Gender Transition

This isn't earth-shatteringly important. Just kind of sweet.

I had become resigned to living the rest of my life as if it belonged to someone I emailed with a few times but never actually met, but then came an unexpected 12-month span that turned everything around. My son had graduated from college and my daughter had just started, so they had clearly moved on with their lives. I discovered home movies of my biological dad, who had died before I was born so I’d never seen anything but some photos of him. I turned 60. And there was a pandemic, which brought with it endless hours of isolation and contemplation.

[…]

Once you’re past 60, your internal “fuck counter” hits zero, so I have none left to give. I don’t have time to waste worrying about what others think of me. I only have time to let others see that it’s never too late to be who you’ve always wanted to be.

It’s taken so long for me to find my path, but now that I have, walking along it appears to suit me. Recently, I had drinks with some friends I hadn’t seen for a while. After a couple of minutes, one of them stared at me, waving her hands in my direction, and said, “This just feels right.” That was a phrase I honestly never thought I’d hear.

This:

It’s important to understand that hormones, surgeries, and other aspects of transition do not always result in the dramatic physical changes many of us hope for. HRT, in particular, is often seen as a miracle cure that will bring about rapid changes in fat distribution, breast development, and softening of facial features. While HRT can bring about incredible and affirming changes, it’s not a magic wand. The results can vary widely depending on factors such as age, genetics, and individual body characteristics.

At 55, my body doesn’t respond to HRT in the same way that a younger person’s might. The progress has been slow, and while I am grateful for every sign of change, the truth is that I may never fully meet the physical expectations that the world imposes on women. And that’s devastating—not because I want to conform to societal ideals of beauty, but because I want to feel comfortable in my own skin and be accepted for who I am.

The relentless pursuit of passing can also lead to harmful behaviors. Some transgender women may resort to extreme dieting, over-exercising, or engaging in risky procedures to try to achieve a more “feminine” appearance. The focus on passing can overshadow the actual goal of transitioning: to live authentically and find inner peace. Anxiety, depression, and a sense of failure can take the place of the joy of transition when the emphasis shifts from self-acceptance to meeting external standards.

There is an increasing demand for trans and gender diverse (TGD) health services worldwide. Given the unique and diverse healthcare needs of the TGD community, best practice TGD health services should be community-led. We aimed to understand the healthcare needs of a broad group of TGD Australians, how health professionals could better support TGD people, and gain an understanding of TGD-related research priorities. An anonymous online survey received 928 eligible responses from TGD Australian adults. This paper focuses on three questions out of that survey that allowed for free-text responses. The data were qualitatively coded, and overarching themes were identified for each question. Better training for healthcare professionals and more accessible transgender healthcare were the most commonly reported healthcare needs of participants. Findings highlight a pressing need for better training for healthcare professionals in transgender healthcare. In order to meet the demand for TGD health services, more gender services are needed, and in time, mainstreaming health services in primary care will likely improve accessibility. Evaluation of training strategies and further research into optimal models of TGD care are needed; however, until further data is available, views of the TGD community should guide research priorities and the TGD health service delivery.

Informed consent means that a trans person could access gender-affirming care without any need for mental health  treatment or a lengthy assessment process. This model is routine in the vast majority of all non-transgender medical care. Cisgender people routinely access similar hormonal medications as trans people without a mental health diagnosis for conditions like polycystic ovarian syndrome, precocious puberty, menopause, loss of virility with age, and birth control.

Many doctors worldwide use a gatekeeping approach to gender-affirming care, but the informed consent model for transgender hormone replacement therapy is also widespread in the United States—a map of IC providers created by activist and journalist Erin Reed lists nearly 1,000 such providers in this country. This has been the result of decades of advocacy by the trans community to have our healthcare approached similarly to other comparable treatments. 

[…]

How do we know that informed consent works better? Well, to start, granting trans people significant levels of autonomy over their medical care is in line with the ethics of the medical profession, which directs doctors to engage in shared decision-making and uphold client autonomy whenever possible. As Bryan Murray puts it in a piece for the American Medical Association Journal of Ethics,  “Informed consent is at the heart of shared decision making—a recommended approach to medical treatment decision in which patients actively participate with their doctors.” Scholar Madeleine Lipshie-Williams points out that the gatekeeping mode for gender-affirming care is at odds with how the majority of medicine is practiced in the U.S.: “[the gatekeeping model], which requires medical professionals to provide official opinions on a trangender patient’s readiness to accept and undergo care, stands in contrast to the majority model of medical consent in the US.” Lipshie-Williams also argues that the informed consent framework is preferable because it is necessary for the normalization of trans identities: “there cannot be a depathologizing of transgender identity as long as transgender individuals are required to be seen by mental health specialists to confirm both the validity of their own self-proclaimed identity, as well as their mental fitness to consent to medical interventions that have been broadly accepted as necessary. There is an inherent contradiction in declaring medical care necessary whilst simultaneously maintaining that those for whom it is necessary continue to lack the capacity to consent to this care without assistance.”

