Pros & Cons of Early SRS

[Karla]

Hi Kate,

Thanks for replying.... I did indeed try it.  Six months, composed of fruitless job interviews, not being able to repay pay student loans or even pay the rent

Why did I stop transition?  No, i did not have doubts.  It was because I couldn't pay the rent, was evicted and faced with the prospect of living on the street ... and then caved in to an ultimatum from my parents, by which I could stay with them as long as I detransitioned and got a job.

Interviewing for the same jobs as a man got me employed quickly... 25 years of wage slavery can pass quickly.

I'm not proud of this at all.   I feel that I was weak and dumb and should have stuck it out, rebelled against my parents... but it's fruitless to dwell on what might have been.   This is how it played out.  Now I'm picking up where I left off, for once living my life for myself rather than for the benefit of others.

If I seem impatient, that's why.... partially.  Having insurance through my job that will pay for SRS today, is no small motivator.  I've always worried.  Some people get laid off.  Other people don't have to worry about money!

Karla

...I believe there still needs to be a process to weed out those who only think transition would be a good idea from those who need it. 

Are you willing to bet your life on something you haven't tried?  Something on which you have gotten only minimal guidance?  Just getting a vagina doesn't make you a woman and doesn't make you able to live as one.  We all want a quick fix...
- Kate

[anjaq]

Hi.
I personally think that the optinions on this topic shifts with time in each person. I certainly can imagine that after the coming out or beginning transition, the desire to get there fast is strong, while later, one is more considerate. For me, this is now about 14 years in the past and I must say that as bad as the process felt back then, I think it was all right. I had some doubts back then, in part if I could manage to be accepted in society as the new me. I was one of those TS who desired SRS more than the social changes though I did not really consider doing SRS without the social changes. They are a package to me. I honestly cannot understand why someone would want to do SRS without transitioning. Yes, it is their choice in a way, but also it is a matter of what works - and I am not sure doing such a think in the long term works without that person getting depressed. After all what is the fundamental motivation for SRS even in these cases? It is the identification as a female. Why do some not desire the role change? My first thought - and I have heard of people who expressed that desires - was that it is out of fear of rejection. They want to be "women in the closet" sort of - know for themselves that they are women with a vagina and maybe even boobs but live as males because it is easier in some way. I doubt that this can work out in the long run - this is just another closet to hide in, that one has to come out again later. Still I think every one is unique and maybe for some thats it, its hard for a surgeon to justify his work though, creating a "guinea pig situation".
For the majority who want to transition as well as SRS, I think the focus on SRS is unhealthy. After all it does not change much at all in the social interaction. It does a couple of things that are desired: enabling sexual intercourse, get a legal gender change, allow participation in places people are naked. As neat as all of these are, they do not have nearly as much impression on your life as HRT or RLE. I think a key point in doing the RLT is to see if a person can adapt to the new social role, if it is healthy, if it works out for the person, if the path feels "right" and if that person can actually pass well and/or deal with not passing in a good manner that does not cause too much depression. If any of this does not work out, SRS will  not change this, so I can understand that "gatekeepers" basically want to see if you can manage transition before they finalize the step. As I have written elsewhere, SRS is sort of a rite of passage - it is an irreversible step, that takes dedication and requires a decision to be made with the knowledge that it is irreversible and the person doing that decision has to be ready for it - rally ready and not just eager to go on or in an emotional longing, but seriously mature enough to be ready. This is not depending on time or months of RLT, but on emotional maturity and dedication. The person has to be able to make an informed decision that is irreversible and stick to it. There can be no rushing this as to avoid later regrets which are not the end of the world, but seriously should be avoided. Agent_J had this experience in a way now that the doctors rushed her towards SRS - the opposite of what was discussed here and finding herself not ready for the passage.
I think doctors are trying to understand and figure out how to determine if a person is ready for such a decision, if the person is dedicated enough. One sign of dedication is of course going through RLT, another is to do HRT and feel great about it. I had the impression that even being a bit rebellious is actually a plus - as I told the therapist that I was doing DIY HRT he disapproved from a medical standpoint but also took this as a sign of dedication I believe, as I am even risking my health at that time to get where I wanted. So the gatekeepers want to see if you are dedicated enough, thats the whole point I think. Plus of course you grow in experience about yourself in that time. One learns abot oneself and ones motivations which informs a later decision for SRS.
If therapists could find a way to shorten this, that would be good. In the end what they do is to assess how stable your wish to transition and SRS is - if it can be swayed by setbacks in RLT or such. I know cases where this took only a few months to show the "gatekeeper" that indeed there is not much to talk about. In fact when I went there - we talked about nothing really - 7 or 8 times that was and then I got my paperwork.

