozen and a half various procedures for FtM bottom surgery, some of which are quite bizarre.

But it‘s also important to realize that “normalization” of the genitalia just isn’t important for many transpersons, male or female. Remember, it’s about gender, not sex! One proof of this, perhaps, is that I’ve actually never yet heard of any transman or transwoman choosing, or wanting, only bottom surgery and nothing else! Because gender isn’t about what you do in the bedroom, or at least not very much. Gender is more about what you do in the office, in the elevator, in the grocery store, and at church; it’s about how others interact with you, how they perceive you, your level of comfort or discomfort in social groupings, and with unspoken assumptions and expectations... and most importantly, the level of comfort or discomfort, of congruence or disjunction, in your own self-perceptions and body-sense.

Anyway, back to the explanation of medical transition... to this morass of confusion, add the fact that some steps are dependent upon other steps having been already completed (e.g., some surgeries can’t be done until hormonal transition is complete) and some steps preclude other steps (e.g. if you’ve already had a mastectomy you’re probably not a candidate for chest reconstruction), and maybe you can see why trying to figure out the whole thing all at once is migraine-inducing. Then add in the fact that the qualifiers for LEGAL change of gender vary from state to state, and many of them require proof of “complete” surgical transition... which many transpersons either cannot financially afford, or do not want because of its far-less-than-perfect outcomes. Did I say “morass”? I could think of some other words...

I stand at the very beginning of this path, not sure how I’ll choose to pass through it - or even how much of that choice will be mine to make. So if I sometimes seem a little preoccupied with it, be gentle with me, please. I may just have a migraine... or some serious jitters. Or perhaps even a rush of joy and excitement, when a door I've watched and waited by suddenly stands fully open at last.