Not Enough Resources!

The recent directive disallowing exclusions in California healthcare plans for care related to gender transition is significant progress! I continue to be excited by what this may mean for transgender CA residents with health insurance.  The next obstacle to overcome? The absolute dearth of trans-friendly/trans-competent resources in many parts of the country.

I get emails from people from all over the US, seeking gender transition and not living near any well-known resources in order to be assisted therapeutically or medically. I often go immediately to Google after receiving such an email, for which I always chide myself. My peeps know how to Google, and Google well. Do I really think I can Google resources in their area, and something is magically going to appear for me that did not for them? No. If a resource was available on the internet, it would have been found. “Did you try Laura’s Playground?”. Yes, they have usually looked for resources on Laura’s Playground. Then I’m stumped. I start reaching out to people who may happen to know of something that is not easily accessed on the web.

(A special shout out to Zander Keig, an incredible advocate for the trans* community and someone who is always willing to help me look for resources when I hit a brick wall.)

It would be one thing if this were just about logistics; it’s not. These are not just emails looking for resources; they are pleas for help. Pleas for help peppered with “I don’t know how much longer I can do this” and “I can’t remember the last time I was happy.” There’s an urgency inherent in these emails that cannot be ignored, and makes finding no resources in their area all the more frustrating.

I may not be able to see them in person, but I can still picture the look in their eyes, and on their faces. It’s a look I’ve seen countless times before in many of the clients I’ve had the honor of meeting with face-to-face.  It’s a look that tells me the internal obstacles they’ve overcome were overwhelming enough; obstacles to resources are sometimes more than they can bear.

There needs to be MORE gender therapists, gender clinics, and endocrinologists/doctors willing to treat this population.  Every major medical center and hospital should have doctors employed who are knowledgeable and equipped to medically prescribe hormones to the transgender citizens of this country.  I think back to my first transgender client; I knew next to nothing about the therapeutic and medical needs of this community.  This first client gave me a chance and the rest, as they say, is history.

If you are a transgender person or a loved one, seek resources where you think there are none. Talk to therapists and doctors to see if they are willing to get educated and begin working with this population. There are excellent sources of information to guide professionals new to this arena, such as the World Professional Association for Transgender Health (WPATH) Standards of Care and the Center for Excellence Primary Care Protocol.  Somehow we’ve got to make this circle bigger so that care is readily available to ALL.

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Physical Transition Options for the Transgender Individual*

In conjunction with my last blog, “What’s in YOUR Pants?”, this blog is about physical transition options for the transgender individual. As stated in the aforementioned blog, many people ask about surgery the first time they hear about a transgender individual’s plans to transition. It may surprise many people to find out the transgender individual has no plans to pursue surgery, specifically genital surgery.

I recently watched a documentary called “Diagnosing Difference” by Annalise Ophelian (excellent; I highly recommend it!).  This quote from that documentary summarizes perfectly what I was trying to say in my last blog, and leads nicely into what I’m going to explain in this blog. “There’s this huge stereotype that trans people all have genital surgery, that we know that someone’s really the new gender because they’ve had genital surgery, and that’s one of the biggest misconceptions about trans people. In reality, the vast majority of trans people will never have any surgery, and many trans people have surgeries that aren’t genital surgeries. [Italics added.]  And some people don’t have surgeries and don’t undergo medical care related to their gender because they don’t want it, it’s not appropriate to them, there’s other ways that they’re expressing their gender, and some people don’t have it because it’s not available to them, it’s not covered by their insurance…and so for both of those reasons, rules that govern are you really trans or have you really transitioned based on genital status or surgical status are very damaging to trans people’s well-being.” –Dean Spade

Hormone Therapy

OK, so before I get to surgery, let me talk a little bit about hormone therapy, or hormone treatment. Hormones are often a huge part of the physical transition process. Transmasculine individuals can opt take Testosterone or “T” (by patch, cream, or injection, most commonly injection). Doses vary depending on the individual and his desire for physical outcomes. Often the first changes that occur from taking Testosterone are the deepening of the voice and facial hair. These are also two irreversible changes that occur from taking T. Other changes include changes in facial features, head shape, clitoral enlargement, and fat redistribution (less on hips/butt/thighs, more to stomach). For more information regarding this type of hormone therapy, visit http://transhealth.vch.ca/resources/library/tcpdocs/consumer/hormones-FTM.pdf or http://www.ohio.edu/lgbt/resources/transoptions.cfm.

Transfeminine individuals may opt to take Estrogen, which can be administered orally or by injection, most commonly in a pill form taken orally. This regimen often includes an anti-androgen such as Spironolactone, which blocks the effects of testosterone.  Results from taking Estrogen include but are not limited to: breast growth, softening of the skin and facial features, lessening of body hair, and changes in fat distribution (less on abdomen, more to hips and bottom). For more information about this type of hormone therapy, visit http://transhealth.vch.ca/resources/library/tcpdocs/consumer/hormones-MTF.pdf, http://www.transgendercare.com/medical/resources/tmf_program/tmf_program_6.asp, or http://www.ohio.edu/lgbt/resources/transoptions.cfm.

Female-to-Male Surgical Options

FTM individuals have the option of two types of surgery, commonly referred to as “top surgery” and “bottom surgery”. Top surgery refers to the removal of breasts, the shaping of a male chest, and re-sizing the nipples. In my experience, this is the most commonly pursued and desired surgery for the FTM individual. A main reason for this is that the removal of breasts eliminates the need to bind (http://www.ftmguide.org/binding.html) and also helps the individual “pass” as male. Many (if not most) FTM individuals pursue this surgery, and those who don’t often cite the obstacle of not having the finances for it. Top surgery commonly costs between $6-10k, out of pocket.  For more information re: FTM “top surgery”, please visit: http://www.ftmguide.org/chest.html.