So i think for SRS it can easily be justified to demand a certain period and several sessions to explore the desire for that and the dedication to that and the matureness of the patient to be able to make an informed irrevocable decision to accept the rite of passage. My opinions on HRT are very different as in contrast to SRS, hormones have an immediate and noticeable effect on social transitioning as well as physical changes - while being reversible to a large degree. To keep this from people who are transitioning for 12 months or more after starting RLT is IMO cruel. So I think that part should be revised, but not the part about SRS.
Greetings

[Cindy]

Anjaq that was a nice post .

I can understand Karla's point of a window of opportunity financially as well. And she may be in a unique position from her past to make the decision.

It is very personal. Not all of us make a good decision based on logic, particularly over surgery like this, it is such an emotive topic.

I'm certain; I have my letters. But I can't decide where to go! Why? Emotions!

Will my vaj be perfect? Hell at my age it will probably never be used!!!

[anjaq]

Cindy, thank you.

Just wanted to say that I understand Karlas situation as well. I was speaking more generally. And tried to point out that the timeframe IS individual. I definitely understand that if financial pressures exist like that, some things may have to get priority and with that past, certainly there are some plus points. I understand also that obviously as transition failed last time due to financial reasons, she does not want to take that risk this time.
Now I am not too familiar with health insurance in the US - except that it seems to be a totally messed up chaotic system - what would happen if you get sick while being insured and then as a result you loose the job and the insurance? Lets say if you have an accident? Would that also mean you have to rush your healing to get it over with before the job is lost? Or do they have to finish payments until the treatment of one diagnosis is finished? If the connection really is that you need RLT for SRS and insurance to cover for SRS and you loose insurance if you start RLT, then that is a serious dilemma. I would hope then to find a therapist that can help. I know some people who "cheated" in the RLT for similar reasons (going to work in DRAB). I think this is a special case though - and it shows to me more the inadequacies of the US health system in terms of paying for needed procedures equally rather than in a problem with the standards of care, as I think most people do benefit from the more or less standard timeframe of 15-30 months.
Here in Germany we are lucky. I was without job and money at the time and still was able to transition and get SRS (and even only had to do a partial payment for BA). So these are different circumstances obviously...

It is very personal. Not all of us make a good decision based on logic, particularly over surgery like this, it is such an emotive topic.

I'm certain; I have my letters. But I can't decide where to go! Why? Emotions!

Will my vaj be perfect? Hell at my age it will probably never be used!!!

Aw dont say that - if you want to, it will be.
Of course the whole issue is emotional. All of transition is and SRS is no exception. But emotional decisions also can need time - not so much to gather more information and make lists and do pro and cons and all that logical stuff - the decision is more made from intuition and is already made when the question comes up, IMO. But it takes time to manifest that decision within ones self, to convince all other parts of the mind that this has to be so and to get emotionally used to it. I think this is needed to ripen that decision and then to make that leap once that internal process has finished. For Karla that may be different again, as she already did some of that work many years ago, but also some things may be different now, the self has changed, some things have to be again emotionally accepted and refreshed. I assume that this time this is a faster process or even done already, I dont know. But for all those who come out and are convinced now that they want to transition and do SRS, that is said emotional decision that was already made before coming out - but this decision has to sit there for a while to be fully accepted by that person, to the point it feels "right" for all parts of ones mind, a time when one is truely ready to make that leap of faith.

[Zumbagirl]

But people do these things....they use their adult right to decide what is best for them in their lives, and make it happen. And they don't need to spend years in therapy, and voluntarily accept the diagnosis of a mental disorder to do it.

