Order of Operations

The head of my workshop said she was struck by the way I insisted that I had no right to make decisions – but then went on to make nothing but decisions.

When you transition, you don’t go to a doctor – internist, endocrinologist, psychiatrist – and tell them that you are going to transition.  You present yourself and ask permission to transition.  Your doctor interviews you to check that you are stable and get a sense of your rationale.  This process usually takes at least a few months, and can take much longer.  Then you are given a prescription for hormones.  Several months later, or even long after that, your doctor will start the process of recommending you for surgery.  In the meantime, you will have to research surgeons and procedures, and your doctor will continue to supervise your response to hormones.  (You could say, “your progress,” but it isn’t necessarily such directed oversight.)

Eventually, months or years after you start hormones, your doctor will write you a recommendation letter for “top” surgery.  After that, you go through the same process for “bottom” surgery.  Along the way, you’ll cooperate with your doctor to negotiate legal and social transition – coming out at work, coming out to your family, changing your name.

Your doctor can impose whatever extra standards they like, including standards based on sexism or transphobia.  They might insist that you attempt to transition or come out before starting hormones; they might insist that you present in an especially feminine or masculine way; they might delay your surgery recommendation if they have reservations about your stability.  Sometimes these standards of care come from a professional association, like WPATH in the United States; sometimes they’re legal requirements or required by a national health service.

Your doctor can impose arbitrary timelines not listed in the current standards of care, or even refuse to see you or cut you off.  If you move or find yourself needing to change doctors for some other reason, you may have to start over.  There’s no petition you can make, no oversight you can invoke; the doctor has the final say in whether or not you are allowed to transition.  You cannot obtain hormones without a prescription, and you cannot undergo surgery without approval.  The doctor, for clinical purposes, decides whether you are really transsexual.  In the United States, you cannot legally change gender without a letter from a doctor attesting to your surgery or transition status (specific requirements vary from state to state).

Pure self-determination was originally a sign of instability – it was a mark against you, and a sign that you were not ready and that you might have unrealistic ideas about what transition involved.  A patient who was impatient or overeager – a patient who seemed unwilling to cooperate with their doctor – was a worse transsexual.  That stigma is outdated, and doctors are no longer encouraged to look askance at patients who want too much or too fast, but doctors are still in control, and delays for vetting and reflection are still standard.

So within the context of clinical practice, the transsexual patient does not have the right to make decisions.  To transition in the care of a doctor is to have training in surrendering a certain level of control over your identity and shape to your doctor.  And the idea of transition as therapeutic process – as treatment with a standard schedule and professional oversight – itself removes transsexuality from lay comprehension.  A transsexual person is not qualified to oversee transition independently; a transsexual person must begin as a patient.

I was a special case.  Properly speaking, I wasn’t transsexual: I belonged in the gender I had been assigned to at birth.

Nor did I need medical intervention to transition.  Since I hadn’t undergone a hysterectomy, my body provided its own hormones.  Since I had only undergone liposuction, and not removed any mammary tissue, my body deposited fatty tissue on my chest by itself.  Because of my cissexual status, my body had begun its first transition as a feminized, “passable” body.  My psychiatrist classed this as an extremely lucky instance of male-to-female transition, but it also meant that my relationship with medicine was less dependent than it might have been.

I don’t know what would have happened if I had needed exogenous hormones or reconstructive surgery.  Since I am not transsexual, I might have been able to access exogenous estrogen as a post-hysterectomy woman.  I might have obtained implants as cosmetic or reconstructive.  My doctors would not have been overwriting an original assignment with its own assumed legitimacy.  I might have been able to present myself as a mutilated or impaired woman – a patient whose natural state was supported by augmented breasts and exogenous estrogen, and whose belief that she was a woman was incontestably sane.

On the other hand, I might have been flagged as unstable – I had been overeager, unsure of what I really needed.  A second surgeon might have wanted a second recommendation letter; my psychiatrist might have wanted a delay before allowing me to obtain surgery.  I might have been required to undergo therapy in preparation for exogenous hormones, or questioned beforehand.  My transition might have tainted my identity, or rendered my desires suspect.  It may even have rendered me volatile: a doctor supervising transition is enjoined to consider not only the eventual outcome, but also the stresses of change.  I could have damaged my equanimity, moving so quickly from one state to another.  Reacting to my initial transition as trauma could have impeached my readiness to transition a second time.

I have no idea what logistical problems I would faced if I had legally changed my gender or my name.  I might have had a right of return; I might not.  I might have had to legally retransition; I might not.  I might have been stuck, or subject to extra scrutiny – the number of people who have legally changed gender twice is vanishingly small.  I may have had to establish precedent in my own state.

I don’t think my therapist would have been unsupportive.  I doubt very much that she would have imposed any significant delay.  I doubt it would have been difficult to find another, more supportive doctor if she had been unhelpful.  I think that law and medicine would both have given extra credence to my birth assignment – I think there likely is a “right of return” for patients who transition and then want to go back, simply because we are trying to reestablish ourselves as cissexual.

I also do not think that I would have faced much difficulty in obtaining breast implants, since they are so common, and typically classed as cosmetic for cissexual women.  I don’t think a responsible doctor would restrict a post-hysterectomy cissexual woman patient’s access to exogenous estrogen.  I don’t think doctors themselves face as much scrutiny for handing birth-control pills to cissexual women, or for referring them for breast implants.

But the doctors would decide.

Whatever rights I might have had, I didn’t feel entitled to any role other than patient.  I felt dependent on my doctors to judge and direct me.  I didn’t think I had any right to say what I wanted; I wasn’t sure I could have what I wanted.  I’m not sure I would have fought any restriction, even though I was desperate to look and feel like a woman again.  I wanted their expertise and I wanted their care.  I would have asked my psychiatrist for guidance on whether I needed breast implants.  I would have sought her help when locating a surgeon.  I would have wanted her blessing, and I sought her approval for the steps I did have to take.

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