As for “bottom surgery” (surgery to construct a penis), most FTM individuals do not pursue any genital reconstruction surgery (GRS). You read that right, most DON’T.  Finances are often a major obstacle; GRS costs anywhere from $20k to $70k, depending on the procedure.  Additionally, many FTM individuals are not happy with the options/projected results; techniques have not been perfected enough to deliver optimal results. Additionally, some FTM individuals don’t have a problem with their genitalia or see the need to have it changed. (Remember, one’s genitalia has more to do with one’s anatomy than gender. For a refresher on the difference between Gender and Sex, visit my blog Gender Vs. Sex.)

For those who do pursue “bottom surgery”, there are a few options. These include but are not limited to: a metoidioplasty, which involves cutting the ligament connecting the (now enlarged, thanks to T) clitoris and removing extra skin, resulting in a small phallus. The urinary tract can also be lengthened if the individual wants to be able to urinate while standing. Another surgery called a “phalloplasty” is basically the creation of a penis using skin from a donor site on the individual’s body, most commonly the forearm.  If the trans man desires testicles, the skin from the labia can be used to create a scrotum. At least six months after a phalloplasty, testicular and penile implants can be inserted.  To quote Hudson’s FTM Resource Guide, “Phalloplasty usually involves a urethral lengthening procedure so that the patient can urinate through the penis. Erections are usually achieved with either a malleable rod implanted permanently or inserted temporarily in the penis, or with an implanted pump device.”   For more information regarding GRS for FTM individuals, please visit http://www.ftmguide.org/grs.html or http://www.savaperovic.com/ftm-srs-metoidioplasty-total-phalloplasty.htm.

There are MANY different options for FTM individuals who don’t choose to or who can’t afford bottom surgery. There are all sorts of accoutrements available for purchase that allow the trans man to stand to urinate, wear a penis, and/or to have intercourse. In order to stand to urinate, there are “stand to pee” (STP) devices. (http://www.ftmguide.org/packing.html#stp)  If the trans man prefers to wear a penis, full-time if desired, this is called “packing”. (http://www.ftmguide.org/packing.html) There are a variety of different packers available for purchase.  (http://www.tranzwear.net/store.php?seller=TranZwear&navt1=101317&navt2=101323. For a 15% discount on purchases from tranzwear.com, use discount code “TRANZ” when checking out.)  For sexual intercourse, there are also a variety of options to choose from (http://www.ftmguide.org/packinghard.html).  I should add here that not all trans men choose to pack or wear any kind of prosthesis. As with any group of individuals, there is a spectrum of preferences about this!

Male-to-Female Surgical Options

Facial feminization is a common surgery pursued by MTF individuals. This can include changing the hairline, frontal bone contouring, mandible contouring, chin augmentation or reduction, rhinoplasty, lip augmentation, etc. I don’t know the exact numbers on this, but the cost of this surgery can be upwards of $30k. For more information on facial feminization, visit: http://en.wikipedia.org/wiki/Facial_feminization_surgery. Some trans women opt to undergo breast augmentation surgery. (Estrogen often does not enlarge one’s breasts to more than a “B” cup.) http://marcibowers.com/grs/breastaug.html

As for MTF “bottom surgery”, often referred to as Sexual Reassignment Surgery (SRS) or Genital Reconstruction Surgery (GRS), many transgender women opt to undergo a vaginoplasty, using skin and tissue from the penis to create a vagina, clitoris, clitoral hood and labia.  This is another expensive surgery not covered by insurance; I don’t know the exact figures but what I could find implied a ballpark figure of $20k. Sue Boyd, LCSW, a trusted colleague of mine who works with more MTF individuals than I do, estimates that about half of her MTF clients opt to pursue this surgery “expense and all”. My guess is because the results are more satisfactory to the consumer than the current results of FTM bottom surgery. For more information on MTF GRS, please visit: http://www.thetransgendercenter.com/transgendersurgerymaletofemaleMTF.html or http://en.wikipedia.org/wiki/Sex_reassignment_surgery_(male-to-female)#Genital_surgery.

I should say again that all of the above depends on personal preference. Some individuals believe opting to get any or all of the above surgeries is a way of buying into the gender stereotypes prescribed by society, particularly about how a man or woman “should” look. To quote the film “Diagnosing Difference” again, “I think ‘passing’ is a word to discriminate us immensely. Not everybody can pass. And passing is something that the doctors will tell you to do, you try to pass. Well, no matter how much I pass, I will never be a biological woman. How about empowering me as the transgender woman that I am?” -Adela Vazquez

A moment on my soap box:

After reading all these extensive options a transgender individual confronts, don’t you wish things could be a little bit easier? They can be. By intervening EARLY with a child or pre-adolescent who has yet to start puberty, their future does not have to hold as many medical interventions! For the MTF individual, staring on hormone blockers pre-puberty would prevent facial hair from growing in, thereby preventing HOURS of painful and expensive electrolysis. Hormone blockers would also prevent one’s Adam’s apple from growing and the voice from deepening, which would eliminate the need for a “trach shave”… ouch! Similarly, staring hormone blockers pre-puberty for the FTM individual would prevent breast growth and ultimately prevent an expensive and painful “top surgery”. Additionally, for the transgender individual who desires to “pass” as their true gender, intervening early gives them the best chance at doing exactly that. For more information about hormone blockers and intervening early for transgender children, please visit http://transhealth.ucsf.edu/trans?page=protocol-youth.

*Disclaimer(s):

  • I am a Licensed Clinical Social Worker, not a medical doctor. The information contained in this blog should not be considered a replacement for medical advice or consultation.
  • The websites used in this blog should not be considered as endorsements but rather sources of information.