I suffer from a birth defect. I was born in a male body. There is no logical reason in my mind that I should not be able to enjoy the benefits of modern medicine, just like any other American, and pay to have my defect surgically corrected at my own judgement.

But I also don't think that any one should be able to tell me how large my soft drink can be

The problem I see is that using this line of reasoning, SRS surgery is equivalent to "cut off my leg because I want to be crippled". Is it safe or ethical for a doctor who swore an oath to "do no harm" to cut off someone's leg? Without having some kind of test then how does a doctor know they are doing no harm? What should a doctor do to make sure in your case they are doing the right thing?

I also agree that no one should tell me how large my soft drink should be

[K8]

Karla, I understand the pressure to zip through this, especially considering the opportunity for your insurance to pay for the SRS.  Your own experience shows some of the hazards of trying to transition socially.  Like anjaq, I really don't understand how anyone can want to transition physically but not socially, other than the physical transition is easier.

I really would like to understand the thinking behind "SRS on demand."  Those who support this view, please explain to me – I'd like to know. 

What is wrong with a doctor wanting some reassurance that he is helping you, not making things worse for you?  What is wrong with a chance to change your mind once you learn what it is like – kind of like the buyer's remorse laws in some places?  What is wrong with transitioning socially, which is reversible, before transitioning physically, which is not?  Having your genitals rearranged is of little help in the social transition unless you live in a nudist colony.

I started RLE less than 3 months after coming out.  I had SRS 367 days after starting RLE.  It can be done quickly.  I had a lot of help during the process and am very grateful I didn't have to do it alone.  I have made some poor decisions in my life.  I was glad to get some guidance as I made a really big one.  I feel very fortunate.

- Kate

[suzifrommd]

I really would like to understand the thinking behind "SRS on demand."  Those who support this view, please explain to me – I'd like to know. 

I'm not sure I support it, but I understand the thinking.

No doctor understands my needs as well as I do. Any test designed by someone else placed in the way would have questionable validity.

As a trans woman, I deeply resent cisgendered people who could not possibly understand my condition making decisions about my medical care.

[Cindy]

I'm not sure I support it, but I understand the thinking.

No doctor understands my needs as well as I do. Any test designed by someone else placed in the way would have questionable validity.

As a trans woman, I deeply resent cisgendered people who could not possibly understand my condition making decisions about my medical care.

I think this is my concern, my medic has about 30 years experience of looking after trans clients. At what point do we say someone doesn't know what they are talking about?

Yes if I have someone with no experience I'll ignore them, but if they have experience?

[suzifrommd]

At what point do we say someone doesn't know what they are talking about?

Yes if I have someone with no experience I'll ignore them, but if they have experience?

Good point. My case is similar to yours. My doctor and therapist are both cisgendered but have decades of experience working with us. Both of them share the point of view that they would never dream of telling a transgender patient what was right for them. Inform us of the risks, yes. Ask probing questions, yes. But both of them respect us enough to believe that we are capable of making adult decisions once we were given all the information.

But I came across other, equally experienced therapists, recognized experts, who gave me horrible advice and did not understand what I needed or what I was going through at all. I guess the common denominator in their cases was arrogance. They assumed they knew better than I what was good for my emotional well being.

Bottom line: If an experienced professional thinks I'm making a decision without all the information I need, then give me the information. Then trust my informed decision about my own medical care.

That being said, there is certain knowledge that can only be gained experientially. I couldn't know whether living as a woman were right for me without doing it.

IMO, SRS is not one of those decisions. There is no experience that will tell me whether life will be better with a different bottom.

[Cindy]

I have to admit, maybe with some alarm, RLE ended up being extremely important to me.
Yes my team supported me to make my own path, and yes I was successful, whatever that means. But there has been nothing like walking into life as me without a mask.

If my life as me had been miserable I had another chance. There is, in my opinion, nothing like trying it out. 

One thing I have realised, there is no magic wand. If I had total control and had grs straight away, I'm not sure in retrospect that I could have coped. I say that with an open mind and some surprise.

