Transgender London

Transition To A New Life

Transition is change. For the transsexual it is often life saving after a long time of anxiety and dysphoria that can be debilitating. What many overlook is the fact that transition itself can be just as stressful and create new anxieties. Equally stressful is that not everyone is a candidate for full transition.

Let's start with the process itself and go from there. It is worth noting at the beginning that this article follows the WPATH protocols. These protocols are required to be proven as being completed to all SRS Surgeons before they will commit to doing the surgery. So, like it or not, they must be followed within the WPATH guidelines.

Therapy

I have written much about therapy on this site because I am a very strong advocate for it. I have met transsexuals who are totally opposed to it on the grounds that their business is theirs and no one else's. It is first of all a foolish attitude in my opinion because we can all make good use of it personally and should before any gender issues are considered.

A life of the terrible trio of Guilt Shame and Fear takes its toll on us; all of us. Anyone who believes their life as a transsexual has been normal should truly seek out help. Full transition will require that the transsexual undergo psychological therapy by a licensed Psychiatrist, Psychologist, or Social Worker with a Master's Degree and specializing in gender. This is a requirement of WPATH and the Harry Benjamin Standards of Care and the psychological caregiver must be able to prove their expertise in the field of gender care.

There are 2 basic forms of therapy, Humanist Existentialist and Cognitive Behaviour. Of these, the former is the recommended protocol for treatment of gender. This approach treats the "whole" person, not just a singular issue. As a result, the life lived is used to identify problems the patient has created for themselves and allows the patient to come to terms with how and why they were created as well understand how they are affecting them today. With this understanding, the patient can then develop strategies to avoid recurrence in similar situations.

Cognitive Behaviour treats the behaviours first. In this case since transsexualism is considered as a physiological/neurological condition, the behaviours are not treatable. This leaves only the choice of attempting to substitute for those behaviours. When it is unsuccessful (which is the case) then the therapist can arrive at a diagnosis of Gender Identity Disorder. The underlying problem with this approach is simply that the barriers the patient has put up over time have not been resolved.

During this time the patient/client must come to terms with their transsexualism as an intrinsic part of their person. They must come to a point of embracing the whole person. This self acceptance is usually a very long and painful process but is essential for personal growth.

In some cases group therapy might be indicated.

Therapy is essential for successful transition past any SRS to ensure that the adjustments are healthy. This may include family counselling. In this writer's opinion it should be essential since often the transitioner is vulnerable and family could easily interfere. In many cases the transitioner discards all but the strongest of familial ties.

The caregiver will insist on the patient living and working in their true gender for a period of not less than one year. During this time therapy will focus more on social adjustments in this new role. Once this requirement has been met, a referral for second opinion of diagnosis is required and two letters recommending SRS are generated. The surgeon will require these letters of recommendation.

Hormone Replacement Therapy (HRT)

This is recommended in a single letter by the primary psychological caregiver. This letter states that in the opinion of the psychological caregiver, the patient has firmly established their gender identity and accepted it. This recommends the patient to begin HRT. HRT can be administered by any qualified medical doctor but most are uncomfortable doing so. They will usually refer the patient to an endocrinologist

The "Endo" will interview the patient so they are satisfied that this is a correct approach. Once they are convinced that HRT is indicated they will order a series of blood tests. These tests are used as a baseline for monitoring the patient's health after HRT has begun.

In a nutshell, the doctor is removing the primary hormone and substituting it with the "correct" hormones according to gender. In the M2F transsexual this will normally include a Testosterone Blocker, a DHT Blocker (if indicated), Estrogen, and possibly Progesterone. The selected medications and dosages are tailored for each individual. What works for Sally may not work for Sue.

Before any SRS, the surgeon will usually insist that the patient be on HRT for a minimum of one year. In some cases where anti androgens create kidney and/or liver problems for the patient, the surgeon may waive that requirement. Doing so allows for only administration of Estrogen and/or Progesterone post SRS since the testes are removed during surgery.

For the F2M the skin will will thicken and become more oily. Hair growth including beard growth and pattern baldness may appear. The voice will deepen slightly. Greater muscle mass will be gained particularly in the upper body. When initially starting testosterone treatment, a massive rise in sexual urges will occur although with time this will level out.

For the M2F the skin will thin and become noticeably softer. Depending upon the antiandrogen regimens used, some pattern baldness may reverse itself and hair regrowth in these areas may occur. Other hair distributions may disappear or become noticeably thinner. Fat will be redistributed to provide a more female appearance to the hips and of course breast growth will occur. Let us not forget the removal of any sex drive.

