Post op regret and detransition - informed consent and psychotherapy

[Gina_Z]

Any man of legal age could walk into a body modification studio, have his penis split in half and then linked together with steel hoops....have his face tattooed with the image of his choosing and then be suspended from the ceiling by hooks through his skin. All he would need to do is sign a waver, and pay.
A woman can walk into a cosmetic surgery practice and have her breasts enlarged to the point where she can barely stand up straight, and her lips pumped with so much collagen that they look like car tires. Again....money and a signature.
But...because I am trans, I am not capable of making decisions about my own body? Why the double standard?

Exactly!  And like I said, where are the gatekeepers when she marries someone who is completely inappropriate and her life becomes a disaster? Right. She is allowed to make her own decisions. She should be allowed. 

[E-Brennan]

Oh I agree it's atypical. However regarding roadblocks I disagree: I'd say SMARTER roadblocks are more important than MORE or HARSHER roadblocks though. The RLT again seems to foster the belief of: you are able to adapt to living in your target gender? Ok you get a vagina (or penis for trans men) - but if you can't? Nope you get nothing, you lose, good day. More of a view on the patients wishes, making sure the patient is informed, and a neutral voice that asks questions I think is more more beneficial IMHO. Would it have stopped me? Maybe. Would MORE roadblocks would have stopped me? Most likely not, unless said roadblock was only getting 1 procedure done at a time. In any case too late for me now, I just want the problem fixed.

I see where you're coming from, and I think we're on the same page.     Smarter roadblocks would be much more preferable than just more roadblocks, particularly those which encourage patients to become more informed and certain of their choice in the interim.  Roadblocks with no purpose other than delay?  Yeah, a bad idea and would cause far more harm than good.

My transition will most likely end when hormones have done their thing.  Maybe an orchi, but full SRS is unlikely.  Provided I'm seen as female in 100% of situations where I have my clothes on, I'll be happy.  Luckily, I have a therapist who has helped reinforce that this is a perfectly acceptable outcome, because sometimes it's easy to fall into the trap of thinking that I'm not really trans unless I want to work towards SRS.

[suzifrommd]

I don't think it is a legal right.  Not in the sense that we have a legal right, under all circumstances, to obtain whatever controlled substances we desire or force medical professionals to operate on us if we have enough cash to pay. 

I specifically said TRANSITIONING is a legal right.

Transition doesn't imply HRT or surgery.

It is a legal right for a male bodied person to live as a female.

Do you disagree with that? That I legally should be prevented from living as a woman if I so choose? That I should need a doctor's permission for taking a woman's name and accepting female pronouns?

[Shantel]

Time to exit, it's getting kind of shrill here.

[Beverly]

Time to exit, it's getting kind of shrill here.

I agree...

[E-Brennan]

I specifically said TRANSITIONING is a legal right.

Transition doesn't imply HRT or surgery.

It is a legal right for a male bodied person to live as a female.

Do you disagree with that? That I legally should be prevented from living as a woman if I so choose? That I should need a doctor's permission for taking a woman's name and accepting female pronouns?

Of course I don't disagree.  I'm not going to butt heads with you, suzifrommd.  Here's what I posted in full:

I don't think it is a legal right.  Not in the sense that we have a legal right, under all circumstances, to obtain whatever controlled substances we desire or force medical professionals to operate on us if we have enough cash to pay.  Perhaps in the sense that we are free to self-identify in whatever manner we choose, but without the consent (to some degree) of someone else who has the keys to the candy store and the knife drawer, we're pretty much powerless.  Nobody can (nor should) transition in a vacuum - that's how mistakes are made.

You don't need a doctor's permission at all.  You're free to identify as you so choose - be that male, female, whatever.  I complete agree with you.

Now, whether it's a legal right or a human right is a whole different issue that I'm not going to get into in much depth.  The law defines what our legal rights are, whether we like it or not, and our own personal preferences have nothing to do with what our legal rights are and aren't.  And the law often lags behind in many areas - gender being one such area.  In some jurisdictions, you can identify as female all you like inside your own head, but in the eyes of the law you're still male and subject to various restrictions based upon that categorization until you've undergone certain medical steps.  In that sense, transition most certainly does imply some degree of medical intervention - from the perspective of our legal rights.