Being me isn't about GRS, being me is far more complex than that - to be brutal, I didn't know that. I thought I did. I was naive, even though I thought I was prepared.

[suzifrommd]

If I had total control and had grs straight away, I'm not sure in retrospect that I could have coped.

Oh, me either. Luckily I was so sure early on that I'd never let someone do that to me, that there wouldn't have been danger of my jumping the gun.

I wonder if some sort of waiting period that wasn't so tightly prescribed would be better. Like asking people to spend a year making themselves certain but letting us decide how to do that. Maybe some of us would want therapy, some of us would want RLE, some would go on a spiritual retreat, some would just think about it once in a while.

Still paternalistic, but at least puts more faith in our own abilities to understand our own minds in our own way.

What do you think of that?

[Cindy]

The problem as I see it is the diversity. Anyone can be whoever they wish. But when we counsel people we do so in a spirit of understanding.

I need to say this carefully and I shall still get criticised.

I had a consult recently and she was a very nice person. Her wig was terrible, make up awful, wearing basically clothes that no one would wear in public, topped with work boots, steel capped at that. She was an impressive sight.

She commented that she had put a special effort in to look feminine for her outing with me. She genuinely and completely thought she looked good, fitted in and would not attract negative attention. She felt safe and comfortable.

Fortunately Adelaide is a welcoming place, and the place I took her for lunch knows me.

She was impressive. She had no concept what so ever of her appearance and the impact it had in public.

She expressed her desire for immediate HRT, she wants "big tits" she wants surgery and I will not repeat why but it would lead to prolonged sexual satisfaction.

She is in danger.

It is not in my power, but if it was, should I sign the papers?

When we criticise the "gatekeepers" are we aware who wants to walk through the gate?

I have had the comment that it is still that persons choice, and we should not have the right to intervene. When I suggest that the client may suicide, I was told that it was the clients choice and I had no right to prevent that.
I can't accept that point of view.

Cindy

[K8]

I got some terrible advice but knew it was terrible.  He was some big expert who knew everything but in the end ruined too many lives.

Fortunately, I was really lucky when I finally decided to transition: My family physician fully supported my medical needs despite the fact I was his first trans patient.  My counselor had limited trans experience but knew me well enough to trust me. 

I learned a lot during RLE.  SRS was just icing on the cake.  I wonder if you have SRS but continue living in your birth gender, wouldn't the dysphoria be even worse?  I've met a couple of women who thought SRS would make them who they wanted to be but were disappointed when it didn't help them pass, didn't change their behavior to more feminine, didn't solve all their problems.  They were the ones who cut corners, so perhaps that's why I think the requirements are good. 

I agree there needs to be some flexibility in the system, on both sides - the professionals and the patients.  But I also think a reality check needs to be built into it somehow.

- Kate

[K8]

It is not in my power, but if it was, should I sign the papers?

When I got my letters, I was a little surprised how much emphasis was on an evaluation of whether I would be successful living as Kate.  But on reflection, it makes sense.  A good surgeon, a good doctor, a good counselor does not want to make life more difficult for the client. 

We don't always see ourselves clearly.  We don't always have realistic expectations.  Sometimes we need a little guidance to help us along the way.  We want to work with the doctor and the counselor to help us.  If the professional is autocratic, you need to find someone else.

[suzifrommd]

It is not in my power, but if it was, should I sign the papers?

Wow, Cindy, I love the way your posts encourage thought.

That one raises really interesting questions.

Should someone of limited intellectual or social ability be deterred from SRS, especially if her limitation will prevent her from passing?

Should interest in being sexy as a female be a disqualifying factor? I hope not. In my case the desire to be attractive was a major player in my interest in transition, and a desire for female sexual response played a huge part in my motivation to start HRT. (I should add that I haven't been disappointed on either count).

All of those things increase the risk of bad effects, but risk is a probabilistic effect. Not everyone at risk has a bad outcome. Do you tell someone that they cannot have a procedure because their risk is higher - their chance of a good outcome is 30% instead of 95% - even thought they might well be part of those 30% who defy the odds?

I don't have answers of course, but the questions are worth thinking about.