It is worth noting that breast growth is not normally large often requiring augmentation surgery. It is usually considered that the M2F will see a breast size of about 1 cup smaller than her mother or sisters' sizes. There are many factors affecting this and breast growth is largely unpredictable. However, Bioidenticals (herbals) have not proven to assist the process and in fact may be harmful. Any evidence to the contrary is anecdotal and therefore suspect.

Many M2F's have reported becoming more sensitive to temperature changes. Normally, emotional responses also become frequent but they too will level out over time.

It is during this time that the transsexual is usually required to begin RLE (Real Life Experience) where s/he must live in their true gender role 24/7.

Real Life Experience (RLE)

This is without a doubt the most difficult phase of transition and in truth is the actual transition. The transsexual is required to live, work and socialize in their true gender role during this time. The birth gender is left behind. This process is a minimum of 1 year and often much longer.

For many, this is a time when "coming out" occurs adding to the already dramatic changes in lifestyle and appearance. Family and friends are informed and jobs are disrupted or lost. A well planned transition would hopefully have this occurring before RLE so that the focus is on the transition and not on trying to deal with family and other support systems.

There is no right or wrong way to "come out" since every case is different. It is impossible to predict how people will react.

It is during this time that legal name change takes place. This is usually accomplished without too much trouble. Documentation change however is another story. Having the "sex" portion of documents changed is largely subject to local law. For instance, some jurisdictions will allow for the sex to be changed with only the proof of RLE while others will require the person to undergo SRS. This is and will remain a sticking point with many since RLE is the actual transition not the surgery. This particularly places many F2M's at a major disadvantage because SRS is not always a viable option for them despite the fact they fully identify as male in all other respects. Equally, many M2F's will not opt for SRS yet their documentation cannot be changed without it. This is a serious setback for many however there are also good reasons for denial without SRS. If one is to travel, the documents could be viewed as false and in some countries, presenting as your true gender without having had SRS could land you in jail.

Beard removal is often done during this time as well as some cosmetic procedures such as Maxillo-Cranial surgery (for Facial Feminization (FFS)), tracheal shave and even breast augmentation.

Of course those planning for SRS spend much time doing so during this phase of transition.

Sexual Reassignment Surgery (SRS)/Genital Reconstructive Surgery (GRS)

This is the icing on the cake, the completion of a long and arduous process. This surgery is often thought of as cosmetic by those outside the community however you will never convince anyone seeking SRS that it is cosmetic; it is not. It is reconstructive. Genital appearance is reconstructed to match the gender identity of the transsexual. It is irreversible and as such approached with the utmost of caution by both the person seeking the surgery as well as the medical community itself.

Not everyone seeking SRS will be granted permission to have it. Many factors can override it. The person must be certified as mentally healthy and suffering from Gender Identity Disorder. If there are any other mental conditions such as Bi-Polar disorder or Obsessive-Compulsive Disorder then surgery is usually contraindicated.

Physical condition is also a consideration. Most surgeons have limits of weight to which they will operate. The patient must also be free of smoking for a minimum period specified by the surgeon. Liver and kidney functions must be normal as well as heart and lungs. In short, the surgeon will not operate on a patient who is not both mentally and physically healthy.

The final determination for SRS is by the surgeon. If there are any doubts at all, s/he may ask for a separate psych evaluation before going ahead, as well as any number of blood tests and/or x-rays which are normally provided in advance.

All of this of course comes after the patient has provided 2 letters recommending SRS from qualified mental health practitioners who must necessarily be independent of one another, be able to certify their qualifications and assure the surgeon that in their expert opinion the patient is a candidate for SRS.

Post operative care and recovery normally takes several months for full recovery at which time secondary procedures such as a labiaplasty may be looked into. This can be done in a well equipped office/clinic by a qualified OB/GYN or by the original surgeon. It is an expensive procedure and purely cosmetic in nature.

HRT is normally indicated for at least another 2 years post op as is therapy.

The process of full transition is long and difficult with many safeguards built in place along the way. This minimizes the potential for error although occasionally someone does slip through the cracks. Still, it is impossible to fathom why anyone would go to these extremes who wasnt first of all sure of their true gender and secondly, willing to make massive and permanent physical changes on a whim. The financial and physical costs of transition are very high and while viewed as a barrier by many, also can be seen as one more check and balance in the system.

This site was last updated 08/11/10