But in general, I fully agree with you.  In an ideal world, our legal rights to transition in any manner we choose would be absolute, but we're not living in that ideal world quite yet.  I wish we were.

I don't disagree at all that we'd all strongly prefer that the law stayed out of our private lives to the fullest extent possible.

Let's not argue over semantics.   

[suzifrommd]

Of course I don't disagree.  I'm not going to butt heads with you, suzifrommd.  Here's what I posted in full:

Sorry for the snippy post. I definitely overreaction. Your post(s) are well-thought-out and worth reading.

Too much T in my system, I guess (well, it's a good excuse, at least). Only two more days until it's gone for good...

[E-Brennan]

Sorry for the snippy post. I definitely overreaction. Your post(s) are well-thought-out and worth reading.

Too much T in my system, I guess (well, it's a good excuse, at least). Only two more days until it's gone for good...

Nyet problemski, suzifrommd.  I didn't take it as snippy at all.

They should put anti-androgens in the water supply, kinda like they do with fluoride.  The world would be a much calmer place...

[TaoRaven]

Exactly!  And like I said, where are the gatekeepers when she marries someone who is completely inappropriate and her life becomes a disaster? Right. She is allowed to make her own decisions. She should be allowed.

Indeed. It is vitally important that we be able to make our own decisions about our own bodies and lives.

And yes, sometimes we will make mistakes. And contrary to what some may have suggested, the attitude from the rest of us is very seldom "sucks for you", but one of support and empathy.

[Roxanne]

And yes, sometimes we will make mistakes. And contrary to what some may have suggested, the attitude from the rest of us is very seldom "sucks for you", but one of support and empathy.

This has changed a lot in recent years though. There is a lot more empathy now. Before it was definitely "sucks for you". Unfortunately so much of the idea of regret has been attached to those who have become very anti transgender after the fact, want surgery outlawed, etc.

I don't want that at all, I just want to be fixed

[Declan.]

I see where you're coming from, and I think we're on the same page.     Smarter roadblocks would be much more preferable than just more roadblocks, particularly those which encourage patients to become more informed and certain of their choice in the interim.  Roadblocks with no purpose other than delay?  Yeah, a bad idea and would cause far more harm than good.

I went to Fenway in Boston for informed consent. The first appointment is medical. Bloodwork and a physical. The second appointment is a discussion with a therapist who spends about an hour with you. He asked questions that were deliberately phrased to weed out the people for whom informed consent may not be the wisest choice. He also asked me to list every effect testosterone could have on my body instead of telling me himself. At the end of the appointment, he informed me that he had to bring my answers before a medical board who would evaluate them and then decide if I needed a few more therapy appointments or to join a support group prior to starting testosterone. (I was approved.)

I'm not sure how it's handled at other informed consent clinics, but I felt that Fenway was as responsible as you can get. I can't imagine how someone could get past the therapy session and medical board without being deliberately manipulative if informed consent actually is not the right path for them.

[E-Brennan]

Declan, that sounds like how IC should be done.  Emphasis on the "informed", and those who aren't are pointed in the direction of resources where the appropriate information can be found.  It seems IC is all too often treated with as little care as buying a used car - once you sign, it's yours.  It's not hard to check if someone is minimally informed before treatment.

[Agent_J]

I see where you're coming from, and I think we're on the same page.     Smarter roadblocks would be much more preferable than just more roadblocks, particularly those which encourage patients to become more informed and certain of their choice in the interim.  Roadblocks with no purpose other than delay?  Yeah, a bad idea and would cause far more harm than good.