[anjaq]

Hmm - The concept of allowing other ways of reflection than RLE and therapy is one that sounds tempting. My concept of this whole roadmap and gatekeeper thing is that transpeople need time to really familiarize themselves emotionally with the change that is happening and is going to happen with SRS and this gives them time and tools to explore this. If there would be other tools that work, I would not deny that this could work. What I think cannot work is to proclaim that each person has the right to decide at any time if SRS is to be done or not. That would cause a lot of misery I believe because people who think they are ready or have unrealistic expectations will go for it and then have regrets or problems coping. Even if SRS would have been the right choice for them, I believe that if it happens too early, the spirit of that person isnot ready for it and then things go sour.
Who should be denied access to SRS by the gatekeepers? People who do not pass? People with sexual feelings at genderchange? I dont think so - this should not be - and IMO usuall yis not - a matter of denying access forever but it is about giving the patient more time to adjust, to prepare spiritually, emotionally and socially for the permanence of SRS. See, one starts with something easiyl reversible - like changing clothes. Then one does something that is harder to reverse but possible - HRT and then something basicall yirreversible like SRS - it is a progression of determination. The person transitioning can learn in that time how to deal with the lasting effects and the increasing permanence of the decisions made and until SRS can basically pull out.I know people who did that - either because transition was not for them or because of practical reasons like not being able to pass ever and notwanting to suffer from that forever. They often state at first that yes they are sure they want to transition and SRS of course. If they had been given SRS right away, I dont want to know what would have happened then...

So I think no one should be denied SRS, but I do think that it is good if there are guides and people who watch the whole thing and basically have the power to steer the transition and the pace of it to a degree as to give the person transitioning the time to make it properly.

[TaoRaven]

The problem I see is that using this line of reasoning, SRS surgery is equivalent to "cut off my leg because I want to be crippled". Is it safe or ethical for a doctor who swore an oath to "do no harm" to cut off someone's leg? Without having some kind of test then how does a doctor know they are doing no harm? What should a doctor do to make sure in your case they are doing the right thing?

I also agree that no one should tell me how large my soft drink should be

Well, in that scenario I would certainly rather assist the patient with conforming their body to their needs, especially when considering that they may try to remove the offending limbs themselves.

Maybe I am a horrible person, but I respect each individual's right to live life in the fashion that they see fit, and to do with their body what they will.

And I expect the same courtesy.

I may not agree with or understand all of these people, but that's not really necessary. It's none of my business. What John Q. Public does with his life and body is his own business.

As is his gender identity, sexual preference, and religion. And I would certainly never dream of imposing my "ethics" on anyone.

[Karla]

Wow.

I wouldn't know where to start, responding to every, equally wonderful post.  And my feet are killing me... here's what I have learned from my first full day of RLE:

• Break in new heels before spending all day in them.
  

Here's my take on transitioning... there are physical, emotional, social, legal and even political aspects (as TaoRaven eloquently expresses). Many aspects, but they all blend together.  The aspects interact: they can't be (or shouldn't be) taken in isolation. 

I would be more comfortable with the idea of gatekeepers if they were themselves transgendered. 

Waiting 6 months for hormones did not benefit me one bit.  It didn't make me wiser.  In fact the anxiety of having to deal with a foot-dragging therapist (whom I've since swapped out for somebody that I 'click' with) probably held back my progress toward RLE... which we all agree is the sine qua non of transition. 

So back to my first day of RLE... I'm soaking my feet in a basin of salt water right now and laughing.  First time I've had a chance to turn on my laptop today. 

Began the day last night, on a red-eye from the West Coast... waited an hour for beverage service to be over and folks to fall asleep.... went to the stall bathroom and changed there, emerging as Karla.

It could have been a pain, in such cramped quarters, but thanks to previous experience and a dry run the day before, I emerged smoothly, glided back to my aisle seat in the darkened cabin... and fell asleep myself.

On landing in the morning, my neighbour appeared not to notice or care that he had fallen asleep next to an androgynous-dressed guy, and woken up next to a younger redheaded woman.  So far so good.  The rest of the trip was uneventful... more smiles than usual seemed to be the only difference.  Maybe they just saw that I was happy, and responded in kind.  Picking up my car, I chatted and laughed with the lady in the booth where I paid too much for parking. 