The study, conducted by experts from the University of Wisconsin School of Medicine and Public Health, examines reported regret rates for dozens of surgeries as well as major life decisions and compares them to the regret rates for transgender surgeries. It finds that "there is lower regret after [gender-affirming surgery], which is less than 1%, than after many other decisions, both surgical and otherwise." It notes that surgeries such as tubal sterilization, assisted prostatectomy, body contouring, facial rejuvenation, and more all have regret rates more than 10 times as high as gender-affirming surgery.

[…]

The review also finds that regret rates for gender-affirming surgeries are lower than those for many life decisions. For instance, the survey found that marriage has a regret rate of 31%, having children has a regret rate of 13%, and at least 72% of sexually active students report regret after engaging in sexual activity at least once. All of these are notably magnitudes higher than gender affirming surgery.

[…]

The review has sharp critiques for those who use claims of “regret” to justify bans on gender affirming care: "Unfortunately, some people seek to limit access to gender-affirming services, most vehemently gender-affirming surgery, and use postoperative regret as reason that care should be denied to all patients. This over-reaching approach erases patient autonomy and does not honor the careful consideration and multidisciplinary approach that goes into making the decision to pursue gender-affirming surgery… [other] operations, while associated with higher rates of post-operative regret, are not as restricted and policed like gender-affirming surgery.”

Look at the range of those publication dates. Some are as old as I am, and only five of them were performed in the last decade. These aren’t lazy providers, for clarity! They’re doing their best! The focus on our health is just that bad. Take this study on progesterone, for example—it set out to see if progesterone affected breast growth in trans women… and ran for three months. On nineteen participants. That’s a ludicrously small sample and time period.

That, coincidentally, kind of brings us to the point: I’ve said a whole bunch that all science has a half-life, right? Well, back when most of the “recent” research was done on the effects of estrogen and testosterone on trans people, “the duration of puberty was [thought to be] 1.96 +/- 0.06 years” for cis girls, for instance, and a similar length for cis boys. In the last twenty years, however, a lot more science has been done, prying that window wider and wider, at least doubling that length, now, strong data says that puberty lasts around 10-14 years. It makes sense that doctors studied HRT the way that they did. When they did it, they thought that that was as long as puberty lasted. That part just… turned out to be wrong.

Simply put: trans folks are a marginalized, oppressed group which relies on the dominant group to research our medical needs. We, in general, don’t get a say in the research done on us, and it’s why I haven’t—and won’t—write an article about best practices on HRT that’s more specific than “stay within either male or female ranges, or work with an endocrinologist to find a nonbinary combination of estrogen and testosterone that’s right for you.”

We don’t have the research data.

And frankly? It’s not coming. I’m not aware of any meaningful, long-term research that compares different methods, doses, or approaches for HRT that’s currently in process.

There’s basically two reasons someone transitioning gets made into a Big Deal: the trans person excitedly making it a big deal, and someone who doesn’t believe trans people should exist gets upset about it.

Trans people usually make a big deal out of our transitions because a lot of us have suppressed this part of ourselves for a long time, and it feels really good to let that part of ourselves out for everyone else to see. Some of us might have known we were trans for most of our lives. Some of us, like me, might not have known until recently. Either way, we had to hold that part of ourselves in, essentially telling ourselves a lie about who we thought we were, or were trying with all our heart to be.

And living like that? Wow, it sucks.

In the early days of overwhelming emotion, it can feel like you’re walking through a conversational minefield. Remember: it’s normal and okay to feel whatever feelings you’re feeling. But it’s not okay to let all that emotion fly out of your mouth without modulation. This is particularly true when your trans loved one is a child. It’s not a kid’s job to solve your struggles; it’s the other way around, and the burden could very well be too much for them to bear.

Regardless of the age of the trans person in your life, the list of statements and questions below are likely to trigger conflict and are best avoided.

Believe it or not, a whole lot of what you’ve heard about being trans—from this to the whole “born in the wrong body” thing to a lot of other stuff—was made up by cisgender doctors back in the 1960’s, because they believed it was their duty to keep as many people from transitioning as possible. It’s… kinda messed up.

In reality, there’s no one way to be trans. There are no rules, no requirements, no “you must be this trans to count.” If you want to be a gender that’s not your AGAB? You’re one of us. Period.