That's the biggest reason I am so critical of my providers; it took 4 over four years for me to get HRT that could reasonable be expected to do anything and having to fight them at every appointment to get anywhere (I finally got it when, after that period, I switched to an Informed Consent clinic where a lot of information was given but no psych profile required - then again, I had already obtained my HRT letter years earlier, met the requirements to have my surgery letters written, etc., but the time I saw her so any such would have been unnecessary gatekeeping of me.) My first endo directly told me that she would not use any codes other than ones that were directly transition related for billing insurance and "they will most likely reject and you will have to pay out of pocket." When they didn't, at each subsequent appointment she mentioned her amazement at that fact...

My transition will most likely end when hormones have done their thing.  Maybe an orchi, but full SRS is unlikely.  Provided I'm seen as female in 100% of situations where I have my clothes on, I'll be happy.  Luckily, I have a therapist who has helped reinforce that this is a perfectly acceptable outcome, because sometimes it's easy to fall into the trap of thinking that I'm not really trans unless I want to work towards SRS.

Alas, whenever we're subject to the approval of others, there's the chance for undue influence, and it happens very easily. If you had my therapist and doctors that would likely be seen as unacceptable and you would have been encouraged to either detransition or "complete" your transition by having SRS.

I've had a lot of people insist that my use of an informed consent HRT provider, at the point that I had already been through so much gatekeeping, was the only reason I regretted SRS, completely absolving the endless pressure to have SRS and requirement that I claim to want it or be denied access to any other parts of transition. Also that the same professionals strongly opposed any other procedures - I was told in fairly direct terms that having BA or FFS would not be viewed well.

I have regrets for SRS because it was a requirement to end the BS medical and metal health treatments. I walked into the OR in Montreal with doubts that I wouldn't voice because I knew Dr. Brassard would refuse if he knew and that, if that happened, I would face serious repercussions from my doctors and therapists when I returned home.

[Shantel]

I don't have the patience for all that so many others are required to tolerate. About 20 years ago I decided that I wanted to transition so I went to a doctor and told him I wanted to go on estrogen. He was a GP and kind of a quack so knowing that up front and the fact that he was known for throwing pills at his patients on request, I decided to take advantage of him. Six months later I went to a well known trans woman doctor here in Seattle and showed her my pill bottle, she did the blood work and wrote me estrogen and spironolactone prescriptions. Four months later I became involved in VA, the endocrinologist who took me under his care, labs and hormones were free from that point on. Until then I was taking care of this privately as an out-of-pocket expense.

I got into a VA counseling program for PTSD and brought up my dysphoria issues during that time mentioned the fact that I was receiving HRT. I pre-wrote a consent letter that the counselor could use for her format which she copied with her official heading and title on it and she signed it for me I got another from the Seattle Trans doctor and yet a third from the VA endocrinologist and went to Portland Oregon's Providence Medical Center where I had an orchiectomy on my own dime, $700 back then in 2001. A year later I took copies of those same three letters along with the orchiectomy confirmation certificate and had my pre-SRS consultation with Dr. Bowers, we were all set to go and I decided against it at the last minute as it would have been the straw that broke the camel's back concerning my marriage which I valued beyond having a vagina.

The entire process was cut and dried, I set my cap to accomplish it and don't have any regrets because I am mentally competent and know my own mindset and have zero tolerance for manipulative controls from anyone. I feel bad for a lot of people that are sure of what they want to accomplish and yet have to deal with roadblocks along the way, but on the other hand I have to agree that some of it is necessary for many as there is a lot of mental health aberrations and delusional thinking in the TG community and unless they have done their homework and are damned sure about what they are doing it's best to suck it up and take the standard route.

[Wynternight]

To get my bariatric surgery I had to do the following:

See the surgeon
Get a tonne of labs drawn
EKG
Sleep study
Visit with psychiatrist
Three month diet

Weight loss surgery is not as life-altering as SRS/transitioning so, as a transwoman, a WLS patient, and a nurse, I think true informed consent and a waiting period to make really, truly, certain that this is what you want to do is not only an ethical issue but a requirment. The consequences of hasty action are too severe to do otherwise.

