A transition story

Reflections on a medical gender transition

The following is Part 1 of a reflection on the steps that led up to my decision to medically transition. My hope is that telling this story will prove helpful to clinicians and healthcare providers in understanding the various complexities of a medical transition pathway.

The timeline of my medical transition

In January 2004 I informed my therapist, a psychiatrist I’d been working with for 3 years, that I thought maybe I was a man. She was encouraging. Up to that point she had been treating me for depression and anxiety with minimal success. We seemed to be at an impasse. Gender dysphoria offered something new to focus on. When I asked her to write me a referral letter to the endocrinologist so that I could start hormones, she was willing. I still have the letter. In it she writes:

“I am a psychiatrist in private practice and have been seeing [birth name] for psychotherapy and medication management since Dec 2001. Her diagnoses are: recurrent major depression and mixed anxiety symptoms. Initially there was a lot of self-harming behaviour which seemed to suggest borderline personality disorder but more recently it has become apparent that one of her main issues is gender dysphoria.

She has decided to try living as a man and is very interested in trying testosterone treatment to enhance a male phenotype. As such, she asked me to make a referral to you. 

As I am not her family doctor, I do not have any lab reports to send however she is in good health.

Her current medications are: Wellbutrin SR 100mg OD; Celexa 20mg OD; Zyprexa 5mg po OD; Ativan 1mg SL qHS prn.

Her mood is currently euthymic, anxiety symptoms are under good control and there has been no self-harm behavior for some time. [Birth name]’s decision to live as a man has brought her a sense of peace, liberation and empowerment.

As such, I am supportive of her decision and would be more than happy to provide you with any further information you may need.

Thank-you so much for seeing [birth name] in consultation.

Sincerely,

[Signed]"

Later that month I started Testosterone — and at first it came with great relief.

Three months later, in March 2004, I saw another psychiatrist, a gender specialist, for a formal diagnosis of gender identity disorder (now known as gender dysphoria in the DSM-5-TR). I needed this second assessment if I planned to go on to have any surgical interventions under the provincial health insurance program. Even though I wasn’t sure I wanted surgery I was encouraged to undergo this assessment just in case, as the waitlist was constantly growing. I saw the second psychiatrist for a single 90 minute appointment. The letter he wrote went as follows.

 [Reader’s note: this letter contains many factual errors that do not reflect what I actually said. For example, I never attended boarding school - although I may have mentioned that my father did. Also, I do not remember saying ‘everyone lived in ghettos’, although I likely did try to describe the financial disparities between different groups in the country at the time I lived there. I also did not leave the country because of being disillusioned with the church, as the letter implies. I left because I wanted to get away from my parents, with whom I had a poor relationship outside of our religious disagreements. The assessor did not have me review the letter before sending it to the endocrinologist.

The letter has been lightly edited to remove identifying information.]

“Dear [endocrinologist’s name],

I saw this 24 year old individual on 4 March. She presented as a person dressed in unisex manner and was an intelligent individual, able to give a good history. I will use the pronoun “he” since this is the patient’s preference.

FAMILY HISTORY

His father was a psychiatrist and they came to Canada for a little time in childhood before they returned to [homeland] again. He was one of three sibs and there was no sexual, emotional or physical abuse in the family.

PERSONAL HISTORY

He states he was always a very happy ‘tomboy’. He never wore dresses and liked to go topless as a youth as did the boys. He was always interested in male pursuits.

In [homeland] he went to a boarding school where he was forced to wear dresses daily and he found the atmosphere very stilting in that there was no freedom, everyone lived in ghettos etc. He felt he never fitted in there and in high school suffered from an anorexic eating disorder since he didn’t want his periods to start or his breasts to develop. He spent most of his high school days isolated in his room and never dated. 

His father was a very religious individual and he rapidly became disillusioned with the church so eventually he left and came to live with his sister.

His parents supported this and they gave him money allowances. He attempted for a while to be female but detested it. He had a boyfriend but when it came to sexual intercourse he kicked him away, feeling that it was “painful and wrong”.

He tried lesbian relationships but again felt that he didn’t fit the mould. He felt that he was attracted to women but didn’t himself want to be a woman.

His parents came last Christmas to visit and they thought he was lesbian at that time. He now has a degree in English and French and is going on to his Masters. One of the courses he took was on Human Sexuality and this together with other reading has convinced him that he is transsexual. He knows several transsexuals around town. 

PSYCHIATRIC HISTORY

He has suffered from recurrent depression for many years and from time to time has cut himself, the last time being in 2002. He is unhappy with his present body and wishes to change. He has been on hormones now for four weeks and is strongly considering going on to mastectomy. He wants to go slow on future changes since he feels sure that his parents will disown him if he admits his real feelings. With regard to psychopathology in the family, he believes his father has been on antidepressants and his mother and grandmother have a cyclic swing in mood. He believes his sister is also depressed.

I understand that Dr. [other psychiatrist] has been treating him for depression and social anxiety. He has taken Celexa 20 mg and Wellbutrin 150 mg for two years now with occasional Ativan and low dose (5 mg) Zyprexa. His father had put him on Paxil years ago but he had a bad reaction to it. He feels his bouts of self harm have usually been stress related. 

DIAGNOSTIC CATEGORIES

Axis I - Gender Identity Disorder - female to male, high intensity 

Axis II - Nil

Axis III - Nil

Axis IV - Stressors: family issues around transsexualism

Axis V - GAF 50 (50: Serious symptoms or any serious impairment in social, occupational, or school functioning)

This individual is now on Delatestryl and feels that because of this he is beginning to become happy. We discussed the present situation with the [provincial health plan] and the fact that he should get a name change when he can afford it. As yet, [the provincial health plan] do not have any criteria set out so that the best thing he can do at this point is to go slowly with hormones until such time as he can effect some sort of positive response from his parents. I will see him again and try and synchronize it with when he is seeing you. Many thanks for the referral.