Watched the speed limits on my way home, worried about what would happen if pulled over...

On returning home, I dropped by the neighbour's for a scotch... had come out to him a few months previously, so no surprises... and again, today we just picked up our friendship as if nothing had happened.  The dress was a marginal change, compared to my personality changes (for the better).

On returning home, discovered a box waiting for me from Zappos: two pairs of heels which did not fit, and a beautiful formal dress that had me in tears of joy when i tried it on, a black side-draped dress that moves really nicely with me, and a designer blouse that pinched me under my arms, looked terrible on me and had me wondering why I bought it... because it cost as much as the formal dress.

Picked up my son from my ex for the weekend... interesting: she was nicer to me than she'd been in months.  Shock?  Perhaps.  We made small talk. 

Must go, time to tidy up and start the woodstove.   I'm so sleepy... but I'd rather stay up!   

Anyway, that was my first full day; it was a good one and I'm happy to share it with all of you as a pleasant switch from my angst of the week previous...

[Doctorwho?]

I think the point many of you are continuing to miss is that this is not just about you and your needs. There are also the needs of the doctors that you employ to feel satisfied that they are treating a valid medical necessity. Now as I said in my earlier post, RLE may not be a great way to do that, and it may indeed fail comprehensively with non binary folks, but until we have a more robust diagnostic test it is all we have.

Now the bottom line to this is while you may WANT to see informed consent - that would only happen if doctors treating the condition were happy for it to do so. My experience suggest to me that the evidence is that they aren't - ergo hell will probably freeze over before anything like this happens. So by all means go on having a lovely debate - but the bottom line is it is all academic because it hasn't got a rats arse of a chance of happening unless you suddenly develop the ability to do the op yourself.

Until that happens you will need someone like me (once I am qualified) to treat you. Now I consider myself pretty sympathetic - I have a couple of friends who have transitioned in the past so I understand the territory better than many, but I have to tell you that even I would baulk at this, so with the best will in the world I really don't think you have much chance of finding a doctor who would operate on that basis.

Every doctor worth his or her salt is likely to have diagnostic criteria which need to be fulfilled before they will operate. Ergo further discussion about informed consent SRS pretty well "on demand" is pretty pointless cos it simply won't be happening anytime soon. endof.

Oh - one other thing occurs to me - ironically I had a lecture on informed consent just today in medical school, and from a clinicians point of view it does not mean what you all seem to think it means. It is NOT licence for a physician to operate recklessly and without due regard to the risks and benefits to the patient. The physician is still charged with acting as the responsible professional and using their best judgement to decide whether a treatment SHOULD BE OFFERED AT ALL - just because you are prepared to sign a form does NOT free the physician from the charge of misconduct if they are deemed to have carried out inappropriate treatment.

Instead informed consent is merely a device to prove that an attending physician has properly explained the process of the treatment proposed, and the likely risks and benefits there from. In effect it is merely informing the patient correctly , and then asking the patients permission to carry out the agreed treatment. It is NOT giving the patient the right to demand a treatment that the doctor does not wish to perform.

[TaoRaven]

Karla, thanks for sharing...that was a wonderful read!

And this is why I am afraid of ordering clothes/wigs/etc online...I need to be able to try stuff on first. That and it's fun



And Dr. Who....there is an entire list and network of ICATH affiliated physicians and therapists who disagree with your assertions. See, I guess the whole "helping people" and "doing what's right" concept is catching on.

And there are therapists who will write referral letters with as little as a single visit, should one wish to employ the services of a WPATH adherent surgeon.

Interestingly, when Colorado first contemplated the ideas of Medical Marijuana, there were those who insisted that no Doctor would prescribe it, for fear of lawsuits, etc. The next thing we knew, we had dispensaries with Doctors on site, who would prescribe on the spot for as little as a muscle ache. Seems those predictions were a little bit short sighted, and on the "wrong side of history".

I don't mean to be rude...but you may want to put aside your predispositions and actually look around a bit. Things aren't quite as cut and dry as you seem to want to believe. endof.