[peky]

I certainly don't want to start and argument, more an intelligent discussion what is your opinion of  'quick' informed consent (basically HRT on demand no questions asked) 'true' informed consent, ( several visits to ensure you understand what you are doing) or extensive psychotherapy so that your problems are aired and discussed fully prior to HRT/surgery?

I come from this issue by comments I have had (not on this site) that quick IC is preferable - even if a number of people suffer or even die from making the wrong decision.

I find that unacceptable, I also BTW find gatekeeping, as generally understood by the community unacceptable. I prefer a model of community based therapy leading to psychiatric informed consent, followed by ongoing community therapy as needed.

Now a given is that everyone involved has to be properly trained and not the fly by night or Bible bashing medical community, but trained sympathetic therapists.

If you have detransitioned or have post op or even post HRT regret how would you like the system changed to a point that would have helped you?

Your thoughts?

Do Cis-women have to have "informed consent" and/or psychotherapy when they are seeking:
facial plastic surgery,
breast augmentation,
body countering
buttocks implants
buttocks lifts  ?

Having said that, it is my opinion the gate was open when HRT was prescribed ! It was at that time that the psychiatrist  had to diagnose the patient with a bona-fide case of GID AND make sure that the patient had no other SIGNIFICANT mental disorders. 

If a year later, and having completed at least 1 year of RLE, either your GP or your Endo should be able to give a letter recommending SRS, after all they (GP or Endo) are the ones who know you best.
One caveat, the Endo or GP should have option of seeking the concurrence of a psychologist or psychiatrist when in doubt.

Basically, it should be done in a case-by-case basis with some flexible and general guiding rules (NOT LAWS)

[Carrie Liz]

I can only voice my own experience in this matter, but here goes anyway:

I started HRT with no consent whatsoever. The whole reason I hadn't transitioned younger was because I didn't know about HRT. Before that, I had (wrongly) assumed that I'd never pass because my body was so big and so masculine, so I didn't even bother looking into it. Then in December of 2012, I discovered this site, and discovered Youtube transition timelines, and I was completely blown away, because there were people with way more masculine features than me who ended up looking completely gorgeous. I realized that the only reason I doubted that I wanted to be female was because I was scared of what other people would think of me, not because I was having any doubts about it myself. I quickly ran through the diagnostic criteria for someone to be trans, and when I fit every single one of them, I knew I couldn't wait any longer, I had to get on hormones NOW. Especially after reading all of the accounts of people who said that HRT was basically the best thing ever.

So, after doing research on what the correct dosages were, I started hormones on my own, via internet pharmacies. And within a week or so, I already knew that I could never go back.

About a month later, when I finally got on my company's health insurance policy, I went legit.

I had to start on informed consent because, again, I wasn't willing to wait. So my doctor wrote me a temporary 3-month prescription to bridge the gap, and told me that the next time I came, I'd have to bring a letter from a therapist stating that I "wasn't crazy."

I REALLY like the method that my therapist used. She said that if at any point I wanted a letter for anything, she'd write it, even if she disagreed with me. Because she believed that it wasn't her place to tell me what I could and couldn't do with my life, even if she thought I shoudn't. And I really like this method, because it made me free to be COMPLETELY honest in our therapy sessions, because I was never scared of having to be "trans enough" to get a diagnosis. Because even if she didn't think I was trans, if I really wanted the letter, she'd give it to me. So I didn't have to pretend, didn't have to hide anything, and so she was able to truly help me. She's been a friend and guide through this whole process rather than a gatekeeper standing in the way.


Now, while I'm really glad that I was able to get hormones so quickly, because I really was at that point where I wasn't willing to wait any longer, I don't recommend this method for anyone else. I went through all degrees of hell transition-wise because I was naive and uninformed at the beginning of it, so I was constantly caught up in my own head about what every single little emotion meant to my life as a whole, and I'm a chronic overthinker, ruminator, and panickier. Before I finally started going to therapy in mid-March, my moods were just all over the place, constantly going from elation to severe depression because I was trying to use how I felt as a measure of whether transition was right or not. It took that official diagnosis from my therapist (which I did get after 4 sessions,) before I finally started accepting myself as trans and calming down a bit. (And even after that, I still went through an absolute hell of emotions due to being fired from two jobs.)