Yours truly,

Dr. [signed]

—

The endocrinologist, in supporting me to get new ID documentation offered her own perspective of my issues as follows:

June 24, 2004

To Whom It May Concern:

This letter will attest to the fact that [name] who resides in [city] is under treatment for a neuroendocrinological condition, known as transsexualism.

This person is living and dressing as a man using the name of [name] during the preoperative phase of treatment. He is in the process of effecting an official name change and is receiving hormone therapy, testosterone. 

[Name] is not criminally inclined, and cross dressing is not intended to perpetrate fraud or cause any harm to any individual.

Sincerely,

XXX, M.D.

—

Three years later, my family doctor wrote the following note on my behalf, as I was on EI and applying to be retrained in film and writing. 

Apr 13/07

Re: [name]

This patient lives with depression, anxiety, agoraphobia and is transgendered. These issues mean that a career where he works alone under his own control, such as film work and writing, is ideal for him. Thus, for medical reasons I support his choice of career.

Yours truly

[Family Dr]

—

Three more years later, in August 2010, I underwent a hysterectomy and oophorectomy on the recommendation of the gynaecologist/laparoscopic surgeon, who informed me that this was the responsible thing to do to avoid cancer. My insurance did not initially want to pay for the procedure. This is what my doctor wrote to them…

“The clinical scenario of gender dysphoria is a MEDICAL CONDITION - the diagnosis made and ratified by mental health professionals qualified and competent to do so.

The acceptable medical Standard of Care in the case of this diagnosis is hormone therapy and sex reassignment surgery in order to bring the physical expressed gender in line with the psychological gender. 

To even suggest that this may be a lifestyle change - which implies choice is offensive and irresponsible and would be considered discriminatory under the Canadian Charter of Human Rights - Do you REALLY want to “go there”

Dr xxx"

***

As I look back on this timeline now, several themes stand out to me. The first is that overall, my healthcare providers truly did seem to want to help me and I think sincerely believed that what they were supporting me in, i.e. gender reassignment, was an appropriate intervention. I also get the sense that they saw themselves as my allies against a state system that seemed restrictive (e.g. my insurance provider calling the medical interventions a ‘lifestyle change’) and discriminatory (e.g. requiring proof that I was ‘not criminally inclined’ and was not attempting to commit a fraud). They were attempting to be advocates for someone they saw as vulnerable and oppressed. And, in truth, I was vulnerable — but perhaps not for the reasons they thought. 

Something else stands out to me as well — the many assumptions that underlie the assessment process itself. In her original letter, addressed to the endocrinologist, my original psychiatrist clearly sees treating the gender dysphoria as the issue that will resolve my other issues, i.e. depression and anxiety, and borderline traits. She is essentially assuming that those issues are symptoms of a deeper issue around my gender and that my struggles in relation to my gender are physical in nature, not psychological. On what basis did she make this assumption? The gynecologist’s letter, which outlines the standard practice for treating gender dysphoria as hormone therapy and sex reassignment surgery is revealing as well. What other psychological condition is treated with such invasive physical interventions? And who determined that psychotherapy could not provide any help for gender dysphoria? 

Knowing what I know now, I question this medicalized approach to gender nonconformity. Especially reading the second assessment letter. At no point did anyone ask about whether my distress might be related to my sexual orientation rather than my so-called gender identity. No one explored in any depth my body dysmorphia and eating disorder, and how this might be related to issues around my embodied gender. I am also struck by the note written by my family doctor, three years after starting hormones, which clearly indicates that I was still struggling with the issues that had preceded my gender transition — depression and anxiety. At no time did anyone seem to question whether the treatments were in fact effective. Gender dysphoria was treated as completely separate from my other mental health issues. How can this be? 

I am also struck by my gynecologist’s insistence that the diagnosis was ‘made and ratified by mental health professionals qualified and competent to do so’. I can’t help wondering — were they competent in doing so? Neither of them followed up with me. The first psychiatrist discharged me as her patient shortly after I started hormones, stating there was nothing more she could do for me. The other, while in his letter indicating that he intended to continue seeing me, did not schedule a follow up appointment with me. No one seemed interested in following up with me to see whether hormones or surgery were actually improving my mental health. 

Looking back, I am struck by the confidence - or was it hubris? - of my care providers, to be so convinced that you are providing the right treatment for the right problem when the treatment itself was at the time still relatively new and experimental. And what of that small detail, found in my family doctor’s letter in 2007, showing that largely my mental health had not improved with my gender transformation? I still suffered from depression, agoraphobia, anxiety three years after starting hormones. Instead of promoting caution, the medical doctors continued on with suggesting ever more invasive physical interventions, perhaps believing that if I just got a mastectomy or a phalloplasty, then my mental health problems would be addressed. No one discussed with me how the medical interventions themselves could further traumatize me. I still have flashbacks to the day my plastic surgeon scraped out the fatty tissue from under my chest under local anesthetic, in an attempt to fix the damage from an earlier hematoma and improve the contouring of my chest.

Another item that strikes me as I read through my medical records is that note in the gender specialist’s assessment recommending that I take it slow until somehow my parents are on board with the treatment. At no point did anyone suggest perhaps our family could benefit from family counselling to navigate all of this. I am struck by how, in comparison, an autism diagnosis often involves interviewing family members, teachers, friends. Yet for gender dysphoria, the assessment process is so much less involved considering the highly invasive interventions that can follow a diagnosis. Why is gender dysphoria treated so differently from any other mental health condition?