So yeah... I like my therapist's method. Take the pressure off, be willing to write the letter no matter what because it's not their place to tell an adult what to do with their own life, but always be there as a guide. Because doing it completely on your own can be a pitfall of emotions and assumptions. So having an experienced professional there to guide you makes a big difference. I'm glad I went to my therapist instead of continuing to self-medicate. I put myself through a hell of uncertainty because of trying to do it on my own.



In regards to SRS, I don't know. I used to think that HRT was enough, but now I realize I do think that RLE might be a good thing. Because ever since going full-time, my genital dysphoria has greatly diminished. Pre-transition, I was obsessed with SRS, thinking of it as this ultimate validating female thing that was the one thing I couldn't have, and wanted more than anything. Now that I've been full-time for 4 months, it doesn't bother me as much. Now that I'm not looking for that silver bullet that would assert my femaleness once and for all anymore, it's not as pressing of a concern. I do think I still want to get it, but I'm glad that I wasn't able to just rush into it.

I don't think a set period, IE the "one year" requirement is necessary, I think it's more a matter of when someone reaches the point where they're settled enough transition-wise to be able to make an objective decision, which could be as short as a few weeks for the very self-assured, or years for those who are still having social doubts despite being full-time. IMO it should depend on whether the individual is mentally ready for it or not, time notwithstanding.



Again, I don't know how this plays into the overall picture, though. This is just my experience. I know there's a lot of self-medicators who are probably completely emotionally stable and don't see therapy as anything other than getting in the way, a lot of people over on Eunuch.org with severe genital dysphoria who wish they could have orchiectomy/penectomy/SRS available without the need to be female socially, and likewise there's people who probably don't do their research as thoroughly as I did, who might need that gatekeeping to make sure they're not rushing into a decision that they'll regret, or using the wrong dosages/prescriptions and doing harm to themselves. I don't know.

True informed consent worked pretty much perfectly for me, so I'm all for that.

[Julia-Madrid]

The approach is Spain, at least in Madrid (health is a regional competence, not a national one), is extremely sensible.

You may ask your health service doctor to refer you to a specialist gender identity unit and they cannot refuse you the referral.  The gender unit where I go has an endocrinologist, sociologist and psyschologst as the core team.  It is slow however, but it does not look like they reasonably deny people hormone treatment at the very least.  They do require a psychologist's report identifying dysphoria, accompanied at least by a passive statement that the psychologst does not perceive a problem if the patient wishes to begin hormone treatment.

You can argue that the psychologist is acting as a gatekeeper but I don't believe this is the case practically speaking.  I think there is a very strong case for a mental health professional to be able to make a decent assessment of the person's psychological state prior to a patient hurtling down a path before they have clarity and insight into the true motivations behind their dysphoria. 

[peky]

The approach is Spain, at least in Madrid (health is a regional competence, not a national one), is extremely sensible.

You may ask your health service doctor to refer you to a specialist gender identity unit and they cannot refuse you the referral.  The gender unit where I go has an endocrinologist, sociologist and psyschologst as the core team.  It is slow however, but it does not look like they reasonably deny people hormone treatment at the very least.  They do require a psychologist's report identifying dysphoria, accompanied at least by a passive statement that the psychologst does not perceive a problem if the patient wishes to begin hormone treatment.

You can argue that the psychologist is acting as a gatekeeper but I don't believe this is the case practically speaking.  I think there is a very strong case for a mental health professional to be able to make a decent assessment of the person's psychological state prior to a patient hurtling down a path before they have clarity and insight into the true motivations behind their dysphoria.

Very sensible indeed (Los Gatos saben)

[Jessica Merriman]

My only concern is when people just can't wait for HRT and either self medicate or do informed consent and then post here wondering why this medication is doing this or if this symptom is normal or not. That tells me the person was not making an Informed